Med. J. Malaysia Vol. 40 No. 2 June 1985.

POPULATION 70 MILLION:A CONSIDERATION OF HEALTH ASPECTS

SITI NORAZAH ZULKIFLIKHAIRUDDIN YUSOF

SUMMARY

A 70 million population for Malaysia by theyear 2010 has been officially targetted for inthe Mid-Term Review of the Fourth MalaysiaPlan, 1981-1985. In response to this, apreliminary investigation was undertaken into thehealth aspects of population growth. For thisexercise, infant mortality rate was used as thehealth indicator. From trends seen vis-a-vispopulation growth, it appears that thus far,population growth has not been associatednegatively with health (as measured by IMR).In recognition of the relevance of the medical,economic and education factors to health, trendsin Malaysia's population ratio, per capita GNP andrates of school enrolment were also drawn; theselection of these as proxies being based oncompleteness of time-serial records. Althoughstatistical regressions established the highcorrelation between medical doctors.populationratio and school enrolment rate with IMR, the

Siti Norazah Zulkifli, BSc, MSc (Ntn)Lectu rer, Social Obstetrics & Gynaecology

Khairuddin Yusof, MBBS (Sydney), FRCOG, FICSProfessor, Social Obstetrics & Gynaecology

Faculty of MedicineUniversity of Malaya51900 Kuala Lumpur, Malaysia

62

limitations in this analysis did not permit anyreliable inferences.

In view of the difficulties in projections oftrends, a comparison of health and relatedvariables was carried out for several countrieswith high populations as near to 70 millionas were available. The characteristics associatedwith low mortality and high life expectancy(health indices) were identified as low populationgrowth, high literacy and high per capita GNP;this being stated with explicit qualifications.Other determinants of health were also discussedin brief, and the need for careful planning in thedistribution of human and material resources wasnoted.

INTRODUCTION

"Recognizing that a large populationconstitutes an important human resource to createa larger consumer base with increasing purchasingpower to generate and support industrial growththrough productive exploitation of nationalresources, Malaysia COUld, therefore, plan for alarger population which could ultimately reach70 million. ,,1

This reversal in Malaysia's policy comes at atime when an industrial ization strategy is beingactively promoted in this country and isadvocated, in part, to alleviate some of theconstraints that a relatively small domestic market

places on the development of industries. Whenconsidering the implications of such a policy,it is necessary to think of the time-frame withinwhich a population of 70 million is expected tobe attained. Ludicrously high fertility rates wouldbe involved if it were to happen, say by the turnof the century, unless one expects massin-migration to make a significant contribution.More realistically, however, the desired populationis expected in about 115 years which thereforenecessitates a transient period of increased ferti Iityto generate sufficient momentum for growth toproceed to that defined population.

With a well-planned distribution of populationand resou rces and as long as the social, pol iticaland economic structures are stable, 70 millioncould probably be easily absorbed. However, suchan ideal remains stubbornly elusive. As far ashistory and current events depict, trends inpopulation seem inextricably linked to trendsin employment, income distribution and socialchange. For the individual and his community,the demand for basic needs is foremost - food,housing, jobs, education and health care. Inaddition, such services as garbage collection, postand telecommunications and public transporthave become, by modern living standards,necessities as well. Health, being a state of mindas well as of body, is influenced by all these needs;the provision of which is an integral part of socio-

economic development.

The relationship between population andeconomic trends is subject to controversy; whetherpopulation affects the economy or vice-versa, orthe two are merely coincidental is debatable.Weeks 2 draws upon evidence from specificcountries and explains three schools of thought.Briefly, the first is the theory, in line withMalthusian principles, that economic growthcannot be achieved without controlling thepopulation. Since population increases qeometri-cally and food supplies arithmetically, Malthus, inthe late 19th centu ry had envisaged teemingmillions outstripping the earth's resources. Povertyand misery were prophesized to be inevitableconclusions.

63

In opposition to this, Marxists contend thatpopulation growth does not impede economicgrowth. Rather, it is the socio-political structurewhich determines events, and a more egalitarianapproach should augu r well for the fate of nations.Finally, the pro-natalists view population growthas economically stimulating, specifically forsparsely populated nations. A priori, more peoplecreate greater demands and th is is claimed to actas a stimulus to innovative thinking, technicaladvancement and increased productivity. There isalso an enlarged potential labour force, anexpanded market for consumer goods, possibilitiesfor economies of scale and increased nationalsecurity. Provided that the available manpoweris gainfully employed, the economy could flourish,

Whichever the ideology, there is no doubt thatpopu lation is closely linked to developmentvariables, of which health is part. In the eventof a population increase, it is imperative thatthe health and related sectors be prepared toaccommodate the increase and that the nation'seconomy allows for this extension. This paperis a preliminary investigation into the healthaspects of a 70 million population.

HEALTH STATUS: INDICATORS ANDTRENDS

The contemporary (WHO) definition of healthis a state of physical, mental and social well-beinq,and not merely the absence of disease or disability.This holistic approach gives due recognition tovarious personal, environmental and communityfactors that have an influence on health and thatneed to be considered when monitoring levelsof health. On account of the multiple and inter-active factors involved, as well as the lack ofobjectivity in individual perceptions of a 'healthy'disposition, a quantitative assessment of healthstatus by any singular yardstick is limited in

accuracy.

Conventionally, mortality rates are consideredto be indicative of morbidity rates and used as ameasure of health status. The advantage is thatdeath, being a final and indisputable event,

circumvents any diagnostic problems and henceinaccurate reporting which disease may be subjectto. Registration of deaths is also a routine practiceworldwide albeit with inconsistencies in qualityof data. On the other hand, shortcomings in theuse of mortality as an index of health statusinclude the fact that it measures an end-point inthe disease-making process, hence is not reallya measure of the health of the survivingpopulation. A high incidence of moderate tosevere malnutrition in children, for example,need not necessarily concur with a high mortalityrate, hut the population is certainly far fromhaving a high standard of health. As an indicator,its sensibility is also dependent on the reliabilityof documentation. Nevertheless, death rates prove

to be very useful as an easily available means ofhealth surveillance in a population.

In this paper, the statistics used as proxies forthe state of health in this country are infant,neonatal, toddler and maternal mortal ity , thesegroups being the most vulnerable in anypopulation. The data was obtained frompublications of the Department of Statistics,Malaysia. Due to insufficient records on the EastMalaysian states of Sabah and Sarawak, thesituation is described for Peninsular Malaysia.

Fig. 1 shows trends in the various mortalitiesfrom 1957-1980. The most dramatic reductionhas been for IMR which has fallen from 76 to 25per 1000 live-births. Significant control overinfant deaths has been achieved by effectivetreatment and prophylaxis of diseases such asmalaria, smallpox, tuberculosis, whooping cough

and diarrhoeal diseases. The improvement in othermortalities have been more gradual.

Generally, in developing countries, considerabledeclines in mortality, achieved particularly around

the middle of this century, have been attributednot only to medical technology but to economic

development and social transitions as wel1.3 Theinfluence each of these has in the control ofdiseases has been variable depending on the

disease aetiology itself and its responsivenesseither to medical intervention, public healthmeasures or improvements in living standards or

lifestyles.

Viewed against trends in population" (Fig. 2),the increase in population size, has so far not beennegatively associated with improvements in healthstatus. It is important to stress however, that thisis true in as far as morbidity can be broadlycorrelated with mortal itv.

HEALTH DETERMINANTS

It was earlier stated that the bulk of mortalitydecline in the third world was contributed bymedical technology and socio-economic progress.More specifically, availability of health care,efficacy of public health measures, education ingeneral and health education in particular and

nutritional adequacy each has a role indetermining health status. Needless to say, forthe individual, having the means to procure therequisites, be it cash or non-cash based, is

critically important. For similar reasons, theeconomy of a country also has crucial relevance.It supports, among others, the capital intensivehealth and education sectors, sewerage andsanitary water systems and to a certain extent,food supply and distribution. On the relationshipbetween education and mortality, Miro andPotter3 quote Preston":

"Indeed, the slope of the relation betweenmortality and education within countries isgenerally so steep (especially at lower levels ofdevelopment and life expectancies) thatexpenditures on education would at first sight,appear to be an effective way to reducemortelitv",

Generally speaking, one would expect the role

of education to be one of instilling an awarenessand understanding of health problems and their

causes, instituting changes in behavioursparticularly in personal hygiene and environmental

"Population censuses are carried out every 10 years and estimates are calculated for intercensal years from compoundaverage annual growth rates, thus Iinearizing the growth curve.

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c1eanliness .and modifying attitudes towardsacceptance of modern medicine, both therapeuticand preventive.

In line with this rationale, trends in selectedsocio-economic variables are also illustrated.Data selected to represent the education andincome variables were % population (five to 19years) enrolled in school (%PES) and per capitaGNP (real terms), respectively. The availabilityof health care was represented by ratios ofmedical doctors: population, nursing staff:population, and government hospital beds:population. The period covered was 1960-1980.Others that could also have been looked at in thesame context were household income, femaleliteracy, and coverage of household piped watersupply. However, the available data wasinsufficient. Fig. 2 shows that growth- in theeconomy has undergone two phases; a slowincline in the sixties followed by a sharper onethereafter. This favourable trend has coincidedwith declines in mortality within the periodspecified, i.e., economic progress has not beennegatively associated with health nor withincreases in population.

In the past two decades, improvements havealso been made in the health services. Thephysician-to-patient and nurse-to-patient ratioshave risen fairly rapidly, more so in the latter(Fig. 3). Data for registered medical personnel,however, excludes the traditional healers, i.e., theChinese sinsehs, Malay bomohs and Indianayurvedic healers. These unorthodox medicinemen and women still play an important rolein health care in Malaysia as well as in neighbour-ing countries. If they were included in thestatistics, the service ratio would improveconsiderably. In the case of hospital beds, supplyhas decreased since the late sixties period.Although contributions from the private sectorwere not included, this does seem to indicatea failure on the part of the government healthservice to keep up with population growth.

Finally, in the field of education, rates ofschool enrolment have increased since 1957

68

amongst the population of school-going age(five to 19 years) (Fig. 4). Correspondingly,literacy rates have also increased. Educationhas long been recognised as an entry-point inpoverty eradication and social progress and tothis end, a heavy portion of public expenditureis allocated each year. The trends .depictedquantify the efforts in this sector.

STATISTICAL CORRELATIONS

Having related certain socio-economic variablesto health, a regression analysis was undertakento test the relationship between IMR (infantmortality used as proxy for health status) andthose variables in the local context. Multipleregression is a general statistical technique whichanalyses the relationship between a dependentor criterion variable, in this case, IMR, and a setof independent or predictor variables. Thepredictor variables selected were medical doctors:population ratio, % school enrolment and percapita GNP, to represent respectively the healthservices, education and economy. Although otherscould have been included, the analysis wasconfined to the three variables described primarilyfor want of sufficient data.

The analysis showed a very high correlationbetween IIViR and medical doctors populationratio and % school enrolment (R2 = 0.94).Furthermore, it showed that the influenceof the income variable (per capita GNP) could befully accounted for by school enrolment alone.The results of the regression analyses weretabulated in Table I.

It might be inferred, prima facie, thatimproving the health service ratio and schoolenrolment rate ensures a low IMR. However,th is regression model merely describes statisticalassociation between sets of data which do notimply cause and effect relationships. A moresophisticated path analysis is required for that.Also the analysis was by no means an exhaustiveone, as only three variables were computed.Thus, as the influence of GNP could be explainedby school enrolment, likewise, the latter, and

% P.E.S.."

TABLE IREGRESSIONS ON THE LINEAR DEPENDENCE OF lOG IMF!: INDEPENDENT VARIABLES

log Per Capita log logR2

DegreesConstant GNP MD: Population % P.E.S. F-Test of Freedom

4.48446 - 0.94* 0.83 89.9** 19

3.16307 -1.'18* 0.86 121.3** 19

7.151118 -3.18* 0.89 138.9** 19

3.96026 - 0.46* - 0.72* 0.93 105.5** 18

7.18751 -0.00 - 3.2* 0.89 66.1 ** 17

5.59876 - 0.55* -1.87* 0.94 138.4*' 17

5.59864 + 0.00 - 0.55* -1.87* 0.94 86.9** 16

* - Sig. at 1%;** - Sig. at F. 99. Variable Mean

IMR per 1000 43.18Per capita GNP M$ 1,158.30MD Population ratio 21.11% P.E.S. 55.32

TABLE 11CATEGORISATION ACCORDING TO

PER CAPITA GNP

It was decided that two countries would be

selected from each category based on a population

as near to 70 million as was found possible.

The possibilities were, in fact, quite limited by

imposing this criterion; no countries from the last

two groups qualified and in the low-income and

industrial market group, the closest figuresavailable were, perforce, rather far off the mark

70 million, one way of approaching the problem

is by looking at situations where the population

is currently thereabouts. For this exercise, a

number of countries were selected from a listing,

on various vital statistics, of 124 countries

compiled by the World Bank.5 They were

categorised into five groups according to per

capita GNP (Table 11).

also medical doctors: population ratio may bemediated by some other factor or factors. In

addition, it has been pointed out that whilst IMR

is used as the dependent variable in this model,

it could also be cast as an independent variable

for percentage school enrolment, l.e., rates of

school enrolment may vary according to IMR

which may affect the number of persons surviving

to school-going age.

Without reviewing in great detail the Iimitations

of statistical analyses, suffice to just reiterate the

main points. The regressions undertaken denote

the close association between medical doctors to

patient ratio and percentage school enrolment

with IMR within the specified time period and

without any further information on the nature

of the relationships. That it has little value in

predicting health outcome or in policy or program

planning goes without saying. Firstly IMR has

certain handicaps as a health indicator and

secondly, the crux of the problem, which isincrease in population, does not enter into this

analysis at all.Categories

Average per capita GNP (1979)US$

CROSS-COUNTRY COMPARISONS

Given the formidable task of attempting a

prediction on health outcome at population

70

Low-income countriesMiddle-incomeIndustrial market economiesCapital surplus oil exportersNon-market industrial economies

2301420944054704230

(see Table Ill). Exceptional consideration wasgiven to the middle-income category to whichMalaysia belongs. Here only one other countrywas selected which was Mexico. Her populationof 65.6 million was the nearest to the stipulated70 million amongst all the selections.

Various statistics from the selected countriesthat were relevant to health were next compared.Data compiled by a single sourcs'' was used forbetter comparability. Even so, this element isuncertain due to discrepancies in definitions ofterms and registration procedures betweencountries. Mortality data, for example, are atrisk of under enumeration in developing countriesand particularly so in destitute areas where ratesare very high. In fact, for the data presented in

Table I the ratios of physician and nurses topopulation have been specified as not comparablecross-country. The general objective was to tryand identify featu res associated with a highstandard of health. Here again, the problemof an adequate index looms large and, as before,there is little alternative to infant mortalityas the most sensitive measure.

Basic and health indicators are listed in TablesIII and IV. Fram the tables, it is apparent thatcertain relevant features can be associated withlow infant and toddler mortalities and lifeexpectancy at birth, these being accepted indicesof health status. These are: low populationgrowth rates, crude birth rates and fertility;high literacy rates; high per capita GNP.

TABLE III

DEVELOPMENT INDICATORS COUNTRIES (1979)

Industrial market economies Middle income Low income

Basic indicatorsJapan Germany Fed. Rep. Mexico Malaysia Pakistan Bangladesh

Total population (M) mid 1979 115.7 61.2 65.5 13.1 79.7 88.9

Average annual growth %(1970-1979) 1.1 0.1 2.9 2.2 3.1 3.0

Urbanization % (1980)

Urban population xTotal population 78.0 85 67 29 28 11

Average annual growth rate% (1970-1980) 1.1 0.4 4.2 3.1 4.3 6.8

Per Capita GNP US $ (1979) 8,810.0 11,730.0 1,640 1,370 260 90

Average annual growth %(1960-1979) 3.3 2.7 4.0 2.9 -0.1

Adult Iiteracy rate % 99 99 82 60 24 26

Crude birth rate (per 1000population)

1960 18 17 45 39 48 491979 15 10 36 28 44

Crude death rate (per 1000population)

1960 8 11 12 9 23 231979 7 12 7 6 14 16

Total fertility rate (1979) 1.8 1.5 5.0 3.8 6.5 5.7

Source: World Development Report 1980 (Supplement on World Indicators).

71

It is fitting to digress at this point for a briefnote on GNP. The weaknesses of GNP as areliable predictor for social development indicatorslike IMR has been emphasized.6 - 8 Very richcountries like Saudi Arabia and Libya, forexample, have very high infant mortalities. In fact,the statistics for Saudi Arabia approximates thatof Bangladesh at a GNP 90 times greater, oneof the highest in the world. On the other hand,there are striking examples like Cuba, a middle-income nation, which has achieved a dramaticimprovement from 70 per 1000 in 1960 to 19 in1981. The effort in Sri Lanka is also worthyof comment; despite being considered a lowincome country, IMR has decreased by about 40%in the past two decades. A UNICEF publicationillustrates the diversity in national incomesfor each of four groups of countries categorisedaccording to IMR, ranging from 'very high'over 100 per 1000 live-births to 'low' (less than25).9 Thus it is less a matter of GNP per se, but

72

of policies and priorities appropriated to socialdevelopment.

Retu rning now to the findings from the cross-country study. Although the Iisted characteristicsfeatured consistently with favourable healthindices, several qualifications need to be made.Firstly, the sampling was based purely on thebasis of population size which excluded twocategories of countries; the capital surplus oilexporters and non-market industrial countries.Secondly, by this non-random technique, thequestion of representatives was simply overlooked.

Be that as it may, it seems within reason toascribe two events as being negative to healthprospects, or at least, not ameliorative inconsequence. These are high growth rates andlow literacy in the population. Presuming theaccuracy of this generalization, it would be useful

to be able to identify the cut-off points wherethese rates can offset efforts to improve health.

Although technically uninspiring, thissection displays some of the options which maybe a reality for Malaysia, if and when herpopulation grows to such extents. Notwithstand-ing the inconsistency in the relationship betweenGNP and mortality, one prospective situationmay be that of Mexico - if the economy growspara passu with population such that incomeper capita is more or less maintained at thesame level, hence mimicking Mexico, mightmortality figures also echo the appalling levels?

DISCUSSION

The health consequences of a 70 millionpopulation would depend on a variety of

factors. The demographic features, age andsex structures and geographic distributiondetermine health needs to some extent.Developmental factors such as labour utilisation,new technology, national priorities and levelsof international assistance have influence as well(Fig. 5). In meeting the increased demand forhealth services, government policies may betargetted either towards maintaining currentlevels or towards desired levels, e.q. aspiringto the standards in developed nations. Budgetallocations to the health sector and the relativeimportance given to its various components,i.e., preventive, curative, research and training,and its organisation are fundamental to how wellthe health services cope with population increase.Government policies and goals in other areas,like food production and prices, housing,education, employment and wages are alsopertinent to health status.

World TechnologicDevelopment

InternationalAssistance

PublicDemand

Natality

Nationalgoals

Healthmortality

fI FoodI

/ Housing/ #'

POPULATIONf.. .GROWTH \\ Education

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~Employment

~ Income

Fig.5 Relationship between population growth and health services [Corsa and Oakley).'O

73

In terms of demography, two different patterns

will emerge depending on whether growth occurslargely by increased fertility or if massin-migration makes a sizeable contribution.Areas of high fertility will show a skewed age-distribution pattern, biased towards theunder-15 age groups. The age distribution ofMalaysia's population reflects this and isrepresentative of the situation in most developingnations (Fig. 6). In 1970, the under-15 groupconstituted 45% of the population and theworking age group 41%. In 1980, these shifted

to 39% and 46%, respectively indicating a loweredfertility level. The proportion of the populationover 60 years has increased only slightly in that

time, illustrating a trend towards the pattern ofthe developed countries, which is characteristically

diamond-shaped. Each of these shifts in thepopulation structure will have an impact ondemands from the health sector. Health plannershave to consider the differential rate of require-

ment or utilisation of personal health services overan individual's lite-span.l ? Precedence may need

to be given to maternal and ch ild health care orto the elderly, particularly those who live aloneor in institutions.

Another implication of a prominently youngpopulation is that more resources will have to bediverted to supporting this dependent age group.The International Planned ParenthoodFederation 11 estimates the proportion of GNP

required to feed, clothe, house, educate andcare for the very young and the old as four timesthe population growth rate. So, the higher thisgrowth, the greater will be the percentage ofGNP needed to absorb the nation's dependentsand correspondingly, the less there will be forother investments and development purposes.

On the other hand, mass in-migration whichinvolves mainly people in the 15-35 yeargroup, will push up the productive segment of thepopulation. International migration flows consist

largely of manpower exchanges between countriesin response to labour shortages or employmentopportunities, the underlying motivation being

economic gain. At present, Malaysia isexperiencing an influx of cheap labour from

74

Indonesia and the Philippines coupled with an

outflow of highly skilled personnel to higherincome countries like Singapore and theMiddle-East. These movements will impinge onthe population structure as well as the social andeconomic set-ups. Highly qualified emigrants areusually over 40's who take their families withthem whereas immigrants tend to be younger(20-35 years), and hence, in their most fertileperiod. In his study, Mehmet12 highlights the

loss in expensive educational investment in the'brain-drain' which is not redressed by theincoming migrants who, in contrast, are low-skilled and poorly educated. Their willingnessto accept low wages also impede attempts toeradicate poverty. And, as ill-health is amanifestation of poverty, health problems arecompounded. Furthermore, migrants from acommon background tend to cluster togetherwhich alienates them from the host society anddistances them from available health resources.

While the influx of Third World migrantsare now creating problems for some developedcountries, e.q., the USA, West Germany andSweden, developing nations are becomingburdened with internal migration, particularlyrural-urban movements. In the cities, the arrivalof young and nubile people speeds up urbangrowth rates significantly. Pollution, jostlingcrowds and nerve-racking traffic are painstakingly

tolerated on account of the many advantagesurban living has to offer; the employment andbusiness. opportunities, available modern facilities,

public services, easier access to medical care,availability and variety of foodstuffs and lastbut not least, the 'bright lights'. In the rural

areas, the comparatively backward conditionsand dearth of economic incentives serve as'push factors' for the people. The rural exodusis thus quite understandable. It is estimatedthat about 60% of urban growth is attributableto natural increase.I? In this country, theacceleration of rural-urban migration coincideswith specific events in her history, namely colonialrule, post-war emergency and finally, the postindependence era.14 Current annual urban growthrate is 4.5%.1

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The literature on the relationships between

population growth, migration and developmentis extensive but yields no hard and fast rules. 1 5

While some defend the economic benefits, otherscontend that the costs far outweigh the gains.

Admittedly, developed nations are highlyurbanised but the examples of Lagos, Mexico Cityand Jakarta lend strong support to the counter

argument. Apparently relationships are peculiarto each place, the time and the conditions.

In the Federal Territory, amidst theseemingly random scatter of impressive towerblocks and array of modern housing schemes, lie144 squatter settlements where some 249,584people make their homes.l " Typically, a squattersettlement consists of wooden self-constructedhouses with communal public stand-pipes. Services

such as garbage disposal and sewerage are rare,but supply of electricity quite common. Theunhealthy environment is conducive to the rapidspread of diseases but fortunately, no seriousoutbreak has yet been documented. The

importance of the environment is shown in theimproved health found amongst re-housedsquatters in Kuala Lumpur as reflected by theirutilization of health services."? Rapid urbanisa-tion thus introduces two separate issues - theinadequacy of urban resources and the under-utilization of rural ones. Congested urban areaswill foster problems associated with overcrowd-ing and lack of basic amenities, which aremagnified in squatter and slum areas. Greaterinterpersonal contact or human interaction islikely to increase risk of disease infection.

The deterioration of health may also manifestindirectly th rough stress, either physical or mental.Malnutrition undermines the body's capacity tofight infections1 8 , 1 9 to the extent that certain

diseases are fatal only in the malnourished child.Similarly, psychological well-being is includedin the definition of health. Cassel,2o reviewing

evidence regarding the health consequences of

population density and crowding, concludes" increasedpopulation density increasesthe importance of the social environment asa determinant of physiological response to various

76

stimuli, including disease-producing agents; thatwithin this social environment, the quality ofsocial interactions and position within the groupseem to be important factors;and that given time,adaptation to these social changes can and doesoccur, but the newcomers to the situation willalways be the segment of the population at risk".

This phenomenon of biological and socialadjustment or adaptation to environmentalchanges will modify health status.

In this paper, national averages of IMR wereused as an index of health status. The data showedthat, by this assessment, health has improved

for the nation as a whole and that this washighly correlated with school enrolment and the

health service ratios. However, average or meanvalues obscure important differentials by ethnicityor comrnunltv.r ' and by area, which may be

considerable and warrant special attention.Table V shows that although mortality fromdiseases of early infancy still ranks high, itscontribution to the total number of deaths inthe past decade has fallen. At the same time, while

certain causes of death, namely communicablediseases like gastroenteritis and TB have been

controlled, others have taken their places. More

people now .die from circulatory diseases, i.e ..diseases of affluence. Thus based only ondeclining IMR, an inference of better healthmay be spurious. Another limitation of usingIMR, is that it gives little indication of thehealth of the su rvivors. Several studies haverevealed that under nutrition, especially Protein-Energy and Iron-deficiency anaemia, andhelminthic gut infestations are still commonamongst the rural and urban poor.22-26 Although

not fatal, these debilitating ailments retard thephysical and mental development of under-privileged children, very often sealing thecycle of poverty.

CONCLUSION

In the preceding paragraphs, some aspects ofhealth were discussed in the context of a largepopulation. Linear regressions on West Malaysian

TABLE V10 MAJOR CAUSES OF DEATH IN GOVERNMENT HOSPITALS IN PENINSULAR MALAYSIA

BY RANK ORDER % PERCENTAGE (1970,1977 AND 1980)

1970 1977 1980

Causes Rank (%) Rank (%) Rank (%)

Accidents 3 ( 8.06) 3 (11.36) 3 (13.14)

Gastroenteritis 8 ( 4.06) 8 ( 2.71) 8 ( 1.87)

Complication of pregnancy 9 ( 1.47) 10 ( 0.66)

Heart disease 1 (13.94) 2 (15.68) 1 (16.44)

Diseaseof early infancy 2 (18.86) 1 (18.65) 2 (14.90)

Cardiovascu lar diseases 6 (16.71 ) 4 ( 7.69), 4 ( 7.93)

Neoplasms 4 ( 7.21) 5 ( 7.07) 5 ( 7.78)

Pneumonia 5 ( 6.55) 6 ( 5.17) 6 ( 4.05)

Tuberculosis 7 ( 5.88) 7 ( 3.16) 7 ( 3.12)

Diseases of the liver 9 ( 2.12)

Source: Facts and Figures. Malaysia National Population and Family Development Programme, 1982.

trends showed a very high correlation between% school enrolment and medical doctors:population ratio with IMR for the period 1957-1980. However, the analysis merely examineddegrees of collinearity and did not consider anypath analytical models i.e., causal relationships,between the variables. Furthermore, only three

variables were involved rendering the correlationexercise rather limited in scope. Therefore, theresults do not lend themselves to any policy-making inferences.

Selected cross-country comparisons showed,fi rst and foremost, that the real issue is not thesize of the population but its pace of growth and

the social and economic climate at the time.Th ree common characteristics were identifiedin countries with low mortality and high lifeexpectancy. These were low fertil ity rates(and low rates of population growth), highliteracy rates and high per capita GNP. The lastof these is included with great reservations in view

of the strong arguments against GNP as a predictorfor social development.

It is not possible to accurately project the ratesof infant mortality or any other measure of healthfrom the methods used in this study. The

77

statistical correlations, drawn from past trends,cannot be extrapolated and the value of thecross-country comparisons is limited by the factthat it would be too presumptuous to considerthe fate of nations as running the same course,even though history has been known to repeat

itself.

Difficulties in forecasting due to limitations intechniques are exacerbated by the unpredictablespontaneity of population behaviour. In addition,nothing can be foretold of medical andtechnological breakthroughs which may alter thedemography of a country considerably. The

health system, for one, may be much moreefficient in its delivery via, perhaps, computerizeddiagnosis or the transfer of simplified therapeutictechniques to the layman. This dispenses withthe need for personal attention from over-burdened physicians. Unforeseeable events suchas these make attempts at predictions highly

vulnerable to error.

In effect, this paper gives an overview of the

issue in question. More importantly, by selectingIMR as the indicator for health status and byusing average values, it neglects morbidity patternsand differentials between areas, communities or

social strata. It is these inequities in distribution,

precipitated or compounded by rapid population

growth, which will be the source of serious social

and medical problems, as exemplified in many

countries today. Another negative aspect of

population growth is rapid urbanisation. This

rising and uncontrollable trend needs extensivelyresearched pol icy and programs in socio-economicdevelopment planning.

Finally, it may be added that the future alsodepends on political stability and global eventsor policies that affect the nation.

ACKNOWLEDGEMENTS

Our sincere appreciation to Professor Fong

Chan Onn for his 'B:MREGPR'; Irene Low

for her assistance; Professor Jason Teoh and

SPM for use of the 'Apple'; Professor Ozav

Mehmet and Dr Ooi Giok Ling.

We are specially grateful to Professor Lee

Kok Huat and Dr Zainal Aznam Yusof for their

precious time and patience in helping with the

regressions; Elena Wong, Rajes K., Norila Zahari

and l.irn Lav Pheng for their tireless effort with

the data collection, A.V.A and typing.

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