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There are two distinct but highly interrelated elements within international population policy. The policy set of goals and activities by states or international entities intended to inﬂuence and shape population outcomes in countries beyond their own national boundaries ﬁnds expression in both bilateral relationships and in multilateral activity. Bilateral activities seek to change population outcomes in speciﬁc countries. The collectivity of policies of the international community, expressed in multiparty international agreements, charters, covenants, and—most important for the population ﬁeld—in international conferences and conference resolutions are multilateral. This activity is designed to standardize views and practices, and to form a world-view of desirable goals and outcomes. The two are linked. Countries with active national or bilateral programs also seek to inﬂuence the direction of multilateral, international population policy.
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1. The Unique Context Of The Twentieth Century
Humans have probably always tried to manage fertility at the level of the individual and family. Rites and rituals to encourage fertility are time honored. There are also speciﬁc hieroglyphs in Egyptian antiquities citing herbal methods of contraception or abortion. More than a century before Christ, Polybius deplored both the tendency of comfortable urban Greeks to delay marriage and sharply reduce family size, and the resultant decline in population.
National concern and international preoccupation with population issues is very much a phenomenon of the last half of the twentieth century. While anxiety for the health impact on women of large families and unwanted pregnancy has been of long standing concern to health care providers, the major upsurge in interest in population issues originated in concern for the impact of rapidly accelerating global population numbers. Some appreciation of the remarkable quality of twentieth century demographic developments is therefore essential to understanding this policy evolution.
Never before the twentieth century did a human being live through a doubling of population; indeed the global population quadrupled between 1900 and 2000. The population increase in the 1990s alone was the equal of all of those who lived in the seventeenth century. In the preceding millennia, a good century for the human race was one in which the population grew at all. Plagues and normal high death rates in most societies ensured that this was not always the case.
Although everyone dies eventually, human death or mortality at an early age is what keeps population levels low. Absent high levels of mortality, migration, or decreasing fertility, population levels will increase. With the relative decline of famines and epidemics and increases in transport, communication, public health, and control of infectious diseases, nineteenth century Europe grew rapidly. About one-third of this increase was exported to colonies and overseas, a series of deliberate but minimally enunciated international population policies. The same spurt happened in post W.W. II in the nonindustrialized countries emerging from colonialism, or ‘developing world.’ The increases in numbers were bigger, and the pressure valve of migration was no longer available. The world was regarded as settled by the major players who controlled immigration ﬂows.
When the global population numbers really began to grow, when the ability to count them improved markedly, and when attitudes regarding sexuality and family issues began to change in the industrialized world, population issues arrived on the global scene and international population policy began.
Twentieth century population growth changed the shape and weight of international relationships. Over 95 percent of the population increase of the last decades took place in the developing world. At the beginning of the century, almost one person in ﬁve was European; at the end, less than one-tenth of the world lived in Europe. The six billionth child was born in the last year of the century. That child will very likely live long enough to see the peak of human population and the stabilization of population numbers. The trends that will cause the decline of high fertility are well begun. Although another huge population increase will take place in the ﬁrst two decades of the twenty-ﬁrst century, the end of the high fertility period is in most places now in sight. International population policy in the twenty-ﬁrst century will likely focus on diﬀerent issues, already emerging.
2. The Content Of Population Policy: Sensitive, Fragmented, Confrontational
There has never been policy consensus on the nature, importance, or remedies in this ﬁeld. The ﬁrst stage of policy making revolved around the question of whether rapid population growth and high levels of fertility were in fact a threat, and what to do about them if they were. Many continued to insist that high levels of population growth were a transitory factor that would decrease with development and progress. The answer was seen to be investment in accelerated general development, not speciﬁcally targeted programs, i.e., ‘development is the best contraceptive.’
Those on the other side of the issue used phrases such as ’population bomb’ to describe what Malthus in the late eighteenth century foresaw as predictable crisis deriving from the geometric nature of human growth expansion, not sustainable by the foreseen linear growth of agricultural production. Concerns about the real and also postulated but never provable impacts of population growth expanded beyond food production.
Early advocates for international fertility reduction eﬀorts voiced fears that such growth would lead to mass starvation, perpetual economic underdevelopment, internal conﬂict, and external wars to expand boundaries. In late 1960s there were conﬁdent assertions from certain US thinkers that the battle to feed humanity was over and that widespread famine would shortly begin. In later years, the list of concerns expanded to include the impact on the environment, climate change, and the battle to preserve biodiversity.
On the other side of the ledger, concern for the human rights implications of family planning programs and the emergence of feminist concerns in their turn signiﬁcantly reshaped the content of international debate and many population programs. Family planning and contraception services began in the industrialized world with Margaret Sanger and Marie Stopes in the USA and UK, respectively. These programs were delivered through the medical model of a doctor–patient relationship. What developed in the 1960s and 1970s was the novel idea that the state, or a public health service provider, should provide these services on a mass basis in order to bring down the number of births. Thus was born the idea of oﬃcially endorsed (or at least tolerated) family planning programs. Begun in Southeast Asia in the 1960s, family planning programs spread throughout the developing world in the subsequent 20–30 years. Internationalization occurred as foreign states and international actors intervened in such domestic programs, sometimes providing the impetus for their creation. The full impact on policy of the multilateralization eﬀorts came somewhat later, with the creation of an international network, inﬂuenced by and inﬂuencing the existing programs.
The tools of the family planning part of population policy were largely unavailable until the 1960s. Such contraceptives as existed in the ﬁrst half of the twentieth century were unwieldy, unmentionable, and often illegal. The advent of the contraceptive pill in 1960 provoked a revolution in behavior in the industrialized world. With it grew the conviction that new contraceptives, especially those which could be injected, implanted, inserted, or swallowed as opposed to being applied at the time of sexual relations, had the potential to stop or slow the rising levels of population in the developing world.
Yet another part of debate centered on the degree of importance that should be accorded to these tools and to the provision of contraception services vis-a-vis other fertility-inﬂuencing interventions such as girls education. This issue was characterized as the ‘beyond family planning’ debate. Later, with feminism came a strong concern that women’s health issues must override concern for demographic increase in the population agenda. Included were preoccupations related to both the mechanism of program delivery, particularly targets, and several of the recently developed contraceptives. This discernibly altered and shaped population policy programs from the 1990s onward. The emergence of AIDS similarly pulled new elements related to the reproductive health of individuals into the population policy ambit.
These debates and uncertainties and the transitory coalitions that have endorsed particular actions at speciﬁc times have given changing goals and forms to international population policy.
While demographic trends can be discussed in statistical and abstract terms, and contraceptive techniques discussed in terms of their mechanisms of action, the reality of population change is grounded in the most personal human relationships, in human sexuality, and in highly sensitive social issues. These include the nature and power relationships that establish marriage, the role and status of women, the behavior of adolescents, deﬁnitions of morality and immorality, the ethical judgments related to sexual activity, and to the very value attached to life at various stages.
For this reason, the myriad of social institutions that deﬁne diﬀerent societies, including organized religions and political forces, have strong interests in most population issues. The major religious have been supportive with the notable exclusion of oﬃcial Roman Catholic policy and the orthodox elements of many established churches. The moral and ethical issues are complex and the introduction of state activity in these areas therefore often highly contentious. That foreign states might have an interest in the decision of a man and woman in another country to have or not have more children could not but raise very complicated issues indeed.
3. Population Issues Enter Foreign Policy
For most of human history, countries did not have population policies, domestic or international. There was a long tradition of hope for population increase as a sign that prosperity was edging out pestilence and disease. The 1901 Census reports for India expressed the cautious hope that population would increase in the decades ahead. Nongovernmental activity preceded both governmental and intergovernmental activities in the national and international spheres. A major step forward was the formation of the International Planned Parenthood Federation (IPPF) in 1952, which grew by the end of the twentieth century to be a federation of advocacy and service providing organizations in over 150 countries, supported by another 20. The Indian Family planning program began the same year, as did several US nongovernmental organizations (NGOs).
There was a major upsurge in population activities in the late 1960s. Governments became less timorous and more active. Several dozen heads of government agreed to come out in favor of moderating global population growth, and agreed to be featured with photos and quotations in a widely used poster campaign. The World Health Organization (WHO) began population activities. The UN Secretary General established in 1967 a Trust Fund which later became the UN Population Fund or UNFPA. The World Bank adopted a policy to lend for population activities after President Robert McNamara declared that population growth constituted a threat second only to the prospect of nuclear war. (Continuing ambivalence within the Bank about the actual impact of population growth on development has, however, meant that while loans are available in aid of Health Ministry programs, Finance and Planning ministries were never pressed by bank oﬃcials to support or give any special priority to population programs. Many other aspects of national management have been subject to such suasion over the years.)
3.1 The International Community Response: A Wide Spectrum Of Policy Perspectives, And Some Domestic Determinants
As foreign policy is the pursuit abroad of domestic policy goals, it could be postulated that even though the desired impact of bilateral population programs was to change outcomes abroad, donor countries would normally not have international population policies until they began to have domestic population policies. This was by and large the case. Most states approached the issue of their domestic population issues with a great deal of diﬃdence. President Eisenhower is widely quoted as saying that he could imagine ‘no subject less ﬁt for government activity’ than family planning. The United States became the unquestioned global leader in this ﬁeld (see Sect. 3.2), while a variety of stances characterized the roles and programs of other countries.
Sweden and the other Nordics countries were early ﬁnancial supporters of family planning in developing countries, reﬂecting their relative lack of embarrassment in dealing with these issues domestically. In the later decades, as the inﬂuence of women’s health advocates grew at home and abroad, Sweden in particular disclaimed linkage between providing contraceptives to women to support them in their own family size decisions and any demographically related outcome.
Successive French governments pursued strong pronatalist policies at home in France and perceived that strong support for family planning programs abroad could well be seen as somewhat racist. There has never been major French support. The UK bilateral programs in many areas included a vigorous population component. Italian governments were widely believed to have exchanged peace with the Vatican on the domestic contraception abortion front in Italy, in exchange for Italian inactivity abroad. Canada was at one time the third largest supporter of population programs. Interest and support declined rapidly in the 1990s, probably reﬂecting aid oﬃcials’ desires to distance themselves from US programs, and some political level wish to avoid exacerbating deemed Quebec sensitivities. Both are longstanding elements of Canadian domestic policy.
The Netherlands from the mid-1990s dedicated a full 4 percent of their aid programs to population and reproductive health. They often played the role of coordinator and host to conferences and meetings on a variety of population-related issues. Their domestic belief in frank discussion and the provision of open explicit information starting at an early age has translated into an active international program.
Japan, under heavy US pressure, dedicated fairly large amounts of funding to population programs, very broadly deﬁned. Once again, the impact of domestic constraints for a long time meant that the nonavailability of hormonal contraceptives to Japanese women precluded their inclusion in the aid package.
The developing world presented a mixed picture. Thinkers in Mexico, Egypt, and India before independence worried about population gains destroying the positive impacts of their own development eﬀorts. India’s 1951 ﬁve-year plan had population program expenditures. The Southeast Asian countries were early and enthusiastic advocates with national programs established in Thailand, Taiwan, Singapore, and Korea. Over a two-decade period, most southern countries adopted some form of population policy, after a period of initial resistance on the part of many. Virtually all countries eventually formulated population policies, inﬂuenced by their own cultural and religious backgrounds, and development aspirations. Until the advent of the international conferences described below, only industrialized countries had international dimensions to their population policies. The advent of the conferences gave developing countries the opportunity to express views on population issues on the world stage.
Bilaterally, the Vatican has acted not as a state but as religious advisor to governments. It has been especially powerful in keeping oﬃcial support away from these services in Latin America, and to some extent in Africa. This reluctance to endorse any form of contraceptive device continued to include proscriptions against condom use, even as the AIDS epidemic aﬀected millions.
The Marxist countries during the Cold War period had an avowedly antifamily planning stance. The states of the former Soviet Union accorded little or no importance to the provision of contraception with subsequent high reliance on abortion. Population levels dropped sharply in many socialist countries and desperate, coercive measures were adopted by several. The pronatalist policies of Ceaucescu in Romania provided the sharpest example. The Marxian view was that diﬃculties caused by population growth really reﬂected maladjustment in wealth distribution. Although they did not proselytize to any major extent, this view was very strongly echoed by many developing countries in the early years. Particularly since it ﬁt well with other themes of the New International Economic Order, the ‘development is the best contraceptive’ theme became the most commonly used rhetorical position in opposition to the new enthusiasm.
3.2 Global Leadership—The United States Role
Unquestionably, the global leader in this ﬁeld has been the United States. American activity began in the 1960s and the US quickly became the most enthusiastic proponent of population programs. A bipartisan, centrist coalition in Congress maintained support for international family planning programs, even in the Reagan years. Domestic NGOs appeared in the US for the express purpose of lobbying for greater global attention to this issue. The early name of one such group—ZPG or Zero Population Growth—indicates the intensity of public policy concern that underlay US policy aimed stabilization of global population levels.
Later with the resurgence of the religious right and the 1990s shift to political conservatism, the abortion issue re-emerged to cause violent schisms in US society. It deﬁned presidential campaigns, ﬁlled the courts, and provoked violence against domestic abortion providers. The bipartisan consensus that had supported the family planning programs shattered. Republicans’ public policy stance became the equation of family planning with abortion, and therefore opposition to all forms of public involvement in it. Democrats remained the champions of such programs.
The international policy reﬂection of this schism caused sharp reductions and severe restrictions on US support. Migration for economic improvement and to escape unfavorable political and social situations around the world will continue to be a growing population issue.
Speciﬁc measures of censure for China’s one-child policy were included in funding conditions. Multi-lateral organizations were cut oﬀ from funding. A so- called gag rule was enacted. It prohibited the release of US family planning funds to international or foreign NGOs which use their own funds to provide abortion services or participate in policy debates on abortion outside the United States. This measure, which would be unconstitutional in the USA itself, was put into eﬀect once by administrative decree in the Reagan years, and again by law in the ﬁnal Clinton years.
The US ﬂag has ﬂown higher over population assistance in most countries than anyone else’s. One of the advantages was the creation of unparalleled expertise in American government, nongovernmental, academic, and program delivery circles. The visibility was also a liability, especially in the early years when sensitivities were high about western enthusiasm for reducing southern births. Because of the intensity of US internal debate, and the rapidity of policy shifts, the US has often been at odds with the rest of the world. It was far out in front on global targets and Malthusian rhetoric in 1974, then pulled back a decade later when just about everyone else was ﬁnally coming to some policy consensus in favor of attenuating population growth.
3.3 The Tools Of Population Policy: Aid Programs
The tools of bilateral population programming have included policy statements, speeches, persuasion, advertising, and funding. Assistance has included policy-inﬂuencing computer simulations, assistance to demographic and census departments, soap opera presentations, and research on a wide variety of reproductive health elements. Much program activity focused very directly on the provision of family planning services. Funds have been provided for contraceptive development, dissemination, and for the creation of national family programs.
Family planning programs had no real counterpart in developed countries, and were often ‘vertical’ or stand-alone programs, like some immunization campaigns. They occasionally became the focus of religious, traditional, and xenophobic criticism. These clinics often provided the only services available or available to poor women. In terms of impact on fertility, family planning programs were deemed to have succeeded; they probably accounted for about 40 percent of the decline in otherwise anticipated births that characterized the world as the demographic transition progressed in the countries of Asia and Latin America.
Because of the sensitivity of population and reproductive health issues, many donor countries directed a substantial percentage of their assistance through multilateral and international delivery mechanisms. Almost US$500 million ﬂowed through multilateral agencies two years after the 1994 Cairo Conference. The programs of the primary multilateral agency, the UN Population Fund, reached $320 million in its high water years, usually providing a channel for about 25 percent of available donor funding. World Bank lending at one point reached $500 but declined at the end of the century. The regional banks have not been major players, with some exception for the Asian Development Bank. An increasingly important element of support was the assistance provided by (largely US) foundations to the population ﬁeld, reaching as high as $150 million just after the 1994 Cairo Conference.
Aid or oﬃcial development assistance to population family planning was never large in relation to overall expenditures in the ﬁeld or to overall levels of overseas development assistance. By the end of the twentieth century, developing countries were paying three-quarters of the costs of their own reproductive health and population programs.
Nor have population programs dominated the overall aid programs. Even within the US program, population assistance only ever represented about 7 percent of all US aid. Australia, Denmark, Finland, The Netherlands, Norway, and UK the population comprised about 3 percent and in France and Italy only 1 percent of their respective ODA programs. In dollar terms, when the totality of all countries’ oﬃcial development assistance was running around US $60 billion per year, population assistance (mostly family planning) never got above $2.0 billion in total. Eight countries almost always supplied 90 percent of all population assistance. The US gave the biggest amount, usually about half of all bilateral aid to population. Denmark, Norway, Sweden, and The Netherlands gave higher percentages, relative to their own economic weight.
If not signiﬁcant as a percentage of overall aid, or as a proportion of each countries’ aid program, foreign aid to population has often been very signiﬁcant in relation to the total health budget of many developing countries. It has had a catalytic impact in determining the scope, content, impact, and in some places existence of programs across the world.
4. Multilateral Policy Making
The second zone of international population policy activity is multilateral or many sided in nature. It is important for two reasons. As just noted, multilateral organizations have been important sources of technical and capital assistance, and vital to program delivery. The second key multilateral activity relates to international population policy making within the international community. Here, all countries have roles; the multilateral organizations provide the venue and organization for this policy-making activity.
4.1 The Population Conferences—Policy Tracers Par Excellence
It is through the phenomenon of the international population conferences that the changes and shifts of international policy in this area can be traced. Margaret Sanger organized an international population conference in Geneva in 1920. It resulted in the formation of the ﬁrst international nongovernmental population organization, the International Union for the Scientiﬁc Study of Population (IUSSP), mostly but not exclusively demographic in purview.
Modern population conferences are not like those of the World International Trade Organization where treaties are negotiated and monitored. Unlike conferences such as the 1948 Universal Declaration of Human Rights, they do not require countries to take legal steps to bring domestic activity into line with new policy norms. They are rather international conclaves of policy expression, where undertakings of good faith are made by all, and statements are made and resolutions drafted which together give a comprehensive picture of how the world’s thinking has evolved on an issue. They also give the world the opportunity to comment on individual programs: the one-child policy of China and the speciﬁc programs of Indonesia and India have from time to time drawn attention.
The preparatory work preceding such conferences is key, often including the collation of detailed country statements which can include reviews and revisions of laws, budgets, policies, and program descriptions. Most important, the preconference activity occasions consultation and negotiation on the domestic front in most countries. As the issue has internationalized, comparable activity takes place on a regional basis, and globally among NGOs. As NGOs and women’s groups have become more important players, both the openness of the preparatory process and the diﬃculty in reaching consensus have grown. At the conferences themselves, NGO representatives have come to take part in the delegations and to play a role in formulating the consensus documents. Generally, countries reﬂect at these conferences the positions they have adopted domestically. The Vatican chooses on this issue to behave as a State in terms of attendance at international conferences. It works through lobbying, diplomatic demarches, and public diplomacy.
Population conferences as international policy making occasions therefore provide highly visible venues for intense debate about sensitive reproductive health issues of safe abortion, genital cutting, violence against women, and services for adolescents. These continue to provoke confrontation and contention.
4.1.1 Bucharest—1974. By the end of the 1960s, there was considerable enthusiasm—in the industrialized world—for serious attention to be given to population levels in the developing world. Serious attention in this era really meant a focus on family planning. In Bucharest, the developing countries both contested the view that population growth was deleterious, and asked to be paid more for going along with the industrialized country view. The socialist states and developing countries successfully insisted on bringing development, broadly and loosely deﬁned, into the equation. The industrialized world did not disagree—John D. Rockefeller stated that ‘… the only viable course is to place population policy solidly within the context of general economic and social development in such a manner that it will be accepted at the highest levels of government and adequately supported.’
Post-Bucharest, program content did not change appreciably, concentrating primarily on family planning with some maternal and child health elements.
4.1.2 Mexico—1984. Many countries in the developing world, notwithstanding enunciated public positions, implemented population-limiting policies and programs in the largest growth period in family planning program activity, from 1974 to 1994. The last region to adopt population policies was Africa, following the landmark African regional conference in 1984, part of the lead-up to the Mexico City Conference. The 1984 world, except for the Vatican and allies, was reasonably united behind these programs, and was demanding more support for them. The US administration was by that time in full retreat from former enthusiasm. ‘Population growth is neither positive nor negative; it is a neutral phenomenon’ became the leitmotif of the American administration position. Despite this policy level coolness, US budgetary and program support for continued growth in these programs were maintained.
4.1.3 Cairo—1994: A Near Universal Consensus On A 20-Year Program Of Action. The preparatory sessions for Cairo were extremely contentious with severe criticisms of the existing approach to population programs coming from both conservative forces and from the new strong feminist voices. The preconference work was arduous, and the result was a complex, far reaching program of action that scarcely touched demographic forecasts and forces, but acknowledged at great length the complex context within which decisions about childbearing are made. The conference and action plan focused on health services, education, economic development, and livelihoods for women.
There was general acceptance that family planning must be voluntary and available, something never before achieved in conference documentation. The programs were to be centered on the needs of the individual and provided in a context which would take the client’s entire reproductive health into account, particularly exposure to sexually transmitted diseases and AIDS. Targeted development interventions such as female education, credit for women, gender equity in inheritance and land ownership, infant and maternal mortality reduction, became explicit components of population policy.
Ninety percent of the 180 governments representing about 95 percent of the world’s population approved the action plan in totality; a few conservative countries and the Vatican approved it in part. A price tag of $17 billion was established for achieving the program.
There is fairly general agreement that the Cairo Conference made an appreciable diﬀerence to the ﬁeld. Five years after Cairo, progress under the Action Plan was reviewed. Although the same issues provoked the same dissent from many of the same sources, there was consensus that considerable progress has been made in policy, program redesign, increased partnership, and collaboration directed toward implementation of the action plan. International aid fell away from rather than toward the $7.5 billion target collectively undertaken in Cairo, but many developing countries were found to have made policy legislative and or institutional changes in the area of population and development and reproductive health and rights. Improved transparency in governance, expanded activity of voluntary associations, improvements in communications, and legal and policy modiﬁcations were found to have advanced the prospects for the participatory approach seen to be at the center of successful implementation of reproductive health and rights programs. Much of course remained to be done: enormous problems of maternal mortality, violence against women, and unmet need for contraceptive services all persisted, and at the end of century, two-thirds of the world’s illiterates were girls and women.
5. The Future Of International Population Policy
Is international attention to population growth ﬁnished? One of the results of the Cairo Conference was a sharp refocusing of debate away from demographic concerns toward reproductive health issues. Analysis has continued but with a sharp diminution on discussion of several former key elements. In terms of program content, many now realized to be most important in addressing high levels of fertility, especially girls education, are being addressed for their own importance. As the world continues to urbanize, and as the situation of women improves in many areas, fertility levels will continue to decline, and with them, demographic growth. It is indeed possible that countries and groups will begin to discuss policy measures that have succeeded in raising family fertility intentions.
Judging from declining ﬂows of development assistance, and of international attention, there will probably be relatively less attention paid to assisting with service provision. Some continuing attention will be given to the high levels of maternal mortality. Violence ainst women will continue to be addressed both nationally and internationally. The same levels of international assistance and interest do not, however, seem to be available in the service of reproductive rights, as could be mobilized to slow population growth, before it became politically incorrect to speak of doing so.
This is the case despite very high levels of measurable unmet need for contraceptive services and even though an additional two billion will be added to the global population before stability is reached, with most of that two billion added in areas where food and water are critical now. These pressing global issues will be addressed primarily by applying resources to freshwater availability, food production and availability, etc., and rather less to addressing the numbers of people in need of them.
There are three main issues that will likely form the core of international population policy in the future: reproductive health issues touching infectious disease, and the linked issues of migration and aging.
Reproductive health issues will occupy an expanding place in the global agenda, particularly those related to the spread of AIDS and other sexually transmitted diseases. The realization of the security threat posed by these diseases began to accelerate with the turn of the century.
Migration for economic improvement and to escape unfavorable political and social situations around the world will continue to be a growing population issue. A diﬀerent set of international institutions and government departments from those concerned with fertility are the central actors on this issue.
While the dramatic nature of fertility increase in the twentieth century is widely known, there is considerably less appreciation of the fact that the equally dramatic decline in fertility has radically changed the number of people within age groups in many countries. Aging may well be the dominant policy issue of the twenty-ﬁrst century. The spread of aging populations is uneven. While there are more Europeans moving into the over-65 year old category than the under 16 year old group, at the turn of the century there was still a 26:1 ratio in the other direction in the totality of the developing world. In developing countries that initiated rapid declines of fertility in the 1960s, such as Taiwan, Korea, China, Thailand, Mexico, and Brazil, issues connected with aging are now rising on the agenda. This issue will internationalize primarily because of the impact on migration created by declining labor force size, and the worries that this creates vis-a-vis social security pressures and health system ﬁnancing.
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