Health Policy, 5 (1985) 15-23

Elsevier 15

HPE 00042

Future technological implications of demographic changes into the 21st century

Ch.0. Pannenborg Ministry of Health, The Hague, The Netherlands

(Accepted for publication 5 May 1985)

Summary

Throughout history there has been a constant interaction between the presence or absence of technological developments and demography. Technology in genera1 and health technologies in particular have contributed to substantial changes in the demographic situation to the extent that even the morbidity and mortality patterns have adapted to technological progress. It is speculated that the demographic impera- tive will, during the third millennium,shiftthecentreofgravityofourworldtowardsthe Pacific basin. This in turn may influence our norms, values and practice of health care to the same extent as colonialism permeated the African, Asian and American health systems during the period of colonialism.

demography; technology assessment; future health scenario’s; post-industrial society; advanced technology

The optics of the new demographic transition and its implication for technology increasingly bring together personalities and organisations who are concerned with how we might best equip the human community for its entry into the 21st century. Recently, the European Health Policy Forum and the World Health Organisation held a joint meeting to address the issue from the specific point of view of ‘health’. The fact that the meeting addressed the overall theme of ‘Technological Implications of Demo-

Paper presented at the 5th Joint Meeting of the European Health Policy Forum and the World Health Organization on: “The new demographic revolution: implications for health policy”, Brussels, 30-31 January 1985. Addressfor correspondence: Dr. Ch.0. Pannenborg, Steering Committee on Future Health Scenario’s, P.O. Box 439, 2260 AK Leidschendam, Tbe Netherlands. Tel.: (070) 209260.

0168-8510/85/$03.30 0 1985 Elsevier Science Publishers B.V. (Biomedical Division)

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graphic Changes’ indicated the recognition that the demographic and technologica determinants of the health of our peoples have to be considered in a very broac framework, if the health of humanity is to evolve into a fullfledged new and viabll concept of dignified harmonious and humane life at the very beginning of the 3r( millennium.

Both demography and technology have always been powerful determinants of the course of history. From the origins of man down to the year 2000 After Date demography has been an important underlying force of the development anddiffusior of technology. On the other hand, however, we can equally observe how influentia technology has been to the transition of demographic patterns throughout civilization in this respect one might as well speak of the demographic implications of technologica changes instead of the technological implications of demographic changes.

Historic trends of technology and demography

Returning all the way to the origins of Homo sapiens and looking first at technolog: as a shaping force, one can observe that, although many still consider language to bl the crucial factor by which man distinguishes himself from the animals, more recen theorems focus on the use of instruments in this respect and more specifically on thr purposeful application of fire.

As far as we know no animal exists or existed capable of handling, what in essence i the very first technology, fire to its own benefit.

“Fire”, with its concomitant effects of heat, warmth and destruction undoubtedk created large consequences for man’s survival, health, fertility, food, shelter, prosperi ty and personal security. The recent article by Goudsbloem [l] makes for importan reading in this respect, also in terms of the demographic history of health.

Making an unpardonable quantum leap through evolution for time’s sake, onI arrives at the emergence of modern technology. Meanwhile demography, i.e. (thi transition of) the condition of communities, had, of course, heavily been moulded b the emerging technologies of war and peace: whole civilizations have appeared am reigned and disappeared or been decimated by superior technologies of warfare o peace and security keeping, as Churchill so vividly described in his “History of th’ English Speaking Peoples” [2]. The monumental work “Propyliien Weltgeschichte” [3 provides an equally unparalleled account in this respect. This specific demography, technology relationship still holds today as can be seen from the 1984 WHO Annua Statistics [4].

The absence of at the time crucial civic technologies, for instance in the field c water resources and management, often had similar effects on demography, as can b witnessed from the disappearance of the Maya culture and its demographic nough from the 8th century onwards due to the lack of appropriate water technologies, a described and propounded by J. Coe in his reputed study on the decline of May, civilisation [5]. The emergence of technologies of transport appeared to become also major factor in the development of world health and disease patterns. McNeil1 in hi famous “Plagues & Peoples” [6] traces the origins, the dynamics of virulence and th

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subsequent rise and fall in incidence and prevalence worldwide of all the major diseases and causes of death over the last thousand years in this respect. Large changes in demographic patterns resulted in many areas in the world from the introduction of new transport technologies, for example, from those heralded by the British Navy [a].

Tedmology and health patterns

Moving now more into the direct field of health and medical care, the most obvious example of technology influencing demographic transition, of course, started with Edward Jenner’s vaccination experiments in 1796, ending less than two centuries later in the eradication of smallpox and a huge body of theory and practice of immunology and vaccines. The demographic consequences for almost all peoples in the world from these health technologies are practically unparalleled in history.

The absence of appropriate health or other technologies can be pictured on the same scale. The transition of plague throughout Europe, setting the demographic scene for much of the 15th, 16th and 17th centuries after its devastating “Black Death” reign and subsequent endemic upsurges, e.g. the one in London in 1664, is a telling example of a technological void at the time. In modem times similar instances can be found with regard to the status of such scourges as leprosy, malaria or schistosomiasis. By an ironic streak of history the Mycobacterium leprue was the first bacillus to be identified by science (by Hansen in 1873) and so far among the last of the great diseases for which no vaccine has yet been developed. Considering the indicators of mortality, morbidity, disability and quality of life, the demographic disability structure of many populations in the world is still heavily determined by these disease patterns.

Unwittingly, we have entered that part of history [7] where technology has grown into a determinant “sui generis”: performing the quantum leap mentioned earlier, the first instance of technology to revolutionize the structure of our societies totally -and with it our traditional demographic patterns in terms of births, children, males and females, elderly and their functional numbers, their roles, their health, their disease and their socio-economic stratification - this first technology was the small “flying shuttle” of John Kay in the textile industries: the first machine replacing human labour with technological labour and the first introduction of the concept of work-without- workers [8].

From the small and seemingly insignificant machine of John Kay in 1733 down the road to the year 2000, the metamorphosis of our society and our lives has been almost complete with the concept of ‘technology’ virtually acting as a metaphor of progress and sometimes even hope [9]. It seems clear that this period of socio-economic and cultural adaptation to the new technological society has profoundly changed not only our morbidity and mortality patterns, but as much our concepts and lifestyles with regard to health, disease and death. We could recount many of these technologies of what Lewis Mumfort called the dehumanized “megamachine” [lo]; restricting our- selves, however, one likes to mention just three or four major ones in order to what Stevenson called “condition our minds” to the technology-demography aspects that will be discussed below.

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Work was already mentioned: the automation and now the computerisation am robotisation of work have had all the old occupational deaths and diseases disappear new health problems resulted, from hazards in chemical production processes tc effects of sedentary work with imaging techniques or effects in terms of stress or o mental health from shifting boundaries of the meaning of work, years of work emancipation of work or patterns of un- and underemployment [ll]. Jonathan Gershuny in his “The After Industrial Society” puts emphasis on the under- o overstimulation in daily life in terms of spare time, shorter working weeks, longe vacations and possibly subsequent hypochondriac sub-cultures [ 121.

A second example concerns the pharmacological revolution. The rise of biochemis try has no better illustration of its effect on demography, of course, than the progres sive worldwide introduction and acceptance of the oral contraceptive, the pill Pharmacology naturally being a technology, certainly so in the definition of medica technology given by the OTA*, the intervention now exactly 30 years ago by Gregor: Pincus and John Rock literally rocked world fertility and population patterns out o their very foundations (John Rock, who just died some months ago) [13].

Preceding biochemistry were physics, mechanics and microbiology. The three o them together generated the combined R&D responsible for the huge improvements ir terms of infant, child and maternal mortality. Water and sewage systems, immuniza tions, pest control methods, electricity, housing techniques, improved farm and nutri tion technologies and so on and so forth, often led directly to urban and rura demographic patterns that were very different from what the world had lived with fo centuries.

Before outlining some of the future technologies one might possibly expect in thl 21st century and their impact on future demographic patterns, the demographic angle and its consequences for technology itself should be considered first.

Demography and health technology patterns

It can be argued that for the first millennium the centre of gravity of our world wa located around the Mediterranean and in the Middle East; civilizations reached thei apex along the demographic structures of this Mediterranean era, Rome for exampls having been for a very long time the only 1 million plus city of the world. In the seconc millennium which is now drawing to a close, the demographic vortex shifted toward North-Western Europe and North America, making the Atlantic hemisphere thl dominant political and technological power-base in the global system of nation-state from John Locke and Alexis de Tocqueville onwards [14].

The third millennium, now, might well again follow the demographic imperative and shift the zenith of the rising sun to the Pacific basin. Last year was the first year ii which the Atlantic hegemony gave way to the Pacific force in that for the first timl trade volumes between East Asia and the Pacific United States outstripped the Atlas

* OTA: Ofke of Technology Assessment U.S. Congress, Washington, D.C.

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tic connection. One should read the signs of the time and it seems that, following the expression “when the wind is right, go sailing”, the Asian wind has started to blow in force [IS].

Undoubtedly this change primarily is adirect consequence ofthe number-game. The new world demographic picture shows Asia in 1985 to harbour more people than Europe, Africa, the Americas and Australia together. Using long-term fertility trend calculations by the Population Reference Bureau, UNFPA and the World Bank, we see that by the year 2050, equal to the timespan back to 1920 only, the demographic might of Asia will total almost three-quarters of the World’s population [16].

This mere fact and the reality of its prospect will in itself fundamentally influence and change our technological societies, including our health sectors, over the coming years. When Tanaka said that the 21st century would be Japan’s, he was referring to a pars-pro-toto [ 171: with regard to the consequences and the commanding all-pervad- ing influences of Asian demography “we haven’t seen anything yet”, as the Americans say.

What then may be the more specified technological health consequences of this demographic transition?

Before entering into these specifics, however, an intercession is in order: one may wonder why at this point no consideration is yet given to the more particular implica- tions for technology of such European demographic changes as the graying of society, or the consequences of the relative absence of European Nachwuchs from 1995 onwards, or the increasing social fragmentation as to age- and sex-specific sub-groups in society with their concomitant differentiated needs and demands in terms of health technologies?

While many of these issues are being dealt with already elsewhere in reports and literature [18] (e.g. the recent Dutch Future Scenario Reports on Health and the Elderly 1985-2030, with such examples as telediagnostics, 5-year postponement tech- nologies on presenile dementia, etc. [18]), we explicitly classify the consequences of such demographic alterations as second or third only in importance to the strategic demographic global shifts outlined in the former paragraphs.

Thus, geopolitically speaking, the said Asian and Pacific demographic transition may ultimately, i.e. in the next century, influence our norms, values and practice of health, health care and health technologies, perhaps even to the same extent as the consequences of our colonial system permeated the African, Asian and American health systems formerly over the last centuries.

One overriding force in this respect will be the market, the consumer, the potential user of health technologies [19]. This implies that in future the potential R&D for health technologies will primarily be determined by the health needs and demands outside Europe, as we have witnessed already over the last decade, health needs and demands which may differ markedly with the age- and sex-specific ones of Europe. Following shipbuilding, steel and electronics, the European position may grow so weak as not to be able any more to pursue European-based supply & demand health strategies; non-European morbidity and mortality patterns may then, of course, dictate the R&D of health technologies, if any by that time, within Europe [20].

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The future demography - technology nexus

It should be realised, of course, that the demography-technology nexus is not a static one, but a dynamic one. Cybernetically, where demography determines technol- ogy over time, technology subsequently determines demography again, thereby chang- ing its own basis in turn. While Asian and Pacific health technologies will be paramount in 25 years time, both in terms of software and hardware (cf. in this respect for instance the new technical universities in Singapore and Seoul, displaying poten- tials unparalleled and nowhere to be found in Europe), these non-European health technologies may equally change the demographic pathological picture in the next century.

Three major areas could be mentioned as examples in this respect. The newly emerging NMR technology now appears to be of such fundamental nature, that it might be compared to the revolution by RGntgen [21]. The combination of imaging and spectroscopy will undoubtedly produce new pathologies based on differential status of the metabolism of the cell in a very early stage of abnormal values. As is at present already the case and may increasingly be so in future, these values and thereby the new pathologies themselves will rather be determined outside Europe according to demographic patterns and priorities, priorities that may well not coincide at all with those we think important.

Secondly, huge strides can be anticipated in molecular biology and genetics. The charting of the total human genome combined with increasingly effective protein- mapping will no doubt result in the possibility of specific individual risk-profiles very early on in life. Health risk patterns per individual (Europe/US) and per social group (Asia) may emerge from the large scale introduction of these techniques, with subse- quent options for new preventive, diagnostic and chronically therapeutic health technologies to respond to (e.g., future preventive interventions against genetic risks for rheumatoid arthritis from early infancy onwards). On the other hand this would have enormous implications for insurance systems, solidarity patterns, social stigmati- sation and even new social stratifications according to the relevant risks and lifestyles following from them (doing away with the by then old-fashioned stratification accord- ing to sex, age, race, religion, nationality, etc.).

Thirdly, reference is to be made to the area of brain research. The combined new vistas of neurophysiology, of molecular switches in terms of bioelectronics, and of artificial intelligence systems (with its huge potential ethical, moral and religious consequences) may from the 1990s onwards very well open a Pandora’s box from which highly selective brain-interventions to all kinds of purposes would become effective. Hope would remain to secure that these purposes would be in line with our basic views of the health of man and the Cartesian foundations of the transition of demographic humankind: if not, global technological domination may well instill norms and values of health into our societies, which previously were undreamed of and may have serious socio-cultural and thereby demographic repercussions. In this respect the expression quoted as the leitmotiv of this EHPF/WHO Seminar, i.e. “the future is no longer what it used to be” (an expression orginally by Paul Vallery) may well change in that “the future will be radically different from what it ever was”.

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One could continue to outline several more of the major strategic health technol- ogies that may occur in the future as a response to certain age and sex groups as they will emerge from the demographic transition and how these then in turn will influence the transition itself. Telecommunication, for example, will probably create the area of telediagnostics and teletherapeutics for the elderly and the handicapped and increase their social mobility enormously; the artificial heart, vaccination against cardiovascu- lar plaque or a pharmacological therapy against lung cancer all may develop in a big way between 1993 and 2010 and change the demographic picture substantially. This holds even more so, of course, for the in vitro fertilisation technologies, androgenesis, gynogenesis, etc. [22].

However, elaboration of the technology-demography nexus with regard to these and many more to be anticipated future developments would at this instance go too far and would require a separate monograph.

Conclusion

I would like to close with an observation from my own personal point of view. Al- though technology, and health technology as a prominent part of it, will increasingly shape the health of our societies, I believe perhaps that homo technologicus is much more a homo ludens than a homo economicus [23].

Only by taking the nondeterministic view of the evolution of mankind may we find the strength to anticipate long term world evolutionary patterns and attempt to put our creative and imaginative energies to the strategic anticipation of the unforeseen into the 3rd millennium [24]. It is then that we may find ourselves confident enough, although never knowing enough, to keep up with Frank Baum in The Wizard of Oz, where the following discussion occurs between the Scarecrow and the Tin Robot Woodman on heart trouble:

“I don’t know enough”, replied the Scarecrow cheerfully, “my head is stuffed with straw you know, and that is why I am going to Oz to ask for some brains.” “0, I see”, said the Tin Woodman, “but after all, brains are not the best things in the world.” “Have you any?‘, inquired the Scarecrow. “No, my head is quite empty”, answered the Woodman, “but once I had brains, and a heart also; so having tried them both, I should much rather have a heart” [25].

References and Notes

1 Goudsbloem, J., Fire and Civilisation: the domestication of fire as a process of civilisation (in Dutch), De Gids, 1984, May, From NRC Handelsblad, Thursday, 17 January 1985, Science and Education Supplement, p. 1.

2 Churchill, Sir W.S., A History of The English Speaking Peoples, Vol. 1, Book I and II, and Vol. 3, Book VIII, London, 1956.

3 Mann, G. and Heuss, A. (Eds.), Propyllen Weltgeschichte - Eine Universalgeschichte, ler Band, Teil I, Berlin 8t Frankfurt, 1961, pp. 128 ff.

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Cf., for instance, the improvement and deterioration of the demographic health indices over the last years in areas of civil strife, civil war and war as opposed to other development areas in the world, as depicted (the red areas) in figures 1 and 2 of WHO, World Health Annual Statistics 1984, Geneva, pp. 3-4. Coe, M.D., The Maya. In Daniel, G. (Ed.), Ancient Peoples and Places, Thames & Hudson, London, 1966. McNeill, W.H., Plagues and Peoples, Blackwell, Oxford, 1977, pp. 77-235. Lem, S., Summa Technologiae, Teil II - Zwei Evolutionen, Frankfurt, 1981, pp. 19-71; also, de Rougemont, D., L’Avenir est Notre Affaire, La Religion de la Croissance, Paris, 1977, pp. 15-61. Freeman, C., Clark, J. and Soete, L., Unemployment and Technical Innovation, London, 1982; also, Forbes, R.J., The Work of Man (in Dutch), Part II, Amsterdam, 1959. Habakerk, H.J. and Postan, M.M., The Industrial Revolution and After, Part II, Technology, New York, 1965; Cf. also, Fromm, E., The Revolution of Hope, The Dehumanized Society, New York, 1968, where he propounds that humanization of society should be the paramount task of future technology, pp. 26-58. Mumford, L., The Myth of the Machine, New York, 1966. Freeman, C., et al., idem; also, Lagergren, M., et al. (Ed.), Time to Care, Oxford, 1984; and Best, F., Technology and the Changing World of Work - The Evolution of Work - Work in a High-Tech Future, The Futurist, April 1984, pp. 37-61. Gershuny, J., The After-Industrial Society - The Emerging Self-Service Economy, London, 1978. Calonius, L.E., Big Drop in Citizenry’s Numbers by Early 21st Century, The Wall Street Journal, January 4, 1985, pp, 1 ff.; “Future Aspects of Contraception”, The Lancet, September 22, 1984. Laslett, P., Two Treatises of Government - John Locke, London, 1960; and de Tocqueville, A., De la Democratic en Amtrique, Vol. II, Genin, Paris, 1951, p. 344 (Democracy in America, Vol. 2; New York, 1954, p. 266). Hawrylyshyn, B., Condemned to Co-exist: Road Maps to the Future, 1980, New York, pp. 125 ff.; also Okita, H., Japan in the Year 2000, Preparing Japan for an Age of Internationalization, Tokyo, 1983. The World Bank, World Development Report 1984, Part II, Population Change and Development, Washington, 1984, pp. 5 l-202; UN Fund for Population Activities, Report on Population Assistance 1981, New York, 1981. Tanaka, K., Building a New Japan -A Plan for Remodeling the Japanese Archipelago, Tokyo, 1973. Steering Committee on Future Health Scenarios, The Future of Aging and Health - Scenarios for the period 1985-2030 (in Dutch), Ministry of Health, The Hague, 1985 (English version in preparation). The innovation-chain of medical technologies with regard to market-forces could be depicted as follows:

1985 Medical Technology Innovation Chain

Fig. 1. Future health and medical technology R&D may increasingly be determined by the right part of th diagram, which, ideally speaking, would constitute one of the major determinants of the process at the lel part of the diagram. From: Ministry of Health, Health 2000 Report, Chapter 6, Technology, The Hague Fall 1985; see also the medical technology diffusion process as described in Office of Technology Asses’ ment-OTA, Congress of the United States, Development of Medical Technology, Washington, DC, 1971

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20 Proceedings, ‘Ihe European Economy in the Year 2000, Top Management Forum, The Economist, Vienna, 14-15 May, 1985.

21 See, for instance, Office of Technology Assessment, U.S. Congress, Nuclear Magnetic Resonance Imaging Technology, Health Technology Case Study Nr. 27, Washington, September 1984.

22 Nau, J.Y., Crisis in vitro, Le Monde, l-2 Juillet, 1984; “The Birthpangs of a new Science”, The Economist, July 14,1984; also Burg, C., The Prospects for Medicine in the Next 20 Years, Address to the 2nd European Seminar for leading Public Health Administrators, Oslo, August 1983, WHO, Copenhagen, July 1983.

23 After Buys, K., Innovation and Intervention (in Dutch), Doctoral Thesis, Technical University, Delft, December 6, 1984, see esp. pp. 169-183.

24 Price, V., Europe Lame Duck or Phoenix - Permanent Decline or Renaissance of Industrial Europe?, Paper to the IMI (the International Management Institute) September 28, 1984, Geneva, also, Soedjatmoko, M., Global Crossroads: which Way to the 21st Century?, A National Assembly, Washington, DC, May 17, 1984, United Nations University, Tokyo, 1984.

25 Baum, F., The Wizard of Oz, Penguin Books, Ltd., Harmondsworth, England, 1982.