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938 www.thelancet.com Vol 383 March 15, 2014

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O ine: The laws of stupidity
In a meeting last week on the future of womens and
childrens health, one respected public health scientist
warned about the population doubling time in Africa. She
estimated it to be around 20 years. (In fact, according to
the UN Population Division, the population doubling time
for sub-Saharan Africa is about 35 years. Still, her general
point remains valid.) She argued that many of the gains in
childrens health won over the past decade would be lost
if this scenario of dramatic population expansion came to
pass. Her view is widely held in the health community. And
our solutionrapid scale-up of family planning services
has received endorsement and support from experts
and donors alike. Family Planning 2020 is a movement
to provide contraceptive services to an additional
120 million women worldwide. This momentum around
family planning is welcome, especially if the denition of
family planning covers a full range of reproductive health
services. But is access to contraception really the answer
to Africasthe worldsdemographic challenge? This
simplistic technical approach illustrates so much of what
is wrong with global health today.
*
In a second-hand bookshop recently, I came across a
worn 299 copy of Carlo Cipollas now out-of-print
volume, The Economic History of World Population. First
published in 1962, his short book was reprinted at least
seven times (my copy dates from 1979). Cipolla was an
Italian economist born in Pavia in 1922. He died in 2000.
His argument is worth summarising as we think about
the health of our planet and its human populations.
Cipolla thought globally. In the preface to the rst edition
of his book, he wrote: Today we have to adjust ourselves
and our ways of thinking to a global point of view (his
italics). He began by describing the two great revolutions
of human civilisationagricultural and industrial. Each
launched a new story for the human species. Industrial
revolutions in the worlds poorest nations are their
great hope to achieve good health, the beginning of
their new story. But one antagonistic force challenging
such an optimistic view is the population problem,
which we continue to this day to see as a threat to
sustainable development. Another is the now widely
accepted paradox that technical progress has also cast a
sinister shadow on the future of industrial societies. An
aspect of technical progress that Cipolla found especially
appalling was our humanitarian urge to give medical
assistance to societies that basically are still agricultural.
By doing so we only fuel the demographic explosion.
Cipolla was worried about our complacent approach
to this menace. He emphasised our over-condence,
our belief that we can easily absorb the consequences
of population pressurenot only embracing the
demographic dividend of an expanded labour force, but
also facing up to a source of new epidemics, intensifying
pollution, and disruptive political and economic crises. Yet
these risks, so prevalent in our conversations today, are
marginal to an even greater threat identied by Cipolla.
*
We neglect the drastic cultural and social changes that
accompany shifts in economic organisation, he claimed.
In the excitement of our progress (the rapid technical
progress of our species), we do not stop to ask how
much [have we ourselves] improved in quality? The
danger is that as our populations grow, the marginal
value of each person will diminish and the dignity of
human life deteriorates correspondingly. In addition
to the technical progress we justly celebrate, we must
also pay attention to our ethical and cultural values and
standards. What we need is not merely more technical
knowledge, but greater investment in the qualitative
improvement of our specieshow we think about and
behave towards one another. Thankfully, another book
by Carlo Cipolla remains in printThe Basic Laws of Human
Stupidity. His Third (and Golden) Basic Law is that, A
stupid person is a person who causes losses to another
person or to a group of persons while himself deriving no
gain and even possibly incurring losses. Our attitudes to
human population growth full Cipollas Third Law. Our
advocacy of technical knowledgeexpanded coverage of
family planning serviceshas paid too much attention
to lifes quantities and too little to its qualities. There is
nothing more dangerous than technical knowledge when
unaccompanied by respect for human life and human
values, writes Cipolla in his Economic History. Look at the
world today, and one sees a scandalous absence of both.
Richard Horton
richard.horton@lancet.com