Combating Cross-Generational Sex in Uganda

(February 2009) Cross-generational sex—or Sugar Daddy syndrome—is a pattern of sexual behavior between young women and much older men that brings increased health risks and consequences for young women. In most cases of cross-generational sex, the women are ages 15 to 19 and unmarried; their male partners are at least 10 years older. Although most cross-generational sex is based on the exchange of favors or material goods, it is different from commercial sex or prostitution.


Cross-generational sex is not limited to sub-Saharan Africa, but most research on the practice has been conducted in that region (see table) because the behavior is associated with a higher risk of HIV infection. Data show that young women ages 15 to 24 in sub-Saharan Africa are three times more likely to be infected with HIV than young men the same age.1 It is clear that in much of Africa, young women bear the brunt of the AIDS epidemic.


Sadly, few large-scale interventions have been undertaken to combat this risky behavior, and even fewer have been evaluated to show how well they actually work. However, in Uganda, an important collaboration between the government, local organizations, and the U.S. Agency for International Development may be leading the way. According to the 2006 Demographic and Health Survey in Uganda, 7 percent of young women ages 15 to 19 reported that they had recently had high-risk sex with a partner 10 or more years older than themselves.2 The survey also reports that age-mixing in sexual relationships is more common among young women who do not know where to get a condom, those in rural areas, and those with only primary-level education.3 These factors often leave young women vulnerable to high-risk sexual behavior and HIV infection.


Cross-Generational Sex



Country, Year of Survey Percentage of Sexually Active Women Ages 15-17 With Partner at Least 10 Years Older in Past Year Percentage of Sexually Active Women Ages 18-19 With Partner at Least 10 Years Older in Past Year
Ghana, 2003  1.7  7.9
Nigeria, 2003  21.3  4.2
Malawi, 2004  0.9  2.4
Tanzania, 2004  4.9  7.8
Lesotho, 2004  7.5  7.0
Uganda, 2004–5  9.4  9.9

Source: Macro International Inc., country survey data.


The Y.E.A.H. Initiative


In 2004, a coalition of Ugandan organizations and Young People’s Advisory Groups, under the auspices of the Uganda AIDS Commission HIV/AIDS Partnership, designed and implemented the Young Empowered and Healthy (Y.E.A.H.) Initiative. The purpose of the initiative was to address the growing need to improve health and social practices among young people in Uganda and answer the government’s call for improved and coordinated behavior change communication efforts. Developed by and for young people ages 15 to 24, Y.E.A.H. is a communication campaign that combines mass media, person-to-person dialogue, and community media. The mission of Y.E.A.H. is to stimulate discussion and action among communities, families, schools, and health institutions; and, through the use of local and national media, to encourage positive practices. Its end goal is a reduction in the incidence of HIV and early pregnancy, and at the same time, an increase in the number of young people who complete primary education and beyond.


‘Something for Something Love’


In 2005, Y.E.A.H. worked with young people and key individuals and groups in adolescent sexual and reproductive health throughout Uganda to determine the most useful focus of a communication campaign. Workshops explaining background research and campaign strategies determined that transactional sex poses a common and significant risk to youth in Uganda. Young people suggested calling these relationships “Something for Something Love,” and Y.E.A.H. used the term as the main theme of its first campaign.


According to campaign organizers, young women are often pressured into compromising situations, such as having unwanted or unprotected sex. These relationships are usually problematic for young women and lead to consequences such as unplanned pregnancy, dropping out of school, abortion, and HIV/AIDS or other sexually transmitted infections. Violence is common in “Something for Something Love,” especially if the young woman refuses sex or tries to end the relationship. For the older married partner, “Something for Something Love” often results in broken marriages or violence if the spouse learns about it.


Y.E.A.H. has made significant progress stimulating dialogue and action around “Something for Something Love,” using its popular “Rock Point 256” radio drama series and reinforcing media materials and community outreach activities. Young people ages 15 to 24 were given three clear messages: abstain from sex until you are ready to settle down for a long-term relationship; set long-term goals that you do not compromise for material gain; and do not give or receive gifts or favors in exchange for sex. Hence, the campaign’s catch phrase, “Short term gain, long term loss.” Adults were also given a message: Examine your personal role in protecting young people.


Political and cultural leaders in Uganda, including the First Lady, have spoken out about the harmful effects of “Something for Something Love” on young people and their health. Media coverage of the issue has not only increased but also become more critical of the practice.


The association of cross-generational sex with unsafe behaviors and HIV risk makes the practice a priority for attention in Africa. While there is much work to be done, this program has successfully involved the community in its efforts. In one year, audiences sent in more than 900 letters with questions and comments about the radio dramas and related materials. Y.E.A.H. has obviously struck a resonant chord in Uganda—one that could possibly be replicated in other countries in sub-Saharan Africa.


Donna Clifton is communications specialist at the Population Reference Bureau.




  1. UNAIDS, Report on the Global AIDS Epidemic (Geneva: UNAIDS, 2006).
  2. The DHS HIV/AIDS Sero-Behavioural Survey for Uganda, 2004-2005, indicated that the prevalence for girls ages 15 to 17 was 9.4 percent and for ages 18 to 19 was 9.9 percent. No data is shown for the 2006 numbers on cross-generational sex, nor is it subdivided by age groups other than 15 to 19. There is no explanation of the decline in the 2006 DHS report.
  3. Uganda Bureau of Statistics and Macro International Inc., Uganda Demographic and Health Survey 2006 (2007).

Fiche de données sur la population mondiale 2008

Produit: Fiche de données

Rédigé par: Population Reference Bureau

Date: 30 décembre 2008

La fracture démographique — ou inégalité entre les profiles de population et de santé entre pays riches et pays pauvres — se creuse. Deux schémas radicalement différents de croissance démographique se dessinent : une croissance limitée — voire même un déclin — dans les pays les plus aisés et une poursuite de la croissance démographique rapide dans les pays les plus démunis. Ces contrastes ressortent clairement de la dernière édition de la Fiche de données sur la population mondiale 2008 publiée par le Population Reference Bureau. Cette Fiche de données fournit les informations les plus à jour sur la démographie, la santé et l’environnement pour 209 pays et 25 régions du monde.

« L’essentiel de la croissance démographique mondiale se produit aujourd’hui dans les pays les palus pauvres du monde », déclare Bill Butz, le président du PRB. « Même la faible augmentation générale de la population enregistrée dans les pays plus riches est attribuable, pour l’essentiel,
à l’immigration. »

En 2008, la population mondiale est de 6,7 milliards : 1,2 milliards vivent dans des régions classées par les Nations Unies comme plus avancées ; 5,5 milliards de personnes vivent dans les régions moins développées. « Il est plus que probable que nous passerons le cap des 7 milliards au cours des quatre prochaines années », déclare Carl Haub, démographe principal au PRB et co-auteur de la Fiche de données de cette année. « Et d’ici 2050, la population mondiale devrait atteindre 9,3 milliards, si les projections actuelles se confirment. D’ici le milieu du siècle, ces schémas divergents de croissance démographique provoqueront une augmentation du pourcentage de population vivant dans les régions actuellement moins développées du monde de 82 à 86 %. »

Comme l’indique le tableau ci-dessous, « les différences entre l’Italie et la République démocratique du Congo illustrent bien l’accentuation de la fracture démographique », explique Mary Mederios Kent, co-auteur de la Fiche de données e cette année. « D’un côté on trouve essentiellement des pays pauvres avec des taux de natalité explosifs et une espérance de vie limitée. De l’autre se trouvent avant tout des pays riches présentant des taux de natalité faibles et un vieillissement rapide. »

Indicateur Etats-Unis Italie Rép. démocratique du Congo
Population à la mi-2008 305 millions 60 millions 67 millions
Population 2050 (projections) 438 millions 62 millions 189 millions
Nombre total de naissances par femme 2,1 1,3 6,5
Pourcentage de la population de moins de 15 ans 20 % 14 % 47 %
Pourcentage de la population de 65 ans et plus 13 % 20 % 3 %
Espérance de vie à la naissance 78 ans 81 ans 53 ans
Nombre de naissances par an 4,3 millions 568.120 2,9 millions
Nombre de décès par an 2,4 millions 575.300 0,8 million
Nombre de naissances annuelles moins nombre de décès annuels (accroissement naturel) 1,9 millions – 7.200 2,1 millions
Pourcentage de la population souffrant de malnutrition <2,5 % <2,5 % 74 %

Autres points saillants de la Fiche de données sur la population mondiale 2008 :

La population mondiale sera en majorité urbaine. En 2008, pour la toute première fois, la moitié de la population mondiale vivra en zone urbaine.

Malgré certaines améliorations, les taux de mortalité maternelle demeurent très élevés dans les pays en développement. Dans ces pays, une femme sur 75 décède des suites de sa grossesse. En Afrique subsaharienne et dans le groupe de 50 pays définis par les Nations Unies comme étant les moins avancés, ce risque atteint le chiffre choquant d’une femme sur 22, un contraste frappant par rapport au taux d’une femme sur 6.000 enregistré dans les pays développés.

A l’échelle mondiale, les femmes ont aujourd’hui en moyenne un total de 2,6 enfants; dans les pays en développement, exception faite de la Chine, ce chiffre est de 3,2, et il atteint 4,7 dans les pays les moins avancés. Les taux synthétiques de fécondité les plus élevés sont enregistrés en Afrique subsaharienne : 5,4 enfants par femme. Dans les pays avancés, les femmes ont en moyenne 1,6 enfants. La moyenne de 2,1 enfants enregistrée aux Etats-Unis constitue une exception à ce schéma de faible fécondité observé dans les pays plus riches du monde.

Dans les pays moins avancés, 18 % de la population souffre de malnutrition. Dans les pays les moins développés, 35 % de la population consomme moins que l’apport calorique requis pour une existence saine et active. Ce chiffre dépasse 60 % dans plusieurs pays d’Afrique subsaharienne.


La lutte contre la malnutrition infantile en Afrique subsaharienne : des progrès mitigés selon les enquêtes

(Octobre 2008) La malnutrition chronique constitue depuis longtemps un problème persistant qui affecte les jeunes enfants de l’Afrique subsaharienne. Un pourcentage élevé de ces enfants n’atteint que rarement les normes internationales en matières de taille pour leur poids, une indication de rachitisme. La région enregistre aujourd’hui le taux le plus élevé au monde de rachitisme infantile — 43 % — sans guère trace d’amélioration au cours des 15 dernières années. À titre de comparaison, le pourcentage d’enfants atteints de rachitisme en Asie du Sud-Est a chuté de 52 % à 42 % entre 1990 et 2006.1

Le nombre de personnes mal nourries (d’un poids trop faible pour leur âge) de tout âge en Afrique subsaharienne est passé d’environ 90 millions en 1970 à 225 millions en 2008, avec une nouvelle augmentation prévue de 100 millions d’ici 2015, et ce avant même l’augmentation actuelle des cours des denrées alimentaires.

Évaluation des progrès par la mesure du rachitisme

Les Objectifs du Millénaire pour le développement (OMD) avaient choisi l’insuffisance de poids comme un indicateur des progrès de la lutte contre la malnutrition, mais un nombre croissant de spécialistes de la nutrition et de la santé publique prône aujourd’hui un indicateur plus conceptuellement valide, une taille trop faible pour l’âge (ou rachitisme), pour mesurer les privations prolongées des besoins fondamentaux de l’être humain. Les enfants atteints d’un rachitisme modéré à sévère (et dont les ratios de taille par rapport à l’âge sont inférieurs de deux écarts-types à la norme internationale) subissent un retard de croissance physique, de développement et de performances scolaires et professionnelles. Les Enquêtes démographiques et de santé (EDS), menées par Macro International avec le soutien de l’Agence des Etats-Unis pour le développement international (USAID), fournissent les indicateurs anthropométriques normalisés recherchés pour 24 pays de l’Afrique subsaharienne pour au moins deux points situés entre 1986 et 2006.

Certains pays ont enregistré quelques progrès. Le Sénégal, la Namibie, le Togo, l’Ouganda, l’Erythrée et la Tanzanie, soit un quart (six) des 24 EDS portant sur des pays d’Afrique subsaharienne ayant des populations et des niveaux de santé et de nutrition comparables, ont observé des réductions importantes des taux de rachitisme chez les enfants de moins de 3 ans ces vingt dernières année, avec des réductions d’au moins 2 points de pourcentage chaque année. . C’est au Sénégal que s’est produit la réduction la plus spectaculaire des taux de rachitisme, de 22 % en 1993 à 14 % à peine en 2005. On ne dispose pas de données de tendances tirées des EDS pour trois autres pays (le Botswana, le Gabon et la Gambie). Cependant, selon l’Organisation mondiale de la Santé (OMS) et l’UNICEF, ces pays présentent déjà des niveaux de rachitisme faibles ou modérés.2

La majorité des pays de l’Afrique subsaharienne n’ont toutefois enregistré aucune amélioration de leurs taux de rachitisme depuis 1990 et/ou présentent des niveaux très élevés. Plus de 40 % des enfants y sont atteints d’un rachitisme modéré à sévère. Sur les 24 pays pour lesquels on dispose de données de tendances tirées des EDS, cinq présentent des taux très élevés et/ou une détérioration des niveaux de rachitisme pour les enfants de moins de 3 ans : le Niger, la Zambie, le Malawi, le Rwanda et Madagascar.

Représentation graphique des schémas de rachitisme les plus prononcés au niveau subrégional : le Sahel et l’Afrique du Sud-Est

La répartition géographique du rachitisme entre les 41 pays d’Afrique subsaharienne ayant une population d’au moins 1 million de résidents et pour lesquels on dispose de données fiables sur les tendances nationales ou de données transversales récentes révèle des schémas intéressants une fois appliquées à une carte. Deux régions présentent des niveaux élevés et stagnants ou des tendances à la détérioration : le Sahel (de l’Est du Mali au Tchad) et l’Afrique du Sud-Est (du Rwanda à la Zambie vers l’est jusqu’au Mozambique et Madagascar). Elles apparaissent en orange foncé sur la carte.

Pour d’autres pays qui sont sources de préoccupation, en jaune, des niveaux élevés de rachitisme ont été enregistrés lors d’enquêtes nationales récentes, mais l’absence d’une mesure de référence empêche la projection de tendances. Au nombre des pays ayant souffert récemment d’une certaine instabilité, qu’elle soit politique ou ethnique : la République Démocratique du Congo, la Sierra Leone et le Burundi.3


Niveaux et tendances du rachitisme infantile en Afrique subsaharienne

Note : Les pays en vert ont enregistré des améliorations importantes, même si dans certains cas les niveaux de rachitisme demeurent élevés.
Sources : Taux fondés sur les informations tirées des Enquêtes démographiques et de santé (, des Enquêtes en grappe à indicateur multiple de l’UNICEF ( et de la base de données mondiale sur la croissance et la malnutrition infantile de l’Organisation mondiale de la Santé (

La carte révèle que, sur une base régionale, les taux de rachitisme demeurent relativement élevés dans l’essentiel de l’Afrique australe (en particulier en Namibie, au Botswana et en Afrique du Sud). Au cours des 20 dernières années, le rachitisme a diminué en Afrique de l’Est, passant de 46 % à
35 %, comme le démontrent les améliorations relevées en Ethiopie, en Ouganda et en Tanzanie, alors qu’il est resté identique ou s’est aggravé en Afrique de l’Ouest, au Sahel et en Afrique du Sud-Est.

D’où viennent ces différences ?

Comment se fait-il que certains pays aient réussi à améliorer l’état de la nutrition infantile entre les années 1980 et 2007 contrairement à d’autres ? Selon les recherches, la nutrition est généralement influencée par cinq facteurs interconnectés : l’instabilité politique, la pauvreté et l’inégalité, le manque d’efficacité des politiques de développement, les changements environnementaux et climatiques, et des programmes de sécurité alimentaire, de nutrition et de prévention sanitaire inadéquats et mal gérés. Nombreux sont les pays présentant des taux de rachitisme élevés ou stagnants qui sont parmi les plus vulnérables, au plan politique, à la suite de récents conflits internes et externes ; il s’agit, notamment, de la République Démocratique du Congo, de la Sierra Leone et de la Somalie.

  • L’accès des ménages aux denrées alimentaires, déterminé par l’accès à la terre, la main d’œuvre extérieure, le pouvoir d’achat, et la répartition interne des ressources du ménage.
  • Le recours par les ménages à des services de santé, de nutrition et de crèche adéquats pour les jeunes enfants (y compris l’allaitement exclusif, les aliments de sevrage et les soins préventifs) auxquels ils ont accès.
  • Les maladies ou conditions environnementales affectant la santé (notamment la mauvaise absorption des aliments) qui ont un impact sur l’utilisation biologique des denrées.4

Mis à part les facteurs d’ordre géographique, démographique, politique et macroéconomiques propres à chaque pays, il existe d’importantes disparités entre les formes prises par le rachitisme parmi d’une part les mères urbaines et plus éduquées et d’autre part les mères rurales et moins éduquées.5 Les membres de ce dernier groupe sont souvent deux fois plus susceptibles d’avoir des enfants de moins de 3 ans atteints de rachitisme. Qui plus est, les disparités entre zones rurales et zones urbaines, et entre ceux qui vivent dans des bidonvilles et les autres, s’amplifient.

Les facteurs démographiques compliquent les efforts de lutte contre le rachitisme

Plusieurs tendances démographiques observées en Afrique subsaharienne sont susceptibles d’entraver les efforts de lutte contre la malnutrition chronique chez les enfants. La première est la poursuite de la croissance rapide de la population, en particulier dans la plupart des pays où les taux de rachitismes restent stagnants, à l’exception du Sénégal et de l’Ouganda. Au sein d’un même pays, les pauvres — qui sont plus susceptibles de souffrir de malnutrition — présentent en général une plus forte fertilité que les non pauvres ; ceci augmente de manière disproportionnée la taille des populations à haut risque. Ces effectifs renforcés de population contribuent en outre à la pression croissante exercée sur les terres arables de moins en moins nombreuses et à la dégradation écologique des zones d’agriculture semi-arides à sèches et des pâturages nomades dans des pays tels que le Rwanda et l’Ethiopie.

Deux autres tendances observées dans la région — l’urbanisation rapide et la fluctuation des schémas de consommation — se traduisent par une demande accrue en produits agricoles par ceux qui bien souvent ne les produisent pas. Par suite, les pauvres de certains bidonvilles urbains, notamment ceux de Nairobi, vivent dans des conditions de nutrition pires que les pauvres des régions rurales.

L’étape suivante : éliminer les taux stagnants de rachitisme

Avant de pouvoir formuler des politiques et des programmes plus efficaces pour réduire les taux élevés et stagnants de rachitisme et d’en assurer la mise en application, les pays de l’Afrique subsaharienne doivent pouvoir mesurer les changements de manière fiable, puis évaluer l’efficacité des politiques et des programmes. Ceci exige des progrès dans quatre domaines :

  • Méthodologie : Il convient de disposer de nouvelles données chronologiques pour les pays les plus instables et les plus fragiles, dans les régions et lors des saisons les plus vulnérables ; le rachitisme doit être considéré comme l’indicateur de choix lors de l’analyse des réductions de plus longue durée de la pauvreté et de la faim ; et les systèmes de surveillance et d’information continus sur la sécurité alimentaire et la nutrition peuvent fournir des données plus ciblées et plus contextuelles concernant le rachitisme au niveau des ménages, au niveau agro-écologique et au niveau des programmes pour la formulation de politiques.
  • Politique : Les politiques multisectorielles basées sur des approches de nature holistique, lorsqu’elles sont mises en application de manière correcte, sont les plus susceptibles de réduire la malnutrition chronique. Ces politiques doivent cibler la réduction de la pauvreté, la sécurité alimentaire, l’éducation, la dynamique sexospécifique, le fardeau de la maladie et la population. L’aide internationale à la lutte contre le rachitisme chronique ne doit pas être interrompue pour les opérations de court terme d’aide alimentaire d’urgence (qui cible les groupes souffrant d’extrême malnutrition), et doit se concentrer sur le volet prévention.6
  • Programmes : Le renforcement des capacités locales de planification et de formulation de politiques, d’une part, et d’évaluation, de suivi et d’analyse des progrès accomplis en direction des objectifs du pays (de préférence parmi les OMD) d’autre part, est absolument essentiel pour réduire la faim et la malnutrition. Les programmes pro-développement et préventifs dans les domaines de la production alimentaire, de la propriété foncière, du travail, de l’éducation, de la dynamique sexospécifique, des soins de santé, et de l’eau sont, à long terme, plus importants que les programmes directs d’alimentation.7
  • Recherche et évaluation des études de cas : Les études de case et les analyses contextuelles des pays parvenant le mieux à réduire les taux de rachitisme peuvent offrir des lignes directrices de grande importance pour les politiques et les programmes de l’avenir. Le soutien de l’USAID, de l’UNICEF, de la FAO, de la Banque mondiale, et d’autres institutions majeures de financement et de conseil permettrait aux chercheurs d’évaluer, par exemple, la raison pour laquelle le Sénégal a enregistré un tel succès dans ses efforts de réduction du rachitisme au cours des deux dernières années (de 36 %), alors que de l’autre côté de la frontière, la Guinée voisine enregistrait une détérioration des niveaux de l’ordre de 31 %, ou celle de l’augmentation des taux de rachitisme de pair avec la réduction spectaculaire de la mortalité infantile en Zambie et au Malawi ;8 ou pourquoi certains pays (notamment l’Ethiopie et l’Erythrée) dans la Grande Corne de l’Afrique si souvent frappée par les grandes sécheresses, ont réussi à réduire le rachitisme malgré la famine et l’instabilité politique, alors que les progrès initiaux du Kenya stagnent depuis 1989.

Les décideurs politiques peuvent se procurer davantage d’informations sur les progrès de suivi des OMD de réduction de la pauvreté concernant le rachitisme en consultant des enquêtes comparatives fiables sur la santé et la nutrition, notamment les EDS, soutenus par l’USAID, et les enquêtes en grappe à indicateurs multiples, soutenues par l’UNICEF.9 Les responsables de la planification et de l’évaluation des programmes ont tout particulièrement besoin de savoir non seulement quels sont les pays dotés de programmes mais aussi l’emplacement, le nombre, le processus et les causes du rachitisme chronique au sein de chaque pays. Ils peuvent le faire encore mieux à partir de systèmes locaux de surveillance intégrés de l’alimentation et de la nutrition tenant compte des contextes, risques et vulnérabilités, ainsi que de la résistance et des capacités dans chaque secteur.

Note : Le présent article s’inspire de la recherché réalisée par les co-auteurs avec Eckhard Kleinau et Kathy Rowan. Voir Charles Teller et al. 2007, et Soumya Alva et al., 2008, cités ci-dessous. Vous êtes invités à envoyer vos commentaires à :

Charles H. Teller est chercheur-invité Bixby (Bixby Visiting Scholar) au Population Reference Bureau. Soumya Alva est analyste principal de la santé publique au Demographic and Health Research Group de Macro International.


  1. Food and Agriculture Organization (FAO), « Soaring Food Prices: Facts, Perspectives, Impacts and Actions Required, » document de référence préparé pour la Conférence à haut niveau sur la Sécurité alimentaire : les défis du changement climatique et de la bioénergie, Rome, 3-5 juin 2008, consulté en ligne à :, le 15 septembre 2008.
  2. Organisation mondiale de la Santé (OMS), World Health Statistics, Child Growth and Nutrition Data Base, consulté en ligne à :, ole 11 août 2008.
  3. Macro International, informations tirées des Enquêtes démographiques et de Santé, consultées en ligne à : le 11 août 2008 ; et UNICEF/Childinfo, Multiple Indicator Cluster Surveys/MICS 3, rapports nationaux consultés en ligne à :, le 15 septembre 2008.
  4. Robert Black et al., « Maternal and Child Undernutrition: Global and Regional Exposure and Health Consequences, » The Lancet 371, no 9608 (2008) : 243-60.
  5. Charles Teller et al., « Five Emerging Patterns of Demographic, Health and Nutrition Transitions and Stalls in Africa, 1986-2006, » rapport préparé pour l’USAID, août 2007.
  6. Marie Ruel et al., « Age-Based Preventive Targeting of Food Assistance and Behavior Change for Reduction of Child Undernutrition in Haiti: A Clustered Randomized Trial, » The Lancet 371, no 9612 (2008) : 588-95 ; Macro International, informations tirées des Enquêtes démographiques et de santé ; et UNICEF/Childinfo, Multiple Indicator Cluster Surveys/MICS 3, rapports pays.
  7. Malawi, National Nutrition Policy and Strategic Plan, 2008-2011 (Lilongwe, Malawi : Bureau du Président et Cabinet, ministère de la Nutrition, juin 2008).
  8. Soumya Alva et al., « A Growing Gap Between Malnutrition and Mortality Among Children in Sub-Saharan Africa, » présenté lors de la réunion annuelle de la Population Association of America, la Nouvelle-Orléans, 19 avril 2008.

Pour d’autres exemples, consulter Teller et al., « Five Emerging Patterns of Demographic and Health Transitions and Stalls » et Alva et al., « A Growing Gap Between Malnutrition and Mortality. »



How People in India 'Really' Live

Media reports on the “exploding” middle class in India would lead any reader to believe that Indian society is undergoing a top-to-bottom transformation into a society of Western-style consumers.

A recent Business Week article quoted a McKinsey Global Institute study that claimed that India, in one generation, would become a nation of upwardly mobile middle-class households, consuming goods ranging from high-end cars to designer clothing. In two decades, India would pass Germany as the world’s fifth-largest consumer market, the article went on. That, in fact, may not be much of an achievement given that India has 1.2 billion people and Germany 82 million! While it is certainly true that even small percentages give rather large numbers in India, a more realistic assessment of the true situation is needed.

Is India’s middle class surging? We first need to consider the term “middle class,” which can convey a variety of images. Those in the West undoubtedly have a fairly clear idea of what they mean by it. In this article, we will not try to define the concept for India but we will take a look at how the average Indian household actually lives. Readers can draw their own conclusions.

Visitors to India who may have spent all of their time in New Delhi might well return home believing India had “arrived,” and that the middle class was thriving. While poverty is always visible in the city, the number of new cars and SUVs, shopping malls, and tony restaurants would leave a lasting impression. Even so, just 7 percent of households in Delhi owned private cars according to the 2001 Census. And this affluent city contains just over 1 percent of the country’s households. Most of India’s population lives in smaller cities or rural areas in extremely simple housing and with few modern amenities.


Household Expenses and Living Conditions

There are two principal official sources for information on such topics as household amenities and consumer expenditures, the decennial census and the National Sample Surveys (NSS) taken by India’s National Sample Survey Organization. The NSS measures monthly per capita expenditure (MPCE) for households each year. MPCE consists of both cash household expenditures for different classes of goods and services and cash equivalents since barter is quite common in the rural areas.1 Actual money income is not asked in the census or in the NSS.

In 2006-2007, the average MPCE in the rural areas, where most Indians live, was 695 rupees or about US$14. In urban areas, it was 1,312 rupees, or about US$27. About 52 percent of MPCE was spent on food in rural areas, while the same figure was 39 percent in urban areas. Housing costs for owner-occupied dwellings are excluded because so many people have constructed their own homes and, in a sense, live rent-free. These estimates do not take into account different price levels in urban and rural areas, but they do provide a rough idea of the level of living.


Large Households

The 2001 Census provides a detailed look housing conditions and living standards. In 2001, there were 138 million rural households and nearly 54 million urban households. It is worthwhile to remember that, although India is often referred to as a billion-strong market, many purchases, such as refrigerators, are peculiar to households. India’s households include more people than they do in the United States and other Western countries, so a billion people does not translate into as large a market for household goods as it would in Western countries. In 2001, the average Indian household consisted of 5.4 people in rural areas and 5.2 people in urban areas. The average was just 2.6 people per household in the United States in 2001.2 Thus, although India’s population is about four times the size of the U.S. population, it has less than twice as many households. India had 192 million households in 2001, compared with 108 million in the United States.


Mud Floors and Walls Common

In 2001, nearly 110 million of India’s households lived in dwellings with a mud floor, 72 percent of rural households and 18 percent of urban households (see Table 1). This represented an improvement over the 1991 Census in which 79 percent of rural households and 27 percent of urban households lived with mud floors. Urban houses are, as one might expect, more solidly constructed and more permanent.

The census also lists 50 percent of houses as being in “good” condition, 44 percent as “livable,” and 6 percent as “dilapidated.” The figures are somewhat better in urban than in rural areas. The overall picture these data show is certainly at odds with a Western view of the middle class. And, the census data do not capture the small size of most houses or their vulnerability to the elements.


Table 1
Percent of Households in India Living in Houses With Given Construction Materials, 2001


Construction Materials Rural Households Urban Households
 Millions Percent  Millions Percent
All households 138.3 100 53.7 100
Grass, thatch, bamboo, wood, etc. 17.5 13 2.1 4
Mud, unburnt brick 54.9 40 6.9 13
Brick (burnt) 47.3 34 36.5 68
Stone 14.5 11 3.6 7
Other material 40.9 3 4.6 9
Grass, thatch, bamboo, wood, etc. 38.3 28 3.7 7
Tiles 51.9 38 10.6 20
Metal, asbestos sheets 13.6 10 8.7 16
Concrete 15.2 11 22.8 42
Stone 8.6 6 3.9 7
Other material 10.5 8 4.1 8
Mud 100.0 72 9.7 18
Cement 25.0 18 25.9 48
Stone 6.2 5 4.9 9
Mosaic, floor tiles 3.0 2 11.0 21
Other material 4.2 3 2.2 4

Source: 2001 Census of India.


Few Household Amenities

Seventy-eight percent of rural households lack a latrine within the house, while less than half of urban households have a flush toilet, or water closet. Only 24 million out of 192 million households have a proper sewage connection (see Table 2). A majority of households use firewood for cooking although LPG (liquid petroleum gas) is widely used in urban areas. The NSS indicates that the proportion using firewood for cooking did not change from 1999-2000 to 2006-2007, although there was an increase in LPG use in both rural and urban areas. Although it is often commented that television ownership is commonplace even in high poverty countries, nearly 63 percent of Indian households did not have one. In villages, however, many televisions are shared by multiple households so that viewership is larger than census data would suggest. Among the most popular programs are cricket matches, religious programs, and game/talent shows.


Table 2

Percent of Households in India With Certain Necessities or Amenities, 2001


Rural Households Urban Households
 Millions Percent  Millions Percent
All households 138.3 100 53.7 100
Toilet within house 30.3 22 39.6 74
With water closet 9.8 7 24.8 46
With pit latrine 14.2 10 7.8 15
Other latrine/toilet 6.2 5 7.0 13
No toilet within house 108.0 78 14.1 26
Type of drainage (sewage)
Open drainage 41.9 30 23.3 43
Closed drainage 5.4 4 18.5 35
No drainage 91.0 66 11.9 22
Availability of kitchen within house
Available 82.2 59 40.8 76
Not available 36.1 26 9.7 18
Cook in open 19.7 14 2.9 6
Fuel used for cooking
Firewood 88.6 64 12.2 23
Crop residue 18.1 13 1.1 2
Cowdung cake 17.7 13 1.1 2
Kerosene 2.2 2 10.3 19
Liquified petroleum gas (LPG) 7.8 6 25.8 48
Other 3.7 3 3.2 6
Amenities owned
Television 26.1 19 34.5 64
Bicycle 59.2 43 24.7 46
Transistor radio 43.5 32 23.9 45
Scooter, motorbike 9.2 7 13.3 25
Telephone (fixed) 5.2 4 12.3 23
Car, jeep, or van 1.8 1 3.0 6
None of the above 56.0 41 10.2 19

Source: 2001 Census of India.



Car, Computer Ownership Rare

That ultimate Western measure of middle class status, the automobile, is a relative rarity in India. Less than 5 percent of households had some type of vehicle. In the rural areas, vehicles tend to be rather old and in disrepair. In Delhi, vehicles more than 15 years old are not allowed, but these vehicles often begin a second life in rural households outside the city. The much-anticipated introduction of the US$2,000 Nano by Tata Motors will undoubtedly boost the number of cars on the road, primarily in larger cities. The Nano is quite small. with a motorcycle-type engine, and the first model will not be air-conditioned. Its price, however, is only a little more than the most expensive motorbikes and it does get one out of the rain. It can be anticipated that some will be purchased by nonresident Indians (NRIs) working in Western countries as wedding and family gifts. Still, the sight of a family of four aboard a scooter or motorbike is likely to remain more common than a family riding in a private car for a very long time to come. The number of two-wheel vehicles increased by 52 percent between 2000 and 2004, from 34 million to 52 million while, over the same period, the number of cars, jeeps, and taxis rose 54 percent, from 6.1 million to 9.5 million.

NSS data for 2002 show that 1.5 percent of urban households in nonslum areas had a personal computer with an Internet hookup and an additional 1.9 percent had a computer with no Internet (see Table 3).


Table 3
Percent of Households in India With Certain Amenities, 2002

Amenity/Consumer Item Rural Urban Nonslum
Electric fan 35.3 82.3
Refrigerator 3.8 30.0
Sewing machine 10.0 26.6
Telephone (fixed) 5.3 26.4
Air cooler 25.5 16.6
Washing machine 0.6 11.8
Water heater 0.7 8.0
Room heater 2.7 4.8
Cellphone 0.9 3.9
Air conditioner 0.1 2.1
Computer, no Internet 0.6 1.9
Computer, with Internet 0.0 1.5


Source: India, National Sample Surveys, 2002.

These figures are probably at odds with the image of urban Indians one often gets from the Western media. Computer ownership was virtually nil in rural areas. Ownership of a telephone in urban nonslum areas was 26.4 percent for fixed phones and 3.6 percent for cell phones.


Electricity Not Always Reliable

The NSS also provides times series data on the source of household energy and lighting. By 2001-2002, the use of electricity surpassed that of kerosene in rural households and stood at 56 percent electricity, 42 percent kerosene in 2006-2007. In urban areas, the availability of electricity rose to 93 percent in 2006-2007. These survey statistics, however, conceal the fact that power cuts are a frequent fact of life in India so that many households are without power for many hours of the day.

Even a cursory examination of the types of data cited in this article shows that many stories written about the contemporary lifestyles of Indians are fraught with exaggeration. There is, without question, a middle class that has been growing slowly over the past few decades. Yet even that group has but a passing similarity to the concept of the middle class in the West.


  1. As in many countries, the official definition of urban areas includes relatively small localities. In India, a village or town with 5,000 or more population and with 75 percent or more of the male labor force not directly engaged in agriculture is considered urban. In India, 28 percent of the population is considered urban and 72 percent rural.
  2. U.S. Census Bureau, “Average Number of People per Household, by Race and Hispanic Origin, Marital Status, Age, and Education of Householder: March 2001,” accessed online at, on Dec. 13, 2008.

'The World Is Fat' – A PRB Policy Seminar With Professor Barry Popkin

(December 2008) On Dec. 10, Barry M. Popkin, professor of nutrition at the University of North Carolina at Chapel Hill and director of the UNC-CH’s Interdisciplinary Center for Obesity, visited PRB to discuss rising obesity worldwide and his new book, The World is Fat, published by Avery in December 2008.

The global confluence of changing diets, increased food marketing, access to technology, and lifestyle changes has led to an upsurge in global obesity, especially in developing countries. According to Popkin, 1.3 billion people are overweight while 800 million are underweight. As people become more sedentary and gain access to cheaper food, including animal products, oils, and caloric beverages (which Popkin feels are especially problematic), the amount of calories people ingest far exceeds their energy expenditures. The social and economic costs of this rising public health problem will be immense and the burden of obesity-related diseases is shifting rapidly toward the poor. Although government action across the board is required, Popkin pointed out that it is much easier to garner political will and public support to address hunger than obesity. Obesity carries a social stigma and the public does not understand its negative social, economic, and health impacts.

Popkin took some time before his PRB policy seminar to answer a few questions on his research.

Seeing how your book is a play on Thomas Friedman’s book, The World is Flat, how is the trend of rising obesity in the developing world tied to globalization?

It’s a play, but it’s a reality. Essentially, we’ve had in the high income world for over 100 years some obesity but everywhere in the world we’ve seen a marked shift from the late 1980s to the present, in particular in every country you think of as the Third World…That acceleration is very much related to huge shifts in the marketing and availability and pricing of food and beverages to huge changes in accessibility, and all sorts of modern technology…Take for example a village in Chiapas…a Mayan village. Five to seven years ago, there were no roads to it. People were living a very simple life, they made their tortillas, they grew their grain and so on. All of a sudden, the Pan-American highway comes in and goes near them, boom, all of a sudden you see Coke and Pepsi everywhere, you see electricity, you see a shift—the men are all heavy, the diet has shifted. They buy tortillas produced in other places, they have gas stoves…This is played over wherever you go in the world in a range of different ways. People are no longer walking or biking to work or carrying their produce to the village themselves and are using buses or tractors…the technology at work has cut [caloric] energy expenditures immensely. There’s not a place in the world where you can’t get access to TV…and home technology. When I started working in China in 1989, no one had refrigerators. Very few had stoves. Today, 70 percent have refrigerators in their homes. They have microwaves, rice cookers. All of these little changes change [caloric] energy expenditures and they change what people eat and buy. And so you go one step further and talk about the modern food sector. Essentially in 1990, 15 to 18 percent of pesos spent in all of South and Central America was spent in supermarkets, a decade later, 65 to 70 percent. Now, closer to 80 percent of all money spent on food in cash goes to supermarkets. These shifts—and it’s not all Wal-Mart or Carrefour, it’s local equivalents as well—this globalization of the food distribution system, globalization of technology, all of these things meld together.


You’ve previously said that this is largely a problem of the poor but is it also a problem of the cities? Is it tied to increased urbanization?


Initially, it affects the urban areas the most. The availability of modern technology and processed foods, the political wherewithal that gives them access to cheaper food than in rural areas, the penetration of modern supermarkets all reach urban areas first…The most rapid increases in obesity in recent years are in the rural areas of the globe. Rural Mexico is not different from urban Mexico today in the way they look. They may have started a little later but today 71 percent of women and 66 percent of men are overweight. In China, over 30 percent are overweight and obese. It’s happening everywhere…I have a friend who came back from working in rural Haiti and told me that in their hospitals, they’re seeing diabetes and obesity in the midst of all of this hunger and famine. It’s this confluence of these forces, be it lower global food prices over the past 30 years, increased access to modern processed foods, the super penetration of caloric beverages, and the technologies, it’s all going hand in hand.


Do you see a link with population growth?


In terms of quality of population, yes in terms of poverty and health. In terms of quantity, clearly the age pyramid is shifting in the world. Particularly in countries where the fertility has really gone down quickly like China, the age pyramid has shifted toward older and older. As that happens, people are living longer and these chronic diseases are going to debilitate them…obesity debilitates, it does not kill…smoking kills. Obesity will kill in the end, but you’ll be sick for a long time.


So then you have wider social costs.


Yes, you have much wider social and economic costs than smoking in that sense. Over half of the 20 to 25 countries with half of the adults overweight are in the Third World. The poverty and burden of diabetes and obesity on the poor is just emerging. It’s there in South America, it’s there in China, it’s there in the higher income places in Southeast Asia, it’s there in the Middle East, but the rest of the world, it will be another decade. But by 2015, the world will be fat and the fat in the world will be poor. The rates of change are pointing that way. Even with the global food price changes, that just hurts a subset of the poor, it actually may shift people away from beef and pork but it won’t shift people away from oils or sugars.


The increasing demand for meat, global food transport, and packaging of foods have huge environmental impacts, don’t they?


Right. You’re getting a global tsunami occurring. On the one hand, you have water being depleted slowly…on the other hand, animal foods is the biggest user of water…it enhances environmental degradation over basic staples of fruits and vegetables. We got that side of the nutrition transition playing into environmental and water problems. Then you have the energy crisis which you would think would push back against this because it will increase the costs of all these energy-rich products, like beef, against ones that are less energy intensive—like grains and legumes. But the world has been shifting to more and more animal foods. It may slow down, but it’s not going to change. India will keep buying more dairy, China’s going to keep eating more pork and poultry…It will penetrate more urban areas in Africa. These problems of transition all play together to exacerbate problems that can only be dealt with by macroeconomic and major government decisions. Very few governments have the guts right now to even take on the animal food aspect of the problem.


How do you address the argument that people should be free to make their own decisions?


Clearly, there are enormous externalities on health costs and debilitation on society. Obesity and diabetes don’t directly affect the health of your neighbor in the same way as smoking. There’s no passive effect. But the social and economic costs of having people without feet and toes and who need insulin are huge. We’re at a point where in some areas of the Middle East in 10 to 15 years, 20 percent of the adults will be debilitated…The economic costs become so huge that the public good becomes concerned with the health costs of debilitated people and countries therefore have the rationale to move forward as you do with any public good such as highways, clean water. And when 1.6 billion people in the world are obese and the rates are not slowing down, you’ve got to do something. Some countries like Mexico are desperate and are taking serious action. I’m working with their congress on taxation issues and essentially banning caloric beverages in some locations. The U.S. is way behind. Believe me, more countries will be moving on this in the next three to five years.


Is there a tension between the interests of private food companies and public oversight?


I don’t think it’s a tension with private processing per se…There are proactive policies in the food industry. In a number of countries, we’re going to have this program called Choices where all food in grocery stores will be labeled…We’re going to be moving toward that in a number of countries including the U.S. The food industry is willing to start moving but in the end, government action to create level playing fields is critical. If McDonald’s says “we’re going to cut portion sizes,” but Burger King says “I’m not,” unless the government says “Everyone has to do this,” it’s not going to work. In the case of the developing world, the global actors to some extent have a little bit more of an ethical side partly because they’re being watched by their home countries and are more vulnerable to public opinion. The local equivalents and processors are actually much more unsanitary, much richer in calories and trans fats. So we need to create a level playing field not only between companies in a sector, but between global and local. It will happen eventually. How costly will it be before we get there, who knows?


Eric Zuehlke is an editor at the Population Reference Bureau.


Why Not Adjust the U.S. Census? A PRB Policy Seminar With Kenneth Wachter

(December 2008) The U.S. decennial population census attempts to count every person living in every corner of the United States. It provides the numbers that determine how many members each state will have in the U.S. House of Representatives and whether the boundaries of congressional districts must be adjusted because of population change. It establishes “winners” and “losers” in the distribution of federal funds based on population size.

But the census does not find and enumerate every U.S. resident: In the last three censuses, between 0.1 percent and 1.8 percent of the population has been missed. The U.S. Census Bureau can estimate this undercount through comprehensive post-census evaluations and demographic analyses using sophisticated statistical methods. This analysis tells us that some groups—such as black males—are much more likely to be missed than others. Accordingly, the population of geographic areas with a large proportion of these hard-to-count groups (such as Newark, N.J., or Detroit, Mich.) are likely to be undercounted in the census.

Adjustment Issues

The census is not adjusted for this known undercount. Why not, when statisticians are capable of producing such good estimates? This question was addressed by demographer and statistician Kenneth Wachter at a PRB Policy Seminar on Nov. 12, 2008. Wachter, long-time chair of the department of demography at the University California-Berkeley, has worked on census adjustment issues for many years: publishing articles, serving on special panels, and appearing as an expert witness in legal proceedings.

Wachter reviewed the thorny issues surrounding the adjustment of U.S. census results. So far, the Supreme Court has ruled against using adjusted census numbers for apportionment but not against using them for redistricting or the distribution of federal funds. There are currently no plans to adjust the next decennial census, which is less than two years away, but Wachter speculated that the question of adjustment may surface again for the Obama administration.

‘Shares Not Counts’

He pointed out that cities that suffered an undercount because they have a large number of hard-to-enumerate minorities; these cities will not necessarily quality for more federal funds if the census numbers are adjusted. Because the numbers would be adjusted for all cities, an individual city would gain a greater share of the pie only if their undercount is much greater than that of other areas.

Professor Wachter explained the basic approaches for evaluating the census count, and outlined the challenges likely to be encountered in the 2010 Census. He noted the important role of the ongoing American Community Survey in supplementing the information collected on the decennial census form.

About Kenneth Wachter

Wachter served on the Special Advisory Panel to the Secretary of Commerce on (1990) Census Adjustment, as consultant to the Secretary of Commerce on the 2000 Census, and as an expert witness in litigation since 1980. He has published 16 articles on statistical issues in the census. Wachter is a member of the National Academy of Sciences and fellow of the American Academy of Arts and Sciences. He is the outgoing chair of the Committee on Population of the National Research Council. Wachter holds a Ph.D. in statistics from Cambridge University. Among his books are Height, Health, and History and Between Zeus and the Salmon. His research extends across mathematical demography, the biodemography of aging, federal statistical policy, kinship, and microsimulation.

Mary Mederios Kent is senior demographic editor at PRB.

For More Information

Robert Bell and M. Cohen, Coverage Measurement in the 2010 Census (Washington, DC: National Research Council, 2008).

David Freedman and Kenneth Watcher, “On the Likelihood of Improving the Accuracy of the Census Through Statistical Adjustment,” in Science and Statistics: A Festscrift for Terry Speed, ed. D. Goldstein and S. Dutoit (Beechwood, Ohio: Institute of Mathematical Statistics (IMS), 2003).

Kenneth Wachter, “The Future of Census Coverage Surveys,” in Probability and Statistics: Essays in Honor of David A. Freedman, ed. D. Nolan and T. Speed (Beachwood, Ohio: IMS, 2008).