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Advancements in Social Sciences Applied to Health in Latin America and the Caribbean  

Aurea Maria Zöllner Ianni and Patricia Tavares Ribeiro

The second half of the 20th century saw the development of social thought in health in Latin America and the Caribbean in which the social sciences had a central role. Such an innovative development was based on the understanding that health and disease are social processes that require the understanding of different health contexts. The origins of this development dates back to the renewal of medical teaching in Latin America, which had important support from the Pan-American Health Organization. The so-called field of social sciences in health then took shape, especially beginning in the 1970s and 1980s. The social sciences became part of teaching and assistance activities in social medicine and public health in many countries and contributed to consolidating postgraduate programs and networks of professors, researchers, professionals, and government agents who were active in public health actions and policies. Regarding Latin American realities, the issues of inequality in incidences of sickness and death and in the healthcare delivered to populations became relevant during this time. In close dialogue with relevant social groups, these actors have been significant in constructing responses to health problems in the region. Given the profound political, social, economic, environmental, and sanitary changes that took place in the transition from the 20th to the 21st century, social thought has attempted to meet the new empirical as well as theoretical and conceptual challenges to social sciences as applied to health. The analysis of the trajectory of this regional development, its details, advancements, and limits, is an important endeavor that should help to encourage suggestions toward bettering public health as well as fairness in these times of uncertainties and of new risks for humanity, as evidenced in an unprecedented way in the handling of the Covid-19 pandemic.


Application of One Health Principles to the Control of Antimicrobial Resistance  

Meghan F. Davis

One Health interventions that address human, animal, and environmental health domains are critical for controlling the global challenge of antimicrobial resistance (AMR). These interventions can target upstream conditions, such as prevention strategies like vaccination or policies, to restrict antimicrobial use in humans, animals, and plants, with a goal to reduce the selective pressure that can drive the emergence and expansion of drug-resistant pathogens. Downstream, environmental hygiene initiatives can target transmission pathways between people and animals to limit exposure to drug-resistant pathogens. Holistic, transdisciplinary approaches that address the factors driving antimicrobial use in people, animals, and the environment hold promise to help curb the global challenge of AMR.


Big Data and Urban Health  

Mark Stevenson, Jason Thompson, and Thanh Ho

Understanding the varied effects of urban environments on our health have arisen through centuries of observation and analysis. Various units of observation, when compiled spatially or linearly, have provided considerable understanding of the causal pathways between environmental exposures in cities and associated mortality and morbidity. With growing urban agglomerations and a digital age providing timely and standardized data, unique insights are being provided that further enhance the understanding of urban health. No longer is there a potential lack of urban data; over the 2010–2020 decade alone, the resolution and standardization of satellite and street imagery, for example, alongside methods of artificial intelligence such as self-supervision methods, have meant that technology and its capacity have surpassed the accuracy and resolution of many administrative data collections typically used for urban health research. From Bills of Mortality in 1665 to 20th century surveillance systems to the innovation and global reach in the period of “big data,” data has been the mainstay of decision support systems over the centuries. This new world of big data characterized by volume, velocity, variety, veracity, variability, volatility, and value is paramount to answering the significant urban health challenges of the 21st century.


Brasília’s Experience With Wastewater Treatment Systems: A Case Study  

Klaus Dieter Neder

Brasília is one of the few large cities in the developing world that provides full coverage of sanitation services for its population, including the collection of wastewater and adequate wastewater treatment. Caesb, the local water and sanitation utility, has developed a lot of experience in the planning, design, construction, and operation of sanitation systems, with a special emphasis on the need to use appropriate treatment technologies. Today, serving a population of more than three million people, Caesb runs 16 wastewater treatment plants, using technologies from very simple natural treatment processes, such as stabilization ponds and overland flow processes, to very sophisticated units, including tertiary activated sludge plants, with flotation as an effluent-polishing treatment step. During the development of the several different sanitation solutions, Caesb has found that it has been best to use simple, natural, low-cost treatment processes to achieve feasible and sustainable solutions even when, in specific circumstances, more sophisticated processes are required. The desire to increase the sustainability of the treatment plants has also stimulated Caesb to improve the performance of the applied treatment processes, which was achieved by the implementation of several modifications aimed at reducing costs and improving the efficiency of the plants. Today, the treatment of all wastewater produced in the city guarantees the quality of the discharge to the point that water bodies located downstream of wastewater treatment plants are used as resources for water supply for the city.


Burn-Related Injuries  

Ashley van Niekerk

A burn occurs when cells in the skin or other tissues are destroyed by hot liquids (scalds), hot solids (contact burns), or flames (flame burns). Injuries to the skin or other organic tissue due to radiation, radioactivity, electricity, friction or contact with chemicals are also identified as burns. Globally, burns have been in decline, but are still a major cause of injury, disability, death and disruption in some regions, with about 120,000 deaths and 9 million injuries estimated in 2017. Low-to-middle-income countries carry the bulk of this burden with the majority of all burn injuries occurring in the African and Southeast Asia regions. Thermal injuries are physically painful and may leave disabling scars not only to the skin or the body, but also impair psychological wellbeing. Severe injuries often impose significant psychological, but also educational consequences and social stigmatization, with the consequent adjustments exacerbated by a range of factors, including the circumstances of the burn incident, the severity and site of the injury, the qualities of the affected individual’s personality, and the access to supportive interpersonal and social relationships. The contributions of: economic progress, enhanced environmental and home structures, energy technology, and safety education interventions have been reported as significant for burn prevention. Similarly, legislative and policy frameworks that support access to modern energies such as electricity, govern domestic appliances and heating technology, and control storage and decanting of fossil fuels are important in energy impoverished settings. The recovery of burn survivors is affected by the availability of specialized treatment, physical rehabilitation and psychosocial support to burn victims and families, but which is still limited especially in resource constrained settings.


Case Study of the Federal District of Brasília: CAESB’s Experience With Condominial Sewerage  

Maria Martinele Feitosa Martins and César Augusto Rissoli

Brasília, the capital of Brazil, which is located in the Federal District, has one of the highest sanitary sewerage connection rates in the country. More than 92% of its more than 3 million inhabitants are served by sewage collection and treatment systems, and Companhia de Saneamento Ambiental do Distrito Federal (CAESB), the local public sanitation company, is firmly committed to reaching universal coverage. A condominial sewerage system has been used by CAESB as a powerful tool to make universal coverage possible. The system offers advantages in reduced costs and guaranteed connections and a close partnership with the community. Installed throughout the Federal District beginning in the early 1990s, this system has provided effective service to more than 1.6 million inhabitants of all social classes, which has contributed to the resurgence of civic participation and improved the population’s quality of life.


Changing Open Defecation Behavior  

Mark Radin

Open defecation (OD) remains a persistent problem in many low-income countries. The international community, through the Sustainable Development Goals (SDGs), has committed itself to eliminating OD by 2030. While access to and use of latrines has steadily increased, much is unknown on how to eliminate OD. The history of the elimination of OD in high-income countries offers potential lessons for achieving the sanitation targets of the SDGs. A desk review of sanitation literature revealed a well-documented effort to eliminate OD in the United States, which faced many of the same obstacles as those encountered in low-income countries in the 21st century. One of the important lessons is that eliminating OD takes sustained efforts over decades and substantial resources. The international efforts to eliminate OD have evolved through numerous phases within the global development agenda. To eliminate OD will require continued investment in new and ongoing programs, which are often led by national governments in partnership with international organizations, civil society, and the private sector. Many successful programs have utilized numerous approaches for eliminating OD as the barriers to sanitation use are different across societies and for each individual. Access to sanitation in institutions such as schools and health care facilities as well as public facilities remains a problem in both high- and low-income countries. Finally, the international community will need to deploy more resources and develop effective approaches for ensuring that latrine adoption and use is sustainable.


Child Development, Major Disruptive Events—Public Health Implications  

Tracy Vaillancourt and Peter Szatmari

The COVID-19 pandemic has upended nearly all the safeguarding systems in the lives of children and youth, such as family life, school, extracurricular activities, sports, unstructured social opportunities, health care, and church. With many of the typical promotive and protective factors disrupted all at once, and for so long, the mental health of children and youth has deteriorated in many areas, but not all, and for many children and youth, but not all. It is important to acknowledge, however, that the mental health of children and youth was in crisis before the pandemic, with 1 in 7 children and youth worldwide having a mental disorder. Given the continued decline in this area of health, children and youth may well be on the cusp of a “generational catastrophe” that could involve lasting harms if immediate action is not taken. Of particular concern are marginalized and vulnerable children and youth—they are the ones unduly enduring the brunt of this global crisis. Accordingly, child and youth mental health recovery must be prioritized, along with the reduction of inequity within and across countries. A commitment to public health strategies that never include harming children and youth as a tolerated side effect must also be made.


Child Health in Latin America  

Célia Landmann Szwarcwald, Maria do Carmo Leal, Wanessa da Silva de Almeida, Mauricio Lima Barreto, Paulo Germano de Frias, Mariza Miranda Theme Filha, Rosa Maria Soares Madeira Domingues, Elisabeth Barboza Franca, Silvana Granado Nogueira da Gama, Cristiano Sigueira Boccolini, and Cesar Victora

Child health has been placed at the forefront of international initiatives for development. The adoption of the Millennium Development Goals has propelled worldwide actions to improve maternal and child health. In the course of the year 2000, the Latin American (LA) countries made marked progress in implementing effective newborn and infant life-saving interventions. Under-five mortality in LA fell by a third between 1990 and 2015, with a sharp decline in diarrheal diseases and respiratory infections. Due to the successful immunization programs in the region, some vaccine-preventable diseases have been eliminated. Many of the LA countries have reached nearly universal coverage of childbirths attended by skilled personnel and >80% coverage for antenatal care. In 2015, 18 countries in the region reported the elimination of mother-to-child transmission for both HIV and syphilis. Although the advances in the public agenda aimed at promoting child health and development in Latin American countries are undeniable, unresolved issues remain. While many stillbirths and neonatal deaths could be averted by improving access to antenatal, intra-partum, and postnatal interventions, Latin America has the highest cesarean rate among all regions of the world with an excessive number of such operations without medical indications. The simultaneous lack and excess of cesarean deliveries in LA countries reflects a model of care that excludes a considerable portion of the population and reveals the persistent gaps and inequalities in the region. One of the main challenges to be faced is the lack of sustainable financing mechanisms to provide integrated and high-quality health care to all children, equal education opportunities, and social services to support disadvantaged families. When planning interventions, equity should be restored as the guiding principle of actions to ensure inclusion and social justice. Children represent the future of society in Latin America and elsewhere. For this reason, social commitment to provide universal child health is the genesis of sustainable development and must be an absolute priority.


Cities, Health, and Intersectorialities  

Marco Akerman, Gabriela Murillo Sancho, and Samuel Jorge Moysés

Cities have been considered in many places and times a cornerstone of innovation and wealth creation in society, fostering the privilege of more comfortable lives, with existential dignity and producing healthier generations, as well as an important source of pathogenic determinants. The concept of health in cities and its intersectoral relationships unfolds in a new era of urban sociability, mediated by technologies that connect citizens in social networks and in many services provided by digital platforms. All changes have their respective economic and cost-effective impacts. Healthy cities, or smart and sustainable cities, intend to express well-being and the fulfillment of good health among people who enjoy social inclusion, effectively using policies and services concentrated in the most developed cities. However, the extent of the challenges that permeate the current urban civilization cycle is also related to the social inequities manifested in health problems and public mismanagement in cities around the world. It is necessary to think about the integration of the intersectoral habitus of conceptualizing health promotion, considering all its inclusive scope of diversity, without leaving any social and identity group out, with a view to the full realization of healthy cities. There is an ethical, political, and cultural imperative to urgently adopt an ecosocial approach to promoting the health of populations in cities around the world, recognizing the interactions between ecological determinants (all planetary systems and living species) and the very internal dispositions of what constitutes human health.


Climate Change and Water-Related Diseases in the Mekong Delta Region  

Nu Quy Linh Tran, Des Connell, Trung Hieu Nguyen, and Dung Phung

The Mekong Delta Region (MDR) in Vietnam, located at the downstream end of the Mekong River, is highly affected by climate change and extreme weather events, such as floods, droughts, soil erosion, and salinization. Due to the specific characteristics of climate, topography, river systems, and population, water-related diseases (WRDs) have been a disease burden in the Mekong Delta. This article aims to critically review the evidence of existing studies on the association between climatic conditions and WRDs in the MDR. Dengue was found to be most sensitive to the changes in ambient temperatures, humidity, and rainfall at a lag of 2 months. The climate-based prediction model was recommended for an early warning system to enhance dengue prevention. Diarrheal diseases are highly correlated with extreme weather events such as high temperatures and floods, but the evidence on the association between climatic conditions and cause-specific WRDs is limited and inconclusive. Despite the preliminary evidence for the development of climate change adaptation strategies in the MDR, studies on other WRDs (i.e., water-washed, water-scarce, and water-contaminated diseases) should be conducted. In addition, future studies should investigate the effects of interaction between climatic factors and sociodemographic, household, and individual factors in predicting climate-sensitive diseases. How to translate and integrate the scientific evidence to the policy and practices that protect the MDR residents from the elevated extreme weather events due to climate change should be warranted.


Collective Health: Theory and Practice. Innovations From Latin America  

Ligia Maria Vieira-da-Silva

Throughout history, knowledge and practices on the health of populations have had different names: medical police, public health, social medicine, community health, and preventive medicine. To what extent is the Brazilian collective health, established in the 1970s, identified with and differentiated from these diverse movements that preceded it? The analysis of the socio-genesis of a social field allows us to identify the historical conditions that made possible both theoretical formulations and the achievement of technical and social practices. Collective health, a product of transformations within the medical field, constituted a rupture in relation to preventive medicine and public health and hygiene, being part of a social medicine movement in Latin America that, in turn, had identification with European social medicine in the 19th century. Focused on the development of a social theory of health that would support the process of sanitary reform, collective health has been built as a space involving several fields: scientific, bureaucratic, and political. Thus, it brought together health professionals and social scientists from universities, health care services, and social movements. Its scientific subfield has developed, and the sanitary reform project has had several successes related to the organization of a unified health system, which has ensured universal coverage for the population in Brazil. It has incorporated into and dialogued with several reformist movements in international public health, such as health promotion and the pursuit of health equity. Its small relative autonomy stems from subordination to other dominant fields and its dependence on the state and governments. However, its consolidation corresponded to the strengthening of a pole focused on the collective and universal interest, where health is not understood as a commodity, but as a right of citizenship.


Community Directed Approaches for Health Improvement  

William R. Brieger and Bright C. Orji

The community-directed intervention (CDI) strategy is an approach in which communities themselves direct the planning and implementation of intervention delivery fostered with support from the Special Programme for Research and Training in Tropical Diseases of the World Health Organization and partners. This approach grew out of the onchocerciasis control effort in Africa and has been piloted in several African countries, such as Nigeria and Kenya. The approach would become a stimulus for developing primary health care (PHC) services in remote and previously unreached rural villages. Empirical works across countries indicated that CDI is an accepted and effective strategy in the mass treatment of schistosomiasis and soil transmitted helminths (STH) infections. That will further support technical skill and institutional knowledge on mass treatment across countries using a standard approach. Staff orientation and training were needed to get programs off the ground since few staff had basic training in the benefits and procedures of organizing community participation. However, technical training to perform these health tasks did not guarantee that services would reach communities where participation was not the underlying value of the system. The team aimed to trace the development and evolution of CDI from community-directed treatment with ivermectin (CDTI), a focused disease control effort for onchocerciasis/river blindness; adapt the approach to address other health and development needs; and examine the challenges CDI has faced, which are not unlike those experienced by PHCs.


Community Empowerment and Health Equity  

Jennie Popay

Empowerment features prominently in public health and health promotion policy and practice aimed at improving the social determinants of health that impact communities and groups that are experiencing disadvantage and discrimination. This raises two important questions. How should empowerment be understood from the perspective of health and health equity and how can public health practitioners support empowerment for greater health equity? Many contemporary definitions link empowerment to improvements in individual self-care and/or the adoption of “healthier” lifestyles. In contrast, from a health equity perspective community empowerment is understood as sociopolitical processes that engage with power dynamics and result in people bearing the brunt of social injustice exercising greater collective control over decisions and actions that impact their lives and health. There is growing evidence that increased collective control at the population level is associated with improved social determinants of health and population health outcomes. But alongside this, there is also evidence that many contemporary community interventions are not “empowering” for the people targeted and may actually be having negative impacts. To achieve more positive outcomes, existing frameworks need to be used to recenter power in the design, implementation, and evaluation of local community initiatives in the health field. In addition, health professionals and agencies must act to remove barriers to the empowerment of disadvantaged communities and groups. They can do this by taking experiential knowledge more seriously, by challenging processes that stigmatize disadvantaged groups, and by developing sustainable spaces for the authentic participation of lay communities of interest and place in decisions that have an impact on their lives.


Community-Oriented Primary Health Care for Improving Maternal, Newborn, and Child Health  

Amira M. Khan, Zohra S. Lassi, and Zulfiqar A. Bhutta

Nearly 80% of the world’s population lives in low- and middle-income countries (LMICs) and these regions bear the greatest burden of maternal, neonatal, and child mortality, with most of the deaths occurring at home. Much of global maternal and child mortality is attributable to easily preventable and treatable conditions. However, the challenge lies in reaching the most vulnerable communities, especially the rural populations, making it imperative that maternal, newborn, and child health (MNCH) interventions focus on communities in tandem with facility-based strategies. There is widespread consensus that delivering effective primary health care (PHC) interventions through the continuum of care, starting from pregnancy to delivery and then to the newborn, infant, and the young child, is an integral component of health strategies in high-, middle- and low-income settings. Despite gaps in research, several effective community-based PHC approaches have been proven to impact MNCH positively. Implementation of these strategies is needed at scale in LMICs and in partnership with all stakeholders including the public and private sector. Community-based PHC, operating on the principles of community engagement and community mobilization, is now more critical than ever. Further robust studies are needed to evaluate certain strategies of community-based PHC and their impact on maternal and child health outcomes, such as the use of mobile technology and social franchises. Recognition of community health workers (CHWs) as a formal cadre and the integration of community-based health services within PHC are vital in strengthening efforts to impact maternal, neonatal, and child health outcomes positively. However, despite the importance of community-based PHC for MNCH in LMICs, the existence of a strong health system and skilled workforce is central to achieving positive health outcomes in these regions.


Comprehensive Abortion Care  

Nathalie Kapp, Mariana Romero, Shamala Dupte, Allison Shaber, and Daniel Grossman

Abortion is a common part of people’s reproductive lives, regardless of where they live in the world. When using World Health Organization-recommended methods of either surgical or medical abortion, procedures are very safe and effective, and providers do not need a lot of information or testing to provide quality services. Both medical and surgical methods may be used to induce or to treat incomplete abortion. Although both methods are safe and effective, they have different characteristics and acceptability; therefore, clients should be given the choice of method in settings where it is possible. Service delivery can include provision of surgical and medical abortion services by many cadres of providers, from nurses and midwives to physicians. Most people (generally around 90%) seek induced abortion before 12 weeks’ gestation, during which time medical abortion can be safely provided either through an in-person clinical encounter or through telemedicine, and there is emerging evidence of safe over-the-counter-like use. Postabortion care includes the timely management of an unsafe or spontaneous abortion (spontaneous loss of pregnancy) that has happened or is in progress; it has been a global strategy to reduce the morbidity and mortality related to less safe abortions. For all people having an abortion, postabortion care includes information and voluntary provision of postabortion contraception or other desired reproductive health services.


Contraceptive Technology  

Timothee Fruhauf and Holly A. Rankin

Contraceptive technology refers to tools that are used to delay or prevent pregnancy. Modern contraceptive technology encompasses female or male sterilization, intrauterine devices, contraceptive implants, contraceptive pills, contraceptive patches, intravaginal rings, diaphragms, external or internal condoms, emergency contraception, and certain fertility awareness–based methods. Duration of these methods’ effects varies from permanent and irreversible to long-lasting and reversible to short term with day-to-day reversibility. The efficacy of modern contraceptive technologies at preventing pregnancy ranges between 76% and 99.95% during the first year of typical use. Mechanisms of action vary from physically impeding meeting of sperm and oocyte to use of exogenous reproductive hormones to alter fertility. Contraceptive counseling for the selection of a method should adopt a shared decision-making framework and can consider advantages, disadvantages, contraindications, and side effects of a method to align with a patient’s contraceptive use goals. Certain clinical contexts, such as post-abortion, postpartum, adolescent patients, and patients with elevated body mass index have contraceptive nuances that are important to consider. Finally, contraceptive technology has many non-contraceptive benefits that provide additional indications for their use.


Convergence Theory and the Salmon Effect in Migrant Health  

Yudit Namer and Oliver Razum

For decades, researchers have been puzzled by the finding that despite low socioeconomic status, fewer social mobility opportunities, and access barriers to health care, some migrant groups appear to experience lower mortality than the majority population of the respective host country (and possibly also of the country of origin). This phenomenon has been acknowledged as a paradox, and in turn, researchers attempted to explain this paradox through theoretical interpretations, innovative research designs, and methodological speculations. Specific focus on the salmon effect/bias and the convergence theory may help characterize the past and current tendencies in migrant health research to explain the paradox of healthy migrants: the first examines whether the paradox reveals a real effect or is a reflection of methodological error, and the second suggests that even if migrants indeed have a mortality advantage, it may soon disappear due to acculturation. These discussions should encompass mental health in addition to physical health. It is impossible to forecast the future trajectories of migration patterns and equally impossible to always accurately predict the physical and mental health outcomes migrants/refugees who cannot return to the country of origin in times of war, political conflict, and severe climate change. However, following individuals on their path to becoming acculturated to new societies will not only enrich our understanding of the relationship between migration and health but also contribute to the acculturation process by generating advocacy for inclusive health care.


Customer Assistance Programs and Affordability Issues in Water Supply and Sanitation  

Joseph Cook

Concerns about water affordability have centered on access to networked services in low-income countries, but have grown in high-income countries as water, sewer, and stormwater tariffs, which fund replacement of aging infrastructure and management of demand, have risen. The political context includes a UN-recognized human right to water and a set of Sustainable Development Goals that explicitly reference affordable services in water, sanitation, and other sectors. Affordability has traditionally been measured as the ratio of combined water and sewer bills divided by total income or expenditures. Subjective decisions are then made about what constitutes an “affordable” ratio, and the fraction paying more than this is calculated. This measurement approach typically omits the coping costs associated with poor supply, notably the time costs of carrying water home. Three less commonly used approaches include calculating (a) the expenditure related to procuring a “lifeline” quantity of water as a percent of income or expenditures, (b) the amount of income left for other needs after water and sewer expenditures are subtracted, and (c) the number of hours of minimum wage work needed to purchase an essential quantity of water. Lowering water rates for all customers does not necessarily help those in need in low- and middle-income countries. This includes tariff structures that subsidize the price of water in the lowest block or tier (i.e., lifeline blocks) for all customers, not just the poor. Affordability programs that do not operate through tariffs can be characterized by (a) how they are administered and funded, (b) how they target the poor, and (c) how they deliver subsidies to the poor. Common types of delivery mechanisms include subsidizing public taps for unconnected households, subsidizing or financing the fees associated with obtaining a connection to the piped network, and subsidizing monthly bills for poor households. Means-tested consumption subsidies are most common in industrialized countries, whereas subsidizing public taps and connection fees are more common in low- and middle-income countries. A final challenge is directing subsidies to renters who are more likely to be poor and who do not have a direct relationship with a water utility because they pay for water through their landlord, either included as part of their rent or as a separate water payment. Based on data from the 2013 American Housing Survey, approximately 21% of all housing units in the United States are occupied by this type of “hard to reach” customer, although not all of them would be considered poor or eligible for an assistance program. This ratio is as high as 74% of all housing units in metropolitan areas like New York City. Because of data limitations, there are no similar estimates in low-income countries. Instead of sector-by-sector affordability policies, governments might do better to think about the entire package of services a poor person has a perceived right to consume. Direct income support, calculated to cover a package of basic services, could then be delivered to the poor, preserving their autonomy to make spending decisions and preserving the appropriate signals about resource scarcity.


Demographic Transition in India: Insights Into Population Growth, Composition, and Its Major Drivers  

Usha Ram and Faujdar Ram

Globally, countries have followed demographic transition theory and transitioned from high levels of fertility and mortality to lower levels. These changes have resulted in the improved health and well-being of people in the form of extended longevity and considerable improvements in survival at all ages, specifically among children and through lower fertility, which empowers women. India, the second most populous country after China, covers 2.4% of the global surface area and holds 18% of the world’s population. The United Nations 2019 medium variant population estimates revealed that India would surpass China in the year 2030 and would maintain the first rank after 2030. The population of India would peak at 1.65 billion in 2061 and would begin to decline thereafter and reach 1.44 billion in the year 2100. Thus, India’s experience will pose significant challenges for the global community, which has expressed its concern about India’s rising population size and persistent higher fertility and mortality levels. India is a country of wide socioeconomic and demographic diversity across its states. The four large states of Uttar Pradesh, Bihar, Madhya Pradesh, and Rajasthan accounted for 37% of the country’s total population in 2011 and continue to exhibit above replacement fertility (that is, the total fertility rate, TFR, of greater than 2.1 children per woman) and higher mortality levels and thus have great potential for future population growth. For example, nationally, the life expectancy at birth in India is below 70 years (lagging by more than 3 years when compared to the world average), but the states of Uttar Pradesh and Rajasthan have an average life expectancy of around 65–66 years. The spatial distribution of India’s population would have a more significant influence on its future political and economic scenario. The population growth rate in Kerala may turn negative around 2036, in Andhra Pradesh (including the newly created state of Telangana) around 2041, and in Karnataka and Tamil Nadu around 2046. Conversely, Uttar Pradesh, Bihar, Madhya Pradesh, and Rajasthan would have 764 million people in 2061 (45% of the national total) by the time India’s population reaches around 1.65 billion. Nationally, the total fertility rate declined from about 6.5 in early 1960 to 2.3 children per woman in 2016, a result of the massive efforts to improve comprehensive maternal and child health programs and nationwide implementation of the national health mission with a greater focus on social determinants of health. However, childhood mortality rates continue to be unacceptably high in Uttar Pradesh, Bihar, Rajasthan, and Madhya Pradesh (for every 1,000 live births, 43 to 55 children die in these states before celebrating their 5th birthday). Intertwined programmatic interventions that focus on female education and child survival are essential to yield desired fertility and mortality in several states that have experienced higher levels. These changes would be crucial for India to stabilize its population before reaching 1.65 billion. India’s demographic journey through the path of the classical demographic transition suggests that India is very close to achieving replacement fertility.