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The Demographic Structure of the Indian Society Improvements in medical cures for these diseases, programmes for mass vaccination, and efforts to improve sanitation helped to control epidemics. However, diseases like malaria, tuberculosis, diarrhoea and dysentery continue to kill people even today, although the numbers are nowhere as high as they used to be in the epidemics of the past. Surat witnessed a small epidemic of plague in September 1994, while dengue and chikungunya epidemics are since reported in various parts of the country. Famines were also a major and recurring source of increased mortality. Famines were caused by high levels of continuing poverty and malnutrition in an agroclimatic environment that was very vulnerable to variations in rainfall. Lack of adequate means of transportation and communication as well as inadequate efforts on the part of the state were some of the factors responsible for famines. However, as scholars like Amartya Sen and others have shown, famines were not necessarily due to fall in foodgrains production; they were also caused by a ‘failure of entitlements’, or the inability of people to buy or otherwise obtain food. Substantial improvements in the productivity of Indian agriculture (specially through the expansion of irrigation); improved means of communication; and more vigorous relief and preventive measures by the state have all helped to drastically reduce deaths from famine. Nevertheless, starvation deaths are still reported from some backward regions of the country. The Mahatma Gandhi National Rural Employment Guarantee Act is the latest state initiative to tackle the problem of hunger and starvation in rural areas. Unlike the death rate, the birth rate has not registered a sharp fall. This is because the birth rate is a sociocultural phenomenon that is relatively slow to change. By and large, increased levels of prosperity exert a strong downward pull on the birth rate. Once infant mortality rates decline, and there is an overall increase in the levels of education and awareness, family size begins to fall. There are very wide variations in fertility rates across the States of India, as can be seen in Chart 1 (on page no. 13). Some states, like Andhra Pradesh, Himachal Pradesh, Punjab, Tamil Nadu and West Bengal have managed to bring down their total fertility rates (TFR) to 1.7 each (2016). This means that the average woman in these states produces only 1.7 children, which is below the ‘replacement level’ and Kerala’s TFR is also below the replacement level, which means that the population is going to decline in future. But there are some states, notably Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh, which still have very high TFRs. In 2016, the TFRs of these states were 3.3, 2.8, 2.7 and 3.1, respectively. According to Sample Registration System, Statistical report 2020, India’s crude birth rate was 19.5. The rural birth rate was 21.1 and urban birth rate was 16.1. As per this statistics, Bihar with 25.5 and Uttar Pradesh with 25.1 account for the highest birth rate in India. Furthermore, as per economic survey 2018-19, these two states will also account for almost half (50%) of the additions 15 to the Indian population up to the year 2041. Uttar Pradesh alone is expected to account for a little less than one-quarter (22%) of this increase. Chart 2 (on page Reprint 2026-27