PopQuiz: Which Country Has the "Worst" Demographics?

An article in The Lancet suggests that the answer to this question is the sub-Saharan country of Niger:

According to the UN Human Development Index, there is no country worse off than Niger. The landlocked West African nation, which is mostly desert, lingers at the bottom of the index: 186th of 186. Its government, heavily dependent on foreign donations, spends a paltry US$10 per person on health care every year. Vast swathes of the country are effectively wild: without schools, roads, or security. There are fewer than two health-care workers per 10 000 population (23 is considered the minimum number for provision of essential care) and more than 2 million people live in chronic food insecurity, of a population of 16 million.

The country’s biggest killer is malaria. In 2012, more than 2·6 million cases of the disease were reported, alongside more than 3000 deaths.

There is something of a vicious circle. Malaria leaves a person vulnerable to malnutrition, and malnutrition leaves them vulnerable to malaria. And of course a person’s nutritional status affects how they recover from infection; so malnutrition both raises the risk of contracting a disease such as malaria and worsens its outcome, which in turn leaves the patient enervated, deprived of nourishment, and vulnerable to infection.

This high level of malaria and malnutrition is clearly an immense problem, but it is aggravated by the country's very high fertility rate which more than compensates for its high mortality.

Niger’s population growth rate is a staggering 3·9%. It means that the population will double in the next 10 years. Female fertility rate is 7·8 births. “This makes demography a key issue”, contends Gerard [Jean Christophe Gerard, Save the Children, Niamey, Niger]. It is common for women to be carrying an unborn child, an infant at their breast, and another on their back. They simply do not have time to recuperate between deliveries, and it leads to problems such as anaemia, lack of vitamin D, and mineral deficiencies.

Women marry young: typically at 14–16 years old; and only 15% of girls enter primary school. “If early and forced marriages are not taken seriously by the international and national actors, what we do is just patchwork”, Gerard concludes.

International agencies are working on some of these problems, but mainly these efforts have brought down the death rate among children without any noticeable decline yet in fertility.