Pasteur, attention was focused on the germ 
theory of disease, and there was a strong 
desire to improve personal hygiene and 
environmental sanitation as a means of 
interrupting the transmission of infectious 
agents. In addition, moves were made to 
meet other needs, such as housing, clothing 
and education. Wealthier and better-
informed societies effected dramatic changes 
The application of economic 
models of development. without 
due consideration for the social 
determinants of health and disease; 
has resulted In an increased risk 
of pollution, stress and aberrant 
life-styles in some countries. 
eonardo Mata 
There is no valid excuse for 
failing to commit substantial 
resources to improving the 
environment 
The primary aim of all governments should 
be to enable all their citizens to satisfy their 
basic human rights of freedom, adequate 
food, health and shelter. In the wake of 
Professor Mata is with the Department of Population 
Sciences, School of Public Health, Harvard University, 
665 Huntingdon Avenue, Boston, MA 02115, USA. 
in the environment and improved health 
education. The concomitant improvement in 
income and living conditions resulted in the 
low infant mortality and high life 
expectancy at birth that characterized many 
advanced nations in the early 1960s. 
However, in the 150 years since Pasteur's 
discoveries certain industrial countries failed 
to achieve expected health goals, while 
suffering from pollution, urban violence, 
mental illness, drug abuse and alcoholism. 
During the same period, most of the less 
developed countries did not fully apply 
scientific knowledge to the betterment of 
hygiene, sanitation and housing, and some 
wasted their limited resources on less 
profitable endeavours, such as food 
distribution programmes. 
The philosophical position of Professor 
Wolman is correct, as attested by the health 
profiles of industrial and less developed 
countries. Western Europe clearly 
demonstrates how better hygiene and living 
conditions can reduce morbidity and 
mortality, especially among young people(. 
World Health Forum Vol. 7 1986 	 123 
Round Table 
The improvement of water supplies and the 
control of faecal waste were so extensive 
that infectious diseases, whether transmitted 
by water, acquired through person-to-person 
contact, or originating in faecal matter, 
became extremely rare. Malaria, once 
present in temperate Europe, was 
eradicated, and tuberculosis and other 
communicable diseases were also controlled. 
The nutritional status of the populations 
improved not only as a result of an overall 
correction of dietary deficiencies, but also 
due to a reduction in episodes of anorexia 
and nutritional wasting after the control of 
infections. These changes occurred prior to 
the discovery of some etiologies, specific 
therapies, and vaccines, and well in advance 
of the advent of antibiotics and nutritional 
science. This strengthens the concept that 
the quality of the environment has a 
primary role in curtailing morbidity and 
averting death. The beneficial effect of an 
improved environment is evident in 
Finland, Sweden, Switzerland, and other 
advanced nations. Gains have recently been 
noted in other European countries that had 
The assumption is that populations 
freed from the ipeet 1001113 of 
infeedon are better able to utilize 
available food. Improve nutrition 
and suivival, and it lase 
production. 
been lagging behind. Unfortunately, the 
application of economic models of 
development, without due consideration for 
the social determinants of health and 
disease, has resulted in an increased risk of 
pollution, stress and aberrant life-styles in 
some countries. 
The current status of many developing 
countries is more complex, in that while 
124 
urban elites enjoy a quality of life similar to 
that observed in industrial nations, the 
majority of the people remain,deprived of 
basic human rights. An added complication 
is the emphasis on short-term solutions, 
many of which are curative rather than 
preventive, while many have little or no 
demonstrable impact (2). Furthermore, action 
is often decided on for political or 
compassionate reasons, without scientific 
assessment of the nature of problems or of 
likely long-term benefits for whole 
populations (3). 
In the Americas there has been a decisive 
international effort to encourage 
governments to undertake long-term 
improvement of the environment. 
Conferences held in South America by the 
Pan American Health Organization resulted 
in formal agreement among governments to 
improve health indices within stated 
intervals. The politicization of health 
concerns, coupled with a greater popular 
demand for health services, exert steady 
pressure for continued improvement. Water 
supplies, sanitation, housing, and incomes 
have improved considerably in several Latin 
American countries, and the changes were 
followed by better nutrition and reduced 
infant mortality, now below 30 per 1000 
live births in several countries and below 20 
per 1000 in two (4). Death rates due to 
diarrhoea! disease are now less than 15 per 
100 000 in several countries, while the 
prevalence of intestinal parasites is declining 
in a few. Most nations benefit from some 
sort of primary health care, with a built-in 
component of rural water supply and 
sanitation. The decline in diarrhoeal disease 
and intestinal parasitic infection has been 
more marked in countries with improved 
water supplies, sanitation and education. 
Housing has improved less than the other 
determinants, but gains have been recorded 
even in certain slums in Caracas, Guatemala 
City, Lima and Rio de Janeiro, where 
World Health Forum Vol. 7 1986 
cardboard walls have been succeeded by 
brick, and earthen floors by cement or tile; 
water, electricity, sewers and other services 
have become available. Not surprisingly, in 
some slums primary health care is lowering 
infant mortality. Some of the gains seem to 
be marred by increased water and air 
pollution, noise, nonrecyclable garbage, and 
urban stress and violence. 
Many poor countries in the last two decades 
have wasted considerable resources in food 
distribution programmes, on the assumption 
---- that the primary cause of malnutrition and 
low survival rates was inadequate food 
consumption. While the primary role of 
infection in the genesis of village 
malnutrition cannot be denied, dietary 
studies in villages around the world have 
shown that the overall level of food intake 
does not vary much from that of affluent 
groups in the United States and Canada. On 
the other hand, there is no sound evidence 
that supplementation of village diets corrects 
malnutrition in the community, whether in 
experimental trials, limited interventions, or 
at national level (5). Famine situations 
constitute an exception because here the 
limited food supply resulting from natural or 
man-made disaster is the main determinant 
of suffering and death. 
A more realistic paradigm proposes that it is 
essential to control and prevent infectious 
diseases if child malnutrition and mortality 
are to be reduced (3,6). The assumption is 
that populations freed from the great stress 
of infection are better able to utilize 
available food, improve nutrition and 
survival, and increase production. This fits 
in partly with the historical evolution of 
European countries. It also agrees with the 
dramatic decrease in malnutrition and 
mortality—without a demonstrable increase 
in food consumption—in several developing 
countries which, in the recent past, have 
improved the environment, raised the level 
World Health Forum Vol. 7 1986 
of education, especially of women, and 
developed primary health care services. I am 
referring to Chile, China, Costa Rica, Cuba, 
India (Kerala State), and Sri Lanka um. 
There seems to be evidence that food 
distribution improved in China and Cuba, 
but this does not appear to have happened 
in Chile and Costa Rica , where there was a 
dramatic decline in infant mortality to 
around 20 per 1000 in less than a decade. In 
these nations there has been a significant 
reduction in infectious diseases and in 
childhood mortality in a short interval; rates 
of severe malnutrition were sharply reduced, 
but those of low weight for age were not. 
Claims that infectious morbidity remains 
unchanged are not valid and detailed studies 
of the incidence of infection and the 
prevalence of intestinal parasites in one of 
these countries clearly showed a drastic 
reduction in the overall level of infection (8). 
It is obvious that the control and prevention 
of infectious diseases cannot be 
accomplished without significant investment 
in environmental sanitation and health 
education. Furthermore, it is not scientific, 
ethical or humane to concentrate on feeding 
populations while disregarding other basic 
human rights, since this amounts to keeping 
people in conditions comparable to those in 
pigsties. 
Many planners and health workers neglect 
water and sanitation requirements on the 
basis that they are costly, and the cost 
always seems high to politicians. However, 
analysis of impact and cost/benefit leave no 
doubt that interventions in this field have a 
monumentally beneficial effect (9). To 
counteract negative attitudes one should 
advance the argument that the cost of illness 
and death averted by environmental 
programmes is always less than the cost of 
suffering and death inflicted by weapons and 
military actions during peace, repression, 
civil conflict or formal warfare. There is no 
valid excuse in modern times for any nation 
125 
Round Table 
failing to commit substantial resources to the 
improvement of the environment. 
	 q 
1. Eubank, D. & Wray, J.D. In: Public health and 
preventive medicine, 9th edition. New York, 
Appleton Century, 1980, pp. 1504-1548. 
2. Foochow., R.G. et al. Bulletin of the World Health 
Organization, 61: 637-640 (1983). 
3. Mats, L In: Nutrition planning. The state of the 
art. New York, IPC Scientific and Technical 
Press,1978, pp. 91-99. 
4. Grant, J.P. The state of the world's children 1986. 
Oxford, Oxford University Press,1986. 
5. Beaton. G.H. & Gbasseml, H. American journal of 
clinical nutrition, 35: 863-916 (1982). 
6. Mons, E. Pediatric infectious diseases, 1: 
212-216 (1982). 
7. Halstead. S. B. et al.. ed. Good health at low 
cost. New York, Rockefeller Foundation, 1985. 
8. Mata, L Assignment children, 61/82: 195-224 
(1983). 
9. Esrey, S, A. et at Bulletin of the World Health 
Organization, 83: 757-772 (1985), 
126 	 World Health Forum Vol. 7 1988