Sustainability Threatens Public Health In The Developing World

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Current conservation policies often clash with public health initiatives in the developing world but they get little attention. There are real harms in advocating water and energy conservation over people.

We take sanitary practices for granted in wealthier countries but hygienic practices require water in quantity and uninterrupted power to supply that water and related sewage systems. Those really help countries that need it most yet those are two things that environmental groups and governments in Europe and North America often oppose. Reports from the World Health Organization and the World Bank have found that lack of water and energy affects 800 million people around the globe. Decentralized heating and cooking in homes in the urban areas of the developing world account for most ambient air pollution and perhaps 80-90 % of the WHO estimate of up to 6.5 million annual deaths linked to such air pollution.

Instead of addressing those issues in the most practical way possible, the US in 2013 declined multilateral (World Bank) aid to build centralized power plants in the poorest countries – because to be affordable they had to use coal. Instead, the US government sided with WHO and Dr. Margaret Chan and insisted on climate change mitigation for poor countries while giving China unlimited emissions until 2030.

Where did we go wrong? When guiding the "Our Common Future" report, Director General of the World Health Organization Dr. Gro Harlem Brundtland chose to deny crucial infrastructural urban development, such as the provision of fresh water supplies and the installation of sewerage systems, unless it could be done "sustainably". But the countries that need such infrastructure are often unable to raise capital on their own and need multilateral assistance from rich countries. By mandating they could only have loans if they agreed to build things that would be too expensive, we doomed those countries to failure.

What has been little discussed is how those initiatives made western governments feel good while dooming developing nations. It has long been known that infectious diseases acquired before the age of one permanently affect the nutritional status of an infant, especially when the infections are frequent or virulent. Just over a decade ago, WHO and the World Bank attributed 50 percent of consequences of undernutrition to unhealthy environments. These are all easily solved – unless sustainability policies triumph over food and sanitation.

Direct human household consumption of water is only 11 percent of all total global consumption of water: this is small especially when compared to water consumption by the agricultural sector but the weight of evidence shows it is vitally important. Yet it is being left behind.

It wasn't always this way. The WHO and its predecessors once emphasized the provision of fresh water and sewerage infrastructure in urban areas. These measures contributed greatly to the public health miracle that was mainly experienced by OECD-countries. Moreover, that agenda enabled the liberal per capita use of tap water by households, communities, hospitals and industries for a variety of hygiene purposes. Today, the current sustainable development agenda is dominated by conservation policies that pay little attention to the health protection needs of the poor.

This article appeared in the Fall 2017 Priorities magazine and was drawn from the longer paper below:




Current sustainable development policies compromise public health in the developing world


It has now lapsed over five years since I first time submitted this manuscript for publication to the Bulletin of the World Health Organization August 22. 2012 with this journal required attached statement:

“Little attention has been paid to water conservation as an overriding principle and its adverse public health repercussions. This paper argues that neglected and forgotten teachings, and new interpretations from institutional reports, of the importance of the hygienic principles that must be rediscovered within WHO realm. This paper bridges classic environmental health agenda with newly discovered ideas of how bad hygiene negatively influences child development and how it is of utmost importance that governments started to advocate cleanliness as a virtue and source of good health again.”

Editor of the Bulletin of the World Health Organization declined to send it to peer review stating that “it lacks scientific quality”.

Since then this manuscript has been re-edited and further improved and re-submitted to the Lancet, the Journal of American Medical Association, American Journal of Public Health, Plos Medicine, BMC Public Health, one Royal Society journal, and a couple of smaller journals.

Not a single editor has ever sent my manuscript to peer review.

I have been writing this essay for over ten years. During this time I have been privileged to participate in countless national and international policy discussions and worked within many task forces or working groups relating health and environment issues in various roles during the past 15 years.

I have my share of publications and merits published in the peer reviewed scientific medical journals. I cannot escape the idea, that it is the political content of this manuscript challenging current neo-malthusian conservation ideals, shared today by many, which have prevented this manuscript not only from being published but also from being challenged by colleagues. I also argue, along with many, that scientific peer review is in crisis because of the former ideals advocating doom and gloom and attitudes amongst the editors of formerly mentioned journals seem to reflect this regrettable state-of-affairs nicely.


Current mainstreamed conservation policies often clash with environmental health practice and interventions. Moreover, little attention has been paid to the public health consequences of implementing sustainable development policies that advocate water and energy conservation as an overriding principle. Hygienic practices in households, industrial settings and hospitals need water in quantity and rely upon an uninterrupted power grid to supply that water and related sewerage system.  Reports from the World Health Organization and the World Bank have found that unhygienic conditions are the root cause of undernutrition that affects 800 million people around the globe: most notably in South-Asia. Recently it has been firmly established that decentralized heating and cooking in homes in the urban areas of the developing world is also responsible for most ambient air pollution and perhaps 80-90 % of the WHO declared 6,5 million annual deaths attributable to air pollution. Barack Obama’s advocated decision in 2013 to decline multilateral (World Bank) aid and investments to centralized coal-fired power plants in the poorest countries not only prevents improvements in ambient air quality there but also prevents eradication of under nutrition. Hence, impact of indoor air pollution e.g. amongst children <5 (acute lower respiratory infection, ALRI) would be much smaller had they not been under nourished in the first place. ALRI is the leading cause of death < 5. WHO under the leadership of Dr. Margaret Chan has questionably promoted climate change mitigation assuming automatic co-health benefits from her anti-fossil fuel stance. Neglect of institutional environmental health in the current development agenda poses a continuous threat to global health security.


According to the renowned urban development researcher David Satterthwaite, chairman of the World Commission on Sustainable Development and later Director General of the World Health Organization (WHO), Dr. Gro Harlem Brundtland, made an unfortunate personal choice by omitting the ‘Brown Agenda’ (1) from her World Commission’s hailed report entitled ‘Our Common Future’ (2). The Brown Agenda promotes crucial infrastructural urban development such as the provision of fresh water supplies and the installation of sewerage systems. ‘Our Common Future’ helped to mainstream global environmental conservation policies supported by the governments under the sustainable development agenda, which now adversely affect investment choices (e.g. investments in coal fired power plants which are needed to support water supply and sewerage systems) in the poorest countries especially. Such countries are often unable to raise capital on their own and need bi- and multilateral assistance from rich countries.

Since the beginning of the global environment debate, many of those policies and interventions that are related to the formerly successful environmental health agenda have been questioned, sidelined or even excluded (see Table), because of the overriding need to protect the natural environment (3-13). Many of these issues have been publicly and vigorously debated. However, the perceived imperative to conserve and protect fresh water by inter alia limiting its provision and the consequences of doing so has been given little attention. This paper focuses on the perceived imperative to conserve water and energy at the expense of providing hygiene and health for the poor, through limiting the provision and distribution of sufficient water and sewerage infrastructure. It also argues that the pursuance of these obsessions have actually had negative impacts on the health of the poor.

The main factor behind the mass-scale adverse health effects of current conservation policies is that an unhygienic living environment is the root cause of common (800 million people worldwide) intergenerational under nutrition. In particular, hyper-endemic loads of diarrhoeal diseases often have permanent negative effects on nutrient balances that inter alia can result in the stunting of a baby or increase mortality to infectious diseases (14-17).


Infections lower infant’s nutritional status

Practically all infectious diseases acquired pre-, peri- or postnatally before the age of one adversely permanently affect the nutritional status of an infant. This is especially the case when the infections are frequent or the infectious agents are virulent (15). These associations were widely recognized by clinicians during the first half of the last century. Examples of such interactions between nutrition and infection include the vitamin deficiencies that were often attributed to bad hygiene (18). The interaction between undernutrition and poor hygiene was systematized in the 1960’s by American nutritionists and finally published in a classic WHO monograph (18). Few cohort studies were available around the time the monograph was published and the idea was gradually forgotten.

Interest was reawakened during the first decade of the new millennium by WHO (16) and the World Bank (14,15). Disease burden estimates were revised according to an expert opinion that attributed 50 per cent of consequences of undernutrition to unhealthy environments (16). Despite this, these publications did not result in major policy discussions in the World Sustainable Development agenda. However, World Health Assembly without significant advocacy silently acknowledged the link between bad hygiene and nutrition in its 2012 resolution 65/6. However, some experts realized the utmost importance (19-21) of these ideas by advancing new and more thorough interpretations.

Institutional environmental health - the forgotten agenda

The former disease primary prevention agenda measures that were implemented by health ministries, the WHO and its predecessors emphasized the provision of fresh water and sewerage infrastructure in urban areas. These measures contributed greatly to the public health miracle that was mainly experienced by OECD-countries. Moreover, that agenda enabled the liberal per capita use of tap water by households, communities, hospitals and industries for a variety of hygiene purposes. In contrast, the current sustainable development agenda is dominated by conservation policies that pay little attention to the health protection needs of the poor. Consequently, no recognition of the remarkable success story, achieved by ensuring uninterrupted and abundant clean water to rich urban communities, has been made by the proponents of these sustainable development agendas.

One should not confuse the classic hygiene or environmental health agendas with the various Environment and Health processes (e.g. WHO/Euro ministerial process) of the past 20 years nor with the new global United Nations third Environment Assembly (UNEA) pollution initiative with misplaced and non-evidence-based public health priorities (22). These new initiatives and processes are not imbued with the classic principles of hygiene that aim at blocking environmental disease transmission, but are merely interested in bringing environmental pollution driven concerns and conservation ideals into the public health debate. The modern health worries behind these newly developed agendas foster ideas that cancers, genetic defects, congenital malformations and hormone-like effects are attributable to pollution and chemicals exposure, and have their origins in Rachel Carson’s book, ‘Silent Spring’ (23).

The inherent problem of these new environment and health processes is their inability to bring effective added value to health ministries, as evidence-based medical literature does not support the notion that the vigorously claimed modern health threats would jeopardize public health (e.g. 24,25).

Water quantity is not mentioned in the Sustainable Development policy texts

Direct human household consumption of water is only 11 per cent of all total global consumption of water: this is small especially when compared to water consumption by the agricultural sector (26). However, the consequence of the perceived water stress and the need to conserve it no matter what, led to the current neglect (1) of bringing fresh water in large quantities and building sewerage systems for the urban poor. Issues such as source protection, rather than providing sufficient clean household water, have become part of the standard policy objectives of adopted declarations. It was only after the acrimonious disputation that ensued in the aftermath of the Johannesburg World Summit of Sustainable Development in 2002 that sanitation was included.

WHO considers 100 liters and above per capita consumption in the home per day as ideal for health (27). This figure is based on the use of multiple taps in a household. Adopted milestone sustainable development texts do not mention this figure or the importance of providing household water in quantity and need to build sewerage to improve hygiene and reduce child mortality, although they even stress the need to improve hygiene (28,29).

Ecocentric Royal Society report

The Royal Society’s report ‘People and the Planet’ (30) published before the ‘Rio+20 World Summit on Sustainable Development’ (WSSD) is a good example of the ecocentric thinking that ultimately ignores the health protection needs of the poor and stresses ad infinitum water scarcity and energy conservation, although it correctly states that only about 10 % of water global water consumption is attributable to municipal and domestic needs. It does acknowledge the need to provide a ‘well-planned water supply’ and need to provide hygienic sanitation and even sewerage, but importantly, that publication failed to acknowledge that many feaco-oral route diseases are not only transmitted by contaminated water but by the contamination of fingers, food, fomites, field crops, other fluids etc. (31,32). Hence, that this report states that ’88 per cent of diarrhoeal diseases are attributable to poor sanitation according to WHO’ without reference to hygiene. This statement would have been strictly correct only in the context of the previously mentioned WHO’s ideal household water provisions (27). Instead the report stresses elsewhere basic water consumption needs (50 liters/day/capita) that ignore laundry and bathing needs of poor people. There is no mention that bad hygiene is a root cause of undernutrition as pointed out by the World Health Organization and the World Bank. 

The report mentions the word ‘hygiene’, but defines it as something that a pristine environment (protected fresh water sources) automatically provides us through nature’s ecosystems. In environmental and public health practice, the word ‘hygiene’ means something very different. Hygiene is promoted through knowledge-based advocacy, investments in infrastructure, education, legislation and related institutional frameworks.

Misconceptions about the role of drinking water in diarrhoeal diseases

An important misconception that prevails, even amongst specialists, has helped to overemphasize the significance of drinking water as a transmission route (33). Such confusion has led to the objective of providing drinking water only, being adopted in sustainable development policy declarations. It probably has its origins in highly publicized waterborne outbreaks in developed countries, which are rare and can be massive. Thus in those settings where hygiene practices are relied upon and have resulted in very low endemic rates of diarrhoeal diseases, the proportion of waterborne transmission of all diarrhoeal disease transmission can be very prominent albeit temporarily. Significantly, this prominence creates the dominant but wrong impression of the absolute importance of drinking water relative to other transmission routes (15).

Clean drinking water alone does not make a difference

Painstaking research has shown that the provision of clean drinking water brings down children’s diarrhoea risk by around 20-25 per cent in a developing country setting (31,32). This is partly because purified water is a harsh environment for those enteric pathogenic microbes that would otherwise enter the system. However more importantly, it is because so many water washable diseases remain transmissible under unhygienic conditions. The very low endemic rates of diarrhoeal diseases in OECD countries resulted from the blocking of all infectious routes by adopting various hygienic practices in different settings. Such hygienic practices include personal hygiene, household hygiene i.e. linen and other laundry, kitchen hygiene (utensils and food), cleanliness of suitable surface materials especially in bathrooms. These require water in substantial quantities for ensuring hygiene by de-contamination and human-waste disposal, in addition to providing solely drinking water. In industrial and public settings (e.g. hospitals) hygienic practices are performed to prevent cross-contamination and to secure cleanliness of surfaces.

Avoidance of heavy fecal soil and ground water contamination - rampant now in the developing world (34) - by sewerage systems, in densely populated developed urban areas, significantly lowered infection pressure during the 20th Century. This contamination is further aggravated by close contact between people and production animals and animal manure in the urban areas of the developing world due to lack of cold chain and advanced food logistics and lack of proper environmental health regulations and enforcement (15). Lack of proper and orderly municipal waste collection adds to already miserable environmental health conditions in poor urban settlements, as un-collected refuse often provides ideal breeding ground to vectors spreading disease (35).  

Today we routinely perform hygienic practices without paying much attention to their significance. In vital settings e.g. in various industries or hospitals, specialists take special care to practice hygiene. These practices are fully institutionalized in OECD countries through multi-sectoral health protection frameworks (3). Hygiene practices are no longer advocated or governed principally by health ministries but rather through compartmentalized mandates from different ministries (3). When an outbreak occurs, it is quickly publicized. Any deficiencies in legislation or inspection or lapses in practice are thoroughly investigated and matters are usually quickly or partly remedied, but the issue is forgotten again.

Hygiene practices have profound effects on disease burdens and help the management of infectious diseases

According to the ‘quick and dirty’ review of a standard handbook (36), the control of approximately 50 per cent of infectious diseases is enhanced by the abovementioned hygiene activities and by other water, sanitation and hygiene (WSH) related measures.

The 50 per cent did not include human immunodeficiency virus (HIV) or AIDS, as AIDS is not directly prevented by adequate access to water. However, the cumulative risk of HIV-transmission to a breast-fed baby can be as high as 10 per cent, if the mother is HIV-positive (37). Obviously, if the mother has no means to clean utensils then she will be unable to safely bottle-feed the baby as an alternative to breast feeding (15).

The global HIV control strategy had relied upon two arms without any reference to special hygiene needs of the HIV infected individuals: 1) the provision of retroviral drugs to those in need and 2) various efforts to block the HIV transmission routes. It took 30 years before the WHO published its first guidelines on how to provide hygienic conditions for HIV-infected people (38).

In the US, special legislation was quietly passed so that AIDS patients can drink tap water without having to fear the often lethal Cryptosporidium infections (39).

Little is known about how Helicobacter pylori is transmitted. However, H. pylori is orally acquired much earlier, under poor hygiene conditions (39). The recent establishment of hygienic conditions in OECD countries has lead to the almost total disappearance of the previously leading lethal malignant tumourgenic proteobacterium (41).

Mills-Reincke phenomenon in the 21st Century

Two sanitation officials: one in Massachussetts State Board (H.F. Mills) and the other in Hamburg (J.J. Reincke) scrutinized death rates in their respective areas at the turn of the last century (42). They both independently discovered that clean water supplies and effective sewerage systems in urban areas brought down child deaths more than expected. For every prevented diarrhoeal death there were two to four additional prevented deaths from inter alia respiratory infections. The Mills-Reincke phenomenon was widely discussed in the 1920’s and 1930’s but was afterwards forgotten.

Our World Bank report (15), gives two non-mutually exclusive explanations of how the phenomenon occurs: 1) Improved hygiene on a mass scale enabled by a sufficient clean water supply and effective sewerage disposal along with improved food security and improved nutrition, lead to significantly lower than expected (≤5) mortality rates and 2) improved hygiene also prevents other diseases than those transmitted by the faecal-oral route, especially those of the lower respiratory tract infections (43,44). Respiratory tract deaths remain the number-one killer of children in developing countries (45). The core control strategy of respiratory tract infections in children in the developing countries today, sadly relies on secondary prevention mediated by the administration of broad-spectrum antibiotics (44). But even here unhygienic conditions hamper administering these pediatric antibiotic regimens.

We have to modify the Mills-Reincke phenomenon in the 21st century with new observations, which found that infection-control also helps prevent many cancers (15,41) and possibly coronary heart disease too (14,15). Coronary heart disease mortality peaked in many industrialized countries in the mid 1970’s and steeply declined since then (46). Those who were born before WWII, and who experienced unhygienic conditions pre- and postnatally, significantly contributed to the high incidences of coronary heart disease in the 1970’s. Those who were born after WWII in much better conditions have significantly lower age-specific morbidity and mortality rates.

The foetal programming or Barker hypothesis (14,47) stresses exactly the same critical age period and the same anatomical parameters as those factors that explain stunting. The hypothesis proposes that adverse effects during the foetal period and early life increase coronary heart disease risk later in life, though it is unclear whether classic risk factors are still more important.

Modern health worries are forcefully discussed in the previously mentioned Environment and Health ministerial process or in the forthcoming (December 2017) third UNEA meeting in Nairobi (22). For example, investigations into the consequences of lead exposure especially in fairly limited impoverished settings in the US, have yielded persuasive literature that points towards the need to prevent cognitive impairment caused by lead exposure (48). This is constantly raised as an example of dangerous chemical exposure. However, compared to the rampant adverse cognitive effects and subsequent economic losses (several GDP percentage points) attributable to undernutrition in the developing countries (15), the concerns about lead contamination are small.

Another claim by the special advocacy groups is that foetal exposure to chemicals in developed countries is a really challenging public health problem. Again the reality is that pre- and perinatal foetal stress due to unhygienic conditions is a far greater threat, as it causes miscarriages, stillbirths and neonatal deaths in horrendous numbers (15). Moreover, a 40 per cent higher congenital malformation prevalence at birth has been observed in poor countries compared to OECD countries (50).  

Nutritionists ‘hijacked’ environmental health agenda

The new Environment and Health processes did not fill the vacuum left behind when WHO’s environmental health arm was downsized about 30 years ago. However, nutritionists made a move and filled the vacuum in the development agenda. There was initially nothing sinister involved but rather a carpe diem type of a situation had emerged whereby researchers jumped onto the bandwagon to secure funding for their research.

A key study (51) that is often referenced in strategic documents (52,53) that promotes nutrition and downplays infection control in the global development agenda, is a small (n=70) observational cohort study on 5-18 month old children in rural Bangladesh. The evidence in that paper, that purports to show the superiority of nutritional interventions over infection control is, weak. The authors concluded, ‘interventions aimed at improving dietary intake may be as important as infection-control programs for improving the growth of children in poor developing nations’ (51). Basing global policy change on a single small study such as this in the face of abundant evidence that supports the value of hygiene is truly remarkable.

Even the most knowledgeable can err as errare humanum est

Yet another vivid example that shows how the important teachings of classic hygiene principles have been ignored in the development agenda and how the agenda was handed over to nutritionists, comes from Björn Lomborg’s 2008 Copenhagen Consensus priority recommendations (54).  A panel of eight distinguished economists (including five Nobel laureates) was asked the following question: ‘What would be the best ways of advancing global welfare, and particularly the welfare of the developing countries, supposing that an additional $75 billion of resources were at your disposal over a four‐year initial period?’

The most favoured interventions these panelists chose were ‘correctly’ targeted to promote nutritional programmes such as micronutrient supplements for children (vitamin A and zinc), micronutrient fortification (iron and salt iodization), Biofortification and Community-based nutrition promotion.

The hygiene needs of the poor were given lower priority, and addressed by secondary prevention relying upon veterinary medicinal products to de-worm poor children with non-sustained efficacy (55).

The ‘WHO Expanded Program for immunization’ aimed at vaccinating poor children in the developing world appeared high (fourth) on the list, but even here the case fatality of measles (and all infectious diseases) has plummeted as basic environmental health conditions and nutritional status have improved in rich countries. Measles has been the single most important disease that affects demographics in human history because of its relatively high case fatality rate under unhygienic conditions and also due to its extreme contagiousness (56,57).

A reliable power grid is needed to secure water supply and to clean indoor and ambient air

Almost all African countries rely on wood to meet basic energy needs. Indeed woodfuel use accounts for 90 to 98 per cent of residential energy consumption in most of sub-Saharan Africa and results in an almost unimaginable exposure particulate matter for mothers and small children, causing a serious public health challenge to both (58) (Table).

The spearhead claim of ‘Our Common Future’ that world energy consumption should be diminished by 50 per cent failed, as it has almost doubled and electricity consumption tripled since then. The OECD and the BRIC (Brazil, India, China) countries account for most of this increase. However, a reliable power grid with a sufficient primary energy supply still remains a dream for billions of people. Without such a grid, it is impossible to provide a safe uninterrupted water supply that meets WHO standards, as electricity is needed to pump clean water in, and waste-water out of households and other settings. Intergovernmental Panel for Climate Change (IPCC) in its Fifth assessment report, in the area of urban development, led by David Satterthwaite already mentioned in the very beginning, now stresses that the key to climate resilience in poor countries is to develop water and sanitation infrastructure (59).

Final conclusions

In a fairly recent game changing article (60) German researchers have shown that ambient air pollution in Asian megacities is attributable to the same source i.e. heating and cooking at homes, which is polluting indoor air there. This means that perhaps up to 80-90 % of the WHO declared 6.5 million air quality victims are attributable to underdevelopment and decentralized heating and cooking with solid biofuels and coal.  Thus, Barack Obama’s advocated decision, which is now - in practice - supported by Director General Dr. Margaret Chan of WHO (61), to decline World Bank investments to coal fired power plants in the developing world, not only prevents improving air quality there especially in urban areas, but prevents the poor of developing much needed water supply systems as well (62). Hence these two major underdevelopment related issues - unhygienic conditions and air pollution - are interrelated as e.g. far fewer indoor air attributable deaths in children < 5 would occur had they not been under nourished.

An often stated argument not to bring Brown Agenda back to the centre of development has been that poor countries cannot afford investments in basic environmental health infrastructure. However, United Kingdom, when she established these revolutionary policies that e.g. effectively abolished cholera pandemics and helped to eradicate under nutrition had a GDP of that of Rwanda today. Urban population will double within a couple of decades. We need a new sanitary revolution.



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