The AMERICAN JOURNAL Of TROPICAL MEDICINE AND HYGIENE VOl. 24, No. 4
Copyright (;) 3975 by The American Society of Tropical Medicine and Hygiene Printed in U.S.A.
MALNUTRITION-INFECTION INTERACTIONS IN THE TROPICS*
LEONARDO J. MATA
Institute of Nutrition of Central America and Panama, Guatemala, and
Institute de Investigation en Salud, Universidad de Costa Rica, Costa Rica
Mr. President Dr. Rozeboom, Officers and pox, yellow fever and cholera, and the devasting 
Members of the Society, ladies and gentlemen: effects of malaria, schistosomiasis and dysentery 
I begin with a word of appreciation to Dr. led to an original emphasis on control and preven-
Desowitz and Members of the Charles Franklin tion of infectious disease. In a preceding Craig 
Craig Lectureship Committee for having invited Lecture, Professor Pandit showed the conse-
me to speak on the problem of malnutrition and quences of such emphasis in India, and left open 
infection in the less developed areas of the world. I the question of how successful were public health 
accept this invitation because it gives me an efforts when they accentuated population growth.' 
opportunity to express to this distinguished Similarly, nutrition achieved full recognition in the 
Society some views on the nature and origin of philosophy of public health in the first half of this 
malnutrition and infection interactions in the poor century when nutrient deficiencies were identified. 
nations of the world. This knowledge prompted measures to control and 
countries can be divided into the highly in- prevent scurvy, pellagra and beriberi, thus 
dustrialized and the less developed or contributing its share to demographic growth.
preindustrial. The industrialized societies Clinical description of kwashiorkor by Dr. Cicely 
generally have larger natural resources, better Williams 30 years ago was followed by surveys to 
developed science and technology, efficient food assess its prevalence and health significance in 
production and higher levels of education and selected areas of the world.' These investigations 
health than the less developed nations. There is eventually led to establish that severe protein-
evidence to indicate that the gap is widening. calorie malnutrition (PCM) in the form of 
Biological factors have had more emphasis than marasmus and kwashiorkor represented only a 
socioeconomic factors in attempted derivation of small part of the problem, with moderate and 
causality in health problems in tropics and sub- milder forms of PCM affecting in fact as much as 
tropics. That effort has provided a relatively good a half of all children in less developed nations .° 
understanding of the health status of human The original descriptions of kwashiorkor showed 
populations in less developed regions, primarily that infection was its common precipitating 
the existence of chronic malnutrition and frequent factor, and highly instrumental as a cause of 
infectious disease, of risk of premature death, death.' Nutritionists were reluctant, however, to 
growth retardation and diminished working ca- recognize the role of infection in the causality of 
pacity. Most less developed countries also are PCM.
experiencing an excessive population growth An opposite situation was the neglect of nutri-
which bears strongly on the future of human kind tional factors by investigators primarily concerned 
as discussed by Professor Snyder in a recent Craig with infectious disease. Professor Scrimshaw and 
Lecture.' coworkers are credited with conceptualizing that 
Dramatic epidemics of plague, typhus, small- malnutrition and infection in less developed 
countries are intimately related and commonly 
* Thirty-ninth Annual Charles Franklin Craig associated with each other.° These workers postu-
Lecture, delivered before the American Society of lated a synergism whereby infection contributes to 
Tropical Medicine and Hygiene, Honolulu, Hawaii, deterioration of the nutritional state while 
4 November 1974.
The lecturer's own research was supported in part by malnutrition reduces or suppresses host resistance, 
the USPHS NIH Grant AI-05405 and NICHD worsens the outcome of infection and thus estab-
Contract NO1-DH-2-2737, and by the Pan American lishes a vicious circle of major public health 
Health Organization. relevance.'
Address for reprint requests: Instituto de Investigación To study these interactions, a long-term pro-
en Salud, Universidad de Costa Rita, San Pedro, 
Mentes de Oca, Costa Rica. spective field study has been conducted in a
5 6 4
CRAIG LECTURE 565
TABLE 1 TABLE 2
Distribution of 415 liveborn single-birth infants Incidence of neonates with high concentrations 
by birth weight and gestational age. Santo of immunoglobulin M (IgM), in four 
Maria Cau- que, 1964-1972 Guatemalan ladino villages, 1972-1973
Birth Gestational Number Number
weight, age range, of infants (and percent) Range of
Class grams weeks and (V) Village Number with fel >0.20 elevated
initials of infants mg/ml' values
Pre-term <2,501 31-36 30 (7.2) S.D.O. 48 10 (21) o.22-0.48
Term small-for- S.J.S. 52 4 (8) 020-0.54
gestational age <2,501 37-42 143 (34.4) E.S. 40 6 (15) 0.27-0.74
Term adequate-for- C. 67 11. (16) 0.23-0.55
gestational age >2,500 37-42 242 (58.3) Total 207 31 (15)
• Elevated values in cord serum were confirmed in infant's 
blood from the femoral vein.
typical highland village of Guatemala! Systematic 
observations in this community and in other high-
land and lowland villages of the country suggest that response to antigens available during the course 
the findings may be extended to other rural of maternal infection, or it may represent fetal 
populations in the tropics. The study consisted in antibodies against maternal immunoglobulins 
recruiting virtually all pregnant women and their syn-thetized during pregnancy as a result of 
newborns, and in a prospective observation of infectious processes. Placental abnormalities 
infants and preschool children in the natural observed in malnourished women of the region" 
village setting. Examinations were frequent and hypothetically could favor appearance of IgM in 
comprised anthropometric, clinical, dietary and the unborn child.
microbiological investigations, as well as a study Of all these possibilities, maternal infection likely 
of environmental factors. seems to be the most important factor, Twelve 
Interactions of malnutrition and infection begin in percent of village women tested sero-logically 
utero. Data on practically all consecutive newborn throughout pregnancy for cytomegalo-viruses, 
infants in the village during 8 years of study herpes simplex viruses, rubella, syphilis and 
revealed that 32% were term-small-for-gestational Toxoplasma showed seroconversion during 
age (or infants having experienced intrauterine pregnancy to one of these agents. Had more agents 
malnutrition), and 7% were pre-term (premature) been included in the tests, the rate probably would 
infants who also had low birth weight (<2,501 have been greater.11 Thus, the occurrence of an 
grams) (Table 1). A review of the medical excess frequency of fetal IgM in less developed 
literature shows a widespread occurrence of low societies seems to reflect high attack rates of 
birth weight throughout less developed nations, a infectious disease. Table 3 shows that pregnant 
circumstance not recognized by public health women often had complications of diarrhea and 
officers in its true perspective.8 dysentery, urinary tract infection, and lower 
There is evidence that infection during pregnancy respiratory disease—mainly tracheitis and 
also is very common in less developed countries. tracheobronchitis. Expectedly, newborn infants of 
In a prospective study in four lowland "ladino" ( women of this village show evidence of an excess 
mestizo) Guatemalan villages, infant's venous frequency of congenital infection. Neonates may 
blood was obtained within 3 days of birth for shed enteroviruses in the first days of life, often in 
investigation of immunoglobulins by radial high titers evidencing replication in utero. 
immunodiffusion. Fifteen percent had levels of Furthermore, the incidence of Toxoplasma-IgM in 
IgM in excess of 0.19 mg/mi (Table 2), a finding cord blood is several-fold greater than in industrial 
strengthening previous observations on IgM.fi societies." While malnutrition-infection 
Since IgM normally does not cross the placental interactions deserve more scrutinity, they un-
barrier, the findings are interpreted as indicative doubtedly relate to the high frequency of pre-
of fetal antigenic stimulation. The presence of maturity and fetal growth retardation in the study 
IgM in the fetus or newborn could reflect an village. In the meantime; current knowledge could 
increased incidence of intrauterine infection or a be applied to control and prevention through
566 LEONARDO J. MATA
TABLE 3
Incidence of infectious diseases among 82 women observed prospectively from conception, Santa Maria Cau-que, 
1972-1973
T r i m e s Respiratory infection Diarrhea Urinary tract
t e r  o f and bacterial Other 
pregnancy Upper Lower dysentery infection* i l lnessest
1st 37 (45)t 5 (6) 7 (9) 8 (10) 7 (9)
2nd 26 (32) 6 (7) 9(11) 8(10) 5 (6)
3rd 41 (50) 14 (17) 13 (16) 6 (7) 8 (10)
Incidence per 100 pregnancies 104 (127) 25 (30) 29 (36) 22 (27) 20 (25)
* At least 100,000 colony forming units per ml of urine.
f Conjunctivitis, otitis media, stomatitis, skin infection.
Number of episodes (rounded percent).
improvement of maternal and child health pro- Giardia in the first months of life. Such infants 
grams. also exhibited greater rates of diarrheal disease 
The quality of the fetus is related to survival and and oral candidosis in the first 6 months than did 
growth of the child. Infant size at birth strongly infants born with larger birth weight (un-
correlates with neonatal survival, to a greater published). An abnormal cell-mediated immune 
extent than does the quality of the extrauterine response has been documented among small-for-
environment. Table 4 compares neonatal gestational age infants.13
mortality in the Indian village with that of a With regard to growth, the various categories of 
population on the east coast of the United States, newborns defined by fetal maturity had similar 
bringing •out that although neonatal mortality is growth rate in the first months of life (Fig. 1). 
greater in the village, the difference is minimal However, initial differences persisted because 
once birth weights are taken into account. A infants tended to remain in growth tracks defined 
practical deduction from this observation is that by gestational age, birth weight or the two criteria 
in developing nations neonatal mortality is less combined.3.14
likely to be reduced by medical services than by Breast-feeding is universal in rural Guatemala as 
improved fetal growth. The cost of intensive care in most rural tropical regions; introduction of 
units for the management of small infants supplementary foods of low nutrient value and 
precludes their practical application to decrease hygiene begins around 6 months of age. Weaning 
neonatal mortality. in this culture is a protracted process averaging 24 
Small-for-gestational age village infants exhibited months, and marks the initiation of deterioration 
a greater risk of malnutrition and infection than of the nutritional status, After the period of growth 
did term infants with adequate birth weight for deceleration, at around 6 months and when 
gestational age. Low birth weight infants (mainly weaning begins, the growth curves depart from the 
small-for-dates) showed greater rates of infection standard and the children become stunted quite 
with Shigella, Entamoeba histblytica and independent of their degree of fetal maturity (Fig. 
1). Such findings indicate that negative 
environmental forces—poor diet and frequent in-
TABLE 4 fection—act on all children with similar intensity, 
Infant deaths per 1,000 live births, Santa Maria Cau-
que and the United States, by birth weight* accounting for the maintenance of differences in 
growth observed at birth and in the first months of 
Neonatal Postneonatal life.
Birth 
weight, S.M.C. U.S. Rt S.M.C. U.S. kJ The relation of infection to nutrition and health has 
grams been well documented. There is no question that 
1,501-2,000 273 210 1.3 303 26 11.7
2,001-2,500 34 45 0.8 34 13 2.6 the nutrition of well nourished individuals 
2,501-3,000 10 10 1.0 43 7 6.1 deteriorates after attacks of hepatitis, bacillary 
3,001-3,500 0 5 23 5 4.6 dysentery, tuberculosis, typhoid fever, malaria, 
* Santa Maria Cauque 1964-1972; United States, Chase amebic liver abscess, schistosomiasis, and many 
(1962). Figures rounded to the nearest integer.
t R = ratio S.M.C./U.S. other diseases. The effects of infection are of
AGE, year
Incap 74.761
FIGURE 1. Mean curves for weight of cohorts of children of Santa Maria Cauqué defined by maturity at birth. 
Prospective observation from birth to 6 years of age. Comparison is with the Iowa curves (Jackson and Kelly, 
J. Pediat., 27; 215-229, 1945). Key: high birth weight >3,000 g; moderate birth weight, 2,501 to 3,000 g; 
severe low birth weight, < 2,001 g.
greater consequence to individuals who already its localization and pathogenesis. In many infec-
are malnourished, particularly infants and young tions there is an increased loss of nitrogen, amino-
children. In less developed societies the establish- acids, electrolytes and vitamins. Even suhclinical or 
ment of an infectious process is often followed by silent infections induce stress responses with 
particular familial or societal behavior that increased nitrogen excretion in urine.' 16
influences diet, care, and treatment, accounting for The metabolic alterations associated with in-
customary diminished food intakes and ques- fection have been studied by Dr. Beisel and co-
tionable methods of management. workers and classed as nutrient over-utilization, 
The direct effects of infection on nutritional state nutrient sequestration and nutrient diversion"' In 
have been reviewed by Scrimshaw and coworkers. over-utilization there is increased expenditure of 
' ° Infections commonly are accompanied by energy sources such as glycogen, mobilization of 
anorexia, vomiting, increased peristalsis, and aminoacids for gluconeogenesis and of fat, 
systemic manifestations which often result in increased synthesis of lipids and over-utilization 
marked reduction of food intake, impaired diges- of vitamins. Sequestration of iron in the liver 
tion and malabsorption. Other alterations are loss occurs in the presence of adequate stores of bemo-
of tissue—particularly epithelium, blood, muscle siderin, a phenomenon apparently mediated by a 
and liver—depending on the type of infection, protein factor released by phagocytes. This
568 LEONARDO J. MATA
FIGURE 2. Weight, infectious, and infectious disease in a male child of Santa Maria Cauqué, first 3 years of life. 
Top: solid line is weight of child; bottom line is median of the Iowa standard. Duration of infectious disease is 
indicated by the length of horizontal lines. Each symbol shows a week positive for the particular infectious 
agent. Bottom: observed weight increments (vertical bars) and expected median increments of the standard (
dots).29
mechanism could explain the anemia of children exposed to far greater risks of infection than well 
with recurring infection who live in hookworm- nourished societies. Present knowledge indicates 
free areas where iron intakes are mildly deficient that the immunoglobulin system is not affected in 
or. adequate. Nutrient diversion is characterized persons with mild and moderate forms of 
by an uptake of plasma amino-acids for incorpo- malnutrition. Serological surveys in the general 
ration into "acute phase reactant" proteins, a population and among vaccinated individuals with 
phenomenon not yet clear. Abnormal synthesis of these forms reveal an adequate antibody response 
haptoglobin, tryptophan-oxigenase, tyroxine- and protection. However, antibody synthesis is 
transaminase and other enzymes has been docu- impaired in children with severe forms of PCM.2'-
mented. Also, the body diverts its biosynthetic 23 Vaccination of untreated kwashiorkor patients 
pathways to produce foreign protein, lipids and with bacterial and viral antigens failed to elicit a 
carbohydrates, as with viral replication. B-cell response.
On the other hand, malnutrition affects the host Alterations in T-cell immunocyte function and in 
capacity to respond to infection, an important the amplification of the immune response 
issue when one considers that more than a half apparently occur more readily among malnour-
of the world's population suffers from mal- ished persons. In moderate and severe forms of 
nutrition is varying degree, while concomitantly PCM there is a decrease in the number of immune
CRAIG LECTURE 569
TABLE 5
Mean daily nutrient intake of 2- and 3-year-old children, Santa Marfa Cauqué, 1964-1969
INCAS' recommendations
14 children 31 children
2 years old 3 years old 2 years old 3 years old
Calories 619 (176)* 992 (272) 1,350 1,550
Total protein, g 17.4 (4.9) 26.9 (6.6) 28 30
Animal protein, g 3.1 (2.5) 9.7 (7.3)
Iron, mg 5.9 (1.8) 9.6 (3.6) 10 • 10
Vitamin A, 'g of retinol 90 (95) 111 (77) 250 250
Thiamin, mg 0.37 (0.17) 0.55 (0.13) 0.5 0.6
Riboflavin, mg 0.29 (0.14) 0.36(0.15) 0.7 0.9
Niacin, mg 3.42 (1.06) 5.81(1.49) 8.9 10.2
Ascorbic acid, mg 16.2 (8.3) 24.3 (10.2) 13.8 15.8
4 Mean (S.D.).
cells in liver, bone marrow, spleen, Peyer's patches food supplements and other means of transmis-
and lymph nodes. The diminished replication of sion. Weight began to deteriorate with the onset of 
immune cells could explain the failure of mal- weaning, and for as long as a full year this 
nourished children to mount a leukocyte response particular child did not gain weight. By 18 months 
to bacterial infection. Alterations in phagocytic he had become accustomed to the solid diet of the 
•cells result in a diminished capacity to ingest and adult villager, and had developed an immunity 
kill bacteria," which appears related more to iron against a variety of infectious agents. The child 
than to protein depletion.' It has already been began to grow but marked stunting was already 
mentioned that iron sequestration occurs during evident. Furthermore, additional infectious 
infection. episodes occurred at the end of the 3rd year, 
Furthermore, malnourished individuals have an followed by weight losses.
altered delayed hypersensitivity." Other mani- Diets of weaned village children are deficient in 
festations of altered cell-mediated immunity in calories, animal protein, vitamin A, riboflavin, 
malnutrition are a depressed capacity of the niacin and iron (Table 5), but not to the extent 
lymphocyte to transform after challenge with once considered. The dNPCal% generally is good; 
mytogens, a diminished rosette formation and the basic staple food (maize) is complemented 
alteration in factors important for the amplifica- with beans, small amounts of animal protein and a 
tion of the immune response. These alterations are variety of wild plants and vegetables.
evident not only in acute PCM, but also in Clinical and epidemiological observations re-
underweight children who had experienced fetal veal, on the other hand, that infection is an 
growth retardation or early nutritional depriva- important cause of weight loss, physical growth 
tion.27 29 retardation and death, sometimes independent of 
The interrelation between malnutrition and the basal nutritional state, or again often related 
infection in the village ecosystem is made evident to the initial malnutrition.8.12 An idea of the 
by prospective observation of individual children. magnitude of infectious disease in the study 
Figure 2 presents the history of a typical child of a village can be obtained by computing rates per 
cohort studied from birth to 3 years of age.' 100 person-months by age (Fig. 3). Rates were 
Despite low birth weight a good nutrition derived high as early as the first 6 months of life but 
from breast-feeding, passive immunity and resis- increased considerably in the second half of the 
tance factors in breast milk permitted adequate first year. Diarrhea and lower respiratory illness 
growth during the first 6 months. Supplementary were more frequent during the weaning period, 
feeding began with broths, gruels and eventually from 12 to 29 months of age. Morbidity for these 
small amounts of solid foods, tortilla (maize), two categories decreased thereafter.
bread and beans. The low level of environmental Summarizing, fetal growth retardation, inade-
sanitation and personal hygiene in the village quate weaning practices and recurring infections 
entails a continuous risk of enteric infection by leave a mark in the child's growth as early as the
570 LEONARDO J. MATA
likely have an impaired immune response which 
appears to be maintained or accentuated during 
infancy and early childhood. Term infants with 
adequate birth weight showed the lowest mor-
tality of all groups but deaths still were rather 
high: malnutrition and infection do not spare 
infants born with adequate birth weight and 
gestational age.
Prospective observations of children into ado-
lescence indicate that stunting is maintained. The 
small size of women of reproductive age (average 
4' 8"; 116 lbs.) attests to this observation. Com-
parison of growth of different ethnic groups but of 
comparable socioeconomic status shows that the 
growth potential of man in different geographic 
localities is similar and independent of race or 
ethnic origin.30 Consequently, the short stature of 
village women is best interpreted as the result of a 
cumulative effect of malnutrition and infection, 
present from birth (or even before) through 
childhood and adolescence, and through 
generations.
What can be done about the health problem just 
described? Any attempt to improve health in this 
kind of society must begin with the mother, to 
influence child care, nutrition and hygiene. 
Improved health and growth of children leads to 
better-nourished adult women more able to sustain 
fetal growth, as seems to have occurred in Japan 
31 With continued action a cumulative effect may 
be expected in following generations. It is also 
known that breast-fed children require adequate 
AGE IN MONTHS
Incap 7a1132 food supplements under hygienic conditions at 
3. Morbidity rates of main groups of in- about 6 months. Water available inside the home FIGURE 
fectious disease. Rates per 100 person-months, by drastically reduces transmission of enteric agents, 
age, for 45 cohort children observed from birth to while better housing and more beds will reduce 
age 3 years, Santa Maria Cauqué, 1964 to 1969. transmission of respiratory and enteric 
infections. Safe and inexpensive vaccines are 
first year of life: there is a diminished immune available for prevention of tetanus, whooping 
response, a high incidence of disease and marked cough, measles and tuberculosis. Appropriate 
growth retardation. drugs and adequate hydration techniques save 
Mortality is a good index of the magnitude of many children with pneumonia and diarrheal 
malnutrition-infection interactions. Neonatal disease. If these measures are put into effect, 
mortality was discussed before. Pre-term infants morbidity and childhood deaths will inevitably 
exhibited greater postneonatal infant mortality than fall; by itself this change eventually will bring a 
other groups (Table 4), but infants who survived response in population control.
the first year, however, fared well there-after. The last paragraphs are easy to put on paper but 
Term-small-for-gestational age infants had higher application of those solutions is utopic under 
postneonatal mortality than term-adequate for present conditions in most less developed nations. 
gestational age infants; their high rates extended To qualify this statement I shall describe now some 
into the 4th year (Table 6). These infants features more directly relevant to the exis-
CRAIG LECTURE 571
TABLE 6
Postneonatal childhood mortality, by fetal maturity, Santa Maria Cauqué, 1964-1972
Postneonatal
Class (29d-11 mo) Second year Third year Fourth year
Pre-term 6 (286),* N = 21 0 N =1St 0 N = 13 0 N = 8
Term, small-for-
gestational age 8 (58), N = 139 8 (76),N=105 3 (39),N= 78 3 (50),N = 60
Term 10 (42), N = 240 9(44),N=204 5 (33),N= 153 1 (8),N=122
Total 24 (60), N=400 17 (52),N=324 8(33),N=244 4(21),N=190
• Number of deaths (deaths per 1,000 infants alive as the period started). N initial population. t 
Attrition in numbers is explained because cohorts have different ages.
tense and action of malnutrition and infection in less constant for decades, is becoming accentuated 
the Guatemalan village. To this effect, the same as judged by a decrease in mean gross domestic 
situation applies to many tropical regions, for product (MGDP)" in all but three of the 20 
instance in the lowlands of Costa Rica, Panama, Departments of Guatemala (Table 7). In the 
Peru, Bolivia and Brazil and in vast areas of Asia Department of Sacatepéquez, where the study 
and Africa. For many years populations in trop- village is located, the MGDP has decreased by 38% 
ical environments have subsisted by planting in 15 years. The lack of social and economic 
small plots of land ("minifundios") or by working development expectedly explains the phenomenon. 
as peasants in large land holdings (fincas or "lati- Recent world inflationary tendencies, coupled with 
fundios"). In rural Guatemala the total land low international prices for products of less 
available for cultivation remains rather fixed, but developed nations, is hitting the villages hard, with 
the area per family obviously has decreased." more infection and malnutrition to be anticipated 
Furthermore, within the prevailing poverty of the in the years ahead. Table 8 illustrates wages and 
village, a few better-off families are acquiring prices of land and food during the last 1.0 years; 
land from others, thus establishing a class dif- wages have remained essentially stable but the 
ferentiation that did not exist in the past. There price of land has risen notably; some land is being 
has been a decrease in independent farmers, and sold to outsiders because the price cannot be met 
an increase in the number of part-time laborers on by most local villagers; food production per capita 
"minifundios" of independent farmers of the has dropped. The cost of
locality." The land saturation is forcing men and 
whole families to move out of the village to the 
cities, enlarging the peripheral slums and shanty TABLE 8
towns, so typical of less developed countries. Wages and value of land and food, quetzals,* Santa 
The poverty of the rural population, more or Maria Cauque, 1963-1974
% increase
in
1963 1971 1974 10 years
TABLE 7
Mean gross domestic product, U. S. dollar P/C, se- Farm labor, 8-10 hrt 0.50 0.50 0.80 60
lected regions of Guatemala* Mason, 8-10 hr 1.50 1.50 2.00 33
Salaried farmer, monthly 20.00 20.00 30.00 50
% change
in Land, cuerda (= 0.3 acres)1951- 1965-
Region 1952 1966 15 years In town 150.00 250.00 300.00 100
Outside town 60.00 80.00 100.00 67
Dept. Guatemala 847 1,071 +26 Maize, 100 lbs
Dept. Sacatepequez 197 123 -38 Harvest time 2.50 3.00 5.00 100
All Guatemala, Off-season 4.00 4.50 8.00 100
excepting 3 Depts. 144 104 -28 Black beans, lb 0.08 0.12 0.20 150
Rural Guatemala 142 105 -26 Stewing beef with
bone, lb 0.20 0.35 0.45 125
Total 265 329 +24
One quetzal = 1 U. S. dollar.
• After Smith (1973).3" t Includes noon meal.
FIGURE 4. Birth and death rates per 1,000 population; population estimates and major epidemics; Santa 
Maria Cauqué, 1936 to 1972. Key: D, diarrheal disease; M, measles; RD, respiratory disease; WC, whoop-
ing cough s2 Key words at the top of epidemic peaks indicate that the base and peak of the epidemic was 
formed mainly by those diseases.
essential items has risen dramatically, reducing to a survival of mankind, cannot be brought under 
half or more the, villagers' purchasing power. control until childhood deaths are reduced. Twenty 
Collaterally, community development proceeds years ago Professor John Gordon already was 
slowly: there are no outstanding programs of talking of the need to improve the quality of 
environmental sanitation, of water supplies, hous- human life to accomplish such reduction." Epi-
ing or education. Agrarian reform is decidedly modest demiologically, improved survival has been fol-
and governmental efforts in improving production lowed by marked reduction in numbers of births, 
of food crops, methods of grain storage, and the two events following each other within inter-
marketing and price control are small in most vals of one or more generations. The nations 
countries of the world. achieving those changes did so at the cost of 
High birth and death rates led to population sacrifices incident to industrialization, through 
stability until World War II. Thereafter a material improvement in the quality of biological and 
reduction in deaths with a rather minimal change social life. Other events played a role in the 
in birth rates resulted in a steady growth of 3% per process. There was opportunity for massive 
year (Fig. 4), similar to the growth rate of migration to the Americas, Asia and Africa and 
Guatemala as a whole.as colonization and neocolonialism permitted gains 
A common thesis of our times is that population in resources and in labor force. Concomitantly, 
explosion, the most serious threat to health and infection remained rampant among the industrial-
CRAIG LECTURE 573
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