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TROPICAL AND GEOGRAPHICAL MEDICINE. 1990 Jul; 42(3):197-206.An exposition of the ethical arguments for placing sustainability as a priority in implementation of public health programs is made, considering the definition of sustainability, theories of the demographic transition, the ecological transition, the relationship between sustainability of the ecosystem and the human birth rate, types of ethical conflicts over the issue of child survival interventions, a suggested way of resolving the dilemma and a possible paradigm shift constituting a scientific revolution in the field of international health. Sustainability means maintenance of the capacity to support life in quantity and variety. Although most demographers are familiar with Notestein's classic definition of the demographic transition, many are unaware of the likelihood that many countries will become entrapped in stage 2, to the extent that they destroy their ecosystem and thus their population, the "demographic trap." The 3 stages of the ecological transition are 1) expanding human demands with sustainable yield; 2) excess human demands with consumption of biological reserves; 3) ecosystem collapse and death or exit of the human population. An early sign of the 3rd phase is a rise in infant mortality. Sustainability can be increased by adjusting the environment or by lowering human birth rate, with Chinese rigor in need be, or by adding sustainable elements to the system that outweigh de-sustaining ones. Unfortunately there are too many unremovable constraints, and not enough time to wait for socioeconomic gains to lower birth rates. The current attempt by UNICEF to lower the child death rate to effect a demographic transition is attractive but unsound, since it has been proven that numbers of child deaths do not affect family fertility sufficiently. Reducing child deaths will only make population pressure worse. Ethical principles arguing for lowering child deaths have been articulated in Western culture, but now the challenge of sustainability may outweigh them all. It may be possible to apply sustaining measures to countries where possible, but for others, it is argued that child survival measures should not be instituted. These would only make the demographic transition impossible and prolong human misery for larger numbers. For these societies, only the kind of care Mother Teresa gives is appropriate. Finally, residents of developed countries must assume a "deep green" behavior code, a sustainable consumption level. WHO's definition of health should be updated to "Health is a sustainable state of complete...well-being."