Data collected in the late 1980s from eight countries in Sub-Saharan Africa (Burundi, Ghana, Togo, and Uganda), Asia/North Africa (Sri Lanka and Morocco), and the Americas (Bolivia and Guatemala) were combined and analyzed to test whether incremental health effects regarding diarrhea and nutritional status result from incremental improvements in water and sanitation conditions. Rural (n = 11,992) and urban (n = 4,888) samples were analyzed separately. Optimal (i.e., on the premises) and intermediate (improved public water) water supplies were compared with unimproved water conditions. Optimal (flush toilets or water-seal-latrines) and intermediate (latrines) sanitation levels were compared with unimproved sanitation. Nationally representative (random) samples of ever-married women age 15-49 years, with or without children, were interviewed in all countries, and children aged 3-36 months with available weight and height data were included in the analyses. Multiple linear regression controlled for household, maternal, and child-level variables; in addition, dummy variables were included for each country. Improvements in sanitation resulted in less diarrhea and in taller and heavier children with each of the three levels of water supply. Incremental benefits in sanitation were associated with less diarrhea and with additional increases in the weights and heights of children. The effects of improved sanitation were greater among urban dwellers than among rural dwellers. Health benefits from improved water were less pronounced than those for sanitation. Benefits from improved water occurred only when sanitation was improved and only when optimal water was present. These findings suggest that public health intervention should balance epidemiologic data with the cost of services and the demand for water. There should be efforts to develop compatible technologies so that incremental improvements in service can be made.

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ObjectiveTo determine risk factors for anaemia in preschool children.DesignA cross-sectional study.SettingTigray province, northern Ethiopia.Subjects2080 of 2373 children aged 6–60 months provided blood to assess anaemia.ResultsAnaemia was highly prevalent (42%) and constituted an important nutritional problem in the region. In a sub-sample of 230 anaemic children, 56% had a low red blood cell (RBC) count, and 43% had a serum ferritin of less than 12 μg l−1 indicating that the anaemia was largely due to iron deficiency. Unlike other regions in developing countries, hookworm (0.4%) and malaria (0.0%) were rare and contributed little to the anaemia. Even though their diet lacked variety, the amount of iron consumed through cereal-based staple foods was adequate. However, the iron in these foods was not readily available and their diets were probably high in iron absorption inhibitors and low in enhancers. Dietary factors associated with anaemia included frequent consumption of inhibitors, such as fenugreek and coffee, and poor health in the child such as diarrhoea and stunting.ConclusionsUnderlying causes of anaemia were lack of safe water and inadequate human waste management, maternal illiteracy and mother being ill, and having no food reserves. The root cause of these factors was poverty. The optimal control strategy for iron deficiency anaemia should have a holistic approach which includes the alleviation of poverty, the empowerment of women and the provision of a safe environment.