Sanitation, Disease Externalities and Anaemia: Evidence From Nepal

Abstract

Anemia impairs physical and cognitive development in children and reduces human capital accumulation. The prior economics literature has focused on the role of inadequate nutrition in causing anemia. This paper is the first to show that sanitation, a public good, significantly contributes to preventing anemia. We identify effects by exploiting rapid and differential improvement in sanitation across regions of Nepal between 2006 and 2011. Within regions over time, cohorts of children exposed to better community sanitation developed higher hemoglobin levels. Our results highlight a previously undocumented externality of open defecation, which is today practiced by over a billion people worldwide.

Exploring associations between water, sanitation, and anemia through 47 nationally representative demographic and health surveys

“…We hypothesize that the direct effects of poor WASH alone may limit nutrient absorption and contribute to anemia . The influence of improved WASH on anemia reduction could operate through several possible mechanisms: preventing infections, reducing elevated hepcidin levels, and/or reduced enteropathy causing improved intestinal surface area leading to better iron absorption and reduced loss of nutrients through lower diarrhea prevalence .…”

Switching to sanitation: Understanding latrine adoption in a representative panel of rural Indian households

“…Unfortunately, achieving such a large first stage change in latrine adoption has proven difficult in rural India. Arguably, recent intervention studies of the effect of open defecation on health (Clasen et al (2014) is a recent example from rural Orissa; Patil et al (2014) is an example from Madhya Pradesh) may have not detected the effects on health outcomes that are found in population-level studies (Hathi et al, 2017; Coffey et al, forthcoming) because too much open defecation remained in the villages they studied even after latrine promotion interventions.…”

Exposure to open defecation can account for the Indian enigma of child height

“…As columns 1 and 2 document, Indian mothers are substantially more likely to be underweight than mothers in SSA. Much of this difference is due to nutritional consequences of women's social status in India ( Das Gupta, 1995 ; Coffey et al 2017a , b ; 2018 ), but column 2 suggests that some minority fraction of the difference is due to the disease environment, as also pointed to by ( Coffey, 2015 ) observation that even a quarter of working-age adult men are underweight in India. The rightmost column confirms that a similarly-sized coefficient on open defecation persists, even with controls for other well-studied predictors of adult weight in India.…”

“…India's infant mortality rate is about one-third higher than those of Bangladesh and Nepal, although these are poorer countries. Anemia, too, is poorly explained by income ( Alderman and Linnemayr, 2009 ) and is unusually common in India ( Kassebaum et al, 2014 ) despite India lacking a high malaria burden similar to sub-Saharan Africa's ( Coffey et al 2017a , b ; 2018 ). Over 40% of women in India are underweight when they become pregnant ( Coffey, 2015 ), and even a quarter of working age adult men are underweight, a fact suggesting shared environmental causes in addition to the social forces that deprive young women.…”

“… 8 To many general-caste Hindus, emptying their family's latrine pit would be unthinkable; to may low-caste Dalits, increasingly hoping for social equality, the stigma is no longer worth the financial payment offered for doing this degrading work ( Coffey et al., 2017a , Coffey et al., 2017b ; 2018 ). In equilibrium, nobody expects a latrine pit to be able to be emptied, so few households are willing to accumulate feces in them, and the obvious widespread practice of open defecation offers social proof both that open defecation is normal and that emptying latrine pits really must be essentially impossible.…”