Dean Spears

Open Defecation and Childhood Stunting in India: An Ecological Analysis of New Data from 112 Districts

Poor sanitation remains a major public health concern linked to several important health outcomes; emerging evidence indicates a link to childhood stunting. In India over half of the population defecates in the open; the prevalence of stunting remains very high. Recently published data on levels of stunting in 112 districts of India provide an opportunity to explore the relationship between levels of open defecation and stunting within this population. We conducted an ecological regression analysis to assess the association between the prevalence of open defecation and stunting after adjustment for potential confounding factors. Data from the 2011 HUNGaMA survey was used for the outcome of interest, stunting; data from the 2011 Indian Census for the same districts was used for the exposure of interest, open defecation. After adjustment for various potential confounding factors – including socio-economic status, maternal education and calorie availability – a 10 percent increase in open defecation was associated with a 0.7 percentage point increase in both stunting and severe stunting. Differences in open defecation can statistically account for 35 to 55 percent of the average difference in stunting between districts identified as low-performing and high-performing in the HUNGaMA data. In addition, using a Monte Carlo simulation, we explored the effect on statistical power of the common practice of dichotomizing continuous height data into binary stunting indicators. Our simulation showed that dichotomization of height sacrifices statistical power, suggesting that our estimate of the association between open defecation and stunting may be a lower bound. Whilst our analysis is ecological and therefore vulnerable to residual confounding, these findings use the most recently collected large-scale data from India to add to a growing body of suggestive evidence for an effect of poor sanitation on human growth. New intervention studies, currently underway, may shed more light on this important issue.

Economic Decision-making in Poverty Depletes Behavioral Control

Abstract Economic theory and conventional wisdom suggest that time preference can cause or perpetuate poverty. Might poverty also or instead cause impatient or impulsive behavior? This paper reports a randomized lab experiment and a partially randomized field experiment, both in India, and analysis of the American Time Use Survey. In all three studies, poverty is associated with diminished behavioral control. The primary contribution of this empirical paper is to isolate the direction of causality from poverty to behavior. Three similar possible theoretical mechanisms, found in the psychology and behavioral economics literatures, cannot be definitively separated. One supported theoretical explanation is that poverty, by making economic decision-making more difficult, depletes cognitive control.

Height and cognitive achievement among Indian children

Taller children perform better on average on tests of cognitive achievement, in part because of differences in early-life health and net nutrition. Recent research documenting this height-achievement slope has primarily focused on rich countries. Using the India Human Development Survey, a representative sample of 40,000 households which matches anthropometric data to learning tests, this paper documents a height-achievement slope among Indian children. The height-achievement slope in India is more than twice as steep as in the U.S. An earlier survey interviewed some IHDS childrens households eleven years before. Including matched early-life control variables reduces the apparent effect of height, but does not eliminate it; water, sanitation, and hygiene may be particularly important for childrens outcomes. Being one standard deviation taller is associated with being 5 percentage points more likely to be able to write, a slope that falls only to 3.4 percentage points controlling for a long list of contemporary and early-life conditions.

Effects of Early-Life Exposure to Sanitation on Childhood Cognitive Skills: Evidence from India's Total Sanitation Campaign

Early-life health shapes cognitive skills and human capital. In India, widespread open defecation without using a toilet is an important source of childhood disease. We study the effects on childhood cognitive achievement of early-life exposure to India’s Total Sanitation Campaign (TSC), a large government program that encouraged local governments to build latrines and promote their use. We find that the TSC caused six-year-olds exposed to it in their first year of life to be more likely to recognize letters and simple numbers. Our results suggest that open defecation is an important threat to human capital in India.

Village sanitation and children's human capital: evidence from a randomized experiment by the Maharashtra government

Open defecation is exceptionally widespread in India, a county with puzzlingly high rates of child stunting. This paper reports a randomized controlled trial of a village-level sanitation program, implemented in one district by the government of Maharashtra. The program caused a large but plausible average increase in child height (95 percent confidence interval [0.04 to 0.61] standard deviations), which is an important marker of human capital. The results demonstrate sanitation externalities: an effect even on children in households that did not adopt latrines. Unusually, surveyors also collected data in districts where the government planned but ultimately did not conduct an experiment, permitting analysis of the importance of the set eligible for randomization.

Village sanitation and child health: Effects and external validity in a randomized field experiment in rural India.

Highlights • Many people in developing countries defecate in the open without using a toilet.• We study a field experiment of the effects of sanitation on child height in India.• We find that the program caused children to grow taller, on average.

Neighborhood Sanitation and Infant Mortality

In this paper, we shed new light on a long-standing puzzle: In India, Muslim children are substantially more likely than Hindu children to survive to their first birthday, even though Indian Muslims have lower wealth, consumption, educational attainment, and access to state services. Contrary to the prior literature, we show that the observed mortality advantage accrues not to Muslim households themselves but rather to their neighbors, who are also likely to be Muslim. Investigating mechanisms, we provide a collage of evidence suggesting externalities due to poor sanitation are a channel linking the religious composition of neighborhoods to infant mortality.

Place and child health : the interaction of population density and sanitation in developing countries

A long literature in demography has debated the importance of place for health, especially children’s health. In this study, we assess whether the importance of dense settlement for infant mortality and child height is moderated by exposure to local sanitation behavior. Is open defecation (i.e., without a toilet or latrine) worse for infant mortality and child height where population density is greater? Is poor sanitation is an important mechanism by which population density influences child health outcomes? We present two complementary analyses using newly assembled data sets, which represent two points in a trade-off between external and internal validity. First, we concentrate on external validity by studying infant mortality and child height in a large, international child-level data set of 172 Demographic and Health Surveys, matched to census population density data for 1,800 subnational regions. Second, we concentrate on internal validity by studying child height in Bangladeshi districts, using a new data set constructed with GIS techniques that allows us to control for fixed effects at a high level of geographic resolution. We find a statistically robust and quantitatively comparable interaction between sanitation and population density with both approaches: open defecation externalities are more important for child health outcomes where people live more closely together.

Caste, ‘Cleanliness’ and Cash: Effects of Caste-Based Political Reservations in Rajasthan on a Sanitation Prize

Abstract Even compared with neighbouring countries, latrine use is especially uncommon in India. How might caste – historically associated with sanitation inequality – interact with government sanitation policy? Using data from Rajasthan state, we investigate the effect of caste-based reservations for village chairmen elected in 2005 on the likelihood of winning the government’s Clean Village Prize by mid 2012. This prize is a large cash award for villages in which open defecation has been eliminated; thus it is intended to be a prize for both latrine construction and use. Villages randomly assigned to a Scheduled (low-ranking) Caste chairman are less likely to win the prize.

What doesn't kill you makes you poorer: Adult wages and early-life mortality in India

Highlights • Studies early-life disease environment and adult wages for men in India.• Robust negative gradient between infant mortality and wages decades later.• 10 point IMR reduction associated with approximately 2 percent wage increase.• Not mediated by level of schooling received.• Due to fiscal externality, public health investments could have low net present cost.