Toilets before temples – lack of toilets stunts growth in India

I tend to take anything coming out of the UN with a very healthy dose of salt. As long as it is separated from policy, not all information from the UN is worthless. Such as this report from UNICEF India from November 2013. Lack of sanitation exemplified by the lack of toilets and open defecation is strongly correlated with stunted growth of children. If Narendra Modi can make good his promise of “toilets before temples”, he will have done very well indeed. To get past the innate conservatism of rural India and get toilets to take a higher priority than the mushrooming (pun intended) shrines and temples is easier said than done.

Of the 1.1 billion people globally who defecate in the open, nearly 60 percent live in India, which means they make up more than half of the population of India. Around 55% of all households in India have no access to a toilet or even a latrine. (But 63% of all households have telephones.) Children in India are shorter, on average, than children in Africa who are poorer, on average and this paradox is called “the Asian enigma”.

UNICEF Report: Madhya Pradesh is also home to some of the most undernourished children in India with 58 per cent of under three’s suffering from malnutrition (compared with 45 per cent nationally). 50 per cent of children under-five also suffer from stunting, an indicator of long-term persistent malnutrition, associated with a child’s low height relative to its age. Stunting is also associated with an under-developed brain and low IQ.

The effects of stunting are said to result in a 10 per cent decrease in future income over the lifetime of stunted adults – with tragic implications for child survival, growth and development, seriously impeding India’s development. The implications for stunted mothers giving birth to stunted children are very real. 

Economists have long debated the ‘Asian Enigma’ of why Indians are more stunted – shorter in height – compared to relatively poorer children in Sub Saharan Africa for example. Now, new research has shown a correlation between long-term under-nutrition with its resultant stunted children in India, and the lack of access to toilets and hygiene. Provide children with the right nutrition at the right time, and ensure an environment free of excreta, and there will be no Asian Enigma.

“The height of Indians is not simply about genetics or down to poverty – there is a strong correlation to the poor sanitation environment many live in. India’s lack of sanitation with its high population density, stunts its children through both the loss of food, and the reduced absorption of nutrients,” says Dean Spears, of the Delhi School for Economics.

Dean Spears, How much international variation in child height can sanitation explain ?, World Bank Policy Research working paper ; no. WPS 6351, May 2013.

PDF (55 pages)

Summary: Physical height is an important economic variable reflecting health and human capital. Puzzlingly, however, differences in average height across developing countries are not well explained by differences in wealth. In particular, children in India are shorter, on average, than children in Africa who are poorer, on average, a paradox called “the Asian enigma” which has received much attention from economists. This paper provides the first documentation of a quantitatively important gradient between child height and sanitation that can statistically explain a large fraction of international height differences. This association between sanitation and human capital is robustly stable, even after accounting for other heterogeneity, such as in GDP. The author applies three complementary empirical strategies to identify the association between sanitation and child height: country-level regressions across 140 country-years in 65 developing countries; within-country analysis of differences over time within Indian districts; and econometric decomposition of the India-Africa height differences in child-level data. Open defecation, which is exceptionally widespread in India, can account for much or all of the excess stunting in India.


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