For taller, smarter kids get toilets & sanitation

For taller, smarter kids get toilets & sanitation

Adding to the debate over celebrity economists blaming India’s malnutrition and stunting vis-à-vis Sub Saharan Africa on genetic differences, Dean Spears, a public health expert and a visiting fellow at Delhi School of Economics, offers evidence connecting our poor sanitation and open defecation with high morbidity and malnutrition. (see both links below).

In an evidence-based paper titled Policy Lessons from Implementing India’s Total Sanitation Campaign (2012), based on the review of literature and data analysis Spears establishes the negative relationship between open defecation and stunting. On an average, children whose households do not defecate in the open are taller than those whose households do. (Link enclosed below). The study has been supported by the NCAER and the Brookings Institute.

Spears finds a positive association between height and cognitive achievement among Indian children. Taller children score higher on learning tests in India with a much steeper association than in the US, thus, establishing that early life sanitation and hygiene matters.

Spears says that differences among developing countries in the prevalence of open defecation explains more than half of the international variation in child height. Indian children are exposed to poor sanitation due to which they suffer from chronic intestinal diseases that makes it difficult for making good use of nutrients in food and cause lasting stunting. Open defecation is a dangerous phenomenon in rural India where population density is quite high. Height deficit among Indian children can be explained partly by poor nutritional status of women. Average height among Indian women is growing slower than average height among men. Indian children suffer from poor early life health and net nutrition and, therefore, they do not grow to their genetic potential.

Spears’ work unwinds the problem of “Asian enigma”. In our popular imagination, the prevalence of malnutrition is considered to be more severe in Sub Saharan Africa (due to high poverty levels) as compared to India. However, the latest UNICEF report shows that by 2011, the number of stunted children in India was 6.17 crore and its share in the world total of stunted children was 37.9 percent. India is home to most number of undernourished children despite experiencing high growth.

Spears uses data and evidence to show that the Total Sanitation Campaign (TSC) of the Government of India made Indian children healthier, taller, and better able to reach their cognitive potential. The TSC, after 10 years of its operation, caused a large but plausible decline in infant mortality of about 4 infant deaths per 1,000 live births. Based on DLHS-3 data, it is found that the more the TSC latrines had been built in a child’s district by its first year of life, the more likely it is to survive to its first birthday.

The TSC reduced infant mortality by improving the disease environment in children’s early lives. Indian children born in districts and years in which more TSC latrines had been built grow taller, on average, than children born in other years in the same district, or other districts in the same year. Children exposed to better sanitation coverage in their first year of life showed greater cognitive ability at age six. Children exposed to more TSC latrines in early life recognized more letters and numbers at age six.

The dirty picture of shining India

Some of the most shocking figures on India's sanitation situation have been provided by WHO/UNICEF joint monitoring report 2012: Progress on Drinking Water and Sanitation. The report states that in India 626 million people practice open defecation. The country accounts for 90 percent of the 692 million people in South Asia who practice open defecation. (See link below)

Based on the results from the Government of India 2008-09 National Sample Survey Office (NSSO) survey, the Water Aid report entitled Off-track, off-target-Why Investment in Water highlights that the poorest section of the population in rural areas is four times less likely to have access to improved sanitation than the richest section, which has just under 60 percent access.

During the recent launch of Lancet series on Maternal and Child Malnutrition, Rural Development Minister Jairam Ramesh emphasized the deeper connection between sanitation and malnutrition. On a previous occasion last year, Jairam Ramesh expressed his shock in the public domain when he found that 53.2 percent Indian households enjoyed mobile phones while 53.1 percent of the households did not have latrines within the premises (Census, 2011).


Policy Lessons from Implementing India’s Total Sanitation Campaign (2012)-Dean Spears, India Policy Forum 2012, NCAER-The Brookings Institution,

Maternal and child nutrition: building momentum for impact (Comment), 6 June, 2013,

Coming up short in India -Dean Spears, Live Mint, 4 July, 2013,

2013 UNICEF report: Improving Child Nutrition: The achievable imperative for global progress,
The Myth of Child Malnutrition in India-Arvind Panagariya, Columbia University, September 2012 Conference, Paper 8,

Commentary: The Asian enigma by Vulimiri Ramalingaswami, Urban Jonsson and Jon Rohde, UNICEF,
WHO/UNICEF joint monitoring report 2012: Progress on drinking water and sanitation,

Off-track, off-target-Why investment in water, sanitation and hygiene is not reaching those who need it most (2011), Water Aid,

Final Figures of Houselisting & Housing Census, 2011 Released, 13 March, 2012,

Houselisting and Housing Census Data Highlights-2011

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