Sanitation, the Disease Environment, and Anemia among Young Children

Diane Coffey, Princeton University

Anemia is a health problem with enormous economic consequences: it impairs cognitive ability, and reduces educational attainment and adult productivity. This paper uses three complementary empirical strategies to provide the first population-based evidence for the hypothesis that lack of sanitation, a public good with important externalities, contributes to a disease environment which causes hemoglobin deficiency. First, it finds a robust cross-country gradient between children's hemoglobin and lack of sanitation. Second, it shows that in India and Nepal, which both have poor sanitation coverage, children exposed to worse community sanitation have lower hemoglobin levels. Third, it shows that improvement in regional sanitation in Nepal between 2006 and 2011 predicts improvement in hemoglobin. Falsification tests and mechanism checks further suggest that the relationship is causal. In places where open defecation is widely practiced, policies to address anemia should put greater emphasis on improving sanitation, a public good with important disease externalities.