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The sanitation environment in urban slums: implications for child health

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I examine the effect of improved sanitation on child health in urban Bangladesh to assess the relative importance of household versus neighborhood characteristics and of adult latrine usage versus safe disposal of children’s feces. Using fixed-effects regression, I calculate the change in weight-for-height in 153 children as a function of changes in latrine usage in the surrounding community. The use of longitudinal data allows children to act as their own controls, a stumbling point of many other sanitation evaluation studies using cross-sectional or case–control methods. Results provide strong evidence that children’s toileting matters more than adult toileting behavior in creating a safe, hygienic environment and reducing diarrheal disease. I conclude that investments in sanitation improvements offer important externalities, and that sanitation programs must encourage the safe disposal of children’s feces in order to produce maximum health gains.

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  1. An interesting exception to this is Bennett’s (2007) study of the negative effects of water supply improvements on sanitation and hygiene behaviors in Metro Cebu, the Philippines. Bennett argues that water supply improvements reduce the incentives for households and communities to maintain adequate sanitation infrastructure, leading to worsening of hygiene behaviors that have negative health externalities.

  2. The latrine types discussed in the study are (1) a hanging or katcha latrine which is usually two boards placed over a sewer, a drainage ditch, or open water. Privacy is provided by flimsy bamboo screens; (2) an unsealed pit latrine that consists of a slab placed over a pit; (3) water-sealed latrines, also called “pour-flush” that are flushed with a bucket of water after each use, and have a u-shaped drain pipe that creates a water seal to prevent odors and flies from coming up from the pit; (4) community toilets that consist of several water-sealed latrines built in “blocks,” often with separate facilities for men and women.

  3. SHAHAR is an acronym for Supporting Households Activities for Hygiene, Assets and Revenue.

  4. Alternative categorization schemes for latrines are discussed below.

  5. Water drawn from tubewells in Bangladesh commonly contains toxic levels of arsenic. The SHAHAR project identified and marked standpipes with unsafe levels of arsenic to discourage use.

  6. The individual fixed-effects specification does not correct for clustering at the community level. While this could ordinarily be addressed through a standard Huber-White correction, this is not an accurate correction when the number of clusters is small, as it is here with only 14 bastis. Following Cameron et al. (2007), I re-estimate all the models presented here with bootstrapped standard errors using 500 replications. Bootstrapped standard errors (not shown) are very close to the standard errors presented in Tables 2, 3, 4.


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This research was supported by a training grant from the National Institute for Child Health and Human Development through the California Center for Population Research at UCLA. The author thanks James Garrett and Wahid Qabili at the International Food Policy Research Institute for access to the dataset, and Anne Pebley, Linda Adair, Elizabeth Frankenberg, Adrienne Lucas, John Strauss, and an anonymous reviewer for very helpful comments.

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Correspondence to Alison M. Buttenheim.

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Buttenheim, A.M. The sanitation environment in urban slums: implications for child health. Popul Environ 30, 26–47 (2008).

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