1. What doesnt kill you makes you shorter Evidence from 15 years of improving sanitation in Bangladesh Payal Hathi August 2013

2. Height, mortality, and early life disease Height as a measure of population wellbeing, determined by genetics and early-life environment Infant mortality may be a measure of the disease environment faced early in life 3. Sanitation and Height Long lasting effects of deficits in height Fecal germs near a child, more likely with poor sanitation and open defecation, can have detrimental effects on child height 4. Stunting in Bangladesh The prevalence of stunting continues to be unusually high in South Asia Within Bangladesh alone, 41% of children under the age of 5 suffer from moderate or severe stunting 5. Sanitation in Bangladesh Bangladesh is often cited as a major success story: national efforts reduced open defecation from 30% in 1994 to just 6.8% by 2009 Still much work to be done: only 56% of the overall population has access to improved sanitation facilities as of 2010 One of the most highly populated countries in the world 6. Adult Height and Mortality (Bozzoli, et al) 7. Main Questions What impact did improving sanitation in Bangladesh have on child height and infant mortality? Does the association between infant mortality rates and child height indeed reflect the disease environment? 8. Data Sources and Key Variables 5 DHS rounds: 1996, 1999, 2004, 2007, 2011 Dependent variable: Height-for-age z-score Independent variables: Local area open defecation Local mortality rates: Infant mortality rate (IMR) Post-neonatal mortality rate (PNM) Neonatal mortality rate (NNM) 9. Identification Strategy Fixed Effects: heightipt = local open defecationipt + Xipt + Aipt + p + t + ipt heightipt = 1 local mortality rateipt + 2 local open defecationipt + Xipt + Aipt + p + t + ipt X = Control variables (demographic, household asset, mothers health) A = Age x Sex dummy variables = Division x Urban/Rural fixed effects = Survey round (year) 10. Increasing Height 1996-2011 -2.2 -2 -1.8 -1.6 -1.4 -1.2 -1 1996 1999 2004 2007 2011 Height-for-ageZ-score Year Height-for-age Z-score 11. Decreasing Open Defecation 1996-2011 0 5 10 15 20 25 30 1996 1999 2004 2007 2011 %ofHHswithnotoilet Year 12. Decreasing Infant Mortality Rate 1996-2011 40 50 60 70 80 90 100 1996 1999 2004 2007 2011 Infantmortalityrate (deathsunder1,per1000births) Year 13. Open Defecation and Child Height -2.4-2.2 -2 -1.8-1.6 0 .2 .4 .6 .8 1 local area open defecation 1996 1999 2004 2007 2011 year averages 14. Open Defecation and Height Over Time 15. Effect of Open Defecation on Height (1) (2) (3) (4) (5) (6) (7) (8) Full Full Full Full Full Full Urban Rural Open Defecation (Local Area) -0.743*** -0.596*** -0.597*** -0.386*** -0.280*** -0.193** -0.483 -0.231** (0.0606) (0.0613) (0.0649) (0.0616) (0.0697) (0.0654) (0.274) (0.0703) Open Defecation (Household) -0.147*** -0.0584 -0.285*** -0.0926** (0.0326) (0.0311) (0.0803) (0.0339) Mother's BMI 0.0518*** (0.00336) Mother's Height 0.0573*** (0.00171) Age x Sex Controls x x x x x x x x Year Fixed Effects x x x x x x x Year & Place Fixed Effects x x x x x x Demographic Controls x x x x x Household Asset Controls x x x x n (children under 5) 29420 29420 29420 29420 29380 29153 8050 21330 16. Open Defecation and Local IMR 406080 100 infantmortalityrate 0 .2 .4 .6 .8 local area open defecation 1996 1999 2004 2007 2011 year averages 17. Effect of IMR on Height (1) (2) (3) (4) (5) (6) hfa hfa hfa hfa hfa hfa Panel A: Infant mortality IMR Probability -1.933*** -0.926*** -0.717*** -0.683*** -0.542*** -0.517** (0.201) (0.186) (0.176) (0.177) (0.164) (0.164) Open Defecation (Local Area) -0.267*** -0.209** (0.0700) (0.0660) Open Defecation (Household) -0.214*** -0.147*** -0.138*** -0.0857** (0.0290) (0.0326) (0.0273) (0.0313) Mother's BMI 0.0591*** 0.0585*** (0.00337) (0.00334) Mother's Height 0.0593*** 0.0593*** (0.00171) (0.00172) Age x Sex Controls x x x x x x Year & Place Fixed Effects x x x x x Demographic Controls x x x x Household Asset Controls x x x x n (children under 5) 29420 29420 29380 29380 29153 29153 18. Mediation Analysis Does mortality mediate the effect of OD on height? Aggregate level correlation, not causal 19. Mediation effects of IMR and PNM Open defecation (OD) OD Height OD Height PNM Postneonatal Mortality Rate (PNM): 49% Mediation Effect Height IMR Infant Mortality Rate (IMR): 71% Mediation Effect -.9037** -.2614 -.4629+ P-values: + p