A recent paper by researchers in India shows that average Bangladeshi children are taller than their counterparts from West Bengal, when wealth is controlled for. These two regions have similar ethno-linguistic and cultural backgrounds, and the authors argue that the difference in height can be attributed to open defecation combined with differences in women status, as measured by female literacy, and maternal nutrition.
Our blog on World Toilet Day discussed how sanitation prevents stunted growth and makes everyone taller by ensuring safe disposal of feces. This new paper adds to the growing body of literature that examines the relationship between sanitation and proxies for nutrition and growth such as height-for-age and weight.
Of course, height and malnutrition is not only explained by open defecation, maternal nutrition, and female literacy. Several other factors including the use of health-care services such as immunization and oral rehydration therapy needs to be taken into account.
Several years ago, I conducted similar research with colleagues at Harvard comparing health indicators across West Bengal and Bangladesh. Our research demonstrated that, despite having a lower GDP per capita, Bangladesh performs better in the provision of immunization and oral rehydration therapy. Here’s the abstract of the paper:
The historical separation and divergence of political institutions across the two Bengals over six decades enables us to explore the determinants of maternal and child health of this ‘natural experiment’. West Bengal and Bangladesh have both made impressive strides in improving health outcomes over the past few decades. An examination of data on maternal and child health shows that, despite having a lower GDP per capita and lower levels of female literacy, Bangladesh performs better than West Bengal in the provision of immunization and oral rehydration therapy. West Bengal, on the other hand, does better in indicators related to antenatal care and institutional delivery. This essay explores the potential impact of the structure and organization of the health delivery system health systems among various factors including economic development and female empowerment in explaining these differences in health indicators. Further research is needed to establish definitively the roles of each of these determinants in explaining the observed outcomes.
Reflecting at this body of research now, I can’t help but observe how interrelated these measures likely are – how nutritional status affects response to diarrhea and oral rehydration therapy and even immunization. And yet both our study and this newer study seem to be deficient and complement each other. Our study did not account for the nutritional status of women or the problem of open defecation in trying to understand differences in health indicators across West Bengal and Bangladesh. Meanwhile, the recent study stopped short of disentangling oral rehydration therapy and immunization.
More research that increases the scope of these two studies and examines the combination of the factors explored in two works discussed needs to be undertaken. Drawing on these natural experiments is also a fruitful area for research – the Two Bengals, Two Punjabs, two Germanys, two Koreas, two Chinas, etc. Any takers, public health students?
Victoria Fan is a research fellow and health economist at the Center for Global Development. The authors thank Richard Cash, Zubin Shroff, Rifat Hasan, and Jenny Ottenhoff for helpful comments. You can follow Victoria Fan at @FanVictoria and Rifaiyat Mahbub at @rifaiyat_mahbub on Twitter.