ch 5 I pericoli di defecare all'aperto

5   Health: Surviving and growing in childhood - Where India Goes: Abandoned Toilets, Stunted Development and the Costs of Caste

Diane Coffey and Dean Spears

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reasons related to beliefs, values and norms about purity, pollution and untouchability.
Note:RIEPILOGO... PERCHÈ DEFECARE ALL APERTO

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exposure to poor sanitation is very bad for health. In the face of this stark and universal medical fact, India is special for two reasons. First, India has much more open defecation than any other country that is as rich. Second, the high population density in India – the fact that people live so close to one another and to one another’s germs – would make any amount of open defecation all the more threatening.
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micro-organisms in faeces spread disease.
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germ theory of disease
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John Snow’s pioneering demonstration of the unsanitary roots of cholera in London was published in the 1850s.
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Good toilets make good neighbours
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Muslims, Baby emphasized, are more interested in using a latrine
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the Muslim mortality paradox. This puzzle was named by economists Sonia Bhalotra, Christine Valente and Arthur van Soest.
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Muslim babies in India are more likely than Hindu babies in India to survive childhood.
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Muslims are, in many other ways, a disadvantaged minority in India.
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open defecation spreads disease that can kill babies: Diarrhoea is only the most obvious cause. They also now knew that Muslims in India are less likely to defecate in the open than Hindus.
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Muslims tend to live near other Muslims and Hindus tend to live near other Hindus.
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Open defecation and infant mortality
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Hindu babies who live in villages where they are surrounded by many Muslims are just as likely to survive as Muslim babies
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perhaps over 200,000, and almost certainly over 100,000, children under five die each year who would otherwise survive if there were no open defecation in India.
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The long and short of it: The average height of children
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richer people are taller than poorer people
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Compared to people in other poor countries, people in India are very short.
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Researchers have named this puzzle the Asian Enigma. This is actually a misleading name – it is really an Indian Enigma.
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the Asian Enigma is that the average five-year-old girl in India is about two-thirds of a centimetre shorter than in sub-Saharan Africa.
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Differences in population height: Environment, not genetics
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History is full of examples of populations that were thought to be genetically short, but whose children grew taller when early-life conditions improved.
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Anthropologist Barry Bogin documented that the difference between average Ladino and Mayan adults was a striking 10 centimetres. But when civil war broke out and thousands of Mayans began to take refuge in the United States, Bogin found that their children grew to be even taller than most Ladinos.
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Lemm Proos, of Uppsala University, tracked Indian children adopted into Sweden.
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Europeans today are much taller than Europeans only a century or two ago
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Is there a Bengali enigma too?
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The average five-year-old girl in West Bengal is about a quarter of a centimetre taller than the average five-year-old girl in Bangladesh.
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Children in Bangladesh are taller than children in West Bengal, at the same level of wealth or poverty
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Why are children in West Bengal shorter than equivalently poor Bangladeshis?
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Women in Bangladesh are more likely than women in India to be able to read and to have jobs.
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An additional difference between Bangladeshi villages and Indian villages is open defecation.
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Living close and growing apart in rural Uttar Pradesh
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Anil’s mother stopped breastfeeding him when he was less than two months old because she got mastitis, an infection in her breast that is common among breastfeeding mothers. Rather than continuing to breastfeed while taking antibiotics to clear the infection, as is recommended, she started giving Anil buffalo milk, mixed with water, and her body stopped making breast milk. The switch from breast milk to watery buffalo milk at such a young age had doubly negative consequences for Anil’s growth. First, it is not the right kind of nutrition for a small baby. Neither buffalo milk nor cow milk has the easy-to-digest proteins found in breast milk,
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bottle-feeding exposed Anil to germs. These germs lived in the milk, which was not always properly boiled,
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interaction between disease and breastfeeding
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Breastfeeding is a barrier against the germs spread by open defecation,
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How faecal germs do their dirty work
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Open defecation deposits faeces on the ground.
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Flies land on these germs; adults step on them; and children play in dirt contaminated with them.
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finger a mother offers for a crying

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The most obvious consequence is diarrhoea.
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enteric dysfunction
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increased permeability of the intestines to disease.
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These parasites stifle child growth in a number of ways. First, they quite literally steal a child’s food: They use the food she eats
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loss of appetite and, sometimes, scarring and bleeding in the intestines that make it difficult to digest food.
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unlike in India, many households in Nepal have been making the switch from open defecation to toilet or latrine use over the past decade. In 2006, about half of Nepali households defecated in the open, but by 2011 that fraction had declined to 35 per cent.
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haemoglobin levels were more favourable in regions where open defecation had fallen
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Deciphering the Asian (Indian) Enigma
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why children in India are shorter than children in sub-Saharan Africa.
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difference between India and sub-Saharan Africa in open defecation is large.
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What about children in India and sub-Saharan Africa who are exposed to the same amount of open defecation? In this case, there is no difference in child height and no Asian Enigma.
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Converging evidence on open defecation and child height
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the strongest conclusions emerge when multiple research strategies point in the same direction.
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Across a range of research strategies, open defecation has proven important for child height.
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One method compares countries
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Another approach looks across places
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an alternative approach sets out to generate differences.
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In many cases, open defecation is something that people choose to do. If the researchers cannot persuade people in the study villages to stop defecating in the open, there will be little hope of learning about health effects by comparing the two groups of villages: In the end, their exposure to faecal germs will stay the same.
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Economist Paul Gertler
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Many people, many germs
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The same fraction of people defecating in the open is more harmful for child health in India than in the average developing country. This is because where population density
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Payal Hathi, Sabrina Haque and Lovey Pant
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the same exposure to open defecation matters approximately twice as much in densely populated South Asia as it does in sub-Saharan Africa, on average.
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One other important problem is maternal nutrition. In India, babies tend to be born to young, low-status women who are far too likely to be underweight
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Open defecation is a relatively egalitarian health hazard.
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Money cannot buy a complete escape from an environment dense with germs.
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