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      Place and Child Health: The Interaction of Population Density and Sanitation in Developing Countries

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          A long literature in demography has debated the importance of place for health, especially children’s health. In this study, we assess whether the importance of dense settlement for infant mortality and child height is moderated by exposure to local sanitation behavior. Is open defecation (i.e., without a toilet or latrine) worse for infant mortality and child height where population density is greater? Is poor sanitation is an important mechanism by which population density influences child health outcomes? We present two complementary analyses using newly assembled data sets, which represent two points in a trade-off between external and internal validity. First, we concentrate on external validity by studying infant mortality and child height in a large, international child-level data set of 172 Demographic and Health Surveys, matched to census population density data for 1,800 subnational regions. Second, we concentrate on internal validity by studying child height in Bangladeshi districts, using a new data set constructed with GIS techniques that allows us to control for fixed effects at a high level of geographic resolution. We find a statistically robust and quantitatively comparable interaction between sanitation and population density with both approaches: open defecation externalities are more important for child health outcomes where people live more closely together.

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          The online version of this article (doi:10.1007/s13524-016-0538-y) contains supplementary material, which is available to authorized users.

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          Most cited references 33

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          Disease and Development: Evidence from Hookworm Eradication in the American South.

           B H Bleakley (2006)
          This study evaluates the economic consequences of the successful eradication of hookworm disease from the American South. The hookworm-eradication campaign (c. 1910) began soon after (i) the discovery that a variety of health problems among Southerners could be attributed to the disease and (ii) the donation by John D. Rockefeller of a substantial sum to the effort. The Rockefeller Sanitary Commission (RSC) surveyed infection rates in the affected areas (eleven southern states) and found that an average of forty percent of school-aged children were infected with hookworm. The RSC then sponsored treatment and education campaigns across the region. Follow-up studies indicate that this campaign substantially reduced hookworm disease almost immediately. The sudden introduction of this treatment combines with the cross-area differences in pre-treatment infection rates to form the basis of the identification strategy. Areas with higher levels of hookworm infection prior to the RSC experienced greater increases in school enrollment, attendance, and literacy after the intervention. This result is robust to controlling for a variety of alternative factors, including differential trends across areas, changing crop prices, shifts in certain educational and health policies, and the effect of malaria eradication. No significant contemporaneous results are found for adults, who should have benefited less from the intervention owing to their substantially lower (prior) infection rates. A long-term follow-up of affected cohorts indicates a substantial gain in income that coincided with exposure to hookworm eradication. I also find evidence that eradication increased the return to schooling.
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            Rural health disparities, population health, and rural culture.

             David Hartley (2004)
            In this commentary, I place the maturing field of rural health research and policy in the context of the rural health disparities documented in Health United States, 2001, Urban and Rural Health Chartbook. Because of recent advances in our understanding of the determinants of health, the field must branch out from its traditional focus on access to health care services toward initiatives that are based on models of population health. In addition to presenting distinct regional differences, the chartbook shows a pattern of risky health behaviors among rural populations that suggest a "rural culture" health determinant. This pattern suggests that there may be environmental and cultural factors unique to towns, regions, or United States Department of Agriculture (USDA) economic types that affect health behavior and health.
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              Health and urban living.

              The majority of people now live in urban areas and will do so for the foreseeable future. As a force in the demographic and health transition, urbanization is associated with falling birth and death rates and with the shift in burden of illness from acute childhood infections to chronic, noncommunicable diseases of adults. Urban inhabitants enjoy better health on average than their rural counterparts, but the benefits are usually greater for the rich than for the poor, thus magnifying the differences between them. Subject to better evidence, I suggest that the main obstacles to improving urban health are not technical or even financial, but rather are related to governance and the organization of civil society.

                Author and article information

                Springer US (New York )
                9 January 2017
                9 January 2017
                February 2017
                : 54
                : 1
                : 337-360
                [1 ]r.i.c.e., a research institute for compassionate economics, New Delhi, India
                [2 ]ISNI 0000 0004 0482 9086, GRID grid.431778.e, , World Bank Water and Sanitation Program, ; Washington, DC USA
                [3 ]ISNI 0000000121548364, GRID grid.55460.32, Department of Sociology & Population Research Center, , University of Texas, ; Austin, TX USA
                [4 ]ISNI 0000 0001 2157 0617, GRID grid.39953.35, , Indian Statistical Institute, ; Delhi, India
                [5 ]ISNI 0000000121548364, GRID grid.55460.32, Department of Economics, , University of Texas, ; Austin, TX USA
                © The Author(s) 2017

                Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

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                © Population Association of America 2017


                south asia, sanitation, population density, infant mortality, child height


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