Proposal preview

Public Health Interventions and the Life Course Approach: Metrics for the Long-Run Success of Interventions, 19th-20th Centuries

This session explores estimating the long-run returns of public health interventions on different socioeconomic and health outcomes. The voluminous literature on sanitary reforms and health interventions in the 19th and 20th century has originally focussed on short-term effects on morbidity and mortality. Recently, more attempts have been made to assess long-run effects on earnings and educational attainment (e.g., Beach et al. 2016; Bleakley 2010). This is logical as the evidence of long-run effects of adverse early life conditions on educational achievement, earnings, morbidity and mortality later in life has cumulated quickly over the recent years (e.g. Almond and Currie 2011; cf. Parman 2015). As the effects unfold over decades and generations, analysis of historical data is essential for working towards more comprehensive estimation of the social returns of various types of interventions. The purpose of this session is to capture emerging research in this vein utilizing new long-run, intra- and intergenerational data and metrics.

One policy implication typically drawn from literature is that the optimum time to intervene is before the children are born or in the very first years of life. This, however, does not mean that second-best interventions regarding timing have no or just little effects. There are many examples that show that school-based public health interventions can be very successful and can increase school enrolment, attendance, and literacy (e.g., Beakley 2007). Schooling itself has also been suggested to have disseminated health-seeking behaviour (Riley 2008). The so-called life course approach therefore incorporates, but is broader than, the foetal origins hypothesis. It is based on the evidence that there are several critical periods of growth and different sensitive developmental stages in childhood and adolescence, and postulates coherent policies that address the totality of human life across ages and generation (e. g. WHO Europe The Minsk Declaration 2015). This approach is based on the plasticity of the human morphology, behaviour and physiology, id est the ability of an organism to modify its biology or behaviour to respond to changes in the environment (Bogin 1999). The life course approach can be enriched by so-called life history theory. It assumes an idea that in its very basic form should be familiar to economists: allocating scarce energy and time resources over the life span to competing functions of the human body – maintenance, growth, reproduction and defence – in view of maximizing chances of survival and reproduction (Stearns 1992). In this perspective, energetic trade-offs might be resolved in favour of reproductive success, rather than health or longevity (Gibson and Mace 2006). The combination of both approaches best reflect the adaptive options that an organism has during its life course to changing environments, and might therefore contribute to explain human health reactions towards changing socioeconomic conditions and new public health interventions.

Against this backdrop, this session will analyse different cases of public health interventions and their respective short and long-term effects in the 19th and 20th century. A particular attention shall be given to sanitary reforms as well as the impact of changes in health care. New metrics are sought to quantify and estimate returns to such changes and interventions on various dimensions (e.g., income, height, schooling, morbidity). The aim is to compare and contrast interventions and to think on the broader and unexpected consequences specific public interventions might have had.

If slots remain in the final line-up, a further open CFP will be organized after acceptance.

Organizer(s)

  • Sakari Saaritsa University of Helsinki sakari.saaritsa@helsinki.fi Finland
  • Jöel Floris University of Zürich and the Institute of Evolutionary Medicine oel.floris@uzh.ch Switzerland

Session members

  • Gregori Galofré-Vilà, University of Oxford
  • David Stuckler, University of Oxford
  • Volha Lazuka, Lund University
  • Maarit Olkkola, Aalto University
  • Philipp Barteska, Universitat Pompeu Fabra
  • Sonja Dobkowitz, University of Bonn
  • Michael Rieser, University of Basel
  • Sakari Saaritsa, University of Helsinki
  • Jarmo Peltola, University of Tampere
  • Joël Floris, University of Zürich and the Institute of Evolutionary Medicine
  • Kaspar Staub, University of Zürich and the Institute of Evolutionary Medicine
  • Kristina Thompson, Vrije Universiteit Amsterdam
  • France R.M. Portrait, Vrije Universiteit Amsterdam
  • Maarten Lindeboom, Vrije Universiteit Amsterdam
  • Mayr Harald, University of Zürich
  • Woitek Ulrich, University of Zürich

Discussant(s)

  • Bernard Harris University of Strathclyde bernard.harris@strath.ac.uk
  • Susan Hautaniemi Leonard Population Studies Center, Institute for Social Research, University of Michigan hautanie@umich.edu

Papers

Panel abstract

This session explores estimating the long-run returns of public health interventions on different socioeconomic and health outcomes. As such effects unfold over decades and generations, analysis of historical data is essential for working towards more comprehensive estimation of the social returns of various types of interventions. The purpose of this session is to capture emerging research in this vein utilizing new long-run, intra- and intergenerational data and metrics. The session will analyse different cases of public health interventions and their respective short and long-term effects in the 19th and 20th century, such as sanitary reforms, new medication and the health impact of economic and social policy. Various metrics are applied to quantify and estimate returns to such changes and interventions on different dimensions of well-being (e.g., income, height, schooling, morbidity). The aim is to compare and contrast interventions and to reflect on their broader and unexpected consequences.

1st half

Infant Health and Later-Life Labour Market Outcomes: Evidence from the Introduction of Sulpha Antibiotics in Sweden

Volha Lazuka

This paper studies the effects of improvements in infant health produced by the introduction of sulphapyridine in the late-1930s as treatment against pneumonia on outcomes in adulthood. Based on longitudinal individual data for the whole population of Sweden 1968–2012 and archival data on the availability of sulphapyridine and applying a difference-in-differences approach, it finds that mitigation of pneumonia infection in infancy increased labour income in late adulthood by 2.8–5.3 percent. The beneficial effects are strong for health, measured by length of stay in hospital, and weaker for years of schooling. These effects are similar between males and females.

This paper studies the effects of improvements in infant health produced by the introduction of sulphapyridine in the late-1930s as treatment against pneumonia on outcomes in adulthood. Based on longitudinal individual data for the whole population of Sweden 1968–2012 and archival data on the availability of sulphapyridine and applying a difference-in-differences approach, it finds that mitigation of pneumonia infection in infancy increased labour income in late adulthood by 2.8–5.3 percent. The beneficial effects are strong for health, measured by length of stay in hospital, and weaker for years of schooling. These effects are similar between males and females.

Survival of the weakest? Culling evidence from the 1918 flu pandemic

Harald Mayr, Kaspar Staub, Ulrich Woitek, Joël Floris

Selective mortality threatens the internal validity of any study estimating the effect of a fetal health shock. Nevertheless, empirical evidence on the importance and nature of culling (i.e. selective fetal mortality) is surprisingly scarce. The fetal origins literature seems to agree on the idea that culling – if important after all – is innocuous in the sense that it induces a bias towards zero. We provide two contributions to this discussion. First, our results confirm earlier evidence that culling was quantitatively important during the 1918 flu pandemic. Second, we discuss how culling can just as well imply a bias away from zero which, we argue, might actually be true for the 1918 flu pandemic.

Selective mortality threatens the internal validity of any study estimating the effect of a fetal health shock. Nevertheless, empirical evidence on the importance and nature of culling (i.e. selective fetal mortality) is surprisingly scarce. The fetal origins literature seems to agree on the idea that culling – if important after all – is innocuous in the sense that it induces a bias towards zero. We provide two contributions to this discussion. First, our results confirm earlier evidence that culling was quantitatively important during the 1918 flu pandemic. Second, we discuss how culling can just as well imply a bias away from zero which, we argue, might actually be true for the 1918 flu pandemic.

Height as a mediator between early-life nutritional status and later-life socio-economic outcomes

Kristina Thompson, France Portrait, Maarten Lindeboom

Adult body height appears to be a relatively accurate summary variable of health related to early childhood exposures, and may be a useful indicator of health in populations where more traditional health-related indicators are lacking. In particular, previous studies have shown a strong, positive relationship between environmental exposures in early life (particularly nutritional availability and the disease environment) and height. Research has also demonstrated positive associations between height and socioeconomic status. We therefore hypothesised that height mediates the relationship between early-life nutritional status and later-life socio-economic outcomes. In our study, we found stronger evidence for the influence of puberty and the influence of a multiplicative, long-term effect of food deprivation than for short-term shocks in early-life.

Adult body height appears to be a relatively accurate summary variable of health related to early childhood exposures, and may be a useful indicator of health in populations where more traditional health-related indicators are lacking. In particular, previous studies have shown a strong, positive relationship between environmental exposures in early life (particularly nutritional availability and the disease environment) and height. Research has also demonstrated positive associations between height and socioeconomic status. We therefore hypothesised that height mediates the relationship between early-life nutritional status and later-life socio-economic outcomes. In our study, we found stronger evidence for the influence of puberty and the influence of a multiplicative, long-term effect of food deprivation than for short-term shocks in early-life.

Life expectancy at birth and mortality changes in Swiss districts 1878-1930

Joël Floris

Between 1850 and 1930, Switzerland developed from a relatively poor economy to a country at the top of the European GDP p. c. Distribution. At the same time, life expectancy at birth increased significantly. In this paper I analyse the development of life expectancy at birth and mortality rates in the various districts of Switzerland between 1878 and 1930. What influence did medical improvements and hygienic-sanitary reforms have on regional mortality rates? What was the role of better nutrition and economic modernisation in regional differences? And what influence did Switzerland's strongly federalist political system have on these developments?

Between 1850 and 1930, Switzerland developed from a relatively poor economy to a country at the top of the European GDP p. c. Distribution. At the same time, life expectancy at birth increased significantly. In this paper I analyse the development of life expectancy at birth and mortality rates in the various districts of Switzerland between 1878 and 1930. What influence did medical improvements and hygienic-sanitary reforms have on regional mortality rates? What was the role of better nutrition and economic modernisation in regional differences? And what influence did Switzerland's strongly federalist political system have on these developments?

2nd half

Vaccine-preventable Childhood Disease and Labor Market Outcomes

Maarit Olkkola, Philipp Barteska, Sonja Dobkowitz, Michael Rieser

We analyze the impact of measles prevention in the first years of life on adult labor market and educational outcomes with the national measles eradication campaign implemented in 1967 in the United States. Our empirical strategy exploits the variation in measles incidence across states before the campaign, which reduced measles exposure close to zero within a year. Our results suggest that reduced measles exposure in the first years of life increased annual earned income around age 32 by about 2 per cent. This result is, however, smaller in magnitude and less precise if we exclude top 1% earners or use log income as the outcome. Our results also suggest that part of the increase in income could be due to increases in educational attainment, but the results are only marginally statistically significant and small in magnitude: years of schooling increased by about two weeks and the probability of completing high...

We analyze the impact of measles prevention in the first years of life on adult labor market and educational outcomes with the national measles eradication campaign implemented in 1967 in the United States. Our empirical strategy exploits the variation in measles incidence across states before the campaign, which reduced measles exposure close to zero within a year. Our results suggest that reduced measles exposure in the first years of life increased annual earned income around age 32 by about 2 per cent. This result is, however, smaller in magnitude and less precise if we exclude top 1% earners or use log income as the outcome. Our results also suggest that part of the increase in income could be due to increases in educational attainment, but the results are only marginally statistically significant and small in magnitude: years of schooling increased by about two weeks and the probability of completing high school by 0.4 percentage points.

Quantifying the Health impact of the US Social Security Act, 1935

Gregori Galofré-Vilà, David Stuckler

The New Deal represented the biggest recovery programme in American history. In this paper we look at the impact of the Social Security Act (one of the New Deal structural programmes) on health across the 1930s and 1940s. We collected data at city, county and state level on different programmes of the Social Security Act and linked them to mortality rates adjusted by cause, race, sex and age. While the New Deal was not designed with public health in mind, some of its programmes had a momentous effect on the public’s health. This paper represents a clear example of how economic policies affect people’s lives in difficult times. It shows that, even in the worst economic scenario, people’s suffering can be prevented when politicians take the right steps to protect citizens’ health by maintaining employment, social security and healthcare programs.

The New Deal represented the biggest recovery programme in American history. In this paper we look at the impact of the Social Security Act (one of the New Deal structural programmes) on health across the 1930s and 1940s. We collected data at city, county and state level on different programmes of the Social Security Act and linked them to mortality rates adjusted by cause, race, sex and age. While the New Deal was not designed with public health in mind, some of its programmes had a momentous effect on the public’s health. This paper represents a clear example of how economic policies affect people’s lives in difficult times. It shows that, even in the worst economic scenario, people’s suffering can be prevented when politicians take the right steps to protect citizens’ health by maintaining employment, social security and healthcare programs.

Iodine deficiency in 19th and 20th century Switzerland and its impact on health and human capital

Kaspar Staub

Hypothyroidism is a condition of mild to severe impairment of physical and mental development due to untreated deficiency of thyroid hormones. Endemic hypothyroidism arises from a diet deficient in iodine. The most common iodine deficiency disorders are goitre (enlarged thyroid gland) and hypothyroidism at all ages, as well as endemic "cretinism", mental impairment, or delayed physical development in growing children. Switzerland was one of the few countries that became completely iodine sufficient before 1990, and was a world pioneer, introducing its iodised salt program in 1922. Did the temporally varying implementation of iodized salt consumption among the cantons have an influence on human growth, educational tests (as a proxy for human capital), and morbidity and mortality levels? Did the levels of iodine deficiency among districts have an influence on human growth, educational performance, morbidity and mortality when controlling for potential confounding factors (GDP per capita, etc.)?

Hypothyroidism is a condition of mild to severe impairment of physical and mental development due to untreated deficiency of thyroid hormones. Endemic hypothyroidism arises from a diet deficient in iodine. The most common iodine deficiency disorders are goitre (enlarged thyroid gland) and hypothyroidism at all ages, as well as endemic "cretinism", mental impairment, or delayed physical development in growing children. Switzerland was one of the few countries that became completely iodine sufficient before 1990, and was a world pioneer, introducing its iodised salt program in 1922. Did the temporally varying implementation of iodized salt consumption among the cantons have an influence on human growth, educational tests (as a proxy for human capital), and morbidity and mortality levels? Did the levels of iodine deficiency among districts have an influence on human growth, educational performance, morbidity and mortality when controlling for potential confounding factors (GDP per capita, etc.)?

Urban water infrastructure, infant mortality and the health transition in a European periphery: Finland 1870-1938

Jarmo Peltola, Sakari Saaritsa

The paper analyzes the role of urban water infrastructure in the health transition of Finland. Estimates based on US data suggest large effects from urban water infrastructure on the late 19th and early 20th century mortality decline, implying policy lessons for developing countries. Finland is relevant due to an early health transition in a predominantly agrarian population with low GDP, nevertheless traditionally explained with a standard urban improvement narrative. We construct panel data on mortality and the initiation of three major water interventions – piped water, sewers and chlorination – in 38 Finnish cities to produce comparable estimates. We calculate the contributions of the interventions to the decline of urban infant mortality and the urban and overall crude death rates. We also introduce tools used in development economics to analyze the variation of the impact at different stages of development. The interventions would seem to explain c. 40 % of...

The paper analyzes the role of urban water infrastructure in the health transition of Finland. Estimates based on US data suggest large effects from urban water infrastructure on the late 19th and early 20th century mortality decline, implying policy lessons for developing countries. Finland is relevant due to an early health transition in a predominantly agrarian population with low GDP, nevertheless traditionally explained with a standard urban improvement narrative. We construct panel data on mortality and the initiation of three major water interventions – piped water, sewers and chlorination – in 38 Finnish cities to produce comparable estimates. We calculate the contributions of the interventions to the decline of urban infant mortality and the urban and overall crude death rates. We also introduce tools used in development economics to analyze the variation of the impact at different stages of development. The interventions would seem to explain c. 40 % of the urban infant mortality decline in Finnish cities in 1870-1938, comparable to the US estimates presented by Cutler & Miller (2005) and Alsan & Goldin (2015). This still accounts for only 5 % of the national fall in crude death rate over the same period, as urbanization was slow and mortality constantly declined in rural areas as well for other reasons. Based on separate estimation for 1900-1935, the contribution reached 14 % of total CDR fall as urbanization progressed and urban IMR decline accelerated in the early 20th century. Quantile regressions suggest that a “threshold-saturation” pattern identified in developing countries applied, with the impact of interventions becoming larger when IMR was already down from the highest levels. Apparently, complementary factors mattered for the effectiveness of water infrastructure investment in historical cases too.