Working papers

Controlling Tuberculosis? Evidence from the Mother of all Community-Wide Health Experiments

(with Karen Clay, Casper Worm Hansen, and Peter Sandholt Jensen). Latest version: March 2018.

Abstract: This paper studies the immediate and long-run mortality effects of the first community-based health intervention in the world, which had a particular focus on controlling tuberculosis – the so-called Framingham Health and Tuberculosis Demonstration. Comparing death and TB-mortality rates between Framingham and seven (pre-selected) control towns during the Demonstration period between 1917 and 1923, the contemporary official evaluation committee concluded that the Demonstration was highly successful in controlling TB and reducing mortality The Framingham Demonstration subsequently became a health example for the world. The findings in our paper question this very positive assessment. We collected and digitized causes-of-death data for towns/cities in Massachusetts and the United States for the period 1901-1934, allowing us to extend the number of control towns (or cities) and study whether the Demonstration reduced mortality in the long run. Compared to the official seven controls towns, we find that TB mortality in Framingham was on average lower between 1917 and 1923. In the extended control samples, these immediate TB mortality differences are smaller and often more than reversed by 1934. However, we do find robust evidence that the Demonstration reduced infant mortality, and these improvements persisted even after the Demonstration ended.

Preventing the White Death: Tuberculosis Dispensaries 

(with Casper Worm Hansen and Peter Sandholt Jensen). Latest version: September 2017.

Abstract: Tuberculosis (TB) is a leading cause of death worldwide and, while treatable by antibiotics since the 1940s, drug resistant strains have emerged. This paper estimates the effects of the establishment of a pre-antibiotic era public health institution, known as a TB dispensary, designed to prevent the spread of the disease. Our annual difference-in-differences estimation reveals that the rollout of the dispensaries across Danish cities led to a 19 percent decline in the TB mortality rate, but exhibits no significant impacts on other diseases in placebo regressions. We next take advantage of the dispensaries’ explicit targeting on TB to set up a triple-differences model which exploits other diseases as controls and obtain a similar magnitude of the effect. Using monthly mortality data in a similar strategy leads to the same conclusion. In addition, we find small positive spillover effects of the dispensaries on productivity as measured by annual income per taxpayer at the city level, digitized from historical tax-assessment records. Overall, the evidence highlights the provision of personalized information on infectious diseases as a cost-effective cause of the historical mortality decline.

Work in progress

Mortality decline and subsistence: Evidence from historical spending on rations in US penitentiaries 

Abstract: The causes of the secular decline in mortality in Europe and the United States starting in the early 19th century have long been debated. This paper investigates the role of improved nutrition and increased food supply for the mortality transition using newly digitized data on spending on inmates’ rations and mortality in US penitentiaries. The findings show that the prisons’ spending on provisions per inmate is significantly negative correlated with mortality, explaining about 26 percent of the decline in mortality in the prisons from 1875 to 1920. The results suggest, that although nutrition accounted for a significant part of the decline in mortality, the bulk of the decline in mortality should be explained by other factors.