Social Science & Medicine

The behavioral economics literature suggests that exposure to traumatic events shifts preference features like risk aversion and time preference. Drawing on this literature, this study explored the relationship between early life exposure to traumatic events and self-control at older ages. The data were obtained from the Health and Retirement Study, which offers retrospective data on trauma exposure and a measure of self-control. The results showed that the experience of serious physical attacks or assaults was associated with a 3.1% reduction in self-control, above and beyond the influence of demographic characteristics and childhood socioeconomic disadvantages. The mean number of years elapsed since the physical attack was about 30, conditional on exposure, indicating that traumatic experiences early in life exert a lasting influence on self-control. Our findings were consistent with evidence that experiences of natural disasters and armed conflicts increased impatience among survivors. JEL classification codeD12, D14, D91

We develop a model where individuals accumulate fatigue from work intensity when choosing hours worked. Fatigue captures intertemporal costs of labour supply and leads to a utility loss. As fatigue increases, individuals optimally choose to work fewer hours. The model also predicts that if individuals cannot easily shift consumption over time, they will work fewer hours but accumulate more fatigue when work intensity increases. Calibration to 19 European countries provides evidence for the claim that a higher share of the service sector is linked to increasing work fatigue and that public provisions of healthcare improves recovery and mental health. JEL codesE71, I12, J22

Child height is a significant predictor of human capital and economic status throughout adulthood. Moreover, non-unitary household models of family behavior posit that an increase in womens bargaining power can influence child health. We study the effects of an inheritance policy change, the Hindu Succession Act (HSA), which conferred enhanced inheritance rights to unmarried women in rural India, on child height. We find robust evidence that the HSA improved the height and weight of children. In addition, we find evidence consistent with a channel that the policy improved the womens intrahousehold bargaining power within the household, leading to improved parental investments for children. These study findings are also compatible with the notion that children do better when their mothers control a more significant fraction of the family. Therefore, policies that empower women can have additional positive spillovers for childrens human capital. (JEL D13, I12, I13, J13, J16, J18, K13, O12, O15, Z12, Z13)

In this paper, we analyze economic costs and consequences of local non-pharmaceutical interventions (NPIs) aimed at containing the COVID-19 pandemic. Using comprehensive data on municipal and regional policies in Norway, we implement a difference-in-differences framework identifying impacts of local NPIs from discontinuous differential shifts in outcomes following the implementation of new policies. In treated municipalities, local NPIs lead to persistent reductions in mobility, persistent increases in unemployment, and transient reductions in consumer spending. Analyses of spatial spillovers show that the implementation of local NPIs increases retail mobility in non-treated neighboring municipalities. Overall, our findings suggest that local NPIs have economic consequences for local economies and induce residents to shift their consumption of goods and services to neighboring municipalities.

A key feature of public sector employment in many countries is rigid civil service rules that effectively limit manager autonomy over hiring, firing, promotion, and compensation decisions. We study the effect of these rules by comparing the quality of healthcare provided by physicians employed as civil servants with physicians hired in the same facilities on fixed-term contracts that give managers more autonomy over personnel decisions. Using data from interactions with unannounced standardized patients, we find that fixed-term contracts motivate greater diagnostic effort without increasing unnecessary treatments. Lower effort among civil servants appears due to both weaker career and wage incentives.

Discussion on the disproportionate impact of COVID-19 on African Americans has been at center stage since the outbreak of the epidemic in the United States. To present day, however, lack of race-disaggregated individual data has prevented a rigorous assessment of the extent of this phenomenon and the reasons why blacks may be particularly vulnerable to the disease. Using individual and georeferenced death data collected daily by the Cook County Medical Examiner, we provide first evidence that race does affect COVID-19 outcomes. The data confirm that in Cook County blacks are overrepresented in terms of COVID-19 related deaths since--as of June 16, 2020--they constitute 35 percent of the dead, so that they are dying at a rate 1.3 times higher than their population share. Furthermore, by combining the spatial distribution of mortality with the 1930s redlining maps for the Chicago area, we obtain a block group level panel dataset of weekly deaths over the period January 1, 2020-June 16, 2020, over which we establish that, after the outbreak of the epidemic, historically lower-graded neighborhoods display a sharper increase in mortality, driven by blacks, while no pre-treatment differences are detected. Thus, we uncover a persistence influence of the racial segregation induced by the discriminatory lending practices of the 1930s, by way of a diminished resilience of the black population to the shock represented by the COVID-19 outbreak. A heterogeneity analysis reveals that the main channels of transmission are socioeconomic status and household composition, whose influence is magnified in combination with a higher black share. JEL CodesI14, J15, N32, N92, R38.

As the COVID-19 pandemic continues, local and state governments must weigh the costs and benefits of social distancing policy. However, the effectiveness of such policies depend on individuals willingness and ability to comply. We propose a simple method to infer sociodemographic heterogeneity in social distancing as measured by Safegraph mobile device data. We document evidence that peoples ability to work from home is a determinant of time spent at home since the beginning of the pandemic. On April 15th, census block groups that are more likely able to work from home spent 3 more hours at home compared to those who were not. We see supporting trends among block groups with differences in income and educational attainment. JELJ19, J69, Z00

BackgroundGovernments worldwide have implemented large-scale non-pharmaceutical interventions, such as social distancing or school closures, to prevent and control the growth of the COVID-19 pandemic. These strategies, implemented with varying stringency, have imposed substantial social and economic costs to society. As some countries begin to reopen and ease mobility restrictions, lockdowns in smaller geographic areas are increasingly being considered as an attractive policy intervention to mitigate societal costs while controlling epidemic growth. However, there is a lack of empirical evidence to support these decisions. MethodsDrawing from a rich dataset of localized lockdowns in Chile, we used econometric methods to measure the reduction in local economic activity from lockdowns when applied to smaller or larger geographical areas. We measured economic activity by tax collection at the municipality-level. FindingsResults show lockdowns were associated with a 10-15% drop in local economic activity, a two-fold reduction compared to municipalities not under lockdown. A three-to-four-month lockdown had a similar effect on economic activity than the year of the 2009 great recession. We found that costs are proportional to the population under lockdown, without differences when lockdowns were measured at the municipality or city-wide levels. ConclusionsOur findings suggest that localized lockdowns have a large effect on local economic activity, but these effects are proportional to the population under lockdown. Our results suggest that epidemiological criteria should guide decisions about the optimal size of lockdown areas; the proportional effects of lockdowns on the economy seem to be unchanged by scale. JEL codesI10, I15, I18, H2

We provide a framework to disentangle the role of preferences and beliefs in health behavior, and we apply it to compliance behavior during the acute phase of the COVID-19 pandemic. Using rich data on subjective expectations collected during the spring 2020 lockdown in the UK, we estimate a simple model of compliance behavior with uncertain costs and benefits, which we employ to quantify the utility trade-offs underlying compliance, to decompose group differences in compliance plans, and to compute the monetary compensation required for people to comply. We find that, on average, individuals assign the largest disutility to passing away from COVID-19 and being caught transgressing, and the largest utility to preserving their mental health. But we also document substantial heterogeneity in preferences and/or expectations by vulnerability status, gender, and other individual characteristics. In our data, both preferences and expectations matter for explaining gender differences in compliance, whereas compliance differences by vulnerability status are mainly driven by heterogeneity in preferences. We also investigate the relationship between own and others compliance. When others fail to comply and trust breaks down, individuals respond heterogeneously depending on their own circumstances and characteristics. When others around them comply less, those with higher risk tolerance and those without prior COVID-19 experience plan to comply less themselves, while the vulnerables plan to comply more. When a high-level public figure breaches the rules, supporters of the opposing political party plan to comply less. These findings emphasize the need for public health policies to account for heterogenous beliefs, preferences, and responses to others in citizens health behaviors. JEL Codes: C25, C83, D84, I12, I18.

IntroductionA supposed lives-livelihood trade-off (LLTO) has been at the centre stage of the COVID-19 pandemic, where policymakers often attempt to balance the health cost of COVID-19, including deaths, and the economic cost of lockdowns. MethodologyThis paper uses country-level panel (longitudinal) data on real GDP, stringency of non-pharmaceutical interventions (NPIs), economic policy support, COVID-19 deaths, and vaccination to quantify the short-run LLTO. Beyond descriptive analysis, adjustments were made -- (1) two-stage least squares instrumental variables in a cross-sectional setting using pre-pandemic institutional quality as the excluded instrument, and (2) two-way fixed effects in a panel data setting. FindingsReal GDP is negatively associated with COVID-19 deaths, as does more stringent containment measures. However, the offsetting positive association of real GDP with economic policy support is substantial. A historical decomposition of average real GDP that the positive attribution of fiscal support roughly equates the negative attribution of lockdown stringency and COVID-19 mortality. ConclusionCross-country empirical evidence suggests no direct tradeoff between the economy, and public health. A change in policy thinking from a LLTO paradigm to a no trade-off entails economic policy treating public health goals as invariant in supporting incomes through adequate, direct, and timely means.

We study how tax deferral policies shape labour supply decisions over the lifecycle. Between 1975 and 2005, Canadian provinces allowed physicians to incorporate, providing high-income professionals with substantial tax deferral opportunities. Using a difference-in-differences identification strategy, we find that incorporation reduced work effort by facilitating earlier retirement. Physician supply fell by 6.8% over the long run, with especially large declines among older physicians and high-earning surgical specialists. These results provide long-run evidence of how these tax deferral policies, designed to affect high-skill labour, can alter timing of retirement and reduce labour supply.

We evaluate impacts heterogeneity of an Early Childhood Intervention in Colombia, with respect to the Educational Attainment Polygenic Score (EA4 PGS) constructed from DNA data based on GWAS weights from a European population. We find that the EA4 PGS is predictive of several measures of child development, mothers IQ and, to some extent, educational attainment. We also show that the impacts of the intervention are significantly greater in children with low PGS, to the point that the intervention eliminates the initial genetic disadvantage. Lastly, we find that children with high PGS attract more parental stimulation; however, the latter increases more strongly in children with low PGS. JEL CodesC21, J13, I24

ObjectivesStandard economic evaluation methods assume that quality-adjusted life years (QALYs) have equal social value, regardless of recipient. However, evidence suggests that people place greater social value on health gains for children. This study examines the factors driving age-related preferences for health gains. MethodsThink-aloud, semi-structured interviews were conducted with Australian adolescents (n=7), non-parents (n=11), parents with healthy children (n=8) and parents of children with health conditions (n=15). Participants completed Person Trade-Off (PTO) and attitudinal questions about resource allocation for improvements in life extension, mental health, mobility, and pain/discomfort choosing between interventions for adults (ages 40 or 55) and younger people (ages one month to 24). ResultsEleven themes emerged, illustrating participants complex reasoning. They considered differences in the impact of health loss at various ages, with difficulty envisaging mental health impacts for very young children. Emotional responses were strongest around children in pain. Adolescents tended to prioritize younger people, while parents often emphasized adults caregiving role. Most participants prioritized based on age in PTO questions, though some adults objected to prioritizing healthcare based on age. ConclusionChoices were shaped by perceptions of the impact of the health states. These findings provide insight into interpreting quantitative results from PTO tasks.

This paper draws from daily death registry data on 4,000 Italian municipalities to investigate two crucial policies that can dramatically affect the toll of COVID-19: the shutdown of non-essential businesses and the management of the emergency care system. Our results, which are robust to controlling for a host of co-factors, offer strong evidence that the closure of service activities is very effective in reducing COVID-19 mortality - this was about 15% lower in municipalities with a 10 percentage points higher employment share in shut down services. Shutting down factories, instead, is much less effective, plausibly because factory workers engage in more limited physical interactions relative to those in the consumer-facing service sector. Concerning the management of the health care system, we find that mortality strongly increases with distance from the intensive care unit (ICU). Municipalities at 10 km from the closest ICU experienced up to 50% higher mortality. This effect - which is largest within the epicenter and in days of abnormally high volumes of calls to the emergency line - underscores the importance of improving pre-hospital emergency services and building ambulance capacity to ensure timely transportation of critical patients to the ICU.

I study households primary health care usage in India, which presents a paradox. I examine why most households use fee-charging private health care services even though (1) most providers have no formal medical qualifications and (2) in markets where qualified doctors offer free care through public hospitals. I present evidence that this puzzling practice has deep historical routes. I examine Indias coercive forced sterilization policy implemented between 1976 and 1977. Utilizing the unexpected timing of the policy, multiple measures of forced sterilization, including at a granular level, and an instrumental variable approach, I document that places heavily affected by the policy have lower public health care usage today. I also show that the instrument I use is unrelated to a battery of demographic, economic, or political aspects before the forced sterilization period. Finally, I explore the mechanism and document that supply-side factors do not explain these differences. Instead, I demonstrate that places with greater exposure to forced sterilization have higher confidence in private hospitals and doctors to provide good treatment.

OBJECTIVESTo estimate the extent to which Canadians are averse to health inequalities, a critical component for equity-informative economic evaluations but lacking in the Canadian context. METHODSWe conducted three experiments among a representative sample of adults living in Canada to elicit value judgements about reducing income-related health inequality vs. improving population health. Each experiment compared two programs: (Experiment 1) universal and tailored vaccination; (Experiment 2) non-specific prevention programs; (Experiment 3) generic health care programs. The programs varied in terms of efficiency (additional life years), and income-related health inequality. Preferences were elicited using benefit-trade off analysis and were classified as: pro-rich (maximizing the health of individuals with the highest income); health maximizer (maximizing total health); weighted prioritarian (willing to trade some health to reduce inequalities); maximin (only improving the health of the individuals with the lowest income); and egalitarian (minimizing health inequalities). RESULTSWe recruited 1,000 participants per experiment. Preferences for the vaccination, prevention, and generic experiments were distributed as follows: pro-rich (Atkinson Index<0): 31%, 22%, and 16% respectively; health maximizers (Atkinson Index=0): 2%, 3%, and 2%, respectively; weighted prioritarians (Atkinson Index>0): 13%, 19%, and 22% respectively; maximins (Atkinson Index={infty}): 0%, 1%, and 3%, respectively; egalitarian (Atkinson Index undefined): 54%, 55%, and 57%, respectively. The median responses reflected a preference for minimizing health inequalities across the three experiments. CONCLUSIONSOur findings suggest a strong aversion to health inequality among people living in Canada with over half of respondents willing to minimize health inequalities regardless of the impact on efficiency.

The effects of democracy on living conditions among the poor are disputed. Previous studies have addressed this question by estimating the average effect of democracy on early-life mortality across all countries. We revisit this debate using a research design that distinguishes between the aggregated effects of democracy across all countries and their individual effects within countries. Using Interrupted Time Series methodology and estimating model parameters in a Bayesian framework, we find the average effect of democracy on early-life mortality to be close to zero, but with considerable variation at the country-level. Democratization was followed by fewer child deaths in 21 countries, an increase in deaths in eight, and no measurable changes in the remaining 32 cases. Transitions were usually beneficial in Europe, neutral or beneficial in Africa and Asia, and neutral or harmful in Latin America. The distribution of country-level effects is not consistent with common arguments about the conditional effects of democratic transitions. Our results open a new line of research into the sources of theses heterogeneous effects.

We examine the mortality effects of a 1947 school reform in Japan, which extended compulsory schooling from primary to secondary school by as much as 3 years. The abolition of secondary school fees also indicates that those affected by the reform likely came from disadvantaged families who could have benefited the most from schooling. Even in this relatively favorable setting, we fail to find that the reform improved later-life mortality up to the age of 87 years, although it significantly increased years of schooling. This finding suggests limited health returns to schooling at the lower level of educational attainment.

The causal effect of hospital length of stay on crucial patient out-comes such as readmissions or mortality is under-investigated and therefore unknown for the vast majority of the US population. Existing evidence stems from association studies that are unable to draw causal conclusions. This study leverages Medicares two-midnight (2MN) and three-day (3D) rules as two natural experiments to establish causal rela-tionships between hospital length of stay (LOS) and patient outcomes. Using a quasi-experimental regression discontinuity design with data from a large US hospital, we find that the 2MN rule increases LOS by 0.10 days and the 3D rule by 0.21 days, confirming the validity of these rules as instruments for causal inference. However, despite these increases in LOS, there are no significant effects on 90-day mortality or 30-day readmission rates. These findings suggest that while the 2MN and 3D rules effectively extend hospital stays, they do not im-prove patient-related outcomes, indicating an inefficient use of hospital resources.

The paper provides some initial evidence that daily mortality rates (for any cause) by municipality or province can be used as a statistically reliable predictor of looming COVID-19 crises. Using recently published deaths figures for 1,689 Italian municipalities, we estimate the growth in daily mortality rates between the period 2015-2019 and 2020 by province. All provinces that experienced a major COVID-19 shock in mid-March 2020 had increases in mortality rates of 100% or above already in early February 2020. This increase was particularly strong for males and older people, two recognizable features of COVID-19. Using a panel fixed effect model, we show that the association between these early increases in mortality for any cause and the March 2020 COVID-19 shock is strong and significant. We conclude that the growth in mortality rates can be used as a statistically reliable predictor of COVID-19 crises.