Healthier People

Kevin Lewis

November 09, 2022

Calculating the Costs and Benefits of Advance Preparations for Future Pandemics
Rachel Glennerster, Christopher Snyder & Brandon Joel Tan
NBER Working Paper, October 2022


The Covid-19 pandemic is estimated to have caused over 7 million deaths and reduced economic output by over $13 trillion to date. While vaccines were developed and deployed with unprecedented speed, pre-pandemic investments could have accelerated their widespread introduction, saving millions of lives and trillions of dollars. Combining estimates of the frequency and intensity of pandemics with estimates of mortality, economic-output, and human-capital losses from pandemics of varying severities, we calculate expected global losses from pandemics of over $800 billion annually. According to our model, spending $60 billion up front to expand production capacity for vaccines and supply-chain inputs and $5 billion every year thereafter would be sufficient to ensure production capacity to vaccinate 70% of the global population against a new virus within six months, generating an expected net present value (NPV) of over $400 billion. A proportionate advance-investment program undertaken by the United States alone would generate an expected NPV of $47 billion ($141 per capita).

Direct and Indirect Effects of Vaccines: Evidence from COVID-19 in Schools
Seth Freedman et al.
NBER Working Paper, October 2022 


Vaccines influence the course of pandemics both directly, by protecting the vaccinated, and indirectly, by reducing transmission to the unvaccinated, a key externality. Estimating direct effects is challenging because of selective vaccine take-up; estimating indirect effects also poses difficulty as it requires exogenous variation in peer vaccination status. We overcome these challenges using unique microdata from Indiana together with a natural experiment. To identify direct effects, we use federal age-based vaccine eligibility rules by which seventh graders were eligible in Fall 2021 but sixth graders and younger were not. To identify indirect effects, we compare sixth graders in middle schools (whose older schoolmates are vaccine eligible) to sixth graders in elementary schools (whose schoolmates are ineligible). This variation in difference-in-differences designs leads to large estimates of direct effects: vaccination reduces COVID-19 incidence by 80 percent. But our estimates of indirect effects are small and statistically insignificant: despite a 20 percentage point increase in vaccination rates across all grades, we find essentially no difference in COVID-19 incidence between sixth graders in middle schools and sixth graders in elementary schools. A complementary identification strategy also finds small indirect effects from vaccinated grade-mates. This evidence from real-world settings matches clinical evidence forCOVID-19 vaccines’ benefits for the vaccinated, and provides new evidence that clinical trials were unable to examine, on indirect effects. Prior work on the influenza and pertussis vaccines has found substantial externalities, thus our findings suggest that prior evidence on one disease and its vaccine need not generalize to others.

Long Social Distancing
Jose Maria Barrero, Nicholas Bloom & Steven Davis
NBER Working Paper, October 2022


More than ten percent of Americans with recent work experience say they will continue social distancing after the COVID-19 pandemic ends, and another 45 percent will do so in limited ways. We uncover this Long Social Distancing phenomenon in our monthly Survey of Working Arrangements and Attitudes. It is more common among older persons, women, the less educated, those who earn less, and in occupations and industries that require many face-to-face encounters. People who intend to continue social distancing have lower labor force participation – unconditionally, and conditional on demographics and other controls. Regression models that relate outcomes to intentions imply that Long Social Distancing reduced participation by 2.5 percentage points in the first half of 2022. Separate self-assessed causal effects imply a reduction of 2.0 percentage points. The impact on the earnings-weighted participation rate is smaller at about 1.4 percentage points. This drag on participation reduces potential output by nearly one percent and shrinks the college wage premium. Economic reasoning and evidence suggest that Long Social Distancing and its effects will persist for many months or years.

Legal access to alcohol and automobile accidents: Potential interactive effects of alcohol and drug consumption
Briggs Depew & Jacob Meyer
Contemporary Economic Policy, forthcoming 


The combination of drugged and drunk driving is an important policy topic as some states and countries have liberalized prohibitions on substance use to varying degrees. In this study, we analyze the effect of legal access to alcohol on suspected drug impaired accidents. We find that accidents with suspected drug impairment significantly increase when a driver gains legal access to alcohol at age 21. Our findings suggest that even if alcohol and drug consumption are substitutes, as much of the literature suggests, potential interactive effects may offset the reduction in decreased alcohol consumption from drugs.

The association of obesity-related traits on COVID-19 severity and hospitalization is affected by socio-economic status: A multivariable Mendelian randomization study
Brenda Cabrera-Mendoza et al.
International Journal of Epidemiology, October 2022, Pages 1371–1383 

Methods: Applying two-sample MR approaches, we evaluated the effects of body mass index (BMI, n = 322 154), waist circumference (WC, n = 234 069), hip circumference (n = 213 019) and waist–hip ratio (n = 210 088) with respect to three COVID-19 outcomes: severe respiratory COVID-19 (cases = 8779, controls = 1 000 875), hospitalized COVID-19 (cases = 17 992, controls = 1 810 493) and COVID-19 infection (cases = 87 870, controls = 2 210 804). Applying a multivariable MR (MVMR) approach, we estimated the effect of these anthropometric traits on COVID-19 outcomes accounting for the effect of SES assessed as household income (n = 286 301).

Results: BMI and WC were associated with severe respiratory COVID-19 [BMI: odds ratio (OR) = 1.51, CI = 1.24–1.84, P = 3.01e-05; WC: OR = 1.48, 95% CI = 1.15–1.91, P = 0.0019] and hospitalized COVID-19 (BMI: OR = 1.50, 95% CI = 1.32–1.72, P = 8.83e-10; WC: OR = 1.41, 95% CI = 1.20–1.67, P = 3.72e-05). Conversely, income was associated with lower odds of severe respiratory (OR = 0.70, 95% CI = 0.53–0.93, P = 0.015) and hospitalized COVID-19 (OR = 0.78, 95% CI = 0.66–0.92, P = 0.003). MVMR analyses showed that the effect of these obesity-related traits on increasing the odds of COVID-19 negative outcomes becomes null when accounting for income. Conversely, the association of income with lower odds of COVID-19 negative outcomes is not affected when including the anthropometric traits in the multivariable model.

Association Between Folic Acid Prescription Fills and Suicide Attempts and Intentional Self-harm Among Privately Insured US Adults
Robert Gibbons et al.
JAMA Psychiatry, November 2022, Pages 1118-1123

Design, Setting, and Participants: A within-person exposure-only cohort design was used to study the dynamic association between folic acid (vitamin B9) prescription fills over a 24-month period and suicide attempts and intentional self-harm. Data were collected from a pharmacoepidemiologic database of US medical claims (MarketScan) for patients with private health insurance who filled a folic acid prescription between 2012 and 2017. The same analysis was repeated with a control supplement (cyanocobalamin, vitamin B12). Data were analyzed from August 2021 to June 2022.

Results: Data on 866 586 patients were collected; 704 514 (81.30%) were female, and 90 296 (10.42%) were 60 years and older. Overall, there were 261 suicidal events during months covered by a folic acid prescription (5 521 597 person-months) for a rate of 4.73 per 100 000 person-months, compared with 895 suicidal events during months without folic acid (8 432 340) for a rate of 10.61 per 100 000 person-months. Adjusting for age and sex, diagnoses related to suicidal behavior, diagnoses related to folic acid deficiency, folate-reducing medications, history of folate-reducing medications, and history of suicidal events, the hazard ratio (HR) for folic acid for suicide events was 0.56 (95% CI, 0.48-0.65), with similar results for the modal dosage of 1 mg of folic acid per day (HR, 0.57; 95% CI, 0.48-0.69) and women of childbearing age (HR, 0.60; 95% CI, 0.50-0.73). A duration-response analysis (1-mg dosage) revealed a 5% decrease in suicidal events per month of additional treatment (HR, 0.95; 95% CI, 0.93-0.97). The same analysis for the negative control, cyanocobalamin, found no association with suicide attempt (HR, 1.01; 95% CI, 0.80-1.27).

Do sugar-sweetened beverage taxes improve public health for high school aged adolescents?
James Flynn
Health Economics, forthcoming 


Sugar-sweetened beverage taxes have become an increasingly popular policy to combat the worldwide obesity epidemic, but relatively little is known about their impact on health outcomes, particularly among high school aged students. In this paper, I use public-use data from the Youth Risk Behavioral Surveillance System to determine whether high school students living in three of the American cities which have implemented Sugar-sweetened beverage taxes have experienced public health improvements. Using an event-study design that compares outcomes in treated districts to a group of similar control districts, I find reductions in soda consumption in Philadelphia and average body mass index in Philadelphia, San Francisco and Oakland, with suggestive evidence that the improvements are concentrated among female and non-white respondents in both cases.

Meatpacking working conditions and the spread of COVID-19
Thomas Patten Krumel & Corey Goodrich
Applied Economics, forthcoming 


This paper explores how working conditions in meatpacking plants contributed to the spread of the COVID-19 virus. Data from the Occupational Information Network was used to construct a set of industry-level working condition variables and compare meatpacking to the sample of other manufacturing industries in our comparison group. This novel approach showed that proximity to others in the meatpacking industry is likely the main factor influencing the spread of COVID-19, more than three standard deviations higher in meatpacking than our comparison sample of other manufacturing industries. Subsequently, we performed a county-level analysis on COVID-19 spread, comparing rural counties with a large share of meatpacking workers to nonmetropolitan counties that were similarly dependent on other single manufacturing industries, using the time frame of mid-March to the end of 2020. In mid-April 2020, COVID-19 cases in meatpacking-dependent rural counties rose to more than 12 times compared to rural counties dependent on other single manufacturing industries. This difference disappeared completely by mid-July and held steady throughout the year. We demonstrate that our results are robust to a battery of robustness checks ruling out the set of plausible alternative hypotheses, including examining data on COVID-19 spread among meatpacking workers directly.

Permanent daylight saving time would reduce deer-vehicle collisions
Calum Cunningham et al.
Current Biology, forthcoming 


Overlap between wildlife and human activity is key to causing wildlife-vehicle collisions, a globally pervasive and growing source of wildlife mortality. Policies regarding clock time often involve abrupt seasonal shifts in human activity, potentially influencing rates of human-wildlife conflict. Here, we harness the biannual shift between standard and daylight saving time as a natural experiment to reveal how the timing of human activity influences deer-vehicle collisions. Based on 1,012,465 deer-vehicle collisions and 96 million hourly traffic observations across the United States, we show that collisions are 14 times more frequent 2 hours after sunset than before sunset, highlighting the importance of traffic during dark hours as a key determinant of deer-vehicle collision risk. The switch from daylight saving to standard time in autumn causes peak traffic volumes to shift from before sunset to after sunset, leading to a 16% spike in deer-vehicle collisions. By reducing traffic after dark, our model predicts that year-round daylight saving time would prevent 36,550 deer (Odocoileus sp.) deaths, 33 human deaths, 2,054 human injuries, and US$1.19 billion in collision costs annually. In contrast, permanent standard time is predicted to increase collisions by an even larger magnitude, incurring an additional US$2.39 billion in costs. By targeting the temporal dimension of wildlife-vehicle collisions, strategies such as year-round daylight saving time that reduce traffic during dark hours, especially during the breeding season of abundant ungulates, would yield substantial benefits for wildlife conservation and reduce the social and economic costs of deer-vehicle collisions.

Understanding Geographic Disparities in Mortality
Jason Fletcher et al.
NBER Working Paper, October 2022 


A rich literature shows that early life conditions shape later life outcomes, including health and migration events. However, analyses of geographic disparities in mortality outcomes focus almost exclusively on contemporaneously measured geographic place (e.g., state of residence at death), thereby potentially conflating the role of early life conditions, migration patterns, and effects of destinations. We use the newly available Mortality Disparities in American Communities (MDAC) dataset, which links respondents in the 2008 ACS to official death records and estimate consequential differences by method of aggregation; the mean absolute deviation of the difference in life expectancy at age 50 measured by state of birth versus state of residence is 0.58 (0.50) years for men and 0.40 (0.29) years for women. These differences are also spatially clustered, and we show that regional inequality in life expectancy is higher based on life expectancies by state of birth, implying that interstate migration mitigates baseline geographical inequality in mortality outcomes. Finally, we assess how state-specific features of in-migration, out-migration, and non-migration together shape measures of mortality disparities by state (of residence), further demonstrating the difficulty of clearly interpreting these widely used measures.

Public health departments and the mortality transition in Latin America: Evidence from Puerto Rico
Brian Marein
Journal of Development Economics, forthcoming 


This paper examines the role of public health in reducing mortality prior to modern medicine by studying Puerto Rico in the early 20th century. From 1930 to 1960, Puerto Rico experienced one of the fastest increases in life expectancy in world history and completed the first mortality transition outside of Europe and Western offshoots. Using municipal-level data in an event study framework, I show that public health units (county health departments) caused around half of the reduction in infant and tuberculosis mortality and one-sixth of the decline in general mortality from 1923 to 1945 — and did so without significantly increasing public expenditures. Public health units also reduced maternal mortality and stillbirths but, consistent with the historical record, did not significantly affect malaria mortality. I present descriptive evidence that more assistant midwives per capita correspond to larger declines in maternal mortality, suggesting the importance of the training and licensing of midwives by health units. This investigation provides a window into Latin America more broadly, since most countries in Latin America adopted public health units after Puerto Rico.


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