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The Role of Public Health Improvements in Health Advances: The 20th Century United States

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  • David M. Cutler
  • Grant Miller

Abstract

Mortality rates in the US fell more rapidly during the late 19th and early 20th Centuries than any other period in American history. This decline coincided with an epidemiological transition and the disappearance of a mortality "penalty" associated with living in urban areas. There is little empirical evidence and much unresolved debate about what caused these improvements, however. This paper investigates the causal influence of clean water technologies - filtration and chlorination - on mortality in major cities during the early 20th Century. Plausibly exogenous variation in the timing and location of technology adoption is used to idetify these effects, and the validity of this identifying assumption is examined in detail. We find that clean water was responsible for nearly half of the total mortality reduction in major cities, three-quarters of the infant mortality reduction, and nearly two-thirds of the child mortality reduction. Rough calculations suggest that the social rate of return to these technologies was greater than 23 to 1 with a cost per life-year saved by clean water of about $500 in 2003 dollars. Implications for developing countries are briefly considered.

Suggested Citation

  • David M. Cutler & Grant Miller, 2004. "The Role of Public Health Improvements in Health Advances: The 20th Century United States," NBER Working Papers 10511, National Bureau of Economic Research, Inc.
  • Handle: RePEc:nbr:nberwo:10511
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    1. Angus S. Deaton & Christina Paxson, 2001. "Mortality, Education, Income, and Inequality among American Cohorts," NBER Chapters,in: Themes in the Economics of Aging, pages 129-170 National Bureau of Economic Research, Inc.
    2. Samuel H. Preston & Michael R. Haines, 1991. "Fatal Years: Child Mortality in Late Nineteenth-Century America," NBER Books, National Bureau of Economic Research, Inc, number pres91-1, June.
    3. Fogel, Robert W, 1994. "Economic Growth, Population Theory, and Physiology: The Bearing of Long-Term Processes on the Making of Economic Policy," American Economic Review, American Economic Association, vol. 84(3), pages 369-395, June.
    4. Viscusi, W Kip & Aldy, Joseph E, 2003. "The Value of a Statistical Life: A Critical Review of Market Estimates throughout the World," Journal of Risk and Uncertainty, Springer, vol. 27(1), pages 5-76, August.
    5. Adriana Lleras-Muney, 2005. "The Relationship Between Education and Adult Mortality in the United States," Review of Economic Studies, Oxford University Press, vol. 72(1), pages 189-221.
    6. William H. Dow & Jessica Holmes & Tomas Philipson & Xavier Sala-i-Martin, 1995. "Disease Complementarities and the Evaluation of Public Health Interventions," NBER Working Papers 5216, National Bureau of Economic Research, Inc.
    7. repec:reg:rpubli:282 is not listed on IDEAS
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    Citations

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    Cited by:

    1. David Cutler & Angus Deaton & Adriana Lleras-Muney, 2006. "The Determinants of Mortality," Journal of Economic Perspectives, American Economic Association, vol. 20(3), pages 97-120, Summer.
    2. Steve E. Hrudey, 2011. "Safe Drinking Water Policy for Canada - Turning Hindsight into Foresight," C.D. Howe Institute Commentary, C.D. Howe Institute, issue 323, February.
    3. Joseph P. Ferrie & Werner Troesken, 2005. "Death and the City: Chicago's Mortality Transition, 1850-1925," NBER Working Papers 11427, National Bureau of Economic Research, Inc.
    4. Sonia Bhalotra, 2007. "Spending to save? State health expenditure and infant mortality in India," Health Economics, John Wiley & Sons, Ltd., vol. 16(9), pages 911-928.
    5. Michael Kremer & Alix Peterson Zwane, 2007. "Cost-Effective Prevention of Diarrheal Diseases: A Critical Review," Working Papers 117, Center for Global Development.
    6. Yusuf, Shahid & Nabeshima, Kaoru & Wei Ha, 2007. "What makes cities healthy ?," Policy Research Working Paper Series 4107, The World Bank.
    7. Nejat Anbarci & Monica Escaleras & Charles A. Register, 2012. "From Cholera Outbreaks to Pandemics: The Role of Poverty and Inequality," The American Economist, Sage Publications, vol. 57(1), pages 21-31, May.
    8. Karen Clay & Werner Troesken, 2006. "Deprivation and Disease in Early Twentieth-Century America," NBER Working Papers 12111, National Bureau of Economic Research, Inc.
    9. David M. Cutler & Grant Miller, 2006. "Water, Water Everywhere. Municipal Finance and Water Supply in American Cities," NBER Chapters,in: Corruption and Reform: Lessons from America's Economic History, pages 153-184 National Bureau of Economic Research, Inc.
    10. Okunade, Albert A., 2004. "Concepts, measures, and models of technology and technical progress in medical care and health economics," The Quarterly Review of Economics and Finance, Elsevier, vol. 44(3), pages 363-368, July.
    11. David Bishai & Divya Nair & Taghreed Adam, 2012. "Economics of Public Health Interventions for Children in Developing Countries," Chapters,in: The Elgar Companion to Health Economics, Second Edition, chapter 5 Edward Elgar Publishing.
    12. Alan Martina, 2007. "A Class of Poverty Traps: A Theory and Empirical Tests," ANU Working Papers in Economics and Econometrics 2007-482, Australian National University, College of Business and Economics, School of Economics.

    More about this item

    JEL classification:

    • H4 - Public Economics - - Publicly Provided Goods
    • I1 - Health, Education, and Welfare - - Health

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