Explaining declines in US rural mortality, 1910–1933: The role of county health departments☆
Introduction
At the beginning of the twentieth century, urban-focused public health in the United States neglected the nearly 60% of the population residing in rural areas. While urban centers were considered magnets of disease and filth, both urban and rural infants faced a one in ten chance of dying before their first birthday.1 To combat the rural health problem, the United States Public Health Service (USPHS) and related organizations encouraged county governments to establish full-time public health departments over 1908–1933. In this study, I question whether the services offered by county-level health departments (CHDs) impacted the local mortality conditions in targeted counties. Reports surrounding the history of CHDs detail the advantages of the program, but the causal inference is limited. For instance, in Tennessee CHD counties over 1927–1929 ”the recorded death rate from diphtheria was about 20% lower and that from typhoid fever about 40% lower” (Lumsden, 1920 pp. 2630). Due to the limited inference from these direct comparisons, a more robust program evaluation is warranted.
I reconsider the effect of the national program using an event-study design that exploits variation in when and where CHDs were adopted. This event-study tracks mortality in each year before and after the CHD arrived.2 To estimate the event study, I digitize a novel dataset of health department administrative records from 1908 to 1933. I combine these records with county-level mortality data, census data, and taxation data.3 Using the event-study design, I find that CHDs persistently reduced local infant mortality but had no consistent impact on overall population mortality.4 Unlike urban public health investments, CHDs were only beneficial for infants and cannot explain the overall mortality transition in rural areas. The estimates suggest that health investments persistently reduced infant mortality by two deaths per 1000 births. Based on the period decline in infant mortality from 88 deaths per 1000 births to 62 deaths per 1000 births, CHD access accounts for eight percent of the rural infant mortality decline over the span of the rollout.5 The magnitude of this effect is similar but slightly lower than the impact of the Sheppard–Towner Act found in Moehling and Thomasson (2014).6 By contrast, the effect is small relative to urban sanitation investment, which (Alsan and Goldin, 2015) attribute with 44% of the decline in infant mortality between 1880 and 1915.
Next, I consider the effect on subpopulations and find that the mortality reductions are highest in worse-off communities. CHDs disproportionately benefited nonwhites, rural-only counties, and counties with lower wealth and limited access to private physicians.7 Ideally, I would also test which diseases CHDs were nationally effective against. Unfortunately, a major limitation of this study is that lack of county-level by-cause mortality data during the rollout. As an alternative, I test the disease-specific effects with by-cause morbidity and mortality data from Michigan, Alabama, and North Carolina. I find that CHDs are associated with declines in cases of diphtheria, typhoid, and smallpox, as well as lower maternal mortality. These findings indicate that CHDs may have targeted infant mortality with treatments, vaccines, or hygiene information.8
This study contributes to the literature by being one of the first to focus on a rural-oriented public health program during the early twentieth century. A closely related study, (Higgs, 1973), documents the rural mortality decline leading up to this study (1890–1915) and argues that standard of living improvements produced the decline rather than rural public health programs. This study picks up where (Higgs, 1973) left off and is one of the first to focus on rural public health in the early twentieth century. While rural health has been sparsely studied, there is an extensive literature covering state and city-level efforts. The city-level literature has shown that urban public health investments led to significant declines in adult and infant mortality (Troesken, 1999, Troesken, 2001, Haines, 2001, Cutler, Miller, 2005, and Alsan and Goldin, 2015). Prior work has also documented the benefit of more unified public health efforts across several states (Olmstead, Rhode, 2004, Bleakley, 2010, and Moehling and Thomasson, 2014). Two closely related studies, Moehling and Thomasson (2014) and Bleakley (2007), have considered similar funding initiatives in related contexts. Moehling and Thomasson (2014) examines the Sheppard–Towner Act and finds decreased state-level infant mortality in targeted areas. Bleakley (2007) considers the efforts of the Rockefeller Sanitation Commission’s participation (RSC) in hookworm eradication.
The remainder of this study proceeds as follows. Section 2 covers the history of the health investment. Section 3 presents the event-study design and then Section 4 describes the administrative, mortality, and tax data used throughout the study. Section 5 displays the event-study results. Section 6 considers the mechanisms behind the effect. Section 7 concludes.
Section snippets
History of funding
The country’s first CHD was internally funded and opened outside of Louisville in Jefferson County, Kentucky. Beginning in 1911, the USPHS piloted a second department in Yakima County, Washington to contain an outbreak of typhoid fever. The Yakima department improved irrigation and water sanitation throughout the county, and subsequently reported a steep decline in typhoid-specific mortality. After that success, the USPHS took the CHD movement to the South and advanced water sanitation to
Event-study specification
To measure whether health departments were effective at improving rural mortality conditions, I exploit variation in the timing and the location of CHD entry. I track mortality before and after health department arrival using a flexible event-study design. The event study accounts for changes in mortality that could have spurred county governments to open a CHD.22
Healthinvestment data
For this study, I digitized the History of County Health Organizations (Ferrell et al., 1936), which tracks the rollout of CHDs from 1908 until 1933. The USPHS compiled the document as a central financial record of the rural health movement. This data source includes detailed annual data regarding the employed staff and the budget by source. The document maintains that it is the complete record of CHDs in the United States.28
Main results
Fig. 6 plots the coefficients from the event-study dummy variables from Eq. (1). Panel A shows the overall mortality rate in green and Panel B shows the infant mortality rate in blue. Each plotted line represents a weighted least squares estimation of the county-level mortality rate, with the overall rate weighted by the population and the infant mortality weighted by the number of births. The plotted points connected by solid lines represent the estimated coefficients on the county-level
Intensive margin effects
The main finding of this paper suggests that CHDs produced a robust and significant decline in infant mortality by two deaths per 1000 births. The channels by which CHDs improved infant mortality remain unclear from the baseline results. To illuminate how health departments improved infant outcomes, I modify my approach to a difference-in-differences estimation and test how infant mortality is affected by altering the intensity of CHD efforts. To test which CHD efforts were most productive, I
Conclusion
This study tracks one of the first and largest rural health programs in US history. The rollout of county health departments was expansive and included roughly 725 counties throughout 38 states. Despite the size and scope of the CHD program, there has been little effort to study the causal impact of the program. The present study is the first to investigate the health effects of CHD access and is one of the first papers to explore rural public health in the early twentieth century. With the
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I am grateful to Claudia Olivetti, S Anukriti, and Robert Margo for their gracious feedback on this project. I thank Jacob Penglase, all the participants at the Harvard Economic History Lunch, the Boston University Economic History Reading Group, the 2016 NBER DAE Summer Institute, the 2016 EHA Annual Meeting, the 2017 WEAI Graduate Student Workshop, the Boston College Applied Micro Workshop, and the Boston College Dissertation Workshop for their valuable suggestions and comments.