Public health investments and the infant mortality gap: Evidence from federal sanitation interventions on U.S. Indian reservations

Abstract

To what extent do differential levels of investment in public health inputs explain observed differences in health outcomes across socioeconomic and racial groups? This study investigates the impact of 3,700 projects that were part of a widespread Federal initiative to improve sanitation infrastructure on U.S. Indian reservations starting in 1960. Sanitation investment substantially reduced the cost of clean water for households, leading to sharp reductions in both waterborne gastrointestinal disease and infectious respiratory disease among Native American infants. The sanitation program was quite cost-effective, in part because improvements in the overall disease environment also reduced infectious respiratory disease among nearby white infants. Despite the health externalities, Federal sanitation interventions explain almost forty percent of the convergence in Native American and white infant mortality rates in reservation counties since 1970. Abstract: To what extent do differential levels of investment in public health inputs explain observed differences in health outcomes across socioeconomic and racial groups? This study investigates the impact of 3,700 projects that were part of a widespread Federal initiative to improve sanitation infrastructure on U.S. Indian reservations starting in 1960. Sanitation investment substantially reduced the cost of clean water for households, leading to sharp reductions in both waterborne gastrointestinal disease and infectious respiratory disease among Native American infants. The sanitation program was quite cost-effective, in part because improvements in the overall disease environment also reduced infectious respiratory disease among nearby white infants. Despite the health externalities, Federal sanitation interventions explain almost forty percent of the convergence in Native American and white infant mortality rates in reservation counties since 1970.3

Effects of Early-Life Exposure to Sanitation on Childhood Cognitive Skills: Evidence from India's Total Sanitation Campaign

“…Cutler and Miller (2005) show an effect of adoption of clean water technology in U.S. cities on mortality rates in the twentieth century. Watson (2006) documents an effect of improving sanitation in U.S. Native American populations on infant mortality.…”

Place and Child Health: The Interaction of Population Density and Sanitation in Developing Countries

“…Poor sanitation can also spread parasitic infections, which are rarely fatal by themselves but contribute to poor health and poor physical growth (Haque 2007). 4 Several studies in economics have also identified important effects of sanitation-related diseases on anemia and early-life mortality (e.g., Coffey et al Forthcoming;Cutler and Miller 2005;Galiani et al 2005;Watson 2006) as well as effects on subsequent human capital accumulation (e.g., Baird et al 2016;Bleakley 2007;Hammer and Spears 2016;Spears and Lamba 2016).…”

What Works in Fighting Diarrheal Diseases in Developing Countries? A Critical Review

“…In a rural setting, Watson (2006) exploits the fact that a series of water and sanitation interventions introduced on Native American reservations in the United States during 1960-1998 were likely uncorrelated with other factors affecting infant health and plausibly exogenous to local community characteristics after accounting for county and year fixed effects. This research suggests that a 10 percent increase in the fraction of homes with improved water and sanitation services reduced infant mortality by 4 percent.…”

“…In the United States, these interventions were jointly responsible for most of the rapid decline in the child mortality rate in the early 20th century (Cutler and Miller 2005), and more recently for substantial health improvements on Native American reservations (Watson 2006). For this class of interventions, a key outstanding question is what institutional arrangements can best support investment in infrastructure and its maintenance.…”