Health Shocks and Their Long-Lasting Impact on Health Behaviors

Journal of Health Economics 54 (2017) 40–55 Contents lists available at ScienceDirect Journal of Health Economics jo urnal homepage: www.elsevier.com/locate/econbase Health shocks and their long-lasting impact on health behaviors: Evidence from the 2009 H1N1 pandemic in Mexico a b,∗,1 Jorge M. Agüero , Trinidad Beleche a University of Connecticut, Department of Economics and El Instituto, 365 Fairfield Way, Storrs, CT 06269-1063, United States b RAND Corporation, 1200 South Hayes Street, Arlington, VA 22202, United States a r a t i b s c t l e i n f o r a c t Article history: Worldwide, the leading causes of death could be avoided with health behaviors that are low-cost but also Received 4 June 2016 difficult to adopt. We show that exogenous health shocks could facilitate the adoption of these behaviors Received in revised form and provide long-lasting effects on health outcomes. Specifically, we exploit the spatial and temporal 19 December 2016 variation of the 2009 H1N1 influenza pandemic in Mexico and show that areas with a higher incidence of Accepted 27 March 2017 H1N1 experienced larger reductions in diarrhea-related cases among young children. These reductions Available online 31 March 2017 continue even three years after the shock ended. Health improvements and evidence of information seeking via Google searches were consistent with changes in hand washing behaviors. Several robustness JEL-codes: I12 checks validate our findings and mechanism. I15 Published by Elsevier B.V. Keywords: Health shocks Health behaviors Hand washing Children Diarrhea 1. Introduction behaviors is very low (Dupas, 2011). For instance, while the role of hand washing as an effective way to reduce gastrointestinal dis- 2 Worldwide, the adoption of low-cost technologies could eases has been known for more than a century (Koplik, 1902), in improve health outcomes and save lives. For example, regular phys- developing countries, only 30% of household members wash their ical activity reduces the risk of diabetes; condoms help reduce the hands before preparing food or after defecation. In some coun- spread of sexually transmitted diseases, including HIV; reductions tries the rate is as low as zero (World Bank, 2005; Chase and Do, in cigarette consumption help avoid pulmonary cancer; and hand 2010). Moreover, intensive small-scale interventions show signif- washing with soap prevents gastrointestinal diseases. However, icant reductions in diarrhea (e.g., Ejemot-Nwadiaro et al., 2008; 3 despite their effectiveness, the take up rates of these products or Luby et al., 2004; Luby et al., 2005), but scaling up similar inter- ∗ Corresponding author. Present address: U.S. Food and Drug Administration, 2 10903 New Hampshire Ave, White Oak Campus Building 32, Room 4263, Silver For example, Koplik (1902) summarizes the research of the previous decade and Spring, MD 20903, United States. recommends the “scrupulously” cleaning of hands and nails (“with brush and file”) E-mail addresses: [email protected] (J.M. Agüero), [email protected] after changing a diaper for nurses handling a newborn. Mothers, he added, “should (T. Beleche). carefully cleanse their hands before feeding the baby” (p. 321). The rationale for 1 We have benefitted from conversations with Mindy Marks, Michael Grossman, this hygiene practice was also well understood “since this way contamination of the Ted Joyce, Jeffrey Harris, Clair Null, Jungbin Hwang and Steve Luby as well as con- infant’s food with fecal bacteria is avoided” (p. 46). 3 ference participants at PAA 2013, LAMES 2013, ASSA 2014, NBER Summer Institute Common interventions to reduce diarrhea have focused on providing infrastruc- 2014, SEA 2015, Ridge 2016 and seminar participants at RAND, FDA, Center for ture or information. Infrastructure projects focus on providing safe water supplies Disease, Dynamics, Economics & Policy (CDDEP), Virginia Tech, University of Col- and sanitation (e.g., Pattanayak et al., 2009; Kremer et al., 2011), micronutrients orado Denver, Vassar College, University of North Dakota, Northeastern University, or vaccinations (Dowling and Yap 2014. Information-based interventions focus on American University, George Washington University and University of the Witwa- hygiene education and community-led total sanitation (CLTS) (Dowling and Yap tersrand. This work was partially conducted while at the RAND Corporation. This 2014. Also, recent papers have discussed the external validity of these studies. See article reflects the views of the authors and should not be construed to represent Hammer and Spears (2016) for a discussion on whether the sites where village FDA’s views or policies. sanitation projects take place might be likely to exhibit large effects. http://dx.doi.org/10.1016/j.jhealeco.2017.03.008 0167-6296/Published by Elsevier B.V. J.M. Agüero, T. Beleche / Journal of Health Economics 54 (2017) 40–55 41 4 ventions does not (e.g., Meredith et al., 2013; Galiani et al., 2012). increase in the incidence of the H1N1 is associated with more Understanding the barriers for the adoption of these preventive searches for this preventive behavior. Other mechanisms, such as behaviors and products is an urgent issue in health and develop- the role of government expenditure and health infrastructure, do ment economics. not seem to play a major role. A growing literature in economics is studying the role that Further incidence of the H1N1 after 2009 allows us to test information plays on health behaviors as a salient input in the whether such “reminders” continue to have an impact on health 5 production of health outcomes (Cawley and Ruhm 2011). In par- outcomes beyond 2009. Using an event study we show that the ticular, an emerging conclusion suggests that the mere provision of contemporaneous negative effect is observed in 2009 and 2010 but information might not matter (e.g., smokers do know that smoking disappears by 2012. However, when testing for the persistence of is harmful and may even overestimate the risk of smoking, Viscusi, the 2009 shock, we find that this effect dominates the contempo- 1990). Rather, the emphasis seems to be on when information alters raneous impact suggesting long-lasting consequences of the larger the decision-making process (Luoto and Carman 2014). Our paper shock. This is an important result because, as we will show later, contributes to this literature by showing that health shocks such the evidence on whether information campaigns have long-lasting as disease outbreaks can operate as “natural nudges” that facilitate effects is scant (e.g., Cairncross et al., 2005). changes in health behaviors that lead to improvements in health Taken together, our results provide empirical support to recent outcomes, and that these types of shock-induced improvements behavioral economics models where large health shocks alter the can have long-lasting effects. risk perceptions of individuals and affect the production of health In particular, we illustrate how in Mexico, a middle-income outcomes. In that regard, our findings are consistent with previ- country with near universal access to water and sanitation but ous studies that have shown, in the case of the United States, that where intestinal infections are the second main cause of child death smokers are more likely to quit when they experience more severe and 11 percent of children under five suffer from acute diarrhea, health shocks (Sloan et al., 2003; Margolis et al., 2014). It is also the onset of the 2009 H1N1 influenza (swine flu) led to a large, consistent with the findings from Philipson and Posner (1994), who robust and long-lasting decline in diarrhea cases of children. This document a rapid reduction in gonorrhea for the male homosexual is done with a difference-in-difference framework using a bal- community in San Francisco as a result of a change towards safer anced panel of annual state-level data aggregated from hospital sex practices soon after the onset of the HIV pandemic. discharges related to diarrhea and the total number of laboratory The rest of the paper is divided into six additional sections. We confirmed cases of the swine flu in Mexico derived from Mexico’s start by briefly describing the H1N1 outbreak in Mexico in section Ministry of Health (Secretaria de Salud). two. Section three describes the data sources and our economet- Relying on administrative data −where trained medical profes- ric model. The main results, including our robustness checks, are sionals register their diagnoses– and several robustness checks, we presented in section four. Section five describes the possible mech- rule out the possibility that our findings are driven by misdiagno- anisms while section six examines the persistence of the effects. sis of either H1N1 or diarrhea cases. Additional placebo tests and Section seven summarizes our findings, discusses policy implica- robustness checks further support our results. For example, we find tions as well as the way our paper expands our understanding of no association between diarrhea-related cases before the H1N1 out- the production of health outcomes and concludes. break (2006–2008) and the number of confirmed swine flu cases observed in 2009. There is also no evidence of people avoiding 2. Mexico and the 2009 swine flu pandemic hospitals altogether due to the H1N1 pandemic. Furthermore, the negative effect on diarrhea is also observed in morbidity cases In March and early April 2009, Mexico experienced an outbreak beyond hospitalizations, as captured by Mexico’s Annual Morbidity of respiratory illnesses which was later confirmed to have been 6 Statistics. caused by the novel influenza A(H1N1) 2009 virus or swine flu. The Unlike the small (and anticipated) nature of the seasonal flu, it H1N1 is a contagious virus transmitted via droplets from coughs quickly became clear that the new H1N1 strain was easily trans- and sneezes or by interacting with infected people. This influenza mittable and that existing vaccines did not prevent contracting the virus can survive on environmental surfaces such as kitchen coun- swine flu.

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