Relative Risk

Kevin Lewis

September 08, 2021

Inequality in Mortality between Black and White Americans by Age, Place, and Cause, and in Comparison to Europe, 1990-2018
Hannes Schwandt et al.
NBER Working Paper, September 2021 

Although there is a large gap between Black and White American life expectancies, the gap fell 48.9% between 1990-2018, mainly due to mortality declines among Black Americans. We examine age-specific mortality trends and racial gaps in life expectancy in rich and poor U.S. areas and with reference to six European countries. Inequalities in life expectancy are starker in the U.S. than in Europe. In 1990 White Americans and Europeans in rich areas had similar overall life expectancy, while life expectancy for White Americans in poor areas was lower. But since then even rich White Americans have lost ground relative to Europeans. Meanwhile, the gap in life expectancy between Black Americans and Europeans decreased by 8.3%. Black life expectancy increased more than White life expectancy in all U.S. areas, but improvements in poorer areas had the greatest impact on the racial life expectancy gap. The causes that contributed the most to Black mortality reductions included: Cancer, homicide, HIV, and causes originating in the fetal or infant period. Life expectancy for both Black and White Americans plateaued or slightly declined after 2012, but this stalling was most evident among Black Americans even prior to the COVID-19 pandemic. If improvements had continued at the 1990-2012 rate, the racial gap in life expectancy would have closed by 2036. European life expectancy also stalled after 2014. Still, the comparison with Europe suggests that mortality rates of both Black and White Americans could fall much further across all ages and in both rich and poor areas.

COVID-19 mortalities in England and Wales and the Peltzman offsetting effect
Sam Williams et al.
Applied Economics, forthcoming

There are two approaches to measuring COVID-19 deaths -- ‘COVID associated deaths’ and ‘excess deaths’. An excess deaths framework is preferable, as there is measurement error in COVID associated deaths, due to issues relating to imperfect information about deaths that are directly attributable to COVID-19. The standard measure of excess deaths (comparison of deaths to a 5-year average) is subject to an omitted variables problem, as it attributes the entirety of the variation in mortality to COVID-19. We propose a method to estimate a refined measure of COVID-19 excess deaths in England and Wales that addresses the omitted impact of the first blanket lockdown. Using the counterfactual, we obtain a first stage estimate of excess deaths. In the second stage, this is decomposed into estimates of a refined measure of COVID-19 excess deaths and the excess mortality impact of lockdown. Our results suggest: (i) a refined estimate of mean weekly COVID-19 excess deaths that is 63% of standard excess deaths; and (ii) a positive net excess mortality impact of the lockdown. We make a case that (ii) is due to the Peltzman offsetting effect, i.e. the intended mortality impact of the lockdown was more than offset by the unintended impact. 

Intensity and frequency of extreme novel epidemics
Marco Marani et al.
Proceedings of the National Academy of Sciences, 31 August 2021 

Observational knowledge of the epidemic intensity, defined as the number of deaths divided by global population and epidemic duration, and of the rate of emergence of infectious disease outbreaks is necessary to test theory and models and to inform public health risk assessment by quantifying the probability of extreme pandemics such as COVID-19. Despite its significance, assembling and analyzing a comprehensive global historical record spanning a variety of diseases remains an unexplored task. A global dataset of historical epidemics from 1600 to present is here compiled and examined using novel statistical methods to estimate the yearly probability of occurrence of extreme epidemics. Historical observations covering four orders of magnitude of epidemic intensity follow a common probability distribution with a slowly decaying power-law tail (generalized Pareto distribution, asymptotic exponent = −0.71). The yearly number of epidemics varies ninefold and shows systematic trends. Yearly occurrence probabilities of extreme epidemics, Py, vary widely: Py of an event with the intensity of the “Spanish influenza” (1918 to 1920) varies between 0.27 and 1.9% from 1600 to present, while its mean recurrence time today is 400 y (95% CI: 332 to 489 y). The slow decay of probability with epidemic intensity implies that extreme epidemics are relatively likely, a property previously undetected due to short observational records and stationary analysis methods. Using recent estimates of the rate of increase in disease emergence from zoonotic reservoirs associated with environmental change, we estimate that the yearly probability of occurrence of extreme epidemics can increase up to threefold in the coming decades.

Clinical evidence that the pandemic from 1889 to 1891 commonly called the Russian flu might have been an earlier coronavirus pandemic
Harald Brüssow & Lutz Brüssow
Microbial Biotechnology, forthcoming

Contemporary medical reports from Britain and Germany on patients suffering from a pandemic infection between 1889 and 1891, which was historically referred to as the Russian flu, share a number of characteristics with COVID-19. Most notable are aspects of multisystem affections comprising respiratory, gastrointestinal and neurological symptoms including loss of taste and smell perception; a protracted recovery resembling long covid and pathology observations of thrombosis in multiple organs, inflammation and rheumatic affections. As in COVID-19 and unlike in influenza, mortality was seen in elderly subjects while children were only weakly affected. Contemporary reports noted trans-species infection between pet animals or horses and humans, which would concur with a cross-infection by a broad host range bovine coronavirus dated by molecular clock arguments to an about 1890 cross-species infection event.

Physical pain, gender, and economic trends in 146 nations
Lucía Macchia & Andrew Oswald
Social Science & Medicine, forthcoming

Methods: The study uses pooled cross-sectional Gallup data from 146 countries (total N > 1,350,000). It estimates fixed-effects regression equations that control for personal characteristics.

Results: More than a quarter of the world's citizens are in physical pain. Physical pain is lower in a boom and greater in an economic downturn. Estimated effect sizes are substantial. Remarkably, increases in pain are borne almost exclusively by women and found principally in rich nations. These findings have paradoxical aspects. The counter-cyclicality of physical pain is not what would be predicted by conventional economic analysis: during an expansion, people typically work harder and longer, and accidents and injuries increase. Nor are the study results due to unemployed citizens experiencing more pain (although they do). Instead, the study's findings are consistent with an important hypothesis proposed recently, using different kinds of evidence, by brain and behavioural-science researchers (e.g., Wiech and Tracey, 2009). The hypothesis is that economic worry can create physical pain.

Evidence and theory for lower rates of depression in larger US urban areas
Andrew Stier et al.
Proceedings of the National Academy of Sciences, 3 August 2021

It is commonly assumed that cities are detrimental to mental health. However, the evidence remains inconsistent and at most, makes the case for differences between rural and urban environments as a whole. Here, we propose a model of depression driven by an individual’s accumulated experience mediated by social networks. The connection between observed systematic variations in socioeconomic networks and built environments with city size provides a link between urbanization and mental health. Surprisingly, this model predicts lower depression rates in larger cities. We confirm this prediction for US cities using four independent datasets. These results are consistent with other behaviors associated with denser socioeconomic networks and suggest that larger cities provide a buffer against depression. This approach introduces a systematic framework for conceptualizing and modeling mental health in complex physical and social networks, producing testable predictions for environmental and social determinants of mental health also applicable to other psychopathologies.

The Opioid Safety Initiative and Veteran Suicides
Joshua Tibbitts & Benjamin Cowan
NBER Working Paper, August 2021 

We investigate the relationship between opioid diverting policy and suicides among the veteran population. The opioid epidemic of the past two decades has had devastating health consequences among U.S. veterans and military personnel. In 2013, the Veterans Health Administration (VA) implemented the Opioid Safety Initiative (OSI) with the goal of discouraging prescription opioid dependence among VA patients. Between 2012 and 2017, prescription opioids dispensed by the VA fell 41% (VA, 2018). Because this involved the aggressive curtailing of opioid prescriptions for many VA patients, OSI may have had a detrimental effect on veterans’ mental health leading to suicide in extreme cases. In addition, because rural veterans have much higher rates of VA enrollment, more prescription opioid use and abuse, and lower rates of substance abuse and mental health treatment utilization, we expect any effect of OSI on veteran suicides to be concentrated in rural areas. We find that OSI raised the veteran suicide rate relative to the non-veteran (“civilian”) rate with rural veterans suffering the lion’s share of the increase. We estimate that OSI raised the rural veteran suicide rate by a little over one-third between 2013 and 2018.

Intended and Unintended Effects of E-cigarette Taxes on Youth Tobacco Use 
Rahi Abouk et al.
NBER Working Paper, September 2021

Over the past decade, rising youth use of e-cigarettes and other electronic nicotine delivery systems (ENDS) has prompted aggressive regulation by state and local governments. Between 2010 and 2019, ten states and two large counties adopted ENDS taxes. Applying a continuous treatment difference-in-differences approach to data from two large national datasets (Monitoring the Future and the Youth Risk Behavior Surveillance System), this study explores the impact of ENDS taxes on youth tobacco use. We find that ENDS taxes reduce youth e-cigarette consumption, with estimated e-cigarette tax elasticities of -0.06 to -0.21. However, we estimate sizable positive cigarette cross-tax elasticities, suggesting economic substitution between cigarettes and e-cigarettes for youth. These substitution effects are particularly large for frequent cigarette smoking. We conclude that the unintended effects of ENDS taxation may more than fully offset any public health gains.

Recreational cannabis laws and opioid-related emergency department visit rates 
Coleman Drake et al.
Health Economics, forthcoming 

The opioid epidemic in the United States has accelerated during the COVID-19 pandemic. As of 2021, roughly a third of Americans now live in a state with a recreational cannabis law (RCL). Recent evidence indicates RCLs could be a harm reduction tool to address the opioid epidemic. Individuals may use cannabis to manage pain, as well as to relieve opioid withdrawal symptoms, though it does not directly treat opioid use disorder. It is thus unclear whether RCLs are an effective policy tool to reduce adverse opioid-related health outcomes. In this study, we examine the impact of RCLs on a key opioid-related adverse health outcome: opioid-related emergency department (ED) visit rates. We estimate event study models using nearly comprehensive ED data from 29 states from 2011 to 2017. We find that RCLs reduce opioid-related ED visit rates by roughly 7.6% for two quarters after implementation. These effects are driven by men and adults aged 25–44. These effects dissipate after 6 months. Our estimates indicate RCLs did not increase opioid-related ED visits. We conclude that, while cannabis liberalization may offer some help in curbing the opioid epidemic, it is likely not a panacea. 

Transition from Injecting Opioids to Smoking Fentanyl in San Francisco, California
Alex Kral et al.
Drug and Alcohol Dependence, forthcoming 

Methods: We used targeted sampling to recruit 395 people who inject drugs (PWID) into an observational cohort study in San Francisco 2018-2020. We assessed changes in injection frequency, opioid injection frequency and fentanyl smoking frequency in four six-month periods. We also conducted qualitative interviews with PWID asking about motivations for injecting and smoking opioids.

Results: The median number of past-month injections steadily decreased by semi-annual calendar year from 92 injections in July to December 2018 to 17 injections in January to June 2020. The rate of opioid injections reduced by half (Adjusted Incidence Rate Ratio = 0.41; 95% Confidence Interval = 0.25, 0.70; p < 0.01). The number of days smoking fentanyl was associated with fewer number of injections (X2(2) = 11.0; p < 0.01). Qualitative interviews revealed that PWID’s motivation for switching from injecting tar heroin to smoking fentanyl was related to difficulties accessing veins. After switching to smoking fentanyl, they noticed many benefits including how the drug felt, improved health, fewer financial constraints, and reduced stigma.

Association of prescription drug monitoring program laws with bedridden and missed work days
Martha Wetzel et al.
Health Services Research, forthcoming

Data Sources: Nationwide data from the National Health Interview Survey for 2006–2015.

Study Design: Generalized difference-in-difference models with state-specific time trends were used to assess the relationship between PDMPs and two outcomes: missed days of work and bedridden days.

Principal Findings: We found an increase of 3.3 and 5.9 bedridden days associated with optional and must-use PDMPs, respectively, for respondents reporting a recent injury or surgery (p-values <0.05; unadjusted population average 12.2 bedridden days). Increases in days of missed work were not statistically significant.

Global kidney chains
Afshin Nikzad et al.
Proceedings of the National Academy of Sciences, 7 September 2021 

Kidney failure is a worldwide scourge, made more lethal by the shortage of transplants. We propose a way to organize kidney exchange chains internationally between middle-income countries with financial barriers to transplantation and high-income countries with many hard to match patients and patient–donor pairs facing lengthy dialysis. The proposal involves chains of exchange that begin in the middle-income country and end in the high-income country. We also propose a way of financing such chains using savings to US health care payers.

Closing Time: The Local Equilibrium Effects of Prohibition
Greg Howard & Arianna Ornaghi
Journal of Economic History, September 2021, Pages 792-830 

How do different local policies in a federal system affect local land values, production, and sorting? We study the question exploiting a large historical policy change: U.S. Alcohol Prohibition in the early twentieth century. Comparing same- state early and late adopters of county dry laws in a difference-in-differences design, we find that early Prohibition adoption increased population and farm real estate values. Moreover, we find strong effects on farm productivity consistent with increased investment due to a land price channel. In equilibrium, the policy change disproportionately attracted immigrants and African-Americans.

Child health, human capital, and adult financial behavior
Marc-André Luik, Amelia Guha Thakurta & Dennis Wesselbaum
Health Economics, forthcoming

This paper provides novel evidence that child health affects adult financial behavior, that is, risky asset market participation. We do so by using a longitudinal dataset with a rich set of covariates and exploit sibling fixed-effects (FE) to control for invariant unobserved heterogeneity. We begin by proposing a new mechanism working via skill formation and portfolio choice. To be precise, we test two hypotheses. First, we expect a negative correlation between poor child health and risky asset market participation. Second, this correlation should be mostly explained by differences in skills. To test these hypotheses, we use data from the National Longitudinal Study of Youth 1979 (NLSY79). Our results show that poor child health is associated with an 11 pp decrease in adult risky market participation conditional on demographics and family background. Moreover, our results suggest that disruption in pre-labor market skill formation is a main mediator of this relationship. These results are robust to a wide range of robustness checks. Our findings have implications for the design of health policies and policies intended to increase financial literacy and asset market participation.

Effects of blast exposure on psychiatric and health symptoms in combat veterans
Sarah Martindale et al.
Journal of Psychiatric Research, November 2021, Pages 189-195

Blast exposure is common among service members, but the chronic psychiatric effects associated with blast exposure are not well-characterized independent of a resulting mild traumatic brain injury (TBI). This analysis evaluated whether blast exposure severity was independently associated with or exacerbated symptom report beyond posttraumatic stress disorder (PTSD) and mild TBI. Participants were Iraq and Afghanistan combat veterans (N = 275; 86.55% male), 71.27% with history of blast exposure, 29.82% current diagnosis of PTSD, and 45.45% with mild TBI. All participants completed diagnostic interviews for PTSD, lifetime TBI, and lifetime blast exposure. Self-reported psychiatric and health outcomes included posttraumatic stress symptoms, depressive symptoms, neurobehavioral symptoms, sleep quality, pain interference, and quality of life. Blast severity was associated with PTSD (B = 2.00), depressive (B = 0.76), and neurobehavioral (B = 1.69) symptoms beyond PTSD diagnosis and mild TBI history. Further, blast severity accounted entirely (i.e., indirect/mediation effect) for the association between TBI and posttraumatic stress (B = 1.62), depressive (B = 0.61), and neurobehavioral (B = 1.38) symptoms. No interaction effects were present. Exposure to blast is an independent factor influencing psychiatric symptoms in veterans beyond PTSD and mild TBI. Results highlight that blast exposure severity may be a more relevant risk factor than deployment mild TBI in combat veterans and should be considered in the etiology of psychiatric symptom presentation and complaints. Further, severity of psychological distress due to the combat environment may be an explanatory mechanism by which blast exposure mediates the relationship between mild TBI and symptom outcomes.


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