Essays on Health and Family Economics in India

Thesis advisor: Arthur LewbelA person's health not only influences her chance of surviving to adulthood and her life expectancy, but also her economic decisions, her productivity, and her well-being. Since a healthy population is a major factor in economic development, it is important to understand the determinants of individuals' health-related decisions and outcomes. The three essays that comprise this dissertation make advancements in this direction and focus on the Indian subcontinent. The first and second essays analyze how intra-household decision making affects individuals' health outcomes and welfare, with a special attention towards within family gender inequality. The third essay studies how exposure to historical medical facilities affects individual health outcomes across generations. From a methodological point of view, this dissertation highlights the advantages of combining economic models with data from a wide range of sources, theory with empirics. I employ both quasi-experimental and structural estimation methods, using the former to uncover relevant causal links and policy levers, and the latter to estimate deep parameters, overcome data limitations and perform counterfactual policy analysis. More broadly, with this work I stress the importance of research in development economics being open to a variety of methodologies and empirical approaches. The ratio of women to men is particularly low in India relative to developed countries. It has recently been argued that close to half of these missing women are of post-reproductive ages (45 and above), but what drives this phenomenon remains unclear. In the first essay, titled “Why Are Older Women Missing in India? The Age Profile of Bargaining Power and Poverty”, I provide an explanation for this puzzle that is based on intra-household bargaining and resource allocation. I use both reduced-form and structural modeling to establish the critical connections between women's bargaining position within the household, their health, and their age. First, using amendments to the Indian inheritance law as a natural experiment, I demonstrate that improvements in women's bargaining position within the household lead to better health outcomes. Next, with a structural model of Indian households, I show that women's bargaining power and their ability to access household resources deteriorate at post-reproductive ages. Thus, at older ages poverty rates are significantly higher among women than men. The analysis indicates that gender inequality within the household and the consequent gender asymmetry in poverty can account for a substantial fraction of missing women of post-reproductive ages. Finally, I demonstrate that policies aimed at promoting intra-household equality, such as improving women's rights to inherit property, can have a large impact on female poverty and mortality. The first essay contributes to a wide literature showing that a relevant determinant of the household decisions and outcomes is the relative bargaining position of the decision makers. Although this link is well-accepted in this literature, intra-household bargaining power is de facto an unobserved variable. In the second essay, joint with Arthur Lewbel and Denni Tommasi and titled “Women's Empowerment and Family Health: A Two-Step Approach”, we propose a novel two-step approach to overcome this data limitation and to directly assess the causal link between women's empowerment and family health. In the first stage, we structurally recover a dollar-based measure of women's intra-household empowerment, with a clear interpretation provided by economic theory; in the second stage, we identify the causal effect of women's decision power relative to men's on household members' health. We demonstrate that women's bargaining power improves their own health outcomes, while not affecting their spouses'. When we turn to children, we find that improvements in women's position within the family does not affect their weight or height, but it increases their likelihood to receive vaccinations. The determinants of individuals' health, however, go beyond the family, and trace back to historical developments. In the third essay, joint with Federico Mantovanelli and titled “Long-Term Effects of Access to Health Care: Medical Missions in Colonial India”, we examine the long-term effect of access to historical health facilities on current individual health outcomes. To this aim, we construct a novel and fully geocoded dataset that combines contemporary individual-level data with historical information on Protestant medical missions. We exploit variation in the activities of missionary societies and use an instrumental variable approach to show that proximity to a Protestant medical mission has a causal effect on individuals' health status. The investigation of potential transmission channels indicates that the long-run effect of access to health care is not driven by persistence of infrastructure, but by changes in individual habits regarding hygiene, preventive care and health awareness, which have been bequeathed over time. Important policy implications can be drawn. First, policies aimed at promoting gender equality within families, such as improving women's property and inheritance rights, can have positive spillovers on women's health, poverty and mortality, and can boost health investments in children. Second, as the population in India and in other developing countries ages, gender asymmetries among the elderly need to be further investigated and promptly addressed by the development practitioners. Third, intra-household inequalities, between genders and across ages, should be taken into account when measuring poverty and evaluating the effect of policies to alleviate it. Finally, in light of the existence of long-run effects, the expansion of health care access in India should become an even more prominent goal for policy makers, as it can beneficially affect both current and future generations.Thesis (PhD) — Boston College, 2016.Submitted to: Boston College. Graduate School of Arts and Sciences.Discipline: Economics

Measuring Women's Empowerment in Collective Households

Measuring women's empowerment within families is challenging. Social scientists often rely on close-ended survey questions on women's participation in household decisions, domestic abuse, and autonomy to measure women's power and agency. Recent advances in family economics have allowed researchers to identify and estimate structural measures of women's power and resource control based on the collective household model. We provide a brief overview of this literature. We then apply machine learning techniques to answer the following questions: How do such measures compare to women's responses to close-ended survey questions? Which survey questions are most predictive of model-based estimates of women's empowerment

LATE with Mismeasured or Misspecified Treatment: An application to Women's Empowerment in India

We show that a local average treatment effect (LATE) can sometimes be point identified and consistently estimated when treatment is mismeasured, or when treatment is estimated using a possibly misspecified structural model. Our associated estimator, which we call Mismeasurement Robust LATE (MR-LATE), is based on differencing two mismeasures of treatment. In our empirical application, treatment is women’s empowerment: whether a wife has significant control of household resources. Due to measurement difficulties and sharing of goods within a household, this treatment cannot be directly observed without error, and so must be estimated. Our outcomes are health indicators of family members. We first estimate a structural model to obtain the otherwise unobserved treatment indicator. Then, using changes in inheritance laws in India as an instrument, we apply our new MR-LATE estimator. We find that women’s empowerment substantially decreases their probability of being anemic or underweight, and children’s likelihood to suffer from cough, fever or diarrhea. We find no significant positive or negative effects on men’s health.info:eu-repo/semantics/publishe

The more the poorer? Resource sharing and scale economies in large families

In large families, individuals must share resources with many others but may benefit from economies of scale. This paper studies individual consumption in different types of households, with a focus on family structures that are common in developing countries. Based on a collective household model, we develop a methodology to identify intra-household resource allocation and the extent of joint consumption. Unlike existing approaches, we do not require consumption data on single-person households, which are rare in low-income countries. We illustrate our methodology using data from Bangladesh and Mexico. We document intra-household consumption inequality in both countries and substantial economies of scale in consumption in Mexico but not Bangladesh. Using our estimates, we then compute poverty rates for men, women, and children. Contrary to existing poverty calculations that ignore either intra-household inequality or economies of scale in consumption, ours account for both dimensions

Effect of thalidomide on clinical remission in children and adolescents with refractory Crohn disease: A randomized clinical trial

IMPORTANCE: Pediatric-onset Crohn disease is more aggressive than adult-onset disease, has high rates of resistance to existing drugs, and can lead to permanent impairments. Few trials have evaluated new drugs for refractory Crohn disease in children. OBJECTIVE: To determine whether thalidomide is effective in inducing remission in refractory pediatric Crohn disease. DESIGN, SETTING, AND PATIENTS: Multicenter, double-blind, placebo-controlled, randomized clinical trial of 56 children with active Crohn disease despite immunosuppressive treatment, conducted August 2008-September 2012 in 6 pediatric tertiary care centers in Italy. INTERVENTIONS: Thalidomide, 1.5 to 2.5 mg/kg per day, or placebo once daily for 8 weeks. In an open-label extension, nonresponders to placebo received thalidomide for an additional 8 weeks. All responders continued to receive thalidomide for an additional minimum 52 weeks. MAIN OUTCOMES AND MEASURES: Primary outcomes were clinical remission at week 8, measured by Pediatric Crohn Disease Activity Index (PCDAI) score and reduction in PCDAI by ≥25% or ≥75% at weeks 4 and 8. Primary outcomes during the open-label follow-up were clinical remission and 75% response. RESULTS: Twenty-eight children were randomized to thalidomide and 26 to placebo. Clinical remission was achieved by significantly more children treated with thalidomide (13/28 [46.4%] vs 3/26 [11.5%]; risk ratio [RR], 4.0 [95% CI, 1.2-12.5]; P = .01; number needed to treat [NNT], 2.86). Responses were not different at 4 weeks, but greater improvement was observed at 8 weeks in the thalidomide group (75% response, 13/28 [46.4%] vs 3/26 [11.5%]; RR, 4.0 [95% CI, 1.2-12.5]; NNT = 2.86; P = .01; and 25% response, 18/28 [64.2%] vs 8/26 [30.8%]; RR, 2.1 [95% CI, 1.1-3.9]; NNT = 2.99; P = .01). Of the nonresponders to placebo who began receiving thalidomide, 11 of 21 (52.4%) subsequently reached remission at week 8 (RR, 4.5 [95% CI, 1.4-14.1]; NNT = 2.45; P = .01). Overall, 31 of 49 children treated with thalidomide (63.3%) achieved clinical remission, and 32 of 49 (65.3%) achieved 75% response. Mean duration of clinical remission in the thalidomide group was 181.1 weeks (95% CI, 144.53-217.76) vs 6.3 weeks (95% CI, 3.51-9.15) in the placebo group (P < .001). Cumulative incidence of severe adverse events was 2.1 per 1000 patient-weeks, with peripheral neuropathy the most frequent severe adverse event. CONCLUSIONS AND RELEVANCE: In children and adolescents with refractory Crohn disease, thalidomide compared with placebo resulted in improved clinical remission at 8 weeks of treatment and longer-term maintenance of remission in an open-label follow-up. These findings require replication to definitively determine clinical utility of this treatment. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00720538. Copyright 2013 American Medical Association. All rights reserved