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Sunday, 30th of September 2012 Print

 'A growing literature shows that events in early life have long-term consequences for adult health, cognition and labor market success, both in developed and in developing countries. . . . 100 percent eradication of malarial infections increased subsequent adult income by 47 percent in the US, 45 percent in Brazil, 45 percent in Colombia, and 41 percent in Mexico.'






Janet Currie

Tom Vogl

Working Paper 18371


Text  excerpts below; best viewed, with equations and annexes, at http://www.nber.org/papers/w18371.pdf



1050 Massachusetts Avenue

Cambridge, MA 02138

September 2012


We would like to thank Anne Case for helpful conversations and Diane Alexander for excellent research assistance. The views expressed herein are those of the authors and do not necessarily reflect the views of the National Bureau of Economic Research.


NBER working papers are circulated for discussion and comment purposes. They have not been peer reviewed or been subject to the review by the NBER Board of Directors that accompanies official NBER publications.


© 2012 by Janet Currie and Tom Vogl. All rights reserved. Short sections of text, not to exceed two paragraphs, may be quoted without explicit permission provided that full credit, including © notice,is given to the source.


Early-Life Health and Adult Circumstance in Developing Countries

Janet Currie and Tom Vogl

NBER Working Paper No. 18371

September 2012

JEL No. I12,I15,J24,O15



A growing literature documents the links between long-term outcomes and health in the fetal period, infancy, and early childhood. Much of this literature focuses on rich countries, but researchers are increasingly taking advantage of new sources of data and identification to study the long reach of childhood health in developing countries. Health in early life may be a more significant determinant of adult outcomes in these countries because health insults are more frequent, the capacity to remediate is more limited, and multiple shocks may interact. However, the underlying relationships may also be more difficult to measure, given significant mortality selection. We survey recent evidence on the adult correlates of early-life health and the long-term effects of shocks due to disease, famine, malnutrition, pollution, and war.


Janet Currie

Princeton University

316 Wallace Hall

Princeton, NJ 08544

and NBER


Tom Vogl

Department of Economics

Princeton University

363 Wallace Hall

Princeton, NJ 08544

and NBER



1. Introduction


A growing body of evidence documents that healthy children tend to become healthy and wealthy adults (Almond and Currie 2010, 2011; Currie 2011). For example, anthropometric markers such as birth weight and child height are related to future schooling, employment, earnings, family formation, and health. Findings from natural experiments suggest that these relationships in large part reflect a pathway running from childhood health to adult outcomes.


Tothe extent that inequalities and shortfalls in adult outcomes are predicted by early-life health,these results may offer additional justification for policies aimed at improving child health.

We argue that the long-term effects of such shocks are likely to be larger in developing countries for several reasons. First, such shocks are simply more frequent in many developing countries than in the industrialized world, suggesting that the lingering effects of early-life health problems may well be more important in developing countries. Second, child health shocks are likely to interact. For example, a child who is malnourished may be less able to ward off, or to recover from, disease. Similarly, a mother who was malnourished may bear a child who is compromised in her ability to cope with health insults. Moreover, if there are non-linearities in the production function for child health, then the same shock may have quite different effects depending on starting levels of health.

 . . .


Changes in Average Height

The literature on height is in part motivated by the remarkable increasing secular trend in heights over the past two centuries. The trend began in Europe, which economic historians attribute to rising living standards (Floud, Wachter, and Gregory 1990; Fogel 2004; Steckel 1995, 2008).8 Japan followed somewhat later (Shay 1994), as the Japanese economy entered a period of rapid growth in the late nineteenth century. Many countries still classified today as “developing” also saw rising average heights across cohorts born in the twentieth century (Strauss and Thomas 1998). These transformations in the average size of the human body occurred too quickly to be driven by evolution.


Indeed, researchers have now amassed considerable evidence that these secular increases in height have antecedents in early-life health. Many studies show that child and adult height are associated with parental socioeconomic status, nutrition, and access to clean water and sanitation during childhood.9 Additionally, a number of the quasi-experimental studies reviewed below suggest that these associations represent .causal effects of childhood conditions.


. . . within Africa, where mortality rates are high, declines in child mortality are associated with decreased height, and national income bears no relation to height after controlling for mortality. These findings suggest that selective mortality may be an important force in determining the distribution of heights among African adults. In this sense, they offer one explanation for why Africans are much taller than one would expect in light of their incomes.

. . .


3. Evidence Regarding the Longer Term Effects of Early-Life Shocks


. . .




Table 3 provides an overview of some recent studies examining the longer-term impacts of poor nutrition in childhood. Here we focus on moderate and chronic malnutrition; we discuss famine in the next section. Recent studies have focused on the roles of specific nutrients, and on the question of whether children recover from nutritional shocks during critical periods, such as while they are in utero or in the first year of life.


In one recent study, Malluccio et al. (2009) report on a long-running randomized INCAP (Institute of Nutrition of Central America and Panama) experiment that involved giving Guatemalan children zero to seven years old a high-protein energy drink (the treatment) or a placebo with a similar number of calories. The findings suggest that the treatment increased schooling attainment among women by 1.2 grades, and cognitive ability by .24 standard deviations for both men and women. Hoddinott et al. (2008) study the same intervention and find that nutritional supplements in the first two years of life increased male wages by 46 percent.13 These large effects suggest that an early diet that is sufficient in calories but not in protein can have severe long-term consequences.


. . . cohorts affected by maternal fasting are 22 to 23 percent more likely to be disabled in adulthood. In comparison, the estimated effect on disability rates among Arab-named adults in the U.S. is only slightly lower, at 19 percent.




Several attributes distinguish famines from the localized rainfall shocks that Maccini and Yang (2009) and Pathania (2009) study. First, in general equilibrium, famines affect both food prices and farmers’ incomes, while localized rainfall shortfalls affect only incomes. Second, perhaps due in part to price adjustments, famines are typically more severe than localized shocks, with massive effects on mortality. As a result, concerns about selective mortality are likely to be more relevant in studies of famine. Third, unlike localized weather shocks, famines arguably have as much to do with politics as with food output (Drèze and Sen 1991). Thus, research strategies designed to measure the effects of localized rainfall shocks may fail to generate plausible estimates of the effects of famine.


. . .


The Chinese famine has received particular attention, and several papers provide evidence complementary to Meng and Qian’s. As with the studies described in the previous paragraph, analyses of the Chinese famine use both pre- and post-famine cohorts as control groups.

Chen and Zhou (2007) examine the effects of the Chinese famine on height, finding a decrease of 3 cm for those born or conceived during the famine. Gørgens et al. (2012) report a similar stunting effect of the famine on the rural Chinese population for whom the famine was most severe. In further analyses of socioeconomic outcomes, Almond et al. (2010) estimate that women (men) exposed to the Chinese famine in utero were 3 percent (5.9 percent) less likely to work and 13 percent (12 percent) more likely to be disabled, and that men were 6.5 percent less likely to be married. Finally, building on earlier research examining the effects of the Dutch “hunger winter” of 1944 on a wide range of outcomes (see for example, Lumey et al. 2011), two papers investigate the effects of the 1959 Chinese famine on other health outcomes. Fung (2009) demonstrates that in utero exposure to famine predicts obesity for women, but not for men, while St. Clair et al. (2005) find that prenatal and infant exposure to famine doubles the likelihood of developing schizophrenia.


Since famine often involves substantial mortality, it can be difficult to interpret the magnitudes of the effects. Indeed, the data suggest that mortality selection may severely dampen the estimated effects of early-life shocks on the average height of adult survivors. For example, data on Chinese adults show little sign of a decline in average heights among cohorts exposed to the Great Famine in early life unless one accounts for selection (Gørgens et al. 2012). In Meng and Qian’s study (2009) stunting effects are most noticeable at the upper quantiles of the height distribution, as would be expected if mortality culled individuals from the bottom tail of the height distribution.




. . .


Three papers apply this method in asking whether early-life malaria exposure affects socioeconomic outcomes in adulthood. Using data from the U.S. South and Latin America, Bleakley (2010) estimates that 100 percent eradication of malarial infections increased subsequent adult income by 47 percent in the US, 45 percent in Brazil, 45 percent in Colombia, and 41 percent in Mexico. Bleakley also finds positive effects on literacy, but mixed results for years of schooling. Cutler et al. (2010), studying India’s malaria eradication campaign of the 1950s, also detect no effect on educational attainment. However, consistent with Bleakley (2010), they find that malaria eradication increased household consumption, perhaps implying that the eradication of malaria increases incomes by allowing people to work more, or at higher productivity jobs.


. . .


Complementing Bleakley’s (2007) work on the historical United States, several studies examine the effect of deworming on medium and long-term outcomes in developing countries. In a well-known paper, Miguel and Kremer (2004) analyze the experimental introduction of deworming treatments in Kenyan schools. The deworming intervention increased school attendance by 7 percent but had no effect on test scores. In a follow-up study, however, Baird et al. (2011) find that self-reported health, years of schooling, and test scores all increased for the treated group. Hours worked rose 12 percent in the full sample and 20 percent among those who were working for wages. Moreover, Ozier (2011) shows that deworming school-aged children had positive externalities on very young children in the same community, fitting for a communicable disease like helminth infection. Children less than one year old during the treatment experienced IQ gains on the order of 0.2-standard deviations, which translated into an additional 0.5-0.8 years of schooling.




. . .

 Brainerd and Menon (2011) find that a 10 percent increase in chemical runoff from fertilizers in the water increases infant mortality by11.26 percent and decreases height for age by 0.14 standard deviations.


There is now considerable evidence from developed countries that air pollution has harmful effects on birth weight and infant mortality (see Currie, 2011 for a recent summary of this literature) and a growing literature showing that this is also true in the developed world. Foster et al. (2009) study air pollution in Mexico using satellite measures of aerosol optical depth. Variation in pollution comes from a voluntary certification program, and regional variation in the supply of auditors available to implement the program. They find that a 3.6 percent improvement in aerosol optical depth resulted in a 16 percent decline in infant mortality due to respiratory illness, but no decline from deaths due to external causes (a control cause). Jayachandran (2009) estimates OLS models where an average aerosol index (TOMS) captures the variation in pollution levels that resulted from the 1997 Indonesian wildfires. Her results indicate that areas affected by the smoke suffered a 1.2 percent reduction in birth cohort size with the largest effects among the poor, a result that highlights the importance of selection once again. Despite these concerns about selection bias, the Wang et al. study mentioned above found that each 100-ug/m3 increase in SO2 (TSP) exposure in the third trimester reduces birth weight by 7.3 (6.9) grams and increased the probability of low birth weight by 11 percent (10 percent).




. . .


A growing literature, reviewed in Table 6, suggests that exposure in early childhood may also have significant long-term scarring effects. Aguero and Deolalikar (2012) estimate the effect of childhood exposure to the Rwandan genocide on women’s height-for-age z-scores. Using difference-in-differences for exposed cohorts with Zimbabwean women as the control group, they find that Rwandan women exposed to the conflict have 0.2-standard deviations lower height-for-age z-scores. Taking Akresh and Verwimp (2006) and Aguero and Deolalikar (2012) together, it appears that the Rwandan civil war greatly affected the height of girls in Rwanda, and that even exposure late in adolescence affected adult female height.


Several papers evaluate the effects of conflict on years of schooling. Alderman et al. (2006) combine maternal fixed effects and IV estimation to show that exposure to civil war and drought shocks in early childhood in Zimbabwe reduced children’s height-for-age z-scores, which subsequently had negative effects on years of schooling and adult height. Akresh and de Walque (2008) estimate a difference-in-difference model and find that children exposed to the Rwandan genocide earned 0.4 fewer years of schooling. In Peru, León (2010) estimates that for each additional year of civil war exposure in early childhood, children acquired 0.07 fewer years of schooling. Therefore, a child exposed for the first three years of life attains, on average, 0.21 fewer years of schooling. Some of this effect on education may work through the destruction of school buildings.


4. Discussion and Conclusions

. . .


Case and Paxson (2011) make the further important point that the societal response to disease can impact long-term child outcomes through its effects on health infrastructure. Using data from fourteen sub-Saharan African countries, they find that in countries heavily impacted by HIV, skilled birth attendance, antenatal care, and immunization rates declined between 1988 and 2005. Countries with a minimal burden from HIV experienced no such declines. This deterioration, which presumably occurred because of a diversion of health resources to fight the AIDS epidemic, may have lasting effects on children even if neither they nor their parents are HIVpositive.


In sum, research in the past decade has shown that health shocks in early-life have longterm effects on adults in both the developed and developing world. But the literature still has little understanding of heterogeneity in these effects. Future research should focus on identifying pathways and mechanisms; measuring the relative magnitudes of the effects of different health shocks; examining interactions between shocks; and revisiting the question of critical periods.




We would like to thank Anne Case for helpful conversations and Diane Alexander for excellent research assistance.




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