Meenakshi Sabina Subbaraman

The Health Effects of Economic Decline

Political pronouncements and policy statements include much conjecture concerning the health and behavioral effects of economic decline. We both summarize empirical research concerned with those effects and suggest questions for future research priorities. We separate the studies into groups defined by questions asked, mechanisms invoked, and outcomes studied. We conclude that although much research shows that undesirable job and financial experiences increase the risk of psychological and behavioral disorder, many other suspected associations remain poorly studied or unsupported. The intuition that mortality increases when the economy declines, for example, appears wrong. We note that the research informs public health programming by identifying risk factors, such as job loss, made more frequent by economic decline. The promise that the research would identify health costs and benefits of economic policy choices, however, remains unfulfilled and will likely remain so without stronger theory and greater methodological agreement.

Hormonal evidence supports the theory of selection in utero.

Antagonists in the debate over whether the maternal stress response during pregnancy damages or culls fetuses have invoked the theory of selection in utero to support opposing positions. We describe how these opposing arguments arise from the same theory and offer a novel test to discriminate between them. Our test, rooted in reports from population endocrinology that human chorionic gonadotropin (hCG) signals fetal fitness, contributes not only to the debate over the fetal origins of illness, but also to the more basic literature concerned with whether and how natural selection in utero affects contemporary human populations.

Natural selection in utero induced by mass layoffs: the hCG evidence

Evolutionary theory, when coupled with research from epidemiology, demography, and population endocrinology, suggests that contracting economies affect the fitness and health of human populations via natural selection in utero. We know, for example, that fetal death increases more among males than females when the economy unexpectedly contracts; that unexpected economic contraction predicts low secondary sex ratios; and that males from low sex ratio birth cohorts live, on average, longer than those from high sex ratio cohorts. We also know that low levels of human chorionic gonadotropin (i.e., hCG) measured in the serum of pregnant women predict fetal death. We do not, however, know whether male survivors of conception cohorts subjected to contracting economies exhibit, as theory predicts, higher hCG than those from other cohorts. We show, in 71 monthly conception cohorts including nearly two million California births, that they do. We thereby add to the literature suggesting that the economy, a phenomenon over which we collectively exercise at least some control, affects population health. Our findings imply that the effect arises via natural selection – a mechanism we largely ignore when attempting to explain, or alter, how collective choice affects our biology.

State Panel Estimates of the Effects of the Minimum Legal Drinking Age on Alcohol Consumption for 1950 to 2002

BACKGROUND Despite strong evidence supporting the effectiveness of the minimum legal drinking age (MLDA), recent movements have attempted to evoke policy changes that will allow 18- to 20-year-olds to buy and drink alcohol legally. The primary aim of this study was to evaluate the effects of both raising and lowering the MLDA on per capita ethanol (EtOH) consumption in longer and more accurate time series panel than any previous study. METHODS Generalized least squares model specifications controlling for income, unemployment rates, and population characteristics were implemented using MLDA and aggregate EtOH consumption data from U.S. states from 1950 to 2002. RESULTS Results from the full 1950 to 2002 period, which include both the lowering and raising of the MLDA, show that an increase in the MLDA by 3 years was associated with decreases in per capita total EtOH consumption (1.51% reduction), as well as in beer (2.31% reduction) and spirits consumption (1.86% reduction). CONCLUSIONS Lowering the MLDA would likely induce increased rates of drinking and subsequent alcohol-related consequences. If increased consumption is of concern, policymakers should resist movements to lower the MLDA.

Identification and Efficient Estimation of the Natural Direct Effect among the Untreated

The natural direct effect (NDE), or the effect of an exposure on an outcome if an intermediate variable was set to the level it would have been in the absence of the exposure, is often of interest to investigators. In general, the statistical parameter associated with the NDE is difficult to estimate in the non-parametric model, particularly when the intermediate variable is continuous or high dimensional. In this article, we introduce a new causal parameter called the natural direct effect among the untreated, discuss identifiability assumptions, propose a sensitivity analysis for some of the assumptions, and show that this new parameter is equivalent to the NDE in a randomized controlled trial. We also present a targeted minimum loss estimator (TMLE), a locally efficient, double robust substitution estimator for the statistical parameter associated with this causal parameter. The TMLE can be applied to problems with continuous and high dimensional intermediate variables, and can be used to estimate the NDE in a randomized controlled trial with such data. Additionally, we define and discuss the estimation of three related causal parameters: the natural direct effect among the treated, the indirect effect among the untreated and the indirect effect among the treated.

Economic Antecedents of Medicaid-Financed Mental Health Services Among Youths in California

Purpose: The literature reports that downturns in the economy may increase utilization of adult mental health services. However, whether economic decline affects the use of mental health services among youth remains unclear. We test whether demand for Californias publicly financed mental health services for children varies with labor market contraction. Methods: We apply time-series methods to monthly counts of unduplicated clients served, from July 2002 to April 2008, for California Childrens Medicaid Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program. We use as the independent variable monthly unemployment insurance claims in California that result from mass layoffs. Results: Increases in the number of unemployment insurance claims due to mass layoffs in California coincide with higher than expected monthly values of EPSDT services. Exploratory analyses find that expansions in public health insurance enrollment do not account for the discovered increase in EPSDT services. Conclusions: Economic contraction may increase the demand for youth mental health services in California by provoking disorder, inducing help-seeking, or both. We discuss the implications of our findings for policy and for research concerned with the antecedents of mental health among youth.

Marijuana Policy Opinions in Washington State Since Legalization Would Voters Vote the Same Way

Background: In 2012, voters in Washington state approved Initiative 502 (I-502) which legalized recreational marijuana use at the state level. This study examines the relationship between demographics, marijuana and alcohol use, and voting outcomes, as well as how these variables relate to (i) whether voters would still vote the same way (a reflection of satisfaction with the new policy) and (ii) the likelihood of using marijuana purchased from legal retail stores. Methods: The sample consists of 2,007 adult Washington state residents recruited through Random Digit Dial between January and October 2014. Bivariate tests and multivariable regressions were used for analyses. Results: Less than 5% of those who voted for marijuana legalization would change their votes, whereas 14% of those who voted against legalization would change their votes. In multivariable models controlling for demographics, substance use, and marijuana-related opinions, those who voted for legalization had half the odds of changing their votes than those who voted against it. Among past-year nonmarijuana users, almost 10% were somewhat/very likely to use marijuana if they could buy it from a legal store. Past marijuana use, the belief that adults should be allowed to grow marijuana for personal use, and the belief that marijuana is not very risky for health were all related to increased likelihood of using marijuana purchased from legal stores. Conclusion: Since November 2012, support for marijuana legalization in Washington state has increased; accounting for the proportion of voters who would change their votes suggests that I-502 would pass today with even more votes in favor.

Transient cultural influences on infant mortality: Fire‐horse daughters in Japan

Parental investment theory suggests that the quality and quantity of parental care depends, in part, on assessments of whether offspring will survive and yield grandchildren. Consistent with this theory, we hypothesize that parental perception that a birth cohort will have low reproductive success coincides with higher than expected infant mortality in the cohort. We test this hypothesis in industrialized Japan in 1966 when cultural aversion to females born in the astrological year of the Fire‐Horse may have jeopardized the life of female infants.

Integrating Addiction Treatment and Mutual Aid Recovery Resources

The most widely used source of help for alcohol problems is Alcoholics Anonymous (AA), and much formal treatment has adapted AA’s methods and concepts. Usually many people seek help from AA at the recommendation of a treatment professional. Even treatment programs that historically have not been 12-step-oriented, such as Therapeutic Communities, may recommend AA or mutual help alternatives post-treatment. Because evidence shows that individuals are more likely to attend these groups after treatment if they are introduced to them during treatment interventions to facilitate 12-step involvement are needed. Twelve-step facilitation can vary, focusing on introducing clients to the 12-step philosophy, helping them work the intial steps of the program, or helping them connect with the fellowship of individuals they encounter in AA. Randomized trials of 12-step facilitation consistently demonstrate abstinence rates 10% higher (or more) than the usual care conditions at 1-year follow-up, with even stronger results in particular subgroups such as those with prior treatment episodes. Manuals are available that guide counselors through these 12-step facilitation interventions, increasing the likelihood that treatment programs will incorporate evidence-based practices which increase clients’ AA involvement during and post-treatment, and reduce relapse. This chapter describes these interventions and summarizes the trial results. Unfortunately, there has been less progress in developing ways to facilitate the utilization of non-12-step alternatives such as Women For Sobriety, Life Ring, or SMART Recovery, which are less widely available yet offer another supportive environment. This is an important area of future research.

Survey Estimates of Changes in Alcohol Use Patterns Following the 2012 Privatization of the Washington Liquor Monopoly

Aims The US state of Washingtons 333 state-run liquor stores were privatized on 1 June 2012 and purchases began in ~1500 licensed stores of a variety of types. A regime of taxes and fees was implemented to replace the revenues generated by the state stores and, 1 year later, the beer tax was reduced by two thirds. This study evaluates the impact of these changes on total alcohol and spirits consumption in a retrospective pre-test design. Methods The study sample consists of 2289 adults recruited in three cross-sectional surveys during 2014 and 2015. Retrospective typical past month quantity-frequency measures for before privatization drinking and current past month quantity-frequency measures were compared within subjects, for all alcohol and for spirits only. Results No change in alcohol volume was seen across privatization while spirits volume was found to decrease, suggesting a shift from spirits to beer. This decline in spirits volume came from a reduction in drinking days while overall drinking days were found to increase. This was offset by a reduction in drinks per drinking day and in heavy occasions. Conclusions These findings accurately mirror the overall flat trend in per capita alcohol sales but seem to exaggerate the very small shift towards beer seen in sales data. Effects of increased spirits availability appear to have been countered by increased spirits prices and a decreased beer tax, leading to a shift to beer consumption. Short summary Survey-based analyses of alcohol use across Washingtons spirits privatization, beer tax reduction and marijuana legalization found no change in alcohol volume, a reduction in spirits volume and a shift to more moderate drinking patterns. Reductions in drinking occurred among marijuana users and those with lower educational attainment reduced spirits volume.