Testing the Fetal Origins Hypothesis in a Developing Country: Evidence from the 1918 Influenza Pandemic

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1 Testng the Fetal Orgns Hypothess n a Developng Country: Evdence from the 1918 Influenza Pandemc Rchard E. Nelson Pharmacotherapy Outcomes Research Center Unversty of Utah May 23, 2008 Summary The 1918 Influenza Pandemc s used as a natural experment to test the Fetal Orgns Hypothess. Ths hypothess states that ndvdual health as well as socoeconomc outcomes, such as educatonal attanment, employment status, and wages, are affected by the health of that ndvdual whle n utero. Repeated cross sectons from the Pesqusa Mensal de Emprego, a labor market survey from Brazl, are used to test ths hypothess. I fnd evdence to support the Fetal Orgns Hypothess. In partcular, compared to ndvduals born n the few years surroundng the Influenza Pandemc, those who were n utero durng the pandemc are less lkely to be college educated, be employed, have formal employment, or know how to read and have fewer years of schoolng and a lower hourly wage. These results underscore the mportance of fetal health especally n developng countres. Key Words: nfluenza, fetal orgns hypothess, Brazl, 1 Introducton Wth the gap between developed and developng countres ever wdenng, there s an ncreased nterest n seekng out determnants of economc growth. Whle there are no slver bullets, one sure fre contrbutor to economc growth s health. Healthy ndvduals are more productve than those who are unhealthy. Per capta ncome can ncrease as a result of a healthy workforce for a varety of reasons. Frst, healthy ndvduals have more dsposable ncome and are therefore better able to save for retrement than

2 unhealthy ndvduals who have hgher health related expenses. Ths ncreased savngs leads to greater nvestment rates and greater per capta ncome. Second, foregn drect nvestment (FDI) s hgher n populatons wth healthy workers (Alsan et al., 2006). Ths relatonshp s not surprsng snce foregn nvestors seek the most conducve envronment for the hghest returns on ther nvestment. They are lkely to avod makng nvestments where populatons are less productve due to hgh dsease burdens. And thrd, healther chldren lead to greater nvestments n educaton. Chld health has been shown to have an mmedate mpacts on educaton attanment therefore makng educaton nvestments more appealng (Mguel and Kremer, 2004). Ths key role that populaton health plays n economc growth prompts a desre for mproved health. Ths paper explores the mpact of poor fetal health (due to poor maternal health) on socoeconomc outcomes later n lfe n Brazl. Followng recent work by Almond ((Almond and Mazumder, 2005) and (Almond, 2006)), I use the 1918 Influenza Pandemc as a natural experment to test the Fetal Orgns Hypothess, whch states that what happens n the womb has consequences later n lfe. My fndngs supprt ths hypothess. Indvduals n utero durng the pandemc are less lkely to be college educated, be employed, have formal employment, or be lterate. In addton, they have fewer years of schoolng and lower wages. These results wll provde a better understandng of fetal nutrton and growth for publc health offcals to be better equpped to focus on the mportance of maternal health. It s straghtforward to conclude that fetal growth s essental to economc growth.

3 2 Fetal Orgns Hypothess The Fetal Orgns Hypothess was frst proposed by Davd Barker n an artcle n the Brtsh Medcal Journal (Barker, 1995). For the purposes of ths paper, t s useful to descrbe ths concept usng economcs termnology. An ndvdual's health producton functon has two dstnct nputs: an ntal level of health endowment wth whch an ndvdual s born, and health nvestments made by ndvduals throughout ther lfetme. An ndvdual uses these two nputs to produce the output "health". An ndvdual's health can have a sgnfcant mpact on socoeconomc outcomes such as educatonal attanment and lteracy as well as labor market outcomes such as employment and wages. The Fetal Orgns Hypothess predcts that changes n an ndvdual's ntal health endowment can affect these socoeconomc outcomes and therefore manfest themselves later n lfe. In other words, adult health and socoeconomc outcomes have fetal orgns. Whle t s not beleved that transmsson of the vrus from an nfected mother to the fetus s common ((Irvng et al., 2000) and (Zou, 2006)), there s evdence of adverse effects of maternal nfluenza on fetal health. Studes have shown that nfluenza may cause negatve secondary effects n fetuses of nfected mothers through bran damage (Fatem et al., 2002) and behavoral changes (Sh et al., 2003). Other possble adverse effects that have been shown n pregnant women wth nfluenza are preterm brth, defects of the central nervous system, and brth defects ((Harrs, 1919), (Nuzum et al., 1918), (Coffey and Jessop, 1963), (Saxen et al., 1960), (Wlson and Sten, 1969)). There s also evdence to suggest that maternal nfluenza s assocated wth negatve health effects n chldren long after brth. Studes have seen an ncreased rsk of chldhood leukema (Kwan et al.,

4 2007), schzophrena (Ebert and Kotler, 2005), and Parknson's dsease (Takahash and Yamada, 2001) n ndvduals whose mothers contracted nfluenza whle they were n utero. The fetus can be adversely affected not only by the vrus tself but also by the hgh fevers that come wth maternal nfluenza. Hypertherma durng pregnancy can be detrmental to the central nervous system (Rasmussen et al., 2008). The nfluenza pandemc of 1918 provdes an excellent natural experment n testng ths hypothess. Ths pandemc was the most devastatng natural dsaster of the 20th century, kllng more people than World War I, and dsproportonately struck women of chldbearng age. In addton, the pandemc rose quckly, wthout warnng, and was gone wthn just a few weeks. Fetuses n utero durng ths tme whose mothers contracted nfluenza would have receved less nutrton and therefore have had lower overall health. The mpact of maternal nfluenza contracton could manfest tself years later n ndvduals who were n utero durng the peak of ths pandemc n one of two ways. Frst, these ndvduals, because they were deprved of nutrton and healthy gestatonal condtons, were born wth lower ntal health endowment nputs n ther health producton functons and therefore have lower health and socoeconomc outcomes later n lfe. Or second, there may be a selecton effect whereby the survvors of the nfluenza pandemc were the strongest and most reslent of those n utero at that tme and wll therefore have hgher health and socoeconomc outcomes later n lfe than cohorts born relatvely close to them. In ths paper, I nvestgate evdence of ether of these effects.

5 The mpact of ntrauterne health on adult health, educatonal attanment, and earnngs has been examned n the Unted States. Brthweght s postvely assocated wth adult schoolng attanment and adult heght, and ncreasng brthweght can ncrease labor market earnngs (Behrman and Rosenzweg, 2004). Chldhood health has been shown to be an mportant determnant of economc status later n lfe. In partcular, (Case et al., 2005) use health ntervew data from the Unted Kngdom that follows ndvduals from brth to mddle age to examne how chldhood health effects manfest themselves n later years. The present study, on the other hand, wll be the frst to examne the mpacts of poor fetal health on adult development and outcomes n a developng country. 3 Spansh Flu Pandemc of 1918 The stran of nfluenza that struck the world's populaton n 1918, referred to by many as the Spansh Flu, was one of the most deadly vruses ever to nfect humans. It s estmated that one-thrd of the world's populaton (roughly 500 mllon people) became nfected. Ths resulted n more than 50 mllon deaths (Taubenberger and Morens, 2006). Recent research has estmated ths number to be even hgher at 100 mllon deaths (Johnson and Mueller, 2002). Experts classfy nfluenza vruses nto three man types: A, B, and C. Types A and B are known to be assocated wth seasonal epdemcs whle pandemcs are made up of only type A. Vaccnes for ths vrus must be updated annually due to the constantly mutatng protens, hemagglutnn and neuramndase. Occasonally, the surface protens can change more dramatcally through mutaton of vruses n other anmals such as brds or

6 swne. When these altered vruses can be successfully transmtted to humans before vaccnes can be dstrbuted, a pandemc can occur (Rasmussen et al., 2008). The vrus that caused the 1918 Influenza Pandemc has been the subject of a great deal of study snce ts ntal appearance. When t frst appeared, some doubted whether t was nfluenza at all. By the 1930 s, smlar vruses from both swne and humans were used to dentfy the 1918 stran as nfluenza (Shope, 1936). The vrus most lkely crculated n humans throughout the subsequent decades. In fact, all nfluenza pandemcs and nearly all cases of human nfecton from nfluenza snce 1918 have been caused from descendants of the 1918 vrus (Taubenberger and Morens, 2006). The frst reports of Spansh Flu n Brazl were shortly after the September 14th arrval of an Englsh flagged shp, the Demerara, at the port of Recfe on the country's northeastern coast. The shp eventually landed near Sao Paulo n the harbor cty of Santos. Havng come from Europe, several of the salors onboard were presentng symptoms of the flu. (Brto, 1997) gves a hstorcal account of the presence of the pandemc wthn the country through artcles n newspapers from Ro de Janero. A week and a half later on September 27th, the newspaper O Pas reported four crew members of another shp, the Pau, had been hosptalzed wth flu symptoms. The artcle reassured readers that there was no reason to be alarmed, that these were solated ncdences. The next day, an artcle ran n a competng newspaper, Correo da Manha, wth a quote from a medcal expert sayng that the vrus that these crew members had caught was just the typcal flu and not the deadly Spansh stran that had struck Europe. Unfortunately, ths was not the case. By the 7th of October, newspapers from Ro de Janero reported that cases of ths flu had

7 spread across the north and northeast. On the 10th of October, 440 ndvduals were hosptalzed n the cty, but that number would soar to 20,000 just four days later. The vrus was at the peak of ntensty n Brazl durng an 8 week perod begnnng n md October. In the largest cty n Brazl, Sao Paulo, the prevalence of nfluenza was 22.32%, wth 116,771 of the 523,194 resdents of contractng the dsease (Texera, 2003). 3.1 Data The data used for ths analyss comes from the Pesqusa Mensal de Emprego (PME). The PME s smlar n scope and purpose to the Current Populaton Survey (CPS) n the Unted States. It s a monthly survey conducted by the Insttuto Braslero de Geografa e Estatstca (IBGE), the Brazlan Statstcal Agency, to calculate the unemployment rate and to gather other nformaton related to the labor force. The dataset has roughly 230,000 observatons per year. The man shortcomng of the PME s that t s conducted only n the sx largest metropoltan areas n the coutnry - Sao Paulo, Ro de Janero, Belo Horzonte, Salvador, Porto Alegre, and Recfe - and s therefore not natonally representatve. However, these metropoltan areas make up almost half of the country's populaton and, n 1997, accounted for 72% of the country's GNP (Blom et al., 2001). Table 1 shows descrptve statstcs for the varables used n the analyss. 3.2 Socoeconomc Outcomes The Fetal Orgns Hypothess s tested usng several measures of socoeconomc outcomes. These nclude measures of educaton, such as college educaton and years of schoolng, and labor market outcomes such as unemployment, formal employment, and

8 log hourly wage. Both the college educaton dummy varable and the years of schoolng contnuous varable are calculated followng the method used by (Lam and Schoen, 1993) and (Blom et al., 2001). The formal employment varable s equal to 1 f the ndvdual has a "cartera assnada" or a "sgned workbook". Employees wth a sgned workbook are typcally n more stable employment and are enttled to benefts. Hourly wages were calculated by dvdng the monthly wage by four tmes the reported workng hours per week. Ths was then converted nto 1998 Reas. 4 Model 4.1 Year of Brth From a statstcal standpont, the deal (albet, unethcal) way to analyze the effects of maternal nfluenza on fetal health would be through a randomzed tral. In ths settng, pregnant women would be randomly assgned to ether the case group (whch contracts nfluenza) or the control group (whch does not). Chldren born to women n both groups would be followed throughout ther lfetmes and the socoeconomc outcomes descrbed above would be documented. The advantages of ths scenaro are that randomzaton elmnates any bas that could confound the mpact of poor fetal health on subsequent socoeconomc outcomes. Unfortunately, there are many dsadvantages, not the least of whch s the dubous ethcal ssues nvolved wth exposng healthy pregnant women to nfluenza. So whle from a statstcal standpont a randomzed tral s the frst best opton, due to ts very nature - swft, unexpected arrval and lastng only a few weeks - the Spansh Flu Pandemc offers a farly smlar set up. The dsease was essentally

9 randomly assgned durng the autumn of 1918 and dsproportonately struck women of chld-bearng age. Therefore, n comparng socoeconomc outcomes of ndvduals who were n utero durng the autumn of 1918 wth those n utero shortly before or shortly after, we can be confdent that most of the dfference can be attrbuted to poor fetal health due to the Spansh Flu. Ths dentfcaton strategy s an excellent example of what economsts call a natural experment 1. Whle (Almond, 2006) uses ths same experment to study the mpact of poor fetal health on the US populaton, ths s the frst paper to apply ths same methodology to a developng country. Let us start wth a descrpton of an ndvdual's health producton functon: H t = ω + I t j= 1 t, (1) where H t s the health of ndvdual at tme t, ω s the health endowment wth whch ndvdual s born, and t I t j= 1 are the health nvestments that ndvdual has made throughout her lfetme untl perod t. An ndvdual's ntal health endowment s a functon of heredtary factors from both the mother and father as well as fetal health whle n the womb. The post-brth health nvestments can be postve such as exercse and healthy eatng, or negatve n the form of smokng and alcohol abuse. In order to test the Fetal Orgns Hypothess, I hypothesze that socoeconomc outcomes are functons of ths health producton functon: 1 see ROSENZWEIG, M. R. & WOLPIN, K. I. (2000) Natural "Natural Experments" n Economcs. Journal of Economc Lterature, 38, for a revew of the lterature on natural experments n economcs.

10 2 y = β + β H + β YoB + YoB + u + e. (2) 1 2 t 3 β 3 t As wth Almond, n estmatng equaton (2), I restrct my sample to those ndvduals born wthn the study perod 1912 to In equaton (2), y s the socoeconomc outcome of ndvdual and β 2 s the effect of ndvdual s health on that outcome. Accordng to the Fetal Orgns Hypothess, we would expect ths coeffcent to be negatve as those wth greater exposure to nfluenza n utero (and therefore worse fetal health) should have worse socoeconomc outcomes. Alternatvely, f the selecton effect s present, β 2 wll be postve. If ths s the case, those ndvduals who survved the flu pandemc n utero to be born n 1919 were only the fttest and therefore were born wth large ntal health endowments. Estmatng ths equaton wll allow us to test whch of these explanatons s correct. Other ndependent varables n equaton (2) nclude YoB and 2 YoB, whch are the year of brth of ndvdual and the year of brth squared. These are ncluded as a way to control for the effect of age on labor market outcomes. Fnally, ut s a set of ndcators for the survey year and s a random error term. Snce the PME doesn't provde any nformaton on health, the flu pandemc s used as a proxy for ths measure. Wth ths proxy, I estmate the followng baselne regresson: e y = β I YoB YoB + u + e β 2 + β 3 + β 3 2 t (3) I 1919 In equaton (3), s an ndcator varable equal to 1 f ndvdual was born n The coeffcent of nterest, β, captures the average effect of nfluenza exposure on 2

11 ndvdual socoeconomc market outcomes. In ths natural experment, ndvduals born n the year 1919 are n the treatment group and those born n other years durng the ten year study perod are n the control group. Not only were parents not able to predct the comng of the pandemc flu, but even f they dd, t s doubtful that they would have been aware of the possble consequences on ther chldren. For these reasons, parents made no dfferent concepton decsons leadng up to the arrval of the flu than they had just before or just after. So the only dfference between those n the treatment group and those n the 2 control group s ther age. Therefore, the varables YoB and YoB are ncluded n equaton (3) to control for dfferences n age. Equaton (3) s estmated as a logstc regresson separately for each bnary outcome varable (college educaton, lteracy, employment, and formal employment) and usng OLS for each contnuous varable (years of schoolng and log hourly wage). The error term, e, s made up of all factors that nfluence the outcomes of nterest but are not observed. Typcally, omtted varable bas would be an ssue as unobserved varables that affect the socoeconomc outcomes are often correlated wth the treatment effect (whether an ndvdual was exposed to the flu). Examples of unobserved nfluences on the socoeconomc varables of nterest nclude work ethc, drve, and study sklls. But because of the nature of ths natural experment, ndvduals were randomly assgned to the treatment, thereby elmnatng the omtted varable bas. It s unlkely that beng born n 1919 s correlated wth any of these unobserved factors.

12 Results from the estmaton of equaton (3) are shown n Table 2. As can be seen, there s support for the Fetal Orgns Hypothess n the college educaton, employment, formal employment, and years of schoolng outcomes. Indvduals born n 1919 were 13% less lkely to graduate from college, 5% less lkely to be employed, 8.6% less lkely to have a sgned workbook, and had.046 less years of schoolng than ndvduals born n other years between 1912 and The coeffcent on the 1919 brth year varable n the lteracy regresson has the expected sgn but s not sgnfcant. For the log hourly wage regresson, ths coeffcent has an unexpected sgn but s not sgnfcant. 4.2 Quarter of Brth The results shown n the prevous subsecton are llustratve and gve us confdence n the Fetal Orgns Hypothess, but t s possble to zero n even more closely on the ndvduals n the treatment group n ths natural experment. Because the 1918 Influenza Pandemc was at the peak of ts ntensty for just a short tme (md October to md December 1918), ndvduals whose mothers were exposed to the vrus would have been born durng the frst two quarters of 1919 as llustrated n Fgure 1. As seen n ths fgure, any typcal nne-month pregnancy that began before the pandemc arrved would result n a brth sometme n the 1st or 2nd quarter of Accordng to the Fetal Orgns Hypothess, we would expect ndvduals born n the frst two quarters on 1919 to have worse socoeconomc outcomes than those born n other quarters durng ths ten year tme perod. To examne ths, I extend equaton (3) as follows: y = β Q1 Q Q Q + β YoB + β YoB + u + e, (4) β 2 + β β β t

13 where Q1, Q2, Q3, and Q4 ndcator varables equal to 1 f ndvdual was born n the frst, second, thrd, or fourth quarter of 1919, respectvely. Ths s a smlar specfcaton to that used n (Almond and Mazumder, 2005) who use health outcomes as the dependent varable. Equaton (4) s estmated usng the same dependent varables as before. Results from these estmatons are shown n Table 3. As can be seen, for each socoeconomc outcome, the coeffcent on ether the frst quarter brth dummy or the second quarter brth dummy, or both, s sgnfcant and wth the sgn that would support the Fetal Orgns Hypothess. Indvduals born n the frst quarter of 1919 are 17.8% less lkely to graduate from college, 17.4% less lkely to be employed, and 27.8% less lkely to have formal employment. Indvduals born n the second quarter of 1919 are 18.8% less lkely to graduate from college, 9.2% less lkely to be lterate, 9.2% less lkely to be employed, have 0.11 less years of schoolng, and earn 26.3% lower hourly wages. 5 Dscusson Ths s the frst study to examne the long-run mplcatons of poor fetal health on socoeconomc outcomes n a developng country. The 1918 Influenza Pandemc was used as a natural experment to test the Fetal Orgns Hypothess usng data from Brazl. The results support the Fetal Orgns Hypothess. In partcular, I fnd that ndvduals born n 1919 have worse socoeconomc outcomes (college educaton, employment, formal employment, and years of schoolng) than ndvduals born n other years n the ten year nterval from 1912 to In addton, ndvduals born n the frst two quarters of 1919 have worse socoeconomc outcomes (college educaton, lteracy, employment,

14 formal employment, years of schoolng, and log hourly wages) than ndvduals born n other quarters durng that same ten year nterval. Ths evdence demonstrates the mpact that poor fetal health can have on an ndvdual's lfe decades after brth. The ntal health endowment s a crucal nput to the health producton functon. These results are consstent wth those found n the two papers by Almond, n whch he uses data from the US. In (Almond, 2006), he estmates a model smlar to equaton (3) usng US Census data from 1960, 1970, and He fnds that ndvduals born n 1919 have worse educaton outcomes, earn less wage and total ncome, are more lkely to be poor (as defned as 150% below the poverty level), are more lkely to have a dsablty that lmts or prevents work, and have more Socal Securty and Welfare ncome than those born n other years between 1912 and Almond also explores the effect of the nfluenza pandemc through an avenue not avalable n ths study. He explots regonal varaton of pandemc strength to demonstrate dfferences of effect wthn the 1919 brth cohort. Requste for ths type of analyss s an ndvdual's state of brth. Ths s avalable n the US Census but not n the PME. However, because ths second analyss supports the frst, we feel that the brth cohort analyss presented here s suffcent to show support for the Fetal Orgns Hypothess. In (Almond and Mazumder, 2005), he estmates a models smlar to equatons (3) and (4) usng data from the Survey of Income and Program Partcpaton (SIPP) wth health, rather than socoeconomc, outcomes. In ths study, he fnds that ndvduals born n 1919 had poor health overall as well as dffculty hearng, speakng, lftng, and walkng, and were more lkely to have dabetes and stroke than other ndvduals born between 1915 and 1923.

15 The results found here suggest that the negatve effects of poor maternal and fetal health are evdent years later. However, ths evdence does not support a selecton effect n whch the Spansh Flu led to the brth of only those ndvduals of greatest strength to survve ts effects. Ths selecton effect would have been evdent f ndvduals born n 1919 (or n the frst two quarters of ths year) had mproved socoeconomc outcomes compared to others born at other tmes durng the ten year study perod. Due to lack of data n the PME, we are unable to control for current health or post-brth health nvestments. Indvduals born n 1919, havng been exposed to the flu n utero and therefore born wth a lower ntal health endowment, may engage n greater amounts of post-brth health nvestments n order to compensate for ther low ntal status. Alternatvely, those wth low ntal health endowments may be unable to nvest as much n health nputs throughout ther lfe. Ether way, t s lkely that ntal health and subsequent health status or nvestments wll be correlated and therefore lead to bas n our results. The ncluson of the age varable goes a small way toward remedyng ths stuaton. Age may be a proxy, albet a poor one, for health nvestments. Another lmtaton of the current study s that t only looks at the mpact of poor fetal health on socoeconomc outcomes and not on health outcomes. Whle socoeconomc outcomes are mportant n ther mplcatons for economc growth, health outcomes are also mportant themselves. Future research could explore the mpact of ths natural experment on health outcomes later n lfe n developng countres as well as strengthen the connecton between ths health shock and economc growth.

16 Although the event at the center of ths analyss occurred 90 years ago ths analyss provdes valuable nsghts nto the mportance of maternal and fetal health years after brth. It s true that health care technology as well as methods of predctng and foreseeng the next nfluenza pandemc have greatly mproved n both developed and developng countres. For ths reason, t s unlkely that another nfluenza pandemc, such as the much publczed Avan Flu, would lead to outcomes of smlar magntude as those seen here. The mportant contrbuton of ths paper, on the other hand, s to document not to absolute magntude of the effects of pandemc flu. Rather, t s to present the relatve effect of ths poor health shock on those who receved t compared to those who dd not receve t. In fact, because the poor methods of detectng nfluenza pandemc at the tme allowed the Spansh Flu to arrve so unexpectedly and the medcal technology at the tme allowed those exposed to the vrus to feel ts full effects, the envronment n place when the pandemc ht n 1918 created an deal natural experment. Ths natural experment allows us to utlze ths tragc natural dsaster to demonstrate the mportance of fetal health. The mplcatons of ths analyss are substantal. Lttle s known about the long-run effects of poor chldhood health on economc growth and development (Glewwe and Mguel, (forthcomng)). Several recent studes have examned the effects of dsease due to hookworms on measures related to economc growth. (Brnkley, 1997) fnds per capta agrcultural output decreased as a result of ncreased hookworm-related dsease. (Bleakley, 2007) fnds that the Rockefeller Santary Commsson's hookworm eradcaton

17 campagn n the Southern Unted States n the 1910s had a substantal mpact on educatonal attanment and ncome. These studes both examne publc health events n the Unted States. The present study presents the mpact of a negatve publc health event n a developng country. These results suggest that developng countres that make concerted efforts to make nvestments n mprovng fetal and maternal health wll see mportant returns on ther nvestments n the form of the benefts that come from a healthy workforce.

18 References ALMOND, D. (2006) Is the 1918 Influenza Pandemc Over? Long-Term Effects of In Utero Influenza Exposure n the Post-1940 U S Populaton. Journal of Poltcal Economy, 114, ALMOND, D. & MAZUMDER, B. (2005) The 1918 Influenza Pandemc and Subsequent Health Outcomes: An Analyss of SIPP Data. Amercan Economc Revew, 95, ALSAN, M., BLOOM, D. & CANNING, D. (2006) The effect of populaton healt on foregn drect nvestment nflows to low-and mddle-ncome countres. World Development, 34, BARKER, D. J. (1995) Fetal orgns of coronary heart dsease. BMJ, 311, BEHRMAN, J. R. & ROSENZWEIG, M. R. (2004) Returns to Brthweght. Revew of Economcs and Statstcs, 86, BLEAKLEY, H. (2007) Dsease and Development: Evdence from Hookworm Eradcaton n the Amercan South. Quarterly Journal of Economcs, 122, BLOM, A., HOLM-NIELSEN, L. & VERNER, D. (2001) Educaton, Earnngs, and Inequalty n Brazl, : Implcatons for Educaton Polcy. The World Bank, Polcy Research Workng Paper Seres. BRINKLEY, G. L. (1997) The Declne n Southern Agrcultural Output, Journal of Economc Hstory, 57, BRITO, N. (1997) La dansarna: a grpe expanhola e o cotdano na cdade do Ro de Janero. Hst Cenc Saude Mangunhos, IV, CASE, A., FERTIG, A. & PAXSON, C. (2005) The Lastng Impact of Chldhood Health and Crcumstance. Journal of Health Economcs, 24, COFFEY, V. P. & JESSOP, W. J. (1963) Maternal nfluenza and congental deformtes. A follow-up study. Lancet, 1, EBERT, T. & KOTLER, M. (2005) Prenatal exposure to nfluenza and the rsk of subsequent development of schzophrena. Isr Med Assoc J, 7, FATEMI, S. H., EARLE, J., KANODIA, R., KIST, D., EMAMIAN, E. S., PATTERSON, P. H., SHI, L. & SIDWELL, R. (2002) Prenatal vral nfecton leads to pyramdal cell atrophy and macrocephaly n adulthood: mplcatons for geness of autsm and schzophrena. Cell Mol Neurobol, 22, GLEWWE, P. & MIGUEL, E. ((forthcomng)) The Impact of Chld Health and Nutrton on Educaton n Less Developed Countres. Handbook of Development Economcs. Elsever. HARRIS, J. (1919) Influenza occurrng n pregnant women. JAMA, 72, IRVING, W., JAMES, D., STEPHENSON, T., LAING, P., JAMESON, C. & OXFORD, J. (2000) Influenza vrus nfecton n the second and thrd trmester of pregnancy: a clncal and seroepdemologcal study. BJOG, 107, JOHNSON, N. P. & MUELLER, J. (2002) Updatng the accounts: global mortalty of the "Spansh" nfluenza pandemc. Bull Hst Med, 76, KWAN, M. L., METAYER, C., CROUSE, V. & BUFFLER, P. A. (2007) Maternal llness and drug/medcaton use durng the perod surroundng pregnancy and rsk of chldhood leukema among offsprng. Am J Epdemol, 165,

19 LAM, D. & SCHOENI, R. F. (1993) Effects of Famly Background on Earnngs and Returns to Schoolng: Evdence from Brazl. Journal of Poltcal Economy, 101, MIGUEL, E. & KREMER, M. (2004) Worms: Identfyng Impacts on Educaton and Health n the Presence of Treatment Externaltes. Econometrca, 72, NUZUM, J., PILOT, I., STANGEL, F. & BONAR, B. (1918) Pandemc nfluenza and pneumona n a large cvlan hosptal. JAMA, 71, RASMUSSEN, S. A., JAMIESON, D. J. & BRESEE, J. S. (2008) Pandemc nfluenza and pregnant women. Emerg Infect Ds, 14, ROSENZWEIG, M. R. & WOLPIN, K. I. (2000) Natural "Natural Experments" n Economcs. Journal of Economc Lterature, 38, SAXEN, L., HJELT, L., SJOSTEDT, J. E., HAKOSALO, J. & HAKOSALO, H. (1960) Asan nfluenza durng pregnancy and congental malformatons. Acta Pathol Mcrobol Scand, 49, SHI, L., FATEMI, S. H., SIDWELL, R. W. & PATTERSON, P. H. (2003) Maternal nfluenza nfecton causes marked behavoral and pharmacologcal changes n the offsprng. J Neurosc, 23, SHOPE, R. (1936) The ncdence of neutralzng antbodes for swne nfluenza n the sera of human bengs of dfferent agese. Journal of Expermental Medcne, 63, TAKAHASHI, M. & YAMADA, T. (2001) A possble role of nfluenza A vrus nfecton for Parknson's dsease. Adv Neurol, 86, TAUBENBERGER, J. K. & MORENS, D. M. (2006) 1918 Influenza: the mother of all pandemcs. Emerg Infect Ds, 12, TEIXEIRA, A. (2003) Vruses, scences, and men. Hst Cenc Saude Mangunhos, 10, WILSON, M. G. & STEIN, A. M. (1969) Teratogenc effects of asan nfluenza. A n extended study. JAMA, 210, ZOU, S. (2006) Potental mpact of pandemc nfl uenza on blood safety and avalablty. Transfus Med Rev, 20,

20 Table 1: Descrptve Statstcs Varable N Mean/N Std Dev/% Mn Max College 379,930 20, % 0 19,357 Upper Secondary 379,930 29, % 0 1 Read 379, , % Unemployed 379, , % 0 1 Employed 379,930 44, % 0 1 Sgned Workbook 379,930 10, % 0 1 Years of Schoolng 379, Log Hourly Wage 31, Born ,930 36, % 0 1 Born Quarter 1 379,930 8, % 0 1 Born Quarter 2 379,930 9, % 0 1 Born Quarter 3 379,930 8, % 0 1 Born Quarter 4 379,930 9, % 0 1 Female 379, , % 0 1 Survey Year ,930 38, % 0 1 Survey Year ,930 38, % 0 1 Survey Year ,930 31, % 0 1 Survey Year ,930 25, % 0 1 Survey Year ,930 23, % 0 1 Survey Year ,930 35, % 0 1 Survey Year ,930 31, % 0 1 Survey Year ,930 30, % 0 1 Survey Year ,930 27, % 0 1 Survey Year ,930 26, % 0 1 Survey Year ,930 24, % 0 1 Survey Year ,930 23, % 0 1 Survey Year ,930 23, % 0 1

21 Table 2: Year of Brth Results Odds Rato or Outcome Coeffcent N College *** 379,930 (0.022) Lteracy ,930 (0.013) Employed *** 379,930 (0.016) Formal Employment *** 379,930 (0.031) Years of Schoolng * 379,930 (0.024) Log Hourly Wage ,184 (0.053) Value n table represents Standard errors n parentheses. * sgnfcant at 10% level, * sgnfcant at 5% level, * sgnfcant at 1% level Table 3: Quarter of Brth Results Outcome Quarter 1 Quarter 2 Quarter 3 Quarter 4 N College *** *** ** ,930 (0.042) (0.041) (0.044) (0.043) Lteracy *** ,930 (0.026) (0.022) (0.025) (0.024) Employed *** *** ,930 (0.029) (0.030) (0.034) (0.033) Formal Employment *** ,930 (0.056) (0.062) (0.062) (0.061) Years of Schoolng ** ,930 (0.046) (0.045) (0.046) (0.044) Log Hourly Wage *** *** * 31,184 (0.104) (0.098) (0.098) (0.091) Standard errors n parentheses. * sgnfcant at 10% level, * sgnfcant at 5% level, * sgnfcant at 1% level

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