Controlling Tuberculosis? Evidence from the Mother of All Community-Wide Health Experiments

Abstract

This paper studies the immediate and long-run mortality effects of the first community-based health intervention in the world, which had a particular focus on controlling tuberculosis - the so-called Framingham Health and Tuberculosis Demonstration. Comparing death and TB-mortality rates between Framingham and seven (pre-selected) control towns during the Demonstration period between 1917 and 1923, the contemporary offcial evaluation committee concluded that the Demonstration was highly successful in controlling TB and reducing mortality. The Framingham Demonstration subsequently became a health example for the world. The findings in our paper question this very positive assessment. We collected and digitized causes-of-death data for towns/cities in Massachusetts and the United States for the period 1901-1934, allowing us to extend the number of control towns (or cities) and study whether the Demonstration reduced mortality in the long run. Compared to the official seven controls towns, we find that TB mortality in Framingham was on average lower between 1917 and 1923. In the extended control samples, these immediate TB mortality differences are smaller and often more than reversed by 1934. However, we do find robust evidence that the Demonstration reduced infant mortality, and these improvements persisted even after the Demonstration ended.