Health outcomes vary substantially across India. Is this variation exclusively determined by present-day factors, or can it be traced back to historical events? This article studies the long-term consequences of the Protestant medical missionary enterprise that spread throughout the country in the 19th century. It finds a robust positive association between proximity to a medical mission and current individuals’ health outcomes.
India is ranked 125th in the world for life expectancy and 97th for undernutrition, and accounts for a substantial proportion of the global burden of disease (World Health Organization, 2016). These country-level figures hide significant regional variation in health conditions. South Indian states, for instance, are doing quite well in terms of health performance, while in some of the most populous northern states health indicators are considerably worse. Strong differences in health outcomes persist at the sub-state level too, and even across areas within the same district. The question is: Where does this health variation come from? Is it exclusively determined by present-day factors? Or can it be traced back to historical events?
Motivated by mounting evidence of the historical persistence of institutions and behaviour1, in a recent study (Calvi and Mantovanelli 2018) we assess the long-term consequences of the Protestant medical missionary enterprise that spread throughout the Indian subcontinent in the late 19th century. In the hope that medicine would facilitate conversion to Christianity, at the turn of the century Protestant missionary societies increased the number of doctors and medical personnel sent to India. In contrast to the official colonial doctors and (at least initially) to Catholic missionaries, Protestant medical missionaries were particularly active within non-European social and institutional milieus, contributing to the diffusion of Western medicine among the local population. Priority was given to women’s medical mission work as a way of improving maternal and child health. By 1912, Protestant missionaries were providing medical treatment to approximately three million patients every year.2
We construct a novel, fully geocoded dataset that combines contemporary individual-level data from the 2003 World Health Survey with archival information on Protestant missions in colonial India and their activities.3 We use this data to study the link between individuals’ proximity to a Protestant medical mission (that is, a mission equipped with a hospital or a dispensary) and their health outcomes today. We focus primarily on anthropometric indicators to measure health and use geocoding tools to compute the distance between the current location of individuals and the location of Protestant health facilities operating in early 20th century India. We show that proximity to a Protestant medical mission is positively associated with current individuals’ health outcomes. This holds even after controlling for unobserved district-level factors and for a wide set of location characteristics that might correlate with individuals’ health today and might have influenced missionaries’ location decisions in the past.4 In particular, we find that halving the distance from a Protestant medical mission is associated with a 0.17 increase in individuals' BMI (body mass index) and with a 0.63 centimeters increase in their height, on average.
To explore this link further, we address two possible sources of bias:
- Unobserved determinants of the location decisions of early missionaries may correlate with current health outcomes.
- Protestant missionaries may have decided to invest in health facilities in some missions but not in others, based on specific factors that are not observed by the researchers.
We tackle the first source of bias in several ways. We show that our results are robust to restricting the analysis to individuals living relatively close to the historical missionary settlements (therefore reducing the degree of within-district unobserved variation across locations). We also explore the link between individuals’ current health and their distance from generic (that is, without a hospital or a dispensary) Protestant missions and Catholic missions. It is reassuring that we do not find any significant relationship between individuals’ health outcomes and the distance from missions without a health facility. Finally, we assess the potential bias due to unobserved factors using a methodology developed by Oster (2017). This analysis indicates that the role of unobserved factors is not critical.
To address the second source of bias, we proceed in two ways. First, we match each Protestant medical mission with a mission with similar characteristics, but without health facilities. We show that the positive health effect of proximity exists for medical missions only. Next, we exploit the fact that Protestant missionary societies around the world differed in their inclination to engage in medical activities. Specifically, we compute each missionary society’s share of medical stations in all regions of the world outside of India and then combine those shares with individuals’ location information to tackle remaining identification concerns.
Long run channels
To shed light on the mechanisms behind the long-term link between proximity to a Protestant medical mission and current individuals’ health outcomes, we analyse four potential transmission channels: religious conversion, persistence of health infrastructure, advancements in health habits (for example, hygiene and health awareness), and improvements in health potential (for example, health outcomes of previous generations). Some interesting features emerge from this analysis:
- Conversion to Christianity does not seem to play a critical role. While the positive long-term health effect is slightly larger for Christians, we do not find proximity to a Protestant medical mission to be a significant predictor of current religious affiliation or practices.
- Once observable location characteristics are accounted for, there is no evidence of a significant positive correlation between individuals’ access to current health facilities and their proximity to a medical mission, which suggests that the long-run health effect is not driven by persistence of infrastructure.
- We show that individuals living close to the location of a Protestant medical mission do significantly better in terms of health habits, such as hygienic practices, maternal and perinatal care, and disease awareness.
- Using historical vital statistics data for the period 1891-1941 (Donaldson and Keniston 2014), we study the relationship between the presence of Protestant medical missions at the turn of the century and district-level outcomes in the intervening period. We find that districts with medical missions experienced significantly lower death rates, but only starting from the third decade of the 20th century.
Our focus on the historical origins of the variation in health outcomes in India is not meant to imply that other short-run factors are unimportant. A number of existing studies examined other crucial determinants, including wealth and income, education, environmental exposures and differences in health infrastructure, and human resources.5 The point we wish to stress is that even accounting for these important factors, there remains a strong persistent link between the medical activities of Protestant missionaries and individuals’ health outcomes today. Taken together, our results shed light on the mechanisms through which health disparities may arise and persist over time, and contribute to a stimulating line of research looking at historical institutions as critical determinants of contemporary outcomes.
- See Nunn (2009) for an effective summary of this literature. Studies focusing on the long-run impact of missionary activities include Woodberry (2004, 2012), Woodberry and Shah (2004), Gallego and Woodberry (2010), Nunn (2010), Nunn et al. (2011), Bai and Kung (2015), Meier zu Selhausen (2014), Cagé and Rueda (2016, 2018), Castelló-Climent et al. (2017), Waldinger (2017), Valencia Caicedo (2018), and Calvi et al. (2018).
- Traditionally, the care of women and the practice of midwifery were in the hands of local dais, who helped during childbirth but were often unable to deal with difficult deliveries and pregnancies. With the aim of reducing maternal and neonatal mortality, Protestant missionaries founded several training school for dais. For an overview of missionary medicine in India see, for example, Fitzgerald (2001) and Hardiman (2008).
- Our archival data on missionary activities and locations is from the ‘Centennial Survey of Foreign Missions’ (1902) and the ‘Statistical Atlas of Christian Missions’ (1910).
- Previous works indeed show that Protestant missionaries chose to locate in geographically favourable and more accessible regions (Nunn 2010, Cagé and Rueda 2016, Jedweb et al. 2018). In our analysis, we control, for example, for altitude, latitude and longitude, access to water sources and historical railways, and current and past population densities within a 5-kilometer radius from each survey respondent.
- See, for example, Banerjee et al. (2004), Banerjee and Duflo (2006), Greenstone and Hanna (2014), Hammer and Spears (2016), Duh and Spears (2017), Geruso and Spears (2018), and references therein.
- Bai, Ying and James Kai-sing Kung (2015), “Diffusing knowledge while spreading god’s message: Protestantism and economic prosperity in china, 1840–1920”, Journal of the European Economic Association, 13(4): 669–698.
- Banerjee, Abhijit, Angus Deaton and Esther Duflo (2004), “Health, Health Care, and Economic Development: Wealth, Health, and Health Services in Rural Rajasthan”, American Economic Review, 94(2): 326–330.
- Banerjee, Abhijit and Esther Duflo (2006), “Addressing Absence”, Journal of Economic Perspectives, 20: 117–132.
- Becker, Sascha O, Steven Pfaff and Jared Rubin (2016), “Causes and Consequences of the Protestant Reformation”, Explorations in Economic History, 62: 1–25.
- Calvi, Rossella and Federico G Mantovanelli (2018), “Long-term Effects of Access to Health Care: Medical Missions in Colonial India”, Journal of Development Economics, 135: 285–303.
- Cagé, Julia and Valeria Rueda (2016), “The Long-term Effects of the Printing Press in Sub-saharan Africa”, American Economic Journal: Applied Economics, 8(3): 69–99. Available here.
- Cagé, J and V Rueda (2018), ‘Sex and the Mission: The Conflicting Effects of Early Christian Investments on Sub-Saharan Africa’s HIV Epidemic’, Working Paper. Available here.
- Calvi, R, F Mantovanelli and L Hoehn-Velasco (2018), ‘The Protestant Legacy: Missions and Human Capital in India’, Working Paper.
- Castelló-Climent, Amparo, Latika Chaudhary and Abhiroop Mukhopadhyay (2017), “Higher Education and Prosperity: From Catholic Missionaries to Luminosity in India”, The Economic Journal, 128(616): 3039–3075.
- Donaldson, D and D Keniston (2014), ‘How Positive Was the Positive Check? Investment and Fertility in the Aftermath of the 1918 Influenza in India’, Working Paper. Available here.
- Duh, Josephine and Dean Spears (2017), “Health and Hunger: Disease, Energy Needs, and the Indian Calorie Consumption Puzzle”, The Economic Journal, 127: 2378–2409.
- Geruso, Michael and Dean Spears (2018), “Neighborhood Sanitation and Infant Mortality”, American Economic Journal: Applied Economics, 10(2): 125–162. Available here.
- Greenstone, Michael and Rema Hanna (2014), “Environmental Regulations, Air and Water Pollution, and Infant Mortality in India”, American Economic Review, 104(10): 3038–3072. Available here.
- Hammer, Jeffrey and Dean Spears (2016), “Village Sanitation and Child Health: Effects and External Validity in a Randomized Field Experiment in Rural India”, Journal of Health Economics, 48: 135–148.
- Nunn, Nathan (2009), “The Importance of History for Economic Development”, Annual Review of Economics, 1(1): 65–92. Available here.
- Gallego, Francisco A and Robert Woodberry (2010), “Christian Missionaries and Education in Former African Colonies: How Competition Mattered”, Journal of African Economies, 19(3): 294–329.
- Hardiman, D (2008), Missionaries and Their Medicine: A Christian Modernity for Tribal India, Manchester University Press.
- Jedwab, R, A Moradi and FM zu Selhausen (2018), ‘The Economics of Missionary Expansion: Evidence from Africa and Implications for Development’, Working Paper. Available here.
- Meier zu Selhausen, Felix (2014), “Missionaries and Female Empowerment in Colonial Uganda: New Evidence from Protestant Marriage Registers, 1880–1945”, Economic History of Developing Regions, 29(1): 74–112.
- Nunn, Nathan (2010), “Religious Conversion in Colonial Africa”, American Economic Review, 100(2): 147–52. Available here.
- Nunn, N (2014), ‘Gender and Missionary Influence in Colonial Africa’, in E Akyeampong, RH Bates, N Nunn and JA Robinson (eds.), African Development in Historical Perspective, Cambridge University Press.
- Oster, Emily (2017), “Unobservable Selection and Coefficient Stability: Theory and Evidence”, Journal of Business & Economic Statistics, 1–18.
- Valencia Caicedo, Felipe (2018), “The Mission: Human Capital Transmission, Economic Persistence and Culture in South America”, Quarterly Journal of Economics, 134(1): 507-556.
- Waldinger, Maria (2017), “The Long-run Effects of Missionary Orders in Mexico”, Journal of Development Economics, 127: 355–378.
- Woodberry, RD (2004), ‘The Shadow of Empire: Christian Missions, Colonial Policy, and Democracy in Postcolonial Societies’, Ph.D. thesis, University of North Carolina at Chapel Hill.
- Woodberry, Robert D (2012), “The Missionary Roots of Liberal Democracy”, American Political Science Review, 106(02): 244–274.
- Woodberry, Robert D and Timothy S Shah (2004), “Christianity and Democracy: The Pioneering Protestants”, Journal of Democracy, 15(2): 47–61.
- World Health Organization (2016), ‘World Health Statistics 2016: Monitoring Health for the SDGs Sustainable Development Goals’.