Over the past decade, and accelerated due to the COVID-19 pandemic, there has been increasing adoption of decentralized diagnostic testing, where the testing is brought closer to the patient. This trend has largely been fueled by the development of more accurate diagnostic tools and faster and more reliable data connectivity. Decentralized testing has been shown to greatly reduce turnaround times while increasing accessibility to users in remote regions. However, there are challenges that limit its widespread adoption. In this dissertation, we detail the development of tools and technologies to overcome these barriers and expedite the shift towards decentralized diagnostic testing. First, we demonstrate the ability to develop point-of-care (POC) diagnostic tests with performance that rivals that of traditional lab-based methods. We developed a rapid, multiplexed, microfluidic serological test for Lyme disease, a tick-borne disease caused by the Borrelia burgdorferi bacterium. The recommended testing, the standard 2-tiered (STT) approach, is not sensitive for early-stage infections, is labor-intensive, has long turnaround times, and requires the use of two immunoassays (enzyme-linked immunosorbent assay (ELISA) and the Western Blot). We developed a standalone multiplexed sandwich ELISA assay and adapted it to the mChip microfluidic platform. We validated the assay on a rigorously characterized panel of human serum samples and demonstrated that our approach outperforms the STT algorithm on sensitivity while matching its specificity. The form factor of this technology is amenable to use in physician’s offices and urgent care clinics. We also showed exploratory work towards adapting the mChip platform for diagnosis of Zika disease, a mosquito-borne disease caused by the Zika virus, and acute kidney injury, a syndrome characterized by loss of kidney excretory function. Next, we worked on increasing the adoption of rapid diagnostic tests for self- and partner-testing designed to be used in at-home settings. We developed a smartphone application to be used alongside the INSTI Multiplex test for detecting HIV and syphilis infections. The application was designed to provide users with i) instructions on running the test, ii) an automated deep-learning-based image interpretation algorithm to interpret the rapid test results from a smartphone image, iii) a way to save test results and display/share them, and iv) resources for follow-up care. We adopted a user-centered, iterative design process where we worked with a cohort of study participants composed of men who have sex with men and transgender women at high risk for contracting sexually transmitted infections. We then field tested the application with 48 participants over a duration of three months and found high acceptability for the application, both in terms of functionality and helpfulness. Finally, we sought to address a key limitation with deep-learning-based image classification techniques, specifically, the requirement for large numbers of annotated images for training. We developed a deep-learning image interpretation algorithm that could be quickly adapted to new rapid test kits using only a fraction of the images that would otherwise be needed for training the model. The interpretation algorithm followed a three-step, modular process. First, the rapid test kit and the membrane were extracted from the smartphone image. Second, the constituent zones were cropped from the extracted membrane. Finally, a classifier detected the presence or absence of a line in the individual zones. Fast adaptation was demonstrated by adapting a base model, trained using images of a single COVID-19 rapid test kit, to four different rapid test kits, each with different form factors, using few-shot domain adaptation. After training with 20 or fewer images, the classification accuracies of all the adapted models were > 95%. This approach can provide a digital health platform for improved pandemic preparedness and enable quality assurance and linkage to care for consumers operating new LFAs in widespread decentralized settings. Together, these methods provide a suite of tools that could expedite the shift towards decentralized, POC testing.

Master of Arts / This thesis is an exploratory study that aims to identify whether it is adequate to apply the current approach of considering policies related to geothermal energy under the general umbrella of renewable policies or we need to use a system-sector based approach specifically for geothermal energy systems. I have identified a total of twenty-three different policy types related to geothermal energy systems in U.S. states. To understand how geothermal related policies diffuse from one U.S. state to another, and, therefore, better design policies to promote the use of geothermal energy in U.S. states, we need to perform several diffusion studies. This process is time consuming and expensive. Thus, focusing on the most promising geothermal related policies, at least as a start, is crucial for future studies focusing on the diffusion of geothermal related policies between U.S. states. Therefore, this thesis focuses on the preliminary step of selecting a limited set of geothermal related policies for future policy diffusion studies. The main conclusions and answers provided in this thesis provide a strong support to the hypothesis that a system-sector based approach is needed when studying policies related to geothermal energy in U.S. states. I explicitly report that each of the three main geothermal systems is impacted by different set of policy categories and types. I also discuss that not all policies have the same impact on all sectors in which the geothermal energy is applied; in other words, the utilization of geothermal energy in the different sectors is promoted by different policies in distinguished ways. Moreover, the discussion in this thesis highlights the shortcomings of the common approach usually used in diffusion v studies of renewable energy policies. This approach considers all renewable energies as a general category, neglecting any potential impacts due to the unique characteristics of each renewable source. I show that, for example, the most popular policy types considered in policy diffusion studies for renewable energies are not the most significant ones for the different geothermal systems. I also highlight the fact that other policy types that are generally overlooked in policy diffusion studies of the generalized renewable energies are more significant for geothermal energy systems. These results indeed support my hypothesis regarding the importance of system-sector based approach when investigating geothermal energy policies.

In the first chapter of this dissertation, I exploit the Covid-19 pandemic and associated government restrictions as a natural experiment in order to study the resilience of businesses in the United States. I use a border-county identification strategy with data on government restrictions, employment and open small businesses, in order to assess the resilience of small businesses in the United States. In my main results, I find negative impacts of stay-at-home orders on the number of open small merchants. In particular, shutdowns of businesses accelerated 8 weeks after imposition of a stay-at-home order, suggesting that many businesses were only resilient enough to handle adverse conditions for 8 weeks. On average, a county with a stay-at-home order experienced an additional 1.51 percentage points loss in the number of open small businesses, relative to January 2020, 8 weeks later compared to a neighboring county that did not have a stay-at-home order. Firms were quicker to resort to layoffs. On average a county with an active stay at home order in a month experienced an additional 1.19 percentage point loss in employment, relative to January 2020, the following month compared to a neighbor that did not have a stay-at-home order the previous month. My results suggest that in future scenarios where governments consider enacting similar restrictions further aid is needed for businesses in order to help them stay afloat. In particular, more assistance should be delivered to businesses within two months from the enacting of the order. In the second chapter of this dissertation, I study economic spillovers in the context of theCovid-19 associated government restrictions. I use a detailed geolocation dataset to construct data on the number of visitors per-capita between neighboring counties in the early stages of the pandemic, which I use as a proxy for economic spillovers. I employ a similar border-county identification strategy as in the first chapter to identify the causal effect of stay-at-home orders on inter-county movement. Additionally, I provide evidence for an assumption used in chapter one by examining if there are reduced spillovers in county-pairs that lie in the different commute zones. I find that stay-at-home orders caused reductions in inter-county visits in both directions in a county-pair. That is, I find a decrease in travel from the county without a stay-at-home order to the county with one, as well as a decrease in the opposite direction. On average, a county that does not have stay-at-home order will receive 408 fewer weekly visitors from their neighboring county that has a stay-at-home order. I also examine the effect of stay-at-home orders on the ratio of travel between the two directions in order to find evidence of a net spillover effect between the two counties and fail to find evidence of a net spillover effect. I also find that spillover effects are indeed reduced in neighbor county-pairs where the two counties are in different commute zones. The results of this paper imply that residents in counties with stay-at-home orders decreased travel to their neighboring counties even when those counties did not issue their own orders. In future situations where policy makers need to consider similar restrictions, they should focus on acting more quickly and not be concerned if neighboring counties are not cooperative. In the third chapter of this dissertation, I test the predictions of career concerns models by studying Major League Baseball umpires. Major League Baseball games can be dramatically shaped by minor lapses in judgement from the umpires officiating the game. Due to the indefinite length a game may have, this can include having the game shaped in a way that ends it faster. I study whether evidence for the career concerns model can be found in baseball umpires. A career concerns model would suggest that older umpires, whose careers and reputations are much more established than younger ones, would be more inclined to improperly make judgements that favor the end of the game in extra innings. I use data on MLB umpires and extra-innings games from the 2010-2018 seasons to conduct my empirical analysis and use a linear probability model to isolate the impact of the umpires’ tenure on the probability they make a “bad call.” I find evidence supporting the career concerns hypothesis and that the probability that an umpire makes a bad call that shortens the length of the game and allows them to go home increases with their tenure. I show that these results are likely driven by career concerns, rather than carelessness, by showing their error rate does not increase with tenure in situations where it would not reduce their workload.

Criminalization, and other forms of punishment, are at the core of the current policy response to prenatal drug use in the United States (U.S.). However, evidence has repeatedly shown that interventions founded on deterrence principles—the idea that punishments deter crimes—more commonly harm rather than advance public health goals. In three aims, this dissertation examines several consequences of prenatal drug use criminalization, first, through a review of the current policy and evidence base (Chapter 2), followed by two empirical studies testing for adverse effects of state-level prenatal drug use criminalization on pregnant people’s participation in drug treatment (Chapter 3) and pregnancy care (Chapter 4). First, in Chapter 2, the legal survey found that by 2022, nearly half of U.S. states had implemented one or more punitive policies, demonstrating that a significant number of pregnant people are vulnerable to the carceral and child custody-related implications of these laws. Moreover, the review of the corresponding literature found that while existing research consistently identified few benefits of punitive law adoption, evidence for potential negative repercussions, including on drug treatment utilization, pregnancy and birth-related outcomes, and family separation, was inconsistent, supporting the need for additional research. In Chapter 3, analyses of national drug treatment program data from 1992 to 2019, revealed that contrary to legislative intent, prenatal drug use criminalization was associated with a decrease in pregnancy-specific drug treatment admissions. Post-criminalization declines were limited to admissions for opioid and amphetamine use in criminalization states, rather than for non- criminalized substances like alcohol, supporting the validity of the primary finding. Further, while treatment reductions appeared to be concentrated among low-income pregnant people receiving public assistance, similar reductions were not observed among pregnant people of color, in contrast to expectations. Lastly, Chapter 4 used birth certificate information from 1989 to 2019, to investigate a potential unintended consequence of prenatal drug use criminalization—reductions in pregnancy care. Results indicated that criminalization was associated with a meaningful decrease in the prevalence of any prenatal care, and a likely, though imprecise, decrease in the prevalence of healthcare facility-based delivery. Results further suggested potential post-criminalization decreases in prenatal care timeliness, but not adequacy, measures defined in terms of the trimester of initiation and the completed number of recommended visits, respectively. The findings from this dissertation support the hypothesis that policies criminalizing prenatal drug use discourage pregnant people from participating in drug treatment and from some types of pregnancy care. Criminalization is therefore a public health strategy that appears to be not only ineffective, but also overtly counterproductive, to the goal of preventing potential harms associated with prenatal drug use.

In this dissertation I analyze patterns of maternal-infant health in developing contexts. My first chapter uses child hemoglobin as a bio-marker for maternal malnutrition in Senegal during the 2008 food price crisis. In early 2008, world rice prices skyrocketed, causing people around the world to plunge into poverty. Senegal, in particular, depends heavily on imported foodstuffs. I find that the crisis had a large, negative impact on child anemia in urban Senegal, most likely reflecting a deterioration of maternal nutrition caused by rising food prices. In the second and third chapters, we introduce a novel indicator of maternal-infant health: childhood sex ratios. Because infant females have lower rates of mortality than infant males, the sex ratio of the surviving population reflects the level of infant mortality. Childhood sex ratios are widely available from census data, meaning we can use them to shed new light on historical populations who lack traditional sources of data on infant mortality, like birth and death records. We apply this new method to the 19th-century US, where the lack of vital statistics has left uncertainty over even approximate levels of infant mortality. We find that the level of infant mortality in the pre-industrial US was much lower than previously thought, but that racial health disparities were much greater.

This dissertation consists of three essays in the field of environmental economics and sustainable finance. The first chapter investigates the impact of localized exposure to heat waves and floods on the pricing of U.S. municipal bonds. I identify a significant relationship between the vulnerability of cities to heat waves and flood-related damages and municipal bond yield spreads. In particular, the effects are more pronounced in the case of municipal bonds with extended maturity periods. Cities demonstrating heightened capacities for adaptation exhibit a discernible mitigating impact on the yield spreads of these bonds. Moreover, my paper underscores the variations in political affiliations, climate attitudes, and risk perceptions across different cities, shaping this dynamic relationship. The second chapter presents empirical insights into the economic and financial effects of natural disasters, focusing on wildfires in California. Integrating financial data with historical wildfire records from 2016 to 2020, the study quantifies how wildfire risks influence municipal tax policies, revealing that local governments adjust tax rates in response to these risks. Furthermore, the study examines how municipalities enhance expenditures on public safety, particularly in fire and disaster preparedness, reflecting proactive measures to mitigate wildfire impacts and ensure community resilience. The third chapter, co-authored with Christina Laskaridis, analyzes sovereign green, social, sustainability, and sustainability-linked (GSS+) bonds in emerging and developing countries. This study maps out trends and characteristics of sovereign GSS+ bond issuances, assessing their potential to finance the energy transition and achieve Sustainable Development Goals (SDGs). The research evaluates the risks and limitations of GSS+ bonds, emphasizing the need for longer maturities, longer costs of capital, and increased funding scales to effectively contribute to sustainable development financing. Overall, these essays contribute multifaceted perspectives on the intersection of climate risks, fiscal policies, and sustainable finance, offering valuable implications for policymakers, investors, and stakeholders aiming to navigate the complexities of climate economics.

This dissertation analyzes how redistricting, minority representation, and perceived polarization— three topics regularly studied at the national level—function at the level of local government. The first two chapters focus on city council redistricting. In the first chapter, I used a new approach, a sequential Monte Carlo algorithm, to simulate city council district plans. By simulating tens of thousands of plans for each city, I was able to compare the plans that are actually implemented to a representative sample of all plausible plans. This analysis represents the first large-N geospatial analysis of city council redistricting. I found that the city council maps that are actually implemented feature more majority-minority districts than the median simulation. This implies that somewhere in the redistricting process, a conscious effort is made to foster minority representation. In the second chapter, I merged city council map data with the results of city council elections. I then analyzed the relationship between the composition of districts and who runs and who wins in city council elections. I found that district-level demographic makeup continues to be the dominant factor in the supply of minority candidates. I also found that, comparing two cities that are otherwise demographically and politically similar, cities that fall under the Voting Rights Act (VRA) pre-clearance had more minorities run for office and win election on average. In the third chapter, I conducted an original survey experiment to determine if respondents’ perceptions of partisan polarization differed in local contexts relative to the national political landscape. I did not find measurable differences in the perceived prevalence of support for different issues. However, I did find that respondents were slightly less willing to endorse generic language about partisans’ issue support when cued to think about ordinary voters in their local area. All together, these studies probe three different aspects of local electoral politics. In doing so, they help reconcile our understanding of electoral politics nationally with areas of local politics that still have many open questions.

Post-World War II public schools in Harlem, New York were segregated, under-resourced and educationally inequitable. Addressing disparities in education was of paramount importance for the socioeconomic mobility and future of the neighborhood. In an effort to understand how race, religion, community, and education intersected in this context, this dissertation answers the following research question: How did St. Philip’s, the first Black Episcopal church in the city and one of the most historic churches in Harlem, participate in education during the post-World War II period? Responding to and preventing inequities in the neighborhood, including the substandard state of the public schools, St. Philip’s served as an educational space and organizational base for the community. St. Philip’s participation accounts for the way a Black church emerged as a space for education when the public schools were foundering. The church’s ethos of education - community engagement - reframes traditional frameworks of teaching and learning beyond schoolhouse doors. During the postwar period, St. Philip’s expanded its in-house programming for Black children, youth and adults, constructing a new community youth center, where classes, tutoring, after-school activities, college counseling, career guidance, day-care, recreation and clubs were community staples. Understanding the importance of inclusivity, continuity and consistency, programming was accessible to the entire neighborhood, regardless of membership with year-round services such as summer camp and career counseling. As an organizational base, the church hosted education talks and committee meetings, facilitating a forum for the community to engage in critical conversations about the state of education. It was a safe space for transparency and troubleshooting. Concerns about education expanded beyond conversations in the church, however. St. Philip’s corresponded directly with city governance, petitioning school-makers with recommendations and demands. This dissertation broadens the traditional civil rights narrative of Black religious activism, which has the tendency to dichotomize who participated and how they participated. This polarization includes regions: North-South, religions: Christian-Muslim, figureheads: Martin Luther King, Jr.-Malcolm X, and strategies: peaceful-militant. Historians Charles Payne and Nikhil Pal Singh push back on this oversimplified interpretation as “King-centric.”* St. Philip’s educational activism foils this paradigm as a Black Episcopal institution in a northern city. St. Philip’s brings nuance to categorizations of Black churches as either being focused on the far-reaching goal of social transformation or compliant with conservative social philosophies based on respectability politics. Its participation was both radical (such as establishing educational programming at the Community youth center that was open to members and non-members alike, regardless of class, age, political or religious beliefs) and conservative (such as sitting out of the 1964 citywide school boycott, while the majority of the Black community participated). In this way, St. Philip’s educational activism in Harlem calls into question criticisms of the Black Episcopal Church that position it as elitist and accommodationist to white values and white power, hence, apathetic to the challenges facing the Black population in cities during the post-World War II period. *Nikhil Pal Singh, Black Is a Country: Race and the Unfinished Struggle for Democracy (Cambridge: Harvard University Press, 2004), 6; and Charles Payne, I’ve Got the Light of Freedom: The Organizing Tradition and the Mississippi Freedom Struggle (Berkeley: University of California Press, 1995), 419.

Background Primary care practices in the United States (US) are currently constrained in their ability to deliver high quality care due to population aging, insurance expansion, and an increasing prevalence of chronically ill patients. The nurse practitioner (NP) workforce plays a critical role in meeting the growing demands for primary care, particularly in rural and underserved areas. NPs are also more likely to deliver care to clinically and socially complex populations such as high-need high-cost (HNHC) patients. HNHC patients are adults who suffer from multiple chronic conditions and experience additional functional, behavioral, or socioeconomic needs. Despite comprising only 5% of the US population, HNHC patients account for nearly half of total health care expenditures and over 90% of Medicare expenditures. HNHC patients with behavioral health diagnoses such as depression or substance abuse face heightened challenges managing their conditions and consequentially have higher preventable spending and emergency department (ED) utilization compared to the overall HNHC population. Significant policy attention has been placed on enhancing primary care practices as a strategy to improve outcomes and reduce costs in HNHC patients. Structural capabilities are features of primary care practices (e.g., after-hours care or care coordination) which are needed to deliver high quality primary care and chronic disease management. Yet, to date little research has been done on structural capabilities in primary care practices where NPs deliver care to HNHC patients. The overall purpose of this dissertation is to understand how to enhance primary care delivery and structural capabilities to improve outcomes for HNHC patients. We have achieved the following specific aims: (1) Establish a clear definition of HNHC patients, (2) Identify existing primary care and payment models used among HNHC patients and evaluate their impact on ED utilization and costs, (3) Evaluate structural capabilities in NP primary care practices located in Health Professional Shortage Areas (HPSAs), and (4) Analyze the association between NP practice structural capabilities and ED utilization among HNHC patients with behavioral health conditions. Dissertation Chapters and Key Findings Chapter One includes an introduction to the landscape of current primary care delivery, the role of the NP workforce in expanding access, and the unique challenges of delivering care to HNHC patients. This chapter also discusses the conceptual framework guiding the dissertation, the specific aims of each study, and how each study will fill a gap in the literature. Chapter Two (Aim 1) consists of a concept analysis of HNHC patients using the Walker and Avant framework. Three subgroups of HNHC patients were identified: adults over the age of 65 who suffer from multiple chronic conditions with functional or behavioral health needs, the frail elderly, and patients under 65 years old with a serious mental health condition or disability. Antecedents that predispose an individual to becoming a HNHC patient include challenges accessing timely care, low socioeconomic status, or unmet needs. Persistent high spending occurs as a result of poorly managed chronic diseases leading to acute exacerbations, preventable health service utilization, and fragmented care between the acute and primary care settings. Chapter Three (Aim 2) is a systematic review of studies conducted from 2000-2020 on primary care and payment models used with HNHC patients. About half of the primary care models evaluated in the systematic review (11 out of 21 studies) showed no significant difference in ED utilization among HNHC patients. Care coordination and care management (15 out of 21 studies) demonstrated both positive and negative associations with ED utilization and costs. Primary care models that demonstrated significant reductions in ED utilization had shared features, including frequent follow-up, multidisciplinary team-based care, enhanced access, and care coordination. Chapter Four (Aim 3) includes a cross-sectional study of NP survey data from 2018-2019 on practice structural capabilities linked with data on primary care shortages (i.e., HPSA designation). Bivariate analyses and multivariable regression models were used to compare NP characteristics and structural capabilities in HSPA practices compared to non-HPSA practices. The majority of NPs in our sample (61%) delivered care in HPSA practices. NP practices located in HPSAs were significantly more likely to deliver care coordination compared to non-HPSA practices. We found no significant difference in prevalence of registries, after-hours care, or shared communication systems. Chapter Five (Aim 4) is a study of cross-sectional NP survey data from 2018-2019 on practice structural capabilities linked with Medicare Part A and Part B claims to identify HNHC patients and ED utilization. Multivariable Poisson models were used to estimate the association between ED utilization and structural capabilities in practices serving HNHC patients with behavioral health conditions including depression, alcohol use, and substance use disorder. Care coordination was associated with decreased rates of ED utilization among the overall HNHC population and those with alcohol use, but not among HNHC patients with depression or substance use disorders. Shared communication systems were associated with decreased rates of all-cause and preventable ED utilization among HNHC patients with alcohol use and substance use disorders. Chapter 6 is a summary of findings across studies in this dissertation and will present the strengths, limitations, and contributions to science. This chapter will also discuss implications for policy, practice, and directions for future research. Conclusion HNHC patients face complex and wide-ranging medical, social, and behavioral health needs resulting in poor clinical outcomes and high costs. Enhancing primary care is an urgent goal for policymakers to improve disease management while reducing overall costs of care. Findings from these studies demonstrate that NPs practice in underserved areas and are significantly more likely to deliver care coordination in HPSA practices and to HNHC patients with behavioral health conditions. Care coordination has the potential to increase effectiveness of primary care delivery by tailoring models to target specific HNHC patients. Shared communication systems also show promise for improving primary care delivery and reducing ED utilization among HNHC patients with alcohol use and substance use disorders. Future research should continue to explore how structural capabilities may enable NPs to deliver timely, high quality, cost-effective primary care for HNHC patients.

There is growing demand for reforms to the U.S. criminal justice system. Nevertheless, there are significant questions and relatively few answers. This dissertation studies multiple U.S. criminal justice system issues using detailed administrative data from Cook County, Illinois: Does policing the police increase crime? Does the composition of a police officer's academy cohort influence their future outcomes? Is pretrial electronic monitoring an attractive alternative to pretrial release and detention? To answer these questions, I use administrative data from Chicago and Cook County, Illinois, on the Chicago Police Department, Cook County Jail, and Circuit Court of Cook County, and a range of econometric methods. In Chapter 1, I study the effect of pretrial electronic monitoring (EM) as an alternative to pretrial release and pretrial detention (jail) in Cook County, Illinois. EM often involves a defendant wearing an electronic ankle bracelet that tracks their movement and aims to deter pretrial misconduct. Using the quasi-random assignment of bond court judges, I estimate the effect of EM versus release and EM versus detention on pretrial misconduct, case outcomes, and future recidivism. I develop a novel method for the semiparametric estimation of marginal treatment effects in ordered choice environments, with which I construct relevant treatment effects. Relative to release, EM increases new cases pretrial due to bond violations while reducing new cases for low-level crimes and failures to appear in court. Relative to detention, EM increases low-level pretrial misconduct but improves defendant case outcomes and reduces cost-weighted future recidivism. Finally, I bound EM's pretrial crime reduction effect. I find that EM is likely an adequate substitute for pretrial detention. However, it is unclear that EM prevents enough high-cost crime to justify its use relative to release, particularly for defendants who are more likely to be released. Chapter 3, joint with Bocar Ba, studies and differentiates between the effects of oversight and outrage on policing. Previous studies estimating the impact of police oversight on crime rely on major policing scandals as shocks to examine the impact of oversight on crime. We argue that the simultaneous effect of public outrage on officer behavior and crime contaminates these results, and we provide a conceptual framework that distinguishes between oversight and outrage. We identify two events relating to unexpected court rulings in Chicago that increased oversight and caused a decline in reported misconduct but had virtually no public reaction. Despite the decrease in reported misconduct, crime and officer activity were unaffected. We contrast this with a major policing scandal, after which we find both a rise in crime rates without an equivalent increase in arrests and a decline in officer stops and use of force. Our results suggest that police oversight can reduce misconduct without increasing crime.