Adam Coutts

The public health effect of economic crises and alternative policy responses in Europe: an empirical analysis

BACKGROUND There is widespread concern that the present economic crisis, particularly its effect on unemployment, will adversely affect population health. We investigated how economic changes have affected mortality rates over the past three decades and identified how governments might reduce adverse effects. METHODS We used multivariate regression, correcting for population ageing, past mortality and employment trends, and country-specific differences in health-care infrastructure, to examine associations between changes in employment and mortality, and how associations were modified by different types of government expenditure for 26 European Union (EU) countries between 1970 and 2007. FINDINGS We noted that every 1% increase in unemployment was associated with a 0.79% rise in suicides at ages younger than 65 years (95% CI 0.16-1.42; 60-550 potential excess deaths [mean 310] EU-wide), although the effect size was non-significant at all ages (0.49%, -0.04 to 1.02), and with a 0.79% rise in homicides (95% CI 0.06-1.52; 3-80 potential excess deaths [mean 40] EU-wide). By contrast, road-traffic deaths decreased by 1.39% (0.64-2.14; 290-980 potential fewer deaths [mean 630] EU-wide). A more than 3% increase in unemployment had a greater effect on suicides at ages younger than 65 years (4.45%, 95% CI 0.65-8.24; 250-3220 potential excess deaths [mean 1740] EU-wide) and deaths from alcohol abuse (28.0%, 12.30-43.70; 1550-5490 potential excess deaths [mean 3500] EU-wide). We noted no consistent evidence across the EU that all-cause mortality rates increased when unemployment rose, although populations varied substantially in how sensitive mortality was to economic crises, depending partly on differences in social protection. Every US

Effects of the 2008 recession on health: a first look at European data

10 per person increased investment in active labour market programmes reduced the effect of unemployment on suicides by 0.038% (95% CI -0.004 to -0.071). INTERPRETATION Rises in unemployment are associated with significant short-term increases in premature deaths from intentional violence, while reducing traffic fatalities. Active labour market programmes that keep and reintegrate workers in jobs could mitigate some adverse health effects of economic downturns. FUNDING Centre for Crime and Justice Studies, Kings College, London, UK; and Wates Foundation (UK).

Alcohol Use During the Great Recession of 2008-2009

2 years ago, we published a paper in The Lancet reviewing the mortality experience of 26 European countries during economic crises over three decades. We showed how increases in unemployment had been associated with increased suicides among people younger than 65 years and with fewer road-traffi c fatalities (refl ecting lower car use). On the basis of our analyses, we predicted that the economic crisis that began in summer, 2008, would have similar conse quences. To what extent have our predictions been fulfi lled? We can now off er a pre liminary assessment based on data on mortality in several European countries for 2009. We extracted mortality rate data by age-group and cause from the WHO European Health for All database, and adult unemployment trends from EUROSTAT. Unfortunately, complete data for the period 2000–09 are currently only available for 10 of the 27 European Union (EU) countries: six in the pre-2004 EU (Austria, Finland, Greece, Ireland, the Netherlands, and the UK) and four in the post-2004 EU (Czech Republic, Hungary, Lithuania, and Romania). We combined data from countries in each group, weighted by population size. The fi gure shows changes in rates of adult unemployment and suicide in people aged 0–64 years in each part of the EU, indexed on 2007, the last complete year before the econ omic crisis. In both old and new EU Member States, offi cial unemployment did not increase until 2009, after the banking crisis. Job loss then increased rapidly, to about 35% above the 2007 level in both parts of Europe (about 2·6 percentage points in the EU overall). However, the steady down ward trend in suicide rates, seen in both groups of countries before 2007, reversed at once. The 2008 increase was less than 1% in the new Member States, but in the old ones it increased by almost 7%. In both, suicides increased further in 2009. Among the countries studied, only Austria had fewer suicides (down 5%) in 2009 than in 2007. In each of the other countries the increase was at least 5%. These changes are at the upper limit of the estimates in our 2009 paper, in which we noted that an increase in unemployment of more than 3% increased suicides in those younger than 65 years (by 4·45%, 95% CI 0·65–8·24). Road-traffi c fatalities also fell substantially, especially in new member countries where they were initially very high. The webappendix shows three countries with high (Lithuania), medium (Hungary), and low (Netherlands) death rates before 2008, indicating that the scale of the postcrisis decline is related to the initial level. Thus, the rate of road-traffi c fatalities in Lithuania fell rapidly, by almost 50%. However, when rates are already very low, as in the Netherlands, there is little scope to fall further. Overall, consistent with our earlier predictions, we found no evidence of a major deviation from past trends in all-cause mortality rates, since the short-term mortality fl uctuations were mainly driven by suicides and road-traffi c fatalities. This initial analysis is inevitably limited by the many gaps in the mortality data, a reminder of the contrast between the substantial eff orts expended by governments to collect up-to-the-minute fi nancial data while Figure: Indexed changes in adult unemployment and in age-standardised suicide rates (age 0–64 years) in old (pre-2004) and new European Union Member States 2007 is the index year, and y-axis values represent proportional change relative to that year. 0 0·8 0·9 1·0 1·1 1·2 1·3 1·4 1·5

Is Urban Regeneration Good for Health? Perceptions and Theories of the Health Impacts of Urban Change

AIMS The aim of this study was to assess changes in alcohol use in the USA during the Great Recession. METHODS Drinking participation, drinking frequency, drinking intensity, total alcohol consumption and frequency of binge drinking were assessed in a nationally representative sample of 2,050,431 US women and men aged 18 and older, interviewed between 2006 and 2010. RESULTS The prevalence of any alcohol use significantly declined during the economic recession, from 52.0% in 2006-2007 to 51.6% in 2008-2009 (P < 0.05), corresponding to 880,000 fewer drinkers (95% confidence interval [CI] 140,000 to 1.6 million). There was an increase, however, in the prevalence of frequent binging, from 4.8% in 2006-2007 to 5.1% in 2008-2009 (P < 0.01), corresponding to 770,000 more frequent bingers (95% CI 390,000 to 1.1 million). Non-Black, unmarried men under 30 years, who recently became unemployed, were at highest risk for frequent binging. CONCLUSION During the Great Recession there was an increase in abstention from alcohol and a rise in frequent binging.

Syria: health in a country undergoing tragic transition

An important issue for the geography of health in urban areas concerns how urban change arising from renewal of inner-city areas relates to health of urban populations. In this paper we examine ways in which urban regeneration schemes in Britain are attempting to incorporate consideration of health impact into their planning and development. It concentrates especially on diverse ways that different stakeholders perceive the outcomes of these schemes and the significance for health. The paper is based on two case studies of urban development projects, focusing on housing improvement and training for unemployed people, in a London borough where levels of deprivation are high and various forms of social exclusion affect large numbers of people. The methods used aimed to represent the views of different types of stakeholders, by means of interviews and focus groups with a range of stakeholders in these schemes. Health impact assessment needs to be evidence based. We discuss the evidence for potential health impact of regeneration projects through effects on housing and employment as determinants of health. We focus especially on the ways in which this evidence can be viewed and used by different stakeholders, and how far their perceptions seemed to match with research findings from public health. We consider the potential and the limitations for health improvement associated with urban regeneration in view of the case studies presented here.

Health workers and the weaponisation of health care in Syria: a preliminary inquiry for The Lancet–American University of Beirut Commission on Syria

ObjectivesTo document the ongoing destruction as a result of the tragic events in Syria, to understand the changing health care needs and priorities of Syrians.MethodsA directed examination of the scientific literature and reports about Syria before and during the Syrian conflict, in addition to analyzing literature devoted to the relief and rebuilding efforts in crisis situations.ResultsThe ongoing war has had high direct war casualty, but even higher suffering due to the destruction of health system, displacement, and the breakdown of livelihood and social fabric. Millions of Syrians either became refugees or internally displaced, and about half of the population is in urgent need for help. Access to local and international aid organizations for war-affected populations is an urgent and top priority.ConclusionsSyrians continue to endure one of the biggest human tragedies in modern times. The extent of the crisis has affected all aspects of Syrians’ life. Understanding the multi-faceted transition of the Syrian population and how it reflects on their health profile can guide relief and rebuilding efforts’ scope and priorities.

Communicable disease surveillance and control in the context of conflict and mass displacement in Syria

The conflict in Syria presents new and unprecedented challenges that undermine the principles and practice of medical neutrality in armed conflict. With direct and repeated targeting of health workers, health facilities, and ambulances, Syria has become the most dangerous place on earth for health-care providers. The weaponisation of health care-a strategy of using peoples need for health care as a weapon against them by violently depriving them of it-has translated into hundreds of health workers killed, hundreds more incarcerated or tortured, and hundreds of health facilities deliberately and systematically attacked. Evidence shows use of this strategy on an unprecedented scale by the Syrian Government and allied forces, in what human rights organisations described as a war-crime strategy, although all parties seem to have committed violations. Attacks on health care have sparked a large-scale exodus of experienced health workers. Formidable challenges face health workers who have stayed behind, and with no health care a major factor in the flight of refugees, the effect extends well beyond Syria. The international community has left these violations of international humanitarian and human rights law largely unanswered, despite their enormous consequences. There have been repudiated denunciations, but little action on bringing the perpetrators to justice. This inadequate response challenges the foundation of medical neutrality needed to sustain the operations of global health and humanitarian agencies in situations of armed conflict. In this Health Policy, we analyse the situation of health workers facing such systematic and serious violations of international humanitarian law. We describe the tremendous pressures that health workers have been under and continue to endure, and the remarkable resilience and resourcefulness they have displayed in response to this crisis. We propose policy imperatives to protect and support health workers working in armed conflict zones.

Response to Syria's health crisis—poor and uncoordinated

OBJECTIVES To describe trends in major communicable diseases in Syria during the ongoing conflict, and the challenges to communicable disease surveillance and control in the context of dynamic, large-scale population displacement, unplanned mass gatherings, and disruption to critical infrastructure. METHODS A rapid review of the peer-reviewed and non-peer-reviewed literature from 2005 to 2015 was performed, augmented by secondary analysis of monitoring data from two disease early warning systems currently operational in Syria, focusing mainly on three diseases: tuberculosis (TB), measles, and polio. RESULTS Trend data show discrepancies in case report numbers between government and non-government controlled areas, especially for TB, but interpretation is hampered by uncertainties over sentinel surveillance coverage and base population numbers. Communicable disease control has been undermined by a combination of governance fragmentation, direct and indirect damage to facilities and systems, and health worker flight. CONCLUSIONS Five years into the crisis, some progress has been made in disease surveillance, but governance and coordination problems, variable immunization coverage, and the dynamic and indiscriminate nature of the conflict continue to pose a serious threat to population health in Syria and surrounding countries. The risk of major cross-border communicable disease outbreaks is high, and challenges for health in a post-conflict Syria are formidable.

Civilian deaths from weapons used in the Syrian conflict

The Syrian conflict is now a humanitarian and public health catastrophe for the country and the region. UN High Commissioner for Refugees (UNHCR) AntÓnio Guterres described the current situation as the greatest humanitarian disaster of the past two decades, requiring the largestever humanitarian appeal. The UN has called for US

The emerging Syrian health crisis

5·2 billion for a regional response plan that includes support to neighbouring Lebanon and Jordan. The G8’s Lough Erne Declaration pledge of