Marc Suhrcke

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).

Judging nudging: can nudging improve population health?

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

Obesity and socioeconomic status in developing countries: a systematic review

Nudging has captured the imagination of the public, researchers, and policy makers as a way of changing human behaviour, with both the UK and US governments embracing it. Theresa Marteau and colleagues ask whether the concept stands up to scientific scrutiny

The Economic Costs of Type 2 Diabetes: A Global Systematic Review

We undertook a systematic review of studies assessing the association between socioeconomic status (SES) and measured obesity in low‐ and middle‐income countries (defined by the World Bank as countries with per capita income up to US

Will the recession be bad for our health? It depends.

12,275) among children, men and women. The evidence on the subject has grown significantly since an earlier influential review was published in 2004. We find that in low‐income countries or in countries with low human development index (HDI), the association between SES and obesity appears to be positive for both men and women: the more affluent and/or those with higher educational attainment tend to be more likely to be obese. However, in middle‐income countries or in countries with medium HDI, the association becomes largely mixed for men and mainly negative for women. This particular shift appears to occur at an even lower level of per capita income than suggested by an influential earlier review. By contrast, obesity in children appears to be predominantly a problem of the rich in low‐ and middle‐income countries.

Altering micro-environments to change population health behaviour: towards an evidence base for choice architecture interventions

BackgroundThere has been a widely documented and recognized increase in diabetes prevalence, not only in high-income countries (HICs) but also in low- and middle-income countries (LMICs), over recent decades. The economic burden associated with diabetes, especially in LMICs, is less clear.ObjectiveWe provide a systematic review of the global evidence on the costs of type 2 diabetes. Our review seeks to update and considerably expand the previous major review of the costs of diabetes by capturing the evidence on overall, direct and indirect costs of type 2 diabetes worldwide that has been published since 2001. In addition, we include a body of economic evidence that has hitherto been distinct from the cost-of-illness (COI) work, i.e. studies on the labour market impact of diabetes.MethodsWe searched PubMed, EMBASE, EconLit and IBSS (without language restrictions) for studies assessing the economic burden of type 2 diabetes published from January 2001 to October 2014. Costs reported in the included studies were converted to international dollars (

Public acceptability of government intervention to change health-related behaviours: a systematic review and narrative synthesis

) adjusted for 2011 values. Alongside the narrative synthesis and methodological review of the studies, we conduct an exploratory linear regression analysis, examining the factors behind the considerable heterogeneity in existing cost estimates between and within countries.ResultsWe identified 86 COI and 23 labour market studies. COI studies varied considerably both in methods and in cost estimates, with most studies not using a control group, though the use of either regression analysis or matching has increased. Direct costs were generally found to be higher than indirect costs. Direct costs ranged from

A cross-sectional study of the microeconomic impact of cardiovascular disease hospitalization in four low- and middle-income countries.

242 for a study on out-of-pocket expenditures in Mexico to

Does active commuting improve psychological wellbeing? Longitudinal evidence from eighteen waves of the British Household Panel Survey

11,917 for a study on the cost of diabetes in the USA, while indirect costs ranged from