Michael McKee

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

Increase in state suicide rates in the USA during economic recession

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 and Russian mortality: a continuing crisis

Evidence from European countries indicates a significant rise in suicides from the economic recession, totalling more than 1000 excess deaths in the UK alone. Among the worst affected economies in Europe, such as Greece, suicides have risen by more than 60% since 2007.2 Thus far, there has been little or no analysis of US mental health data, mostly owing to delays in data availability. Here, we extend our previous analyses of recessions and suicides in Europe to assess trends in all 50 US states. We use data on suicide mortality rates from 1999 to 2010 from the Centers for Disease Control and Prevention. Unemployment data come from the Bureau of Labor Statistics. Time-trend regression models were used to assess excess suicides occurring during the economic crisis -- ie, deaths over and above the level that would be expected if historical trends continued (see appendix for methodological details). Although there are concerns that suicide data are under-reported in the USA, these biases are likely to have been consistent over this relatively short period, although they might lead to a conservative estimate of the mental health effects of the crisis. Looking across US states between 1999 and 2010, we found that the strongest correlation between unemployment and suicides was in Texas (r=0·91), but overall the correlations were statistically indistinguishable between the north, south, east, and west, or when disaggregating states by Democrat and Republican governors (appendix). Small numbers of suicides in small populations limit a state-by-state comparison for all 50 states. Similar patterns were seen if absolute numbers of suicides were used instead of overall rates. Suicide is a rare outcome of mental illness; these data are likely to be the most visible indicator of major depression and anxiety disorders, as seen in primary-care settings in Spain and in the Greek population. The pattern of accelerating suicides noted in the USA mirrors that recorded for economic reasons in Italy. Future research should explore other risk factors such as foreclosures and job and income losses, and modifying factors such as gun control policies, access to the means of self-harm, and vulnerable groups, which could explain the remaining portion of the suicide rise observed during the recession. Our findings have immediate implications for policy. Given that some countries have avoided increases in suicides despite significant economic downturns, there is a clear need to implement policy initiatives that promote the resilience of populations during the ongoing recession. Active labour market programs--projects that immediately help the unemployed find social support and new work opportunities (even part time)--and mental health prevention programs seem to mitigate significantly the negative mental health effects of recessions. The fact that countries such as Sweden have been able to prevent suicide rises despite major recessions reveals opportunities to protect Americans from further risks of suicide during the continued economic downturn. Language: en

The effect of the late 2000s financial crisis on suicides in Spain: an interrupted time-series analysis

BACKGROUND Russia remains in the grip of a mortality crisis in which alcohol plays a central role. In 2007, male life expectancy at birth was 61 years, while for females it was 74 years. Alcohol is implicated particularly in deaths among working-age men. AIMS To review the current state of knowledge about the contribution of alcohol to the continuing very high mortality seen among Russian adults RESULTS Conservative estimates attribute 31-43% of deaths among working-age men to alcohol. This latter estimate would imply a minimum of 170 000 excess deaths due to hazardous alcohol consumption in Russia per year. Men drink appreciably more than women in Russia. Hazardous drinking is most prevalent among people with low levels of education and those who are economically disadvantaged, partly because some of the available sources of ethanol are very cheap and easy to obtain. The best estimates available suggest that per capita consumption among adults is 15-18 litres of pure ethanol per year. However, reliable estimation of the total volume of alcohol consumed per capita in Russia is very difficult because of the diversity of sources of ethanol that are available, for many of which data do not exist. These include both illegal spirits, as well as legal non-beverage alcohols (such as medicinal tinctures). In 2006 regulations were introduced aimed at reducing the production and sale of non-beverage alcohols that are commonly drunk. These appear to have been only partially successful. CONCLUSION There is convincing evidence that alcohol plays an important role in explaining high mortality in Russia, in particular among working age men. However, there remain important uncertainties about the precise scale of the problem and about the health effects of the distinctive pattern of alcohol consumption that is prevalent in Russia today. While there is a need for further research, enough is known to justify the development of a comprehensive inter-sectoral alcohol control strategy. The recent fall in life expectancy in Russia should give a renewed urgency to attempts to move the policy agenda forward.

Prevalence and socio-economic distribution of hazardous patterns of alcohol drinking: study of alcohol consumption in men aged 25–54 years in Izhevsk, Russia

BACKGROUND The current financial crisis is having a major impact on European economies, especially that of Spain. Past evidence suggests that adverse macro-economic conditions exacerbate mental illness, but evidence from the current crisis is limited. This study analyses the association between the financial crisis and suicide rates in Spain. METHODS An interrupted time-series analysis of national suicides data between 2005 and 2010 was used to establish whether there has been any deviation in the underlying trend in suicide rates associated with the financial crisis. Segmented regression with a seasonally adjusted quasi-Poisson model was used for the analysis. Stratified analyses were performed to establish whether the effect of the crisis on suicides varied by region, sex and age group. RESULTS The mean monthly suicide rate in Spain during the study period was 0.61 per 100 000 with an underlying trend of a 0.3% decrease per month. We found an 8.0% increase in the suicide rate above this underlying trend since the financial crisis (95% CI: 1.009-1.156; P = 0.03); this was robust to sensitivity analysis. A control analysis showed no change in deaths from accidental falls associated with the crisis. Stratified analyses suggested that the association between the crisis and suicide rates is greatest in the Mediterranean and Northern areas, in males and amongst those of working age. CONCLUSIONS The financial crisis in Spain has been associated with a relative increase in suicides. Males and those of working age may be at particular risk of suicide associated with the crisis and may benefit from targeted interventions.

Mass incarceration can explain population increases in TB and multidrug-resistant TB in European and central Asian countries

Aim To estimate the prevalence of hazardous drinking and its socio-economic distribution among Russian men. Design Participants were an age-stratified, population-based random sample of men aged 25–54 years living in Izhevsk, a city in the Urals, Russia. Interviewers administered questionnaires to cohabiting proxy respondents about behavioural indicators of hazardous drinking derived from frequency of hangover, frequency of drinking beverage spirits, episodes in the last year of extended periods of drunkenness during which the participant withdraws from normal life (zapoi), consumption of alcoholic substances not intended to be drunk (surrogates) and socio-economic position. Logistic regression was used to examine associations between socio-economic position and indicators of hazardous drinking in the past year. Findings Of 1750 men, 79% drank spirits and 8% drank surrogates at least sometimes in the past year; 25% drank spirits and 4% drank surrogates at least weekly and 10% had had an episode of zapoi in the past year. After adjustment for other socio-economic factors, education was strongly associated with indicators of hazardous drinking. Men with the lowest level of education compared to the highest level of education had an odds ratio of surrogate drinking of 7.7 (95% CI 3.2–18.5), of zapoi of 5.2 (2.3–11.8) and of frequent hangover of 3.7 (1.8–7.4). These indicators of hazardous drinking were also independently strongly associated with being unemployed (versus employed) and with levels of household wealth/amenities. Associations of all these variables with daily consumption of beverage spirits were weaker. Conclusion Using a novel range of indicator variables of hazardous drinking, this paper shows that the prevalence of these behaviours is high among working-age men in this Russian city. Moreover, these hazardous behaviours show very clear socio-economic patterns, with particularly high prevalence among those who have had the least education and are not in employment. In contrast, more conventional measures of heavy drinking, based on frequency of consumption of beverage spirits, are less prevalent and show much weaker associations with socio-economic position.

The changing nature of murder in Russia

Several microlevel studies have pinpointed prisons as an important site for tuberculosis (TB) and multidrug-resistant TB in European and central Asian countries. To date, no comparative analyses have examined whether rises in incarceration rates can account for puzzling differences in TB trends among overall populations. Using longitudinal TB and cross-sectional multidrug-resistant TB data for 26 eastern European and central Asian countries, we examined whether and to what degree increases in incarceration account for differences in population TB and multidrug-resistant TB burdens. We find that each percentage point increase in incarceration rates relates to an increased TB incidence of 0.34% (population attributable risk, 95% C.I.: 0.10–0.58%, P < 0.01), after controlling for TB infrastructure; HIV prevalence; and several surveillance, economic, demographic, and political indicators. Net increases in incarceration account for a 20.5% increase in TB incidence or nearly three-fifths of the average total increase in TB incidence in the countries studied from 1991 to 2002. Although the number of prisoners is a significant determinant of differences in TB incidence and multidrug-resistant TB prevalence among countries, the rate of prison growth is a larger determinant of these outcomes, and its effect is exacerbated but not confounded by HIV. Differences in incarceration rates are a major determinant of differences in population TB outcomes among eastern European and central Asian countries, and treatment expansion alone does not appear to resolve the effect of mass incarceration on TB incidence.

Banking crises and mortality during the Great Depression: evidence from US urban populations, 1929–1937

The death rate from homicide in Russia increased rapidly during the 1990 s. It is now about 20 times higher than in western Europe and is among the highest recorded anywhere in the world. However, this issue has received little attention so far from public health researchers or policymakers. This paper describes the changing nature of homicide during the 1990 s in Russia as a whole and, in more detail, in the Udmurt Republic. The study uses data from three sources: routine mortality data for Russia from 1970 to 1999; statistics on criminal investigations and convictions in Russia between 1990 and 1997; and an in-depth study of homicide trial records in the Udmurt Republic in 1989-1991 and 1998.Deaths from homicide increased between 1970 and 1985, falling slightly during the 1985 anti-alcohol campaign and then resuming their increase until 1994. Another fall in the late 1990 s was arrested in 1998, with an increase in 1999. By 1999 the age standardised homicide death rate in Russia was 81% higher than in 1990, an increase almost twice that of all causes of death combined. Throughout the 1990 s about 10% of those convicted of homicide were female. Of those homicides leading to convictions in the Udmurt Republic, 71% of those killed by males were male, as were 76% of those killed by females. Killings of women by men often involved sexual assaults. In Russia as a whole, about 80% of those convicted of homicide were reported to be under the influence of alcohol at the time. In the Udmurt Republic, where data on both offender and victim were available, victims were also commonly intoxicated. The nature of homicide in Russia has changed considerably in less than a decade, with many more now involving aggravating circumstances, such as murder to conceal another crime, in association with robbery or rape, or by a group of people. Although still a small proportion of the total convicted, the number of murders by hired killers is also on the rise. The characteristics of those convicted of homicide have also changed during the 1990 s. They are now younger, less likely to have previous convictions, and to have a more diverse range of educational levels. The previous urban-rural gap, with higher levels in rural areas, has also narrowed.

Alcohol Use During the Great Recession of 2008-2009

Background Previous research suggests that the Great Depression led to improvements in public health. However, these studies rely on highly aggregated national data (using fewer than 25 data points) and potentially biased measures of the Great Depression. The authors assess the effects of the Great Depression using city-level estimates of US mortality and an underlying measure of economic crisis, bank suspensions, at the state level. Methods Cause-specific mortalities covering 114 US cities in 36 states between 1929 and 1937 were regressed against bank suspensions and income data from the Federal Deposit Insurance Corporation Database, using dynamic fixed-effects models and adjustments for potential confounding variables. Results Reductions in all-cause mortalities were mainly attributable to declines in death rates owing to pneumonia (26.4% of total), flu (13.1% of total) and respiratory tuberculosis (11.2% of total), while death rates increased from heart disease (19.4% of total), cancer (8.1% of total) and diabetes (2.9%). Only heart disease can plausibly relate to the contemporaneous economic shocks. The authors found that a higher rate of bank suspensions was significantly associated with higher suicide rates (β=0.32, 95% CI 0.24 to 0.41) but lower death rates from motor-vehicle accidents (β=−0.18, 95% CI −0.29 to −0.07); no significant effects were observed for 30 other causes of death or with a time lag. Conclusion In contrast with existing research, the authors find that many of the changes in deaths from different causes during the Great Depression were unrelated to economic shocks. Further research is needed to understand the causes of the marked variations in mortality change across cities and states, including the effects of the New Deal and Prohibition.

Economic shocks, resilience, and male suicides in the Great Recession: cross-national analysis of 20 EU countries

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.