Sanjay Basu

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

Financial crisis, austerity, and health in Europe

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).

Health effects of financial crisis: omens of a Greek tragedy

The financial crisis in Europe has posed major threats and opportunities to health. We trace the origins of the economic crisis in Europe and the responses of governments, examine the effect on health systems, and review the effects of previous economic downturns on health to predict the likely consequences for the present. We then compare our predictions with available evidence for the effects of the crisis on health. Whereas immediate rises in suicides and falls in road traffic deaths were anticipated, other consequences, such as HIV outbreaks, were not, and are better understood as products of state retrenchment. Greece, Spain, and Portugal adopted strict fiscal austerity; their economies continue to recede and strain on their health-care systems is growing. Suicides and outbreaks of infectious diseases are becoming more common in these countries, and budget cuts have restricted access to health care. By contrast, Iceland rejected austerity through a popular vote, and the financial crisis seems to have had few or no discernible effects on health. Although there are many potentially confounding differences between countries, our analysis suggests that, although recessions pose risks to health, the interaction of fiscal austerity with economic shocks and weak social protection is what ultimately seems to escalate health and social crises in Europe. Policy decisions about how to respond to economic crises have pronounced and unintended effects on public health, yet public health voices have remained largely silent during the economic crisis.

The mental health risks of economic crisis in Spain: evidence from primary care centres, 2006 and 2010

www.thelancet.com Vol 378 October 22, 2011 1457 Submissions should be made via our electronic submission system at http://ees.elsevier.com/ thelancet/ with 2009, and of 8% in the fi rst half of 2011 compared with the same period of 2010. Major private health providers, although comprising a smaller proportion of care delivery than public providers, were also hit by pressure on personal budgets and registered losses after the onset of the crisis. A 2010 study reported a 25–30% decline in admissions to private hospitals. There are signs that health outcomes have worsened, especially in vulnerable groups. We noted a signifi cant rise in the prevalence of people reporting that their health was “bad” or “very bad” (1·14, 1·02–1·28; fi gure). Suicides rose by 17% in 2009 from 2007 and unoffi cial 2010 data quoted in parliament mention a 25% rise compared with 2009. The Minister of Health reported a 40% rise in the fi rst half of 2011 compared with the same period in 2010. The national suicide helpline reported that 25% of callers faced fi nancial diffi culties in 2010 and reports in the media indicate that the inability to repay high levels of personal debt might be a key factor in the increase in suicides. Violence has also risen, and homicide and theft rates nearly Health eff ects of fi nancial crisis: omens of a Greek tragedy

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

BACKGROUND Nearly all European countries have been affected by the economic crisis that began in 2007, but the consequences have been among the worst in Spain. We investigated the associations of the recession on the frequency of mood, anxiety, somatoform, alcohol-related and eating disorders among those visiting Spanish primary care settings. METHODS Primary care physicians selected randomized samples of patients attending primary care centres representing Spains consulting populations. A total of 7940 patients in 2006-07 and 5876 in 2010-11 were administered the Primary Care Evaluation of Mental Disorders (PRIME-MD) instrument to diagnose mental disorders. Multivariate logistic regression models were used to quantify overall changes in the frequency of mental disorders, adjusting for potential socio-demographic differences in consulting populations unrelated to economic factors. RESULTS Compared with the pre-crisis period of 2006, the 2010 survey revealed substantial and significant increases in the proportion of patients with mood (19.4% in major depression), anxiety (8.4% in generalized anxiety disorder), somatoform (7.3%) and alcohol-related disorders (4.6% in alcohol dependence), all significant at P < 0.001, but not in eating disorders (0.15%, P = 0.172). Independent of observed risks of unemployment [odds ratio (OR) = 1.72, P < 0.001], we observed a significantly elevated risk of major depression associated with mortgage repayment difficulties (OR = 2.12, P < 0.001) and evictions (OR = 2.95, P < 0.001). About one-third of the overall risk in the consulting populations attendance with mental health disorders could be attributed to the combined risks of household unemployment and mortgage payment difficulties. CONCLUSION Recession has significantly increased the frequency of mental health disorders and alcohol abuse among primary care attendees in Spain, particularly among families experiencing unemployment and mortgage payment difficulties.

Manufacturing epidemics: the role of global producers in increased consumption of unhealthy commodities including processed foods, alcohol, and tobacco.

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

Comparative Performance of Private and Public Healthcare Systems in Low- and Middle-Income Countries: A Systematic Review

In an article that forms part of the PLoS Medicine series on Big Food, David Stuckler and colleagues report that unhealthy packaged foods are being consumed rapidly in low- and middle-income countries, consistent with rapid expansion of multinational food companies into emerging markets and fueling obesity and chronic disease epidemics.

The relationship of sugar to population-level diabetes prevalence: an econometric analysis of repeated cross-sectional data.

A systematic review conducted by Sanjay Basu and colleagues reevaluates the evidence relating to comparative performance of public versus private sector healthcare delivery in low- and middle-income countries.

Raising the priority of preventing chronic diseases: a political process

While experimental and observational studies suggest that sugar intake is associated with the development of type 2 diabetes, independent of its role in obesity, it is unclear whether alterations in sugar intake can account for differences in diabetes prevalence among overall populations. Using econometric models of repeated cross-sectional data on diabetes and nutritional components of food from 175 countries, we found that every 150 kcal/person/day increase in sugar availability (about one can of soda/day) was associated with increased diabetes prevalence by 1.1% (p <0.001) after testing for potential selection biases and controlling for other food types (including fibers, meats, fruits, oils, cereals), total calories, overweight and obesity, period-effects, and several socioeconomic variables such as aging, urbanization and income. No other food types yielded significant individual associations with diabetes prevalence after controlling for obesity and other confounders. The impact of sugar on diabetes was independent of sedentary behavior and alcohol use, and the effect was modified but not confounded by obesity or overweight. Duration and degree of sugar exposure correlated significantly with diabetes prevalence in a dose-dependent manner, while declines in sugar exposure correlated with significant subsequent declines in diabetes rates independently of other socioeconomic, dietary and obesity prevalence changes. Differences in sugar availability statistically explain variations in diabetes prevalence rates at a population level that are not explained by physical activity, overweight or obesity.

Increase in state suicide rates in the USA during economic recession

Chronic diseases, especially cardiovascular diseases, diabetes, cancer, and chronic obstructive respiratory diseases,are neglected globally despite growing awareness of the serious burden that they cause. Global and national policies have failed to stop, and in many cases have contributed to, the chronic disease pandemic. Low-cost and highly effective solutions for the prevention of chronic diseases are readily available; the failure to respond is now a political, rather than a technical issue. We seek to understand this failure and to position chronic disease centrally on the global health and development agendas. To identify strategies for generation of increased political priority for chronic diseases and to further the involvement of development agencies, we use an adapted political process model. This model has previously been used to assess the success and failure of social movements. On the basis of this analysis,we recommend three strategies: reframe the debate to emphasise the societal determinants of disease and the interrelation between chronic disease, poverty, and development; mobilise resources through a cooperative and inclusive approach to development and by equitably distributing resources on the basis of avoidable mortality; and build one merging strategic and political opportunities, such as the World Health Assembly 2008–13 Action Plan and the high level meeting of the UN General Assembly in 2011 on chronic disease. Until the full set of threats—which include chronic disease—that trap poor households in cycles of debt and illness are addressed, progress towards equitable human development will remain inadequate.