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David Stuckler, MPH PhDMy research integrates the sciences of public health with political economy and development economics. Currently I am focusing on three areas of population health and development: 1) Macro-social and -economic determinants of health, 2) Political economy of global health and development, and 3) Comparative social welfare.
The first branch of research empirically evaluates the devastating mortality crisis that occurred after the collapse of the Soviet Union. More specifically, the role of economic processes, and their interactions with culture, firms and the state, is analyzed using quasi-experimental approaches; The second branch focuses upon the political economy of global health: understanding the current and changing roles of global institutions, states, NGOs, the private sector, civil society and the interactions among them for control of chronic and infectious diseases. The final branch seeks to model and analyze the effects of market forces on patient decision-making, medical errors, and access to and quality of healthcare.
Selected Publications
PubMed
Google Scholar
Financial Times Coverage
BBC Coverage
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 inter-relation 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 on emerging 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.
Many of the Millennium Development Goals are not being achieved in the world's poorest countries,
yet only five years remain until the target date. The financing of these Goals is not merely insufficient;
current evidence indicates that the temporary nature of the financing, as well as challenges to coordinating
its delivery and directing it to the most needy recipients, hinder achievement of the Goals in countries that may
benefit most. Traditional approaches to providing development assistance for health have not been able to address both
prevalent and emergent public health challenges captured in the Goals; these challenges demand sustained forms of
financial redistribution through a coordinated mechanism. A global social health protection fund is proposed to address
recurring failures in the modern aid distribution mechanism. Such a Fund could use established and effective strategies
for aid delivery to mitigate many financial problems currently undermining the Millennium Development Goals initiative.
Health ministers from across Europe came together in
Moscow in September at the 60th meeting of the European
regional committee of the World Health Organization. High
on their agenda was the ongoing economic di@culty facing
many of their countries. Their experiences varied. Some
had seen their budgets frozen whereas others had experienced
real cuts. A fortunate few, however, had seen budget
increases, as a result of recognition by their cabinet colleagues
of the necessity of protecting the most vulnerable at
times of crisis. As ministers and institutional partners shared
experiences and challenges, they endorsed WHO Europe’s
call to move forward as a region under a consolidated European
Health Policy, which will foster e9ective and coordinated
action to bolster health systems in the face of evolving
challenges.
Three main messages on the financial crisis emerged from
member states during a technical briefing devoted to this
topic.
On May 13, 2010, the United Nations General Assembly passed resolution 265, 'Prevention and control of non-communicable diseases',
a major political statement calling for Heads of State to address NCDs in a 'High Level' plenary meeting scheduled for September 2011.
Out of this meeting, and its associated "outcome document", will come a series of programmatic steps by all UN members. We cannot
understate the potential of this UN resolution to make chronic non-communicable diseases (NCDs) a global priority among
international leaders. While in the past there have been numerous resolutions in the World Health Organization World Health
Assembly for greater action on NCDs, this UN resolution has special significance, as it comes with the hope to achieve
multisectoral commitment and promise to deliver change. However, its overall effectiveness will depend on the ability of the
international community to take advantage of this powerful political opportunity to institutionalize NCD prevention and control
into policies and programmes within the broader development agenda. In this editorial we describe the kinds of outcomes that are
possible and needed, and outline strategies for generating global interest as part of a social movement so to ensure commitment by
Heads of State.
Does the current economic crisis require the deep cuts in public spending announced in the June 2010 emergency budget, with potential
implications for public health? The arguments for and against such cuts in response to economic recession are complex, but if public health
professionals are to engage in debates about future public spending, they should be informed by relevant evidence. In this perspective, we
note that opinions among politicians and economists about how to respond to economic downturns are divided, while other EU countries,
many with greater levels of debt than the UK, are protecting public expenditure unless required to do so by the International Monetary Fund.
Current UK debt may in fact be viewed as sustainable given current information about interest rates, inflation and economic growth. Before
accepting large cuts in public spending, it is important to contrast the lack of evidence for such short-term fixes with potentially dire
repercussions for population health and welfare.
Health policy in Europe is at a crossroads. Longstanding challenges, such as
persisting social and geographical inequalities, ageing populations, and rising
burdens of chronic diseases, are being compounded by new, global threats, such
as pandemic influenza and crises in the world’s financial markets. Significant
improvement in the health of Europe’s population has been driven by factors both
inside and outside the health sector. Key obstacles to improving population health
in Europe result from underlying failures to overcome political and economic
issues, including those shaping healthcare financing and delivery systems. How can
the public health community respond to these challenges? This paper discusses
three examples of how power and politics have shaped the world in which public
health works. The focus on individual risk factors diverts attention from underlying
determinants, such as the dominance of the market in healthcare, and the political
decision to favour a rapid transition from communism in the 1990s. Effective public
health policy requires addressing these political forces, seeking to understand the
dominant paradigms, how they have been defined and shaped, and how they might
be changed. Their effects are often subtle but powerful, shaping the language that is
used, the assumptions that are made, and the rules that are implied. We can formulate
key policy options to help improve health outcomes by reshaping the critical forces
that affect public health risk factors among those populations currently most
burdened by significant disease in Europe today.
Governments may feel they are protecting health by safeguarding healthcare budgets, yet David
Stuckler, Sanjay Basu, and Martin McKee argue that social welfare spending is as important,
if not more so, for population health.
Despite findings indicating that both national income level and income inequality are each determinants
of public health, few have studied how national income level, poverty and inequality interact with each
other to influence public health outcomes. We analyzed the relationship between gross domestic
product (GDP) per capita in purchasing power parity, extreme poverty rates, the gini coefficient for
personal income and three common measures of public health: life expectancy, infant mortality rates,
and tuberculosis (TB) mortality rates. Introducing poverty and inequality as modifying factors, we then
assessed whether the relationship between GDP and health differed during times of increasing,
decreasing, and decreasing or constant poverty and inequality. Data were taken from twenty-two Latin
American countries from 1960 to 2007 from the December 2008 World Bank World Development
Indicators, World Health Organization Global Tuberculosis Database 2008, and the Socio-Economic
Database for Latin America and the Caribbean. Consistent with previous studies, we found increases in
GDP have a sizable positive impact on population health. However, the strength of the relationship is
powerfully influenced by changing levels of poverty and inequality. When poverty was increasing,
greater GDP had no significant effect on life expectancy or TB mortality, and only led to a small reduction
in infant mortality rates. When inequality was rising, greater GDP had only a modest effecton life expectancy
and infant mortality rates, and no effect on TB mortality rates. In sharp contrast, during times of decreasing or
constant poverty and inequality, there was a very strong relationship between increasing GDP and higher life
expectancy and lower TB and infant mortality rates. Finally, inequality and poverty were found to exert
independent, substantial effects on the relationship between national income level and health. Wealthier is
indeed healthier, but how much healthier depends on how increases in wealth are distributed.
Objectives. We estimated the relationship between mining and tuberculosis
(TB) among countries in sub-Saharan Africa.
Methods. We used multivariate regression to estimate the contribution of
mining activity to TB incidence, prevalence, and mortality, as well as rates of TB
among people living with HIV, with control for economic, health system, and
population confounders.
Results. Mining production was associated with higher population TB incidence
rates (adjusted b=0.093; 95% confidence interval [CI]=0.067, 0.120; with
an increase of mining production of 1 SD corresponding to about 33% higher TB
incidence or 760000 more incident cases), after adjustment for economic and
population controls. Similar results were observed for TB prevalence and
mortality, as well as with alternative measures of mining activity. Independent
of HIV, there were significant associations between mining production and TB
incidence in countries with high HIV prevalence (‡4% antenatal HIV prevalence;
HIV-adjusted B=0.066; 95% CI=0.050, 0.082) and between log gold mining
production and TB incidence in all studied countries (HIV-adjusted B=0.053;
95% CI=0.032, 0.073).
Conclusions. Mining is a significant determinant of countrywide variation in
TB among sub-Saharan African nations. Comprehensive TB control strategies
should explicitly address the role of mining activity and environments in the
epidemic.
World leaders currently making tough economic decisions should be guided by the
physicians’ mantra: “First, do no harm”. Austerity programmes, even if justifiable in terms of promoting growth (itself highly
questionable), may exacerbate the health risks posed by financial crises. Inflicting short-term pain constitutes a massive, uncontrolled
experiment with people’s lives. Recessions themselves pose a risk to health, but empirical data reveal that the decisions made by governments crucially determine
how bad the outcome will be... Foreign currency debt is widely believed to increase risks of
financial crisis, especially after being implicated as a cause of the
East Asian crisis in the late 1990s. In this paper, we study the
effects of foreign currency debt on currency and debt crises and its
indirect effects on short-term growth and long-run output effects
in both 1880–1913 and 1973–2003 for 45 countries. Greater ratios
of foreign currency debt to total debt are associated with increased
risks of currency and debt crises, although the strength of the
association depends crucially on the size of a country’s reserve
base and its policy credibility. We found that financial crises,
driven by exposure to foreign currency, resulted in significant
permanent output losses. We estimate some implications of our
findings for the risks posed by currently high levels of foreign
currency liabilities in eastern Europe
What we hear is often very different from what we are told.
British readers of the BMJ will soon get to vote on the competing
visions of the political parties at the general election. Although the
mainstream parties each claim the middle ground, there are important differences in
how they will approach the economic challenges that lie ahead, with potentially major implications for
health and health care. How fast and how deep should cuts in public spending be? Are targets a good or a
bad thing? What is the appropriate role of private healthcare providers?
Voters must decide which of the different answers they agree with,
yet—as seen in recent disputes between leading economists about how to
tackle the government deficit—it is possible for two well informed groups of people faced with
the same evidence to reach completely different conclusions about what should be done.
How do voters interpret such complex information and what influences them?
There is considerable evidence that people presented with balanced arguments
place weight on those they already agree with...
Background: Many low- and middle-income countries are not on track to reach the public health targets set out in the
Millennium Development Goals (MDGs). We evaluated whether differential progress towards health MDGs was associated
with economic development, public health funding (both overall and as percentage of available domestic funds), or health
system infrastructure. We also examined the impact of joint epidemics of HIV/AIDS and noncommunicable diseases (NCDs),
which may limit the ability of households to address child mortality and increase risks of infectious diseases.
Methods and Findings: We calculated each country’s distance from its MDG goals for HIV/AIDS, tuberculosis, and infant and
child mortality targets for the year 2005 using the United Nations MDG database for 227 countries from 1990 to the present.
We studied the association of economic development (gross domestic product [GDP] per capita in purchasing-powerparity),
the relative priority placed on health (health spending as a percentage of GDP), real health spending (health system
expenditures in purchasing-power-parity), HIV/AIDS burden (prevalence rates among ages 15–49 y), and NCD burden (agestandardised
chronic disease mortality rates), with measures of distance from attainment of health MDGs. To avoid spurious
correlations that may exist simply because countries with high disease burdens would be expected to have low MDG
progress, and to adjust for potential confounding arising from differences in countries’ initial disease burdens, we analysed
the variations in rates of change in MDG progress versus expected rates for each country. While economic development,
health priority, health spending, and health infrastructure did not explain more than one-fifth of the differences in progress
to health MDGs among countries, burdens of HIV and NCDs explained more than half of between-country inequalities in
child mortality progress (R2-infant mortality = 0.57, R2-under 5 mortality = 0.54). HIV/AIDS and NCD burdens were also the
strongest correlates of unequal progress towards tuberculosis goals (R2 = 0.57), with NCDs having an effect independent of
HIV/AIDS, consistent with micro-level studies of the influence of tobacco and diabetes on tuberculosis risks. Even after
correcting for health system variables, initial child mortality, and tuberculosis diseases, we found that lower burdens of HIV/
AIDS and NCDs were associated with much greater progress towards attainment of child mortality and tuberculosis MDGs
than were gains in GDP. An estimated 1% lower HIV prevalence or 10% lower mortality rate from NCDs would have a similar
impact on progress towards the tuberculosis MDG as an 80% or greater rise in GDP, corresponding to at least a decade of
economic growth in low-income countries.
Conclusions: Unequal progress in health MDGs in low-income countries appears significantly related to burdens of HIV and
NCDs in a population, after correcting for potentially confounding socioeconomic, disease burden, political, and health
system variables. The common separation between NCDs, child mortality, and infectious syndromes among development
programs may obscure interrelationships of illness affecting those living in poor households—whether economic (e.g., as
money spent on tobacco is lost from child health expenditures) or biological (e.g., as diabetes or HIV enhance the risk of
tuberculosis).
The International Monetary Fund’s recent claims concerning its impact on
public health are evaluated against available data. First, the IMF claims that
health spending either does not change or increases with IMF-supported
programs, but there is substantial evidence to the contrary. Second, the IMF
claims to have relaxed strict spending requirements in response to the 2008–9
financial crisis, but there is no evidence supporting this claim, and some
limited evidence from the Center for Economic Policy Research contradicting
it. Third, the IMF states that wage ceilings on public health are no longer part
of its explicit conditionalities to poor countries, as governments can choose
how to achieve public spending targets; but in practice, ministers are left with
few viable alternatives than to reduce health budgets to achieve specific
IMF-mandated targets, so the result effectively preserves former policy.
Fourth, the IMF’s claim that it has increased aid to poor countries also seems
to be contradicted by its policies of diverting aid to reserves, as well as
evidence that a very small fraction of the Fund’s new lending in response to
the financial crisis has reached poor countries. Finally, the IMF’s claim that it
follows public health standards in tobacco control contrasts with its existing
policies, which fail to follow the guidelines recommended by the World Bank
and World Health Organization. The authors recommend that the IMF (1)
become more transparent in its policies, practices, and data to allow improved
independent evaluations of its impact on public health (including Health
Impact Assessment) and (2) review considerable public health evidence
indicating a negative association between its current policies and public
health outcomes.
Summary: Tuberculosis incidence appears to be amplified by mineral mining operations in southern Africa. A number of immediately-available measures to improve
continuity of care for miners, change recruitment and compensation practices, and reduce the primary risk of infection
may critically mitigate the negative association between mineral mining and tuberculosis.
Abstract: What will the current economic crisis mean for the health of the people of Northern Ireland? We review the experience
of three major economic crises in the 20th century: the Great Depression (1929), the Post-communist Depression (early
1990s) and the East Asian financial crisis (late 1990s). Available evidence suggests that health is at risk in times of rapid
economic change, in both booms and busts. However the impact on mortality is exacerbated where people have easy access to the
means to harm themselves and is ameliorated by the presence of strong social cohesion and social protection
systems. On this basis, Northern Ireland may escape relatively unscathed in the short term but as every crisis
also provides an opportunity, this is an appropriate time for the Northern Ireland Executive to reflect on whether
they are making a sufficient investment in the long term health of their population.
Abstract: In April 2009, the G20 countries committed US$750 billion to the International Monetary Fund (IMF),
which has assumed a central role in global economic management. The IMF provides loans to financially ailing countries,
but with strict conditions, typically involving a mix of privatization, liberalization, and fiscal austerity programs.
These loan conditions have been extremely controversial. In principle, they are designed to help countries balance their books.
In practice, they often translate into reductions in social
spending, including spending on public health and health care delivery. As more countries are being exposed to IMF policies,
there is a need to establish what we know and do not know about the IMF’s effects on global health. This article
introduces a series in which contributors review the evidence on the relationship between the IMF and public health
and discuss potential ways to improve the Fund’s effects on health. While more evidence is
needed for some regions, there is sufficient evidence to indicate that IMF programs have been significantly associated
with weakened health care systems, reduced effectiveness of health-focused development aid, and
impeded efforts to control tobacco, infectious diseases, and child and maternal mortality. Reforms are urgently needed
to prevent the current wave of IMF programs from further undermining public health in financially ailing countries and
limiting progress toward the health Millennium Development Goals.
Abstract: Large increases in food prices have occurred at many times and in many places throughout history.
The recent increases differ in their global reach and degree of volatility. Between January 2006 and July 2008 global food
prices rose by an average of 75%, causing an estimated 75 million additional people to become undernourished worldwide. We
evaluate how several factors have contributed to rising food prices and analyse the potential consequences of these rises for
food security and public health. As food prices are predicted to remain high for several years, we discuss policy responses that
could help secure an affordable, healthy global food supply.
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$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.
Background: During the early-1990s, adult mortality rates rose in most post-communist European countries.
Substantial differences across countries and over time remain unexplained. Although previous studies
have suggested that the pace of economic transition was a key driver of increased mortality rates,
to our knowledge no study has empirically assessed the role of specific components of transition policies.
We investigated whether mass privatisation can account for differences in adult mortality rates in such countries.
Methods: We used multivariate longitudinal regression to analyse age-standardised mortality rates in working-age men (15–59 years) in post-communist countries of eastern Europe and the former Soviet Union from 1989 to 2002. We defined mass privatisation programmes as transferring at least 25% of large state-owned enterprises to the private sector within 2 years with the use of vouchers and give-aways to firm insiders. To isolate the effect of mass privatisation, we used models to control for price and trade liberalisation, income change, initial country conditions, structural predispositions to higher mortality, and other potential confounders.
Findings: Mass privatisation programmes were associated with an increase in short-term adult male mortality rates of
12·8% (95% CI 7·9–17·7; p<0·0001), with similar results for the alternative privatisation indices from the European
Bank for Reconstruction and Development (7·8% [95% CI 2·8–13·0]). One mediating factor could be male unemployment rates,
which were increased substantially by mass privatisation (56·3% [28·3–84·3]; p<0·0001). Each 1% increase in the percentage
of population who were members of at least one social organisation decreased the association of privatisation with mortality
by 0·27%; when more than 45% of a population was a member of at least one social organisation, privatisation was no longer
significantly associated with increased mortality rates (3·4% [95% CI –5·4 to 12·3]; p=0·44).
Interpretation: Rapid mass privatisation as an economic transition strategy was a crucial determinant
of differences in adult mortality trends in post-communist countries; the effect of privatisation was
reduced if social capital was high. These findings might be relevant to other countries in which similar policies
are being considered.
Background: Ministers of health, donor agencies, philanthropists, and international agencies will meet at Bamako,
Mali, in November, 2008, to review global priorities for health research. These individuals and
organisations previously set health priorities for WHO, either through its regular budget or extra-budgetary funds.
We asked what insights can be gained as to their priorities from previous decisions within the context of WHO.
Methods: We compared the WHO biennial budgetary allocations with the burden of disease from 1994—95 to 2008—09.
We obtained data from publicly available WHO sources and examined whether WHO allocations varied with the burden of disease
(defined by death and disability-adjusted life years) by comparing two WHO regions—Western Pacific and Africa—that are at
differing stages of epidemiological transition. We further assessed whether the allocations differed on the basis of the source
of funds (assessed and voluntary contributions) and the mechanism for deciding how funds were spent.
Findings: We noted that WHO budget allocations were heavily skewed toward infectious diseases. In 2006—07,
WHO allocated 87% of its total budget to infectious diseases, 12% to non-communicable diseases, and less than 1% to
injuries and violence. We recorded a similar distribution of funding in Africa, where nearly three-quarters of mortality
is from infectious disease, and in Western Pacific, where three-quarters of mortality is from non-communicable disease.
In both regions, injuries received only 1% of total resources. The skew towards infectious diseases was substantially greater
for the WHO extra-budget, which is allocated by donors and has risen greatly in recent years, than for the WHO regular budget,
which is decided on by member states through democratic mechanisms and has been held at zero nominal growth.
Interpretation: Decision makers at Bamako should consider the implications of the present misalignment of global health priorities and
disease burden for health research worldwide. Funds allocated by external donors substantially differ from those allocated by
WHO member states. The meeting at Bamako provides an opportunity to consider how this disparity might be addressed.
Background: Previous studies have indicated that International Monetary Fund (IMF) economic programs
have influenced health-care infrastructure in recipient countries. The post-communist Eastern
European and former Soviet Union countries experienced relatively similar political and
economic changes over the past two decades, and participated in IMF programs of varying size
and duration. We empirically examine how IMF programs related to changes in tuberculosis
incidence, prevalence, and mortality rates among these countries.
Methods and Findings: We performed multivariate regression of two decades of tuberculosis incidence, prevalence,
and mortality data against variables potentially influencing tuberculosis program outcomes in
21 post-communist countries for which comparative data are available. After correcting for
confounding variables, as well as potential detection, selection, and ecological biases, we
observed that participating in an IMF program was associated with increased tuberculosis
incidence, prevalence, and mortality rates by 13.9%, 13.2%, and 16.6%, respectively. Each
additional year of participation in an IMF program was associated with increased tuberculosis
mortality rates by 4.1%, and each 1% increase in IMF lending was associated with increased
tuberculosis mortality rates by 0.9%. On the other hand, we estimated a decrease in
tuberculosis mortality rates of 30.7% (95% confidence interval, 18.3% to 49.5%) associated with
exiting the IMF programs. IMF lending did not appear to be a response to worsened health
outcomes; rather, it appeared to be a precipitant of such outcomes (Granger- and Sims-causality
tests), even after controlling for potential political, socioeconomic, demographic, and
health-related confounders. In contrast, non-IMF lending programs were connected with
decreased tuberculosis mortality rates (-7.6%, 95% confidence interval,-1.0% to -14.1%). The
associations observed between tuberculosis mortality and IMF programs were similar to those
observed when evaluating the impact of IMF programs on tuberculosis incidence and
prevalence. While IMF programs were connected with large reductions in generalized
government expenditures, tuberculosis program coverage, and the number of physicians per
capita, non-IMF lending programs were not significantly associated with these variables.
Conclusions: IMF economic reform programs are associated with significantly worsened tuberculosis
incidence, prevalence, and mortality rates in post-communist Eastern European and former
Soviet countries, independent of other political, socioeconomic, demographic, and health
changes in these countries. Future research should attempt to examine how IMF programs may
have related to other non-tuberculosis–related health outcomes.
In January, 2009, a new administration will assume power in Washington, DC, USA. Whichever of the
current presidential candidates wins, US foreign policy will change direction.
One element of this policy will be global health, a subject often characterised by controversy.
The debate that will shape the next administration’s approach to global health has begun,
including the decision by the US Institute of Medicine to update its 1997 report on US global-health
priorities. What principles might inform this debate? Policy makers often reason by
metaphors to boil down a set of complex policy tradeoffs into a few consistent strategies and principles.
We suggest that there are at least five metaphors that can be applied to global health (table).
These are global health as foreign policy, global health as security, global health as charity,
global health as investment, and global health as public health...
If privatisation ever had a significant impact on health, it would show up in the former Soviet Union.
Compare Margaret Thatcher the “Great Privatiser”, who privatised roughly 30 state-owned companies during
her 11-year tenure, to Boris Yeltsin’s regime, which under the guidance of Jeffrey Sachs and World Bank
economists, privatised over 15 000 large state-owned companies in less than 2 years. Such an episode of
privatisation as that seen in Russia during the early- to mid-90s remains unparalleled in both its scale
and its scope. Not all former Soviet countries took such a radical approach to privatisation...
Context: The mortality numbers and rates of chronic disease are rising faster in developing than in
developed countries. This article compares prevailing explanations of population chronic disease trends
with theoretical and empirical models of population chronic disease epidemiology and assesses some
economic consequences of the growth of chronic diseases in developing countries based on the experiences
of developed countries.
Methods: Four decades of male mortality rates of cardiovascular and chronic noncommunicable diseases were
regressed on changes in and levels of country income per capita, market integration, foreign direct investment,
urbanization rates, and population aging in fifty-six countries for which comparative data were available.
Neoclassical economic growth models were used to estimate the effect of the mortality rates of chronic
noncommunicable diseases on economic growth in high-income OECD countries.
Findings: Processes of economic growth, market integration, foreign direct investment, and urbanization
were significant determinants of long-term changes in mortality rates of heart disease and chronic
noncommunicable disease, and the observed relationships with these social and economic factors were
roughly three times stronger than the relationships with the population's aging. In low-income countries,
higher levels of country income per capita, population urbanization, foreign direct investment, and market
integration were associated with greater mortality rates of heart disease and chronic noncommunicable disease,
less increased or sometimes reduced rates in middle-income countries, and decreased rates in high-income countries. Each 10 percent increase in the working-age mortality rates of chronic noncommunicable disease decreased economic growth rates by close to a half percent.
Conclusions: Macrosocial and macroeconomic forces are major determinants of population rises in chronic disease
mortality, and some prevailing demographic explanations, such as population aging, are incomplete on
methodological, empirical, and policy grounds. Rising chronic disease mortality rates will significantly
reduce economic growth in developing countries and further widen the health and economic gap between the
developed and developing world.
Much is heard of late about the high costs of chronic diseases like diabetes: chronic diseases are going to ‘break the bank’,
impose tremendous costs on already struggling healthcare systems, and, very possibly,
hinder growth in developing countries. Often, however, the suffering of people with chronic diseases
seems to be lost in all the talk of money. In this article, David Stuckler discusses how economic arguments –
beyond the strictly financial considerations – can help raise the profile among policy-makers of chronic disease
prevention and control as a public health priority, and make intervention efforts more effective. The author uses
simple examples to explain the economic causes and consequences of chronic diseases, and the case for
intervention, and discusses the potential for economic perspectives to help build a stronger case for
global action on chronic diseases. BACKGROUND: To assess whether a banking system crisis increases short-term population cardiovascular mortality rates.
METHODS: International, longitudinal multivariate regression analysis of cardiovascular disease mortality data from 1960 to 2002
RESULTS: A system-wide banking crisis increases population heart disease mortality rates by 6.4% (95% CI: 2.5% to 10.2%, p < 0.01) in high income countries, after
controlling for economic change, macroeconomic instability, and population age and social distribution. The estimated effect is nearly four times as large in low
income countries. CONCLUSION: Banking crises are a significant determinant of short-term increases in heart disease mortality rates, and may have more severe consequences
for developing countries.
Overweight and obesity, the main drivers of type 2 diabetes, have long been regarded as health risks associated with
affluence. Over the last decade, profound changes in the quality, quantity and source of food consumed in many
developing countries, combined with a decrease in levels of physical activity among the population, have led to
an increase in the prevalence of diabetes and its complications. Here, we present quantitative estimates of the
epidemiological and economic impact of obesity and diabetes on developing countries. We provide the economic
rationale for public policy action. We stress the importance of creating a roadmap to guide the development of
comprehensive policies involving governments and private companies, and emphasize the need for experimentation in
building the evidence while testing theories.
Despite increasing recognition of the link between health and economic development in low-income countries, the relationship has to date received scant attention in rich
countries. We argue that this lack of attention is not justifiable. While the economic argument for investing in health in rich
countries may differ in detail from that in low-income countries, there is considerable and convincing evidence that significant
economic benefits can be achieved by improving health not only in poor, but also in rich countries. Better health increases labour
supply and productivity and historically, health has been a major contributor to economic growth. In spite of remaining evidence gaps,
economic policymakers also in developed countries should consider investing in health as one (of few) ways by which to achieve their
economic objectives
Print:
Rise in TB is linked to loans from IMF, New York Times
Bank crises 'increase heart attacks', Financial Times, pg.3 (UK)
Why market crashes are a health hazard, MacLean's (Canada)
Could IMF loans be causing TB deaths? , Scientific American
Sick borrowing, Slate
Bank crises 'deadly' for health, BBC Online (UK)
IMF loans 'lead to TB deaths', New Scientist
Northern-Rock like crises bring heart attacks, Telegraph (UK)
Bank crises increase rate of heart attacks , Guardian (UK)
Scourge of the IMF, The Huffington Post
Crisis bancarias de infarto, El Mundo (Spain)
Rompen Bancos Corazones, El Porvenir (Spain)
Crisis bancarias podrían ocasionar la muerte de miles de personas, El Comercio (Peru)
Surges in heart attacks correlates with bank failures, SciDev Magazine
Financial Times Special Healthcare & the
Recovery: Painful cuts and trade-offs in prospect
Books and Book Chapters
In September, world leaders will meet at the United Nations in New York to discuss non-communicable diseases. A decade ago, at a similar meeting on HIV/AIDS, they created the Global Fund for HIV/AIDS, Tuberculosis and Malaria — a revolutionary new global health funding mechanism.
The September meeting will focus on four leading conditions—heart disease, cancer, diabetes, and respiratory
disease—that together cause more than half of all deaths in low and middle income countries. Without action, the number of premature deaths (age < 60) caused by non-communicable diseases is expected to rise from 3.8 million each year to 5.1
million in poor countries by 2030, trapping a generation of families in cycles of poverty and disease. As Thomas Frieden, director of the US Centers for Disease Control and Prevention, recently stated, developing countries must immediately tackle the rapid rise of non-communicable
diseases because they will “kill four times as many people by 2020 as infectious diseases.” Hopes are therefore high...
Note: Click on any link to close the panel.
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-traffic fatalities (reflecting lower car use).
On the basis of our analyses, we predicted that the economic crisis that began in summer, 2008, would have similar
consequences. To what extent have our predictions been fulfilled? We can now offer a preliminary assessment based on
data on mortality in several European countries for 2009.
Web Appendix Figure
Note: Click on any link to close the panel.
There is concern among public health professionals that the current economic downturn, initiated by the financial crisis that
started in 2007, could precipitate the transmission of infectious diseases while also limiting capacity for control. Although
studies have reviewed the potential effects of economic downturns on overall health, to our knowledge such an analysis has
yet to be done focusing on infectious diseases. We performed a systematic literature review of studies examining changes in
infectious disease burden subsequent to periods of crisis. The review identified 230 studies of which 37 met our inclusion
criteria. Of these, 30 found evidence of worse infectious disease outcomes during recession, often resulting from higher
rates of infectious contact under poorer living circumstances, worsened access to therapy, or poorer retention in treatment.
The remaining studies found either reductions in infectious disease or no significant effect. Using the paradigm of the ‘‘SIR’’
(susceptible-infected-recovered) model of infectious disease transmission, we examined the implications of these findings
for infectious disease transmission and control. Key susceptible groups include infants and the elderly. We identified certain
high-risk groups, including migrants, homeless persons, and prison populations, as particularly vulnerable conduits of
epidemics during situations of economic duress. We also observed that the long-term impacts of crises on infectious disease
are not inevitable: considerable evidence suggests that the magnitude of effect depends critically on budgetary responses
by governments. Like other emergencies and natural disasters, preparedness for financial crises should include
consideration of consequences for communicable disease control.
Summary Points:
-Institutional relationships in global health are a growing area of study, but few if any previous analyses have examined private foundations.
-Tax-exempt private foundations and for-profit corporations have increasingly engaged in relationships that can influence global health.
-Using a case study of five of the largest private global health foundations, we identify the scope of relationships between tax-exempt foundations and for-profit corporations.
-Many public health foundations have associations with private food and pharmaceutical corporations. In some instances, these corporations directly benefit from foundation grants, and foundations in turn are invested in the corporations to which they award these grants.
-Personnel move between food and drug industries and public health foundations. Foundation board members and decision-makers also sit on the boards of some for-profit corporations benefitting from their grants.
-While private foundations adopt standard disclosure protocols for employees to mitigate potential conflicts of interests, these do not always apply to the overall endowment investments of the foundations or to board membership appointments. The extent and range of relationships between tax-exempt foundations and for-profit corporations suggest that transparency or grant-making recusal of employees alone may not be preventing potential conflicts of interests between global health programs and their financing.
Supporting Information Figure: Network map, Bill & Melinda Gates Foundation
Supporting Information Text: Full Stock Listings
Noncommunicable diseases (NCDs) cause more than half of all deaths in low- and middle-income countries,
claiming an estimated 29 million lives each year (of 36 million NCD deaths worldwide).
About 30% of these deaths occur before the age of 60. Death and disability due to NCDs are rising in all
regions of the world but most rapidly in sub-Saharan Africa, where the projected increases in NCDs
will outpace reductions in infectious diseases (contributing to a rising “double-burden” of disease).
In sub-Saharan Africa, women aged 15–49 are already dying from NCDs at a rate four times higher than
women living in high-income countries. This burden of premature mortality and disability poses a threat to human, social and economic development...
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 (b=0.32, 95% CI 0.24 to 0.41)
but lower death rates from motor-vehicle accidents (b=-0.18, 95% CI -.29 to -.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.
Tuberculosis outbreaks originating in prisons, mines, or hospital wards can spread to the larger community. Recent proposals have targeted these high-transmission institutional amplifiers by improving case detection, treatment, or reducing the size of the exposed population. However, what effects these alternative proposals may have is unclear. We mathematically modeled these control strategies and found case detection and treatment methods insufficient in addressing epidemics involving common types of institutional amplifiers. Movement of persons in and out of amplifiers fundamentally altered the transmission dynamics of tuberculosis in a manner not effectively mitigated by detection or treatment alone. Policies increasing the population size exposed to amplifiers or the per-person duration of exposure within amplifiers potentially worsened incidence, even in settings with high rates of detection and treatment success. However, reducing the total population size entering institutional amplifiers significantly lowered tuberculosis incidence and the risk of propagating new drug-resistant tuberculosis strains.
Objectives. We assessed the determinants of health care funding allocations among South Africa’s provinces and their effects on health care from 1996 through 2007. Methods. We performed multivariate regression of funding allocation data against measures of disease burden and health system infrastructure by province. Results. Disease burden was increasingly negatively correlated with funding allocations and explained less than one quarter of the variation in allocations among provinces. Nearly three quarters of the variation in allocations was explained by preexisting hospital infrastructure and health care workers. The density of private hospitals in the preceding year was associated with greater government allocations (bprivate=0.12; 95% confidence interval [CI]=0.08, 0.15), but public hospital density in the preceding year was not (bpublic=0.05; 95% CI=– 0.02, 0.11). Greater allocations were associated with a higher number of doctors (b=0.54; 95% CI=0.34, 0.75) but fewer nurses (b=–0.37; 95% CI=–0.72,–0.25) in the same year. Conclusions. Regions with a greater capacity to spend funds received more funding and created more infrastructure than those with greater health needs. Historical infrastructure inequalities may have created an infrastructure–inequality trap, in which the distribution of funds to those with greater ‘‘absorptive capacity’’ exacerbates inequalities.
Several recent papers find evidence that global health aid is being diverted to reserves, education, military, or other sectors, and is displacing government spending. This is suggested to occur because ministers of finance have competing, possibly corrupt, priorities and deprive the health sector of resources. Studies have found that development assistance for health routed to governments has a negative impact on health spending and that similar assistance routed to private nongovernmental organizations has a positive impact. An alternative hypothesis is that World Bank and IMF macroeconomic policies, which specifically advise governments to divert aid to reserves to cope with aid volatility and keep government spending low, could be causing the displacement of health aid. This article evaluates whether aid displacement was greater when countries undertook a new borrowing program from the IMF between 1996 and 2006. As found in existing studies, for each $1 of development assistance for health, about $0.37 is added to the health system. However, evaluating IMF-borrowing versus non-IMF-borrowing countries reveals that non-borrowers add
about $0.45 whereas borrowers add less than $0.01 to the health system. On average, health system spending grew at about half the speed when countries were exposed to the IMF than when they were not. It is important to take account of the political economy of global health finance when interpreting data on financial flows.
Mining in southern Africa has amplified HIV and tuberculosis (TB) epidemics across the continent through social, political, and biological risks posed to miners and their communities. Aware of these risks for decades, policymakers have done little to regulate the mining sector’s remarkable impact on Africa’s two largest epidemics. Here, we analyze the governance of mining in southern Africa to evaluate the sources of ineffective responses and identify mechanisms for ensuring effective cross-border care and global norms of responsible mining. We argue that action is needed by international agencies to spur the development of effective governance systems currently being constrained by domestic vested interests.
Comment by H. Annett
Comment by D. Hunter
Comment by A. Davis
Selected media
doi:10.1186/1744-8603-5-11
Guest editor of a new series
‘Debates on International Agencies’, starting with the IMF.
R. Batniji. 2009. Reviving the International Monetary Fund: Concerns for the
Health of the Poor.
Int J Health Serv.39(4). 783-787
A. Gilmore, G. Fooks and M. McKee. 2009.The International Monetary Fund and tobacco: A product like any other?
Int J Health Serv. 39(4): 789-793
G. Ooms and R. Hammond. 2009. Scaling up global social health protection: Prerequisite reforms to the International Monetary Fund.
Int J Health Serv.39(4): 795-801
A. Marphatia. 2010. The Adverse Effects of International Monetary Fund Programs on the Health and Education Workforce.
Int J Health Serv.40(1). 165-178
B. Cave and M. Birley. 2010. The Need for Health Impact Assessment of the
International Monetary Fund. Int J Health Serv.40(1). 179-181
R. Rowden. 2010. Why Health Advocates Must Get Involved in Development Economics: the case of the International Monetary Fund.
Int J Health Serv.40(1). 183-7
S. Gupta. 2010.
Response of the IMF. Int J Health Serv. 40(2). 323-26.
D. Stuckler, S. Basu, A. Gilmore, et al. 2010.
An evaluation of the IMF's claims about public health. Int J Health Serv. 40(2). 327-32.
R. Rowden. 2010. IMF sacrifices higher growth, employment, spending, and public investment in health systems
in order to keep inflation unnecessarily low Int J Health Serv. 40(2). 333-38.
E. Keefe and A. Scott-Samuel. 2010. Health Impact Assessment as an accountability mechanism for the IMF: the case of sub-Saharan
Africa Int J Health Serv. 40(2). 339-45.
B. Baker. 2010. The impact of IMF's macroeconomic policies
on the AIDS pandemic Int J Health Serv. 40(2). 347-63.
doi: 10.1136/bmj.b2403
Comment by T.Lang
doi:10.1016/S0140-6736(09)61124-7
Comment by A.Lundin
Additional Web Appendix
doi:10.1016/S0140-6736(09)60005-2
Comment by M. Bobak and Sir M. Marmot.
doi:10.1016/S0140-6736(08)61656-6
Comment by A. Lopez.
Additional Web Appendix with sources and details of WHO Budget Data
doi: 10.1073/pnas.0801200105
TV:
Taking Money Matters to Heart, CNBC
Primetime Market Watch , CNBC
Twitter: @davidstuckler