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The public health effect of economic crises and alternative policy responses in Europe: an empirical analysis
Abstract
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.Funding Centre for Crime and Justice Studies, King's College, London, UK; and Wates Foundation (UK).
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“an economic recession may have an adverse impact on suicide rates ( Chang et al., 2013; Stuckler et al., 2009).”
From The impact of the COVID-19 pandemic on self-harm and suicidal behaviour: update of living systematic review (2021) · cites this paper as Stuckler et al., 2009
In the citing paper
“Each was based on different assumptions, but the models largely focused on the well-characterised impact on suicide rates of periods of economic recession and rises in unemployment ( Chang et al., 2013; Stuckler et al., 2009).”
From The impact of the COVID-19 pandemic on self-harm and suicidal behaviour: a living systematic review (2020) · cites this paper as Stuckler et al., 2009
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ResultCrises econômicas, mortalidade de crianças e o papel protetor do gasto público em saúde
Tejada, C. A. O., Triaca, L. M., Liermann, N. H., Ewerling, F., & Costa, J. C. (2019) · Ciência & Saúde Coletiva · doi:10.1590/1413-812320182412.25082019 · Cited by 51
Financial Stress, Unemployment, and Suicide – A Meta-Analysis
Roelfs, D. J., & Shor, E. (2023) · Crisis · doi:10.1027/0227-5910/a000908 · Cited by 51
“Studies have shown that suicide rates increase notably in times/places where unemployment rises (Catalano et al., 2011; Chang et al., 2010, 2013; Stuckler et al., 2009).”
BackgroundEconomic crisis and communicable disease control in Europe: A scoping study among national experts
Rechel, B. P. D., Suhrcke, M., Tsolova, S., Suk, J. E., Desai, M., McKee, M., Stückler, D., Abubakar, I., Hunter, P. R., Senek, M., et al. (2011) · Health Policy · doi:10.1016/j.healthpol.2011.06.013 · Cited by 51
Self-citationStückler, D., Reeves, A., Karanikolos, M., & McKee, M. (2014) · Health Economics Policy and Law · doi:10.1017/s1744133114000255 · Cited by 51
“Our 2009 re-analysis of mortality associated with economic changes in Europe over three decades has confirmed the association of suicides with recessions and a decline in road traffic deaths (Stuckler et al., 2009).”
BackgroundSelf-citationBartoll, X., Toffolutti, V., Malmusi, D., Palència, L., Borrell, C., & Suhrcke, M. (2015) · BMC Public Health · doi:10.1186/s12889-015-2204-5 · Cited by 50
“Furthermore, it is noteworthy that in the context of austerity policies, such as those implemented in Spain, population health may be negatively affected by reduced investment in social and health-related public services, such as active labour market programs [29], infection control programs [30], or universal health…”
BackgroundSelf-citationHuijts, T., Reeves, A., McKee, M., & Stückler, D. (2015) · European Journal of Public Health · doi:10.1093/eurpub/ckv108 · Cited by 52
Self-citationBasu, S., Rehkopf, D. H., Siddiqi, A., Glymour, M. M., & Kawachi, I. I. (2016) · American Journal of Epidemiology · doi:10.1093/aje/kwv249 · Cited by 51
Self-citationMultilevel Outcomes of Economic Stress: An Agenda for Future Research
Shoss, M. K., & Probst, T. M. (2012) · Research in occupational stress and well being · doi:10.1108/s1479-3555(2012)0000010006 · Cited by 53
The Labour Market Impacts of Obesity, Smoking, Alcohol Use and Related Chronic Diseases
Devaux, M., & Sassi, F. (2015) · OECD health working papers · doi:10.1787/5jrqcn5fpv0v-en · Cited by 51
Impact of the economic crisis on health-related behaviors in Italy
Mattei, G., Vogli, R. D., Ferrari, S., Pingani, L., Rigatelli, M., & Galeazzi, G. M. (2017) · International Journal of Social Psychiatry · doi:10.1177/0020764017726097 · Cited by 50
Alam, M. S., Shahbaz, M. Q., & Paramati, S. R. (2015) · Social Indicators Research · doi:10.1007/s11205-015-1040-4 · Cited by 53
“Stuckler et al. (2009) examine the public health effect of economic crises, particularly the effect of unemployment on health.”
BackgroundAguilar‐Palacio, I., Carrera‐Lasfuentes, P., & Rabanaque, M. J. (2015) · International Journal of Public Health · doi:10.1007/s00038-015-0668-9 · Cited by 51
“health effects of economic recessions manifest themselves when the economy recovers (Stuckler et al. 2009).”
BackgroundInfluentialWork characteristics and suicidal ideation in young adults in France
Dalglish, S. L., Melchior, M., Younès, N., & Surkan, P. J. (2014) · Social Psychiatry and Psychiatric Epidemiology · doi:10.1007/s00127-014-0969-y · Cited by 53
Saurina, C., Bragulat, B., Sáez, M., & Casasnovas, G. L. I. (2013) · Journal of Epidemiology & Community Health · doi:10.1136/jech-2013-202645 · Cited by 53
Stefanoff, P., Rosińska, M., Samuels, S. J., White, D. J., Morse, D. L., & Randolph, S. (2012) · PLoS ONE · doi:10.1371/journal.pone.0045511 · Cited by 50
“This strong empiric evidence for unemployment and relatively lowly paid work as important contributing factors for public health problems (see also [40,41,42,43]) is backed by several plausible mechanisms in relation to this particular infectious disease that have already been substantiated with respect to high risk b…”
Promoting Global Population Health While Constraining the Environmental Footprint
McMichael, A. J., & Butler, C. D. (2011) · Annual Review of Public Health · doi:10.1146/annurev-publhealth-031210-101203 · Cited by 50
“Korea, and Iraq (mostly reflecting extremes of social-political change and disruption) (92).”
BackgroundSuccesses and failures of health policy in Europe
Mackenbach, J. P. (2013) · European Journal of Public Health · doi:10.1093/eurpub/ckt125.002 · Cited by 50
Can we expect an increased suicide rate due to Covid-19?
Devitt, P. (2020) · Irish Journal of Psychological Medicine · doi:10.1017/ipm.2020.46 · Cited by 52
“The authors speculated that active supportive labour-market programmes were partly responsible (Stuckler et al. 2009).”
BackgroundAllik, M., Brown, D. S., Dundas, R., & Leyland, A. H. (2020) · International Journal for Equity in Health · doi:10.1186/s12939-020-01329-7 · Cited by 52
Global Imperative of Suicidal Ideation in 10 Countries Amid the COVID-19 Pandemic
Cheung, T. C. C., Lam, S. C., Lee, P. H., Xiang, Y., & Yip, P. S. F. (2021) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2020.588781 · Cited by 55
Health in financial crises: economic recession and tuberculosis in Central and Eastern Europe
Arinaminpathy, N., & Dye, C. (2010) · Journal of The Royal Society Interface · doi:10.1098/rsif.2010.0072 · Cited by 50
“There exists a diverse literature on relationships between the economy and health in the broadest sense (Ruhm 2000; Bezruchka 2009; Stuckler et al. 2009).”
BackgroundHolland, P., Nylén, L., Thielen, K., van der Wel, K. A., Chen, W., Barr, B., Burström, B., Diderichsen, F., Andersen, P. K., Dahl, E. S., et al. (2011) · International Journal of Health Services · doi:10.2190/hs.41.3.b · Cited by 50
Decomposing change in China's suicide rate, 1990–2010: ageing and urbanisation
Sha, F., YIP, P. S. F., & Law, Y. W. (2016) · Injury Prevention · doi:10.1136/injuryprev-2016-042006 · Cited by 50
Toffolutti, V., & Suhrcke, M. (2019) · Economics & Human Biology · doi:10.1016/j.ehb.2019.03.002 · Cited by 50
Self-citation
Metadata
- Authors
- Stuckler, D., Basu, S., Suhrcke, M., Coutts, A., & McKee, M.
- Affiliations
- San Francisco General Hospital (US)
- University of East Anglia (GB)
- University of Oxford (GB)
- European Observatory on Health Systems and Policies (BE)
- Venue
- The Lancet
- Publisher
- Elsevier BV
- Published
- 2009-07
- Volume
- 374
- Issue
- 9686
- Pages
- 315-323
- ISSN
- 0099-5355 (ISSN-L)
- 0140-6736
- OpenAlex
- W2146860307
- Cited by
- 1,486
- References
- 42
- Citations by year
- 2026: 39 · 2025: 37 · 2024: 42 · 2023: 67 · 2022: 64 · 2021: 146 · 2020: 115 · 2019: 71 · 2018: 87 · 2017: 95 · 2016: 111 · 2015: 119 · 2014: 183 · 2013: 101 · 2012: 77
- FWCI
- 125.81
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- The Lancet (publishedVersion)
- PubMed (publishedVersion)
- Archivio istituzionale della Ricerca - Bocconi (submittedVersion)
- LSHTM Research Online (London School of Hygiene and Tropical Medicine) (submittedVersion)
- UEA Digital Repository (University of East Anglia) (submittedVersion)
- Funders
- World Bank Group
- Economic and Social Research Council (ES/G007462/1)
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Employment and Welfare Studies
- Social Sciences › Economics, Econometrics and Finance › Economics and Econometrics › Unemployment and Economic Growth
- Social Sciences › Psychology › Clinical Psychology › Suicide and Self-Harm Studies
- Keywords
- unemployment, economic crisis, mortality, suicide, homicide, traffic fatalities, alcohol-related mortality, social protection, active labour market programmes, government spending, unemployment insurance, public health policy, premature mortality, EU member states, population aging, health infrastructure, health disparities
- MeSH terms
- Accidents, Traffic, Adolescent, Adult, Aged, Cause of Death, Europe, European Union, Health Expenditures, Health Policy, Health Status, Homicide, Humans, Middle Aged, Mortality, Population Surveillance, Public Health, Regression Analysis, Suicide, Unemployment, Effect Modifier, Epidemiologic, Multivariate Analysis, Age Distribution, Community Health Planning, Young Adult
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