The public health effect of economic crises and alternative policy responses in Europe: 
an empirical analysis

David Stuckler PhD a b, Sanjay Basu PhD c d, Marc Suhrcke PhD e f, Adam Coutts PhD g, Martin McKee MD b h
a Department of Sociology, Oxford University, Oxford, UK
b Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
c Department of Medicine, University of California San Francisco, CA, USA
d Division of General Internal Medicine, San Francisco General Hospital, CA, USA
e School of Medicine, Health Policy and Practice, University of East Anglia, Norwich, UK
f Centre for Diet and Activity Research (CEDAR), Cambridge, UK
g Oxford Department of Politics and International Relations, Oxford, UK
h European Observatory on Health Systems and Policies, Brussels, Belgium

The Lancet, Early Online Publication, 8 July 2009
doi:10.1016/S0140-6736(09)61124-7 

Background http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)61124-7/fulltext 

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).