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1.  The global financial crisis and health equity: Early experiences from Canada 
Background
It is widely acknowledged that austerity measures in the wake of the global financial crisis are starting to undermine population health results. Yet, few research studies have focused on the ways in which the financial crisis and the ensuing ‘Great Recession’ have affected health equity, especially through their impact on social determinants of health; neither has much attention been given to the health consequences of the fiscal austerity regime that quickly followed a brief period of counter-cyclical government spending for bank bailouts and economic stimulus. Canada has not remained insulated from these developments, despite its relative success in maneuvering the global financial crisis.
Methods
The study draws on three sources of evidence: A series of semi-structured interviews in Ottawa and Toronto, with key informants selected on the basis of their expertise (n = 12); an analysis of recent (2012) Canadian and Ontario budgetary impacts on social determinants of health; and documentation of trend data on key social health determinants pre- and post the financial crisis.
Results
The findings suggest that health equity is primarily impacted through two main pathways related to the global financial crisis: austerity budgets and associated program cutbacks in areas crucial to addressing the inequitable distribution of social determinants of health, including social assistance, housing, and education; and the qualitative transformation of labor markets, with precarious forms of employment expanding rapidly in the aftermath of the global financial crisis. Preliminary evidence suggests that these tendencies will lead to a further deepening of existing health inequities, unless counter-acted through a change in policy direction.
Conclusions
This article documents some of the effects of financial crisis and severe economic decline on health equity in Canada. However, more research is necessary to study policy choices that could mitigate this effect. Since the policy response to a similar set of economic shocks has globally varied and led to differential health and health equity outcomes, comparative studies are now possible to assess the successes and failures of specific policy responses. This raises the question of what types of public policy can mitigate against the negative health equity effects of severe economic recessions.
doi:10.1186/1744-8603-10-2
PMCID: PMC3974147  PMID: 24393250
Health equity; Global financial crisis; Social determinants of health; Austerity; Canada
2.  Economic crisis and suicidal behaviour: the role of unemployment, sex and age in Andalusia, Southern Spain 
Introduction
Although suicide rates have increased in some European countries in relation to the current economic crisis and austerity policies, that trend has not been observed in Spain. This study examines the impact of the economic crisis on suicide attempts, the previously neglected endpoint of the suicidal process, and its relation to unemployment, age and sex.
Methods
The study was carried out in Andalusia, the most populated region of Spain, and which has a high level of unemployment. Information on suicide attempts attended by emergency services was extracted from the Health Emergencies Public Enterprise Information System (SIEPES). Suicide attempts occurring between 2003 and 2012 were included, in order to cover five years prior to the crisis (2003–2007) and five years after its onset (2008–2012). Information was retrieved from 24,380 cases (11,494 men and 12,886 women) on sex, age, address, and type of attention provided. Age-adjusted suicide attempt rates were calculated. Excess numbers of attempts from 2008 to 2012 were estimated for each sex using historical trends of the five previous years, through time regression models using negative binomial regression analysis. To assess the association between unemployment and suicide attempts rates, linear regression models with fixed effects were performed.
Results
A sharp increase in suicide attempt rates in Andalusia was detected after the onset of the crisis, both in men and in women. Adults aged 35 to 54 years were the most affected in both sexes. Suicide attempt rates were associated with unemployment rates in men, accounting for almost half of the cases during the five initial years of the crisis. Women were also affected during the recession period but this association could not be specifically attributed to unemployment.
Conclusions
This study enhances our understanding of the potential effects of the economic crisis on the rapidly increasing suicide attempt rates in women and men, and the association of unemployment with growing suicidal behaviour in men. Research on the suicide effects of the economic crisis may need to take into account earlier stages of the suicidal process, and that this effect may differ by age and sex.
doi:10.1186/1475-9276-13-55
PMCID: PMC4119181  PMID: 25062772
Suicide attempts; Economic crisis; Unemployment; Spain; Andalusia; Intento de suicidio; Crisis económica; Desempleo; España; Andalucía
3.  Crisis, leadership, consensus: The past and future federal role in health 
This paper touches on patterns of federal government involvement in the health sector since the late 18th century to the present and speculates on its role in the early decades of the 21st century. Throughout the history of the US, government involvement in the health sector came only in the face of crisis, only when there was widespread consensus, and only through sustained leadership. One of the first health-related acts of Congress came about as a matter of interstate commerce regarding the dilemma as to what to do about treating merchant seamen who had no affiliation with any state. Further federal actions were implemented to address epidemics, such as from yellow fever, that traveled from state to state through commercial ships. Each federal action was met with concern and resistance from states' rights advocates, who asserted that the health of the public was best left to the states and localities. It was not until the early part of the 20th century that a concern for social well-being, not merely commerce, drove the agenda for public health action. Two separate campaigns for national health insurance, as well as a rapid expansion of programs to serve the specific health needs of specific populations, led finally to the introduction of Medicaid and Medicare in the 1960s, the most dramatic example of government intervention in shaping the personal health care delivery system in the latter half of the 20th century. As health costs continued to rise and more and more Americans lacked adequate health insurance, a perceived crisis led President Clinton to launch his 1993 campaign to insure every American—the third attempt in this century to provide universal coverage. While the crisis was perceived by many, there was no consensus on action, and leadership outside government was missing. Today, the health care crisis still looms. Despite an economic boom, 1 million Americans lose their health insurance each year, with 41 million Americans, or 15% of the population, lacking coverage. Private premiums are going up again as federal programs are capped and the lack of a federal framework for quality assurance leads to growing problems of access and quality that will need to be addressed as we enter the 21st century. What role will government play?
doi:10.1007/BF02344675
PMCID: PMC3455986  PMID: 10924029
4.  The financial crisis, health and health inequities in Europe: the need for regulations, redistribution and social protection 
In 2009, Europe was hit by one of the worst debt crises in history. Although the Eurozone crisis is often depicted as an effect of government mismanagement and corruption, it was a consequence of the 2008 U.S. banking crisis which was caused by more than three decades of neoliberal policies, financial deregulation and widening economic inequities.
Evidence indicates that the Eurozone crisis disproportionately affected vulnerable populations in society and caused sharp increases of suicides and deaths due to mental and behavioral disorders especially among those who lost their jobs, houses and economic activities because of the crisis. Although little research has, so far, studied the effects of the crisis on health inequities, evidence showed that the 2009 economic downturn increased the number of people living in poverty and widened income inequality especially in European countries severely hit by the debt crisis. Data, however, also suggest favorable health trends and a reduction of traffic deaths fatalities in the general population during the economic recession. Moreover, egalitarian policies protecting the most disadvantaged populations with strong social protections proved to be effective in decoupling the link between job losses and suicides.
Unfortunately, policy responses after the crisis in most European countries have mainly consisted in bank bailouts and austerity programs. These reforms have not only exacerbated the debt crisis and widened inequities in wealth but also failed to address the root causes of the crisis. In order to prevent a future financial downturn and promote a more equitable and sustainable society, European governments and international institutions need to adopt new regulations of banking and finance as well as policies of economic redistribution and investment in social protection. These policy changes, however, require the abandonment of the neoliberal ideology to craft a new global political economy where markets and gross domestic product (GDP) are no longer the main national policy goals, but just means to human and health improvements.
doi:10.1186/s12939-014-0058-6
PMCID: PMC4222559  PMID: 25059702
Great recession; Health; Europe; Financial crisis; Inequality; Neoliberalism; Austerity and Global Health
5.  Economic crisis, immigrant women and changing availability of intimate partner violence services: a qualitative study of professionals’ perceptions in Spain 
Introduction
Since 2008, Spain has been in the throes of an economic crisis. This recession particularly affects the living conditions of vulnerable populations, and has also led to a reversal in social policies and a reduction in resources. In this context, the aim of this study was to explore intimate partner violence (IPV) service providers’ perceptions of the impact of the current economic crisis on these resources in Spain and on their capacity to respond to immigrant women’s needs experiencing IPV.
Methods
A qualitative study was performed based on 43 semi-structured in-depth interviews to social workers, psychologists, intercultural mediators, judges, lawyers, police officers and health professionals from different services dealing with IPV (both, public and NGO’s) and cities in Spain (Barcelona, Madrid, Valencia and Alicante) in 2011. Transcripts were imported into qualitative analysis software (Atlas.ti), and analysed using qualitative content analysis.
Results
We identified four categories related to the perceived impact of the current economic crisis: a) “Immigrant women have it harder now”, b) “IPV and immigration resources are the first in line for cuts”, c) “ Fewer staff means a less effective service” and d) “Equality and IPV policies are no longer a government priority”. A cross-cutting theme emerged from these categories: immigrant women are triply affected; by IPV, by the crisis, and by structural violence.
Conclusion
The professionals interviewed felt that present resources in Spain are insufficient to meet the needs of immigrant women, and that the situation might worsen in the future.
Electronic supplementary material
The online version of this article (doi:10.1186/s12939-014-0079-1) contains supplementary material, which is available to authorized users.
doi:10.1186/s12939-014-0079-1
PMCID: PMC4172960  PMID: 25205287
Intimate partner violence; Immigrant women; Crisis; Qualitative study; Spain; Violencia del Compañero Íntimo; Mujeres inmigrantes; Crisis; Estudio cualitativo; España
6.  The World – Socio-economically and politically: What you need to know 
The gravest challenge facing the USA and the nations of the world is the coming economic crisis of the world economies, if present policies are pursued. Few are aware or believe that this event could happen. The spread of centralized government control of the economies, the growth of the welfare state worldwide, the expenditures on entitlements beyond what any nation or even most states can afford, the cost of wars, the rapidly climbing debt of the USA and other countries and their inability to pay for these excessive expenses, the actions of many countries to print “fiat” (false) money to pay for their debts, the raising of taxes to pay for these debts, the rise in immigration to developed countries from the undeveloped world, the associated costs to their societies of this immigration, the promises made by politicians to get elected that cannot be fulfilled, and the desire of the public to have what they want, now, paid for by credit cards (debt), are all contributing to the coming economic crisis.
The unfunded promised benefits to the citizens of the USA in Medicare, Medicaid, Social Security, and pensions plus the USA debt amount to about $140 trillion. The total value of all the assets of all the people in the USA is $99 trillion dollars. So, one can see that the people of the USA do not have the resources to pay their expenses. Besides, these entitlements, the rest of the expenses are paid for with borrowed or printed (fiat) money that has little chance of being repaid unless perhaps by subsequent generations or by increases in taxes. Efforts to correct this coming economic crisis by austerity and sacrifice have been rejected by the public and the politicians worldwide. The Governments and the Press have participated in deception of the public about these issues in order to maintain their positions of power, for the truth would destroy them. No solution is in sight except more spending and valueless money printing.
This unchecked desire for more of everything without the responsibility to work or pay for these entitlements, has touched many countries and people with a few exceptions. This problem is the result of a worldwide breakdown of ethics and morality in society and a desire of the few for centralized control and power over the people. No country has instituted a solution to these problems that results in reducing expenditures or the growing debts. As many have stated in this paper, this policy cannot be sustained. The result of this scenario will be a worldwide economic crisis.
Fundamental to this impending economic crisis is the failure of centrally controlled economies and socialistic programs. Those selected groups, who benefit from having control, are the politicians, bankers, some selected industry leaders, and socialist planners, who will stop at nothing to maintain power and control over the people. Liberty of the people is in jeopardy worldwide. Read the evidence presented and decide if this summary is correct.
The troubling question is, “What will happen if the world economy collapses?” Will this crisis be a time for the few to take more control of the people through fear, crisis decisions, misinformation, prevention of the public from protecting themselves with guns, and pervasive spying technology on each citizen or will more democratic governments arise from the failure of centralized control, the welfare state, and the loss of liberty? Such crises have been repeated throughout 4000 years of recorded history. What happened in those past times? Read the quotations of Vladimir Lenin, developer of Marxism–Leninism, the foundation of Communism and judge what you have read from his statements.
An alternative to this dismal scenario is little discussed also in the Press. Why not? In the past 150 years, the alternative has happened with a rapid growth in democracy, communications technology, and life expectancy from advances in science and medicine. To unleash this huge human potential, at this time, will require individual freedom to create and innovate with the opportunity for risk and reward in an environment aided by unrestrictive governments even at the community and organizational levels. History records the success of the alternatives in the great leadership and creativity of humankind. The USA and the world are at the critical choice for their futures. We are experiencing the results of centrally controlling governments worldwide that are not working. Is it time for an alternative option? Read the evidence in this paper and decide for yourself.
Reading this paper will take you time, but you will not read all of this information elsewhere. It is key to your future. Decide for yourself what you should do after reading it. The URLs of many of the references are included so that you can read further about the many subjects presented yourself.
doi:10.4103/2152-7806.119730
PMCID: PMC3815094  PMID: 24231906
Economics; politics; socialism; socioeconomics; welfare
7.  Impact of the 2008 Economic and Financial Crisis on Child Health: A Systematic Review 
The aim of this study was to provide an overview of studies in which the impact of the 2008 economic crisis on child health was reported. Structured searches of PubMed, and ISI Web of Knowledge, were conducted. Quantitative and qualitative studies reporting health outcomes on children, published since 2007 and related to the 2008 economic crisis were included. Two reviewers independently assessed studies for inclusion. Data were synthesised as a narrative review. Five hundred and six titles and abstracts were reviewed, from which 22 studies were included. The risk of bias for quantitative studies was mixed while qualitative studies showed low risk of bias. An excess of 28,000–50,000 infant deaths in 2009 was estimated in sub-Saharan African countries, and increased infant mortality in Greece was reported. Increased price of foods was related to worsening nutrition habits in disadvantaged families worldwide. An increase in violence against children was reported in the U.S., and inequalities in health-related quality of life appeared in some countries. Most studies suggest that the economic crisis has harmed children’s health, and disproportionately affected the most vulnerable groups. There is an urgent need for further studies to monitor the child health effects of the global recession and to inform appropriate public policy responses.
doi:10.3390/ijerph110606528
PMCID: PMC4078594  PMID: 25019121
adolescent; child health; economic and financial crisis; inequalities
8.  Crisis Communication in the Area of Risk Management: The CriCoRM Project 
Background
During the last H1N1 pandemic has emerged the importance of crisis communication as an essential part of health crisis management. The Project aims specifically to improve the understanding of crisis communication dynamics and effective tools and to allow public health institutions to communicate better with the public during health emergencies.
Design and methods
The Project will perform different activities: i) state of the art review; ii) identification of key stakeholders; iii) communicational analysis performed using data collected on stakeholder communication activities and their outcomes considering the lessons learnt from the analysis of the reasons for differing public reactions during pandemics; iv) improvement of the existing guidelines; v) development of Web 2.0 tools as web-platform and feed service and implementation of impact assessment algorithms; vi) organization of exercises and training on this issues.
Expected impact of the study for public health
In the context of health security policies at an EU level, the project aims to find a common and innovative approach to health crisis communication that was displayed by differing reactions to the H1N1 pandemic policies. The focus on new social media tools aims to enhance the role of e-health, and the project aims to use these tools in the specific field of health institutions and citizens. The development of Web 2.0 tools for health crisis communication will allow an effective two-way exchange of information between public health institutions and citizens. An effective communication strategy will increase population compliance with public health recommendations.
Significance for public healthThe specific aim of the project is to develop a European strategy approach on how to communicate with the population and with different stakeholders groups involved in the crisis management process, based on an analysis of the communication process during the H1N1 pandemic (content analysis of press releases, press coverage and forum discussions) and on interviews with key stakeholders in health crisis communication. The development of web 2.0 tools, providing rapid responses will allow real-time verification of awareness of social trends and citizens’ response. Furthermore, the project would like to offer these resources to the EU Public Health Institutions and EU citizens to improve their interaction, and hence reinforce citizens’ right to patient-centred health care. The project proposal has been designed in accordance with the general principles of ethics and the EU Charter of Fundamental Rights with regard to human rights, values, freedom, solidarity, and better protection of European citizens.
doi:10.4081/jphr.2013.e20
PMCID: PMC4147738  PMID: 25170491
9.  Inequities in the Global Health Workforce: The Greatest Impediment to Health in Sub-Saharan Africa 
Health systems played a key role in the dramatic rise in global life expectancy that occurred during the 20th century, and have continued to contribute enormously to the improvement of the health of most of the world’s population. The health workforce is the backbone of each health system, the lubricant that facilitates the smooth implementation of health action for sustainable socio-economic development. It has been proved beyond reasonable doubt that the density of the health workforce is directly correlated with positive health outcomes. In other words, health workers save lives and improve health. About 59 million people make up the health workforce of paid full-time health workers world-wide. However, enormous gaps remain between the potential of health systems and their actual performance, and there are far too many inequities in the distribution of health workers between countries and within countries. The Americas (mainly USA and Canada) are home to 14% of the world’s population, bear only 10% of the world’s disease burden, have 37% of the global health workforce and spend about 50% of the world’s financial resources for health. Conversely, sub-Saharan Africa, with about 11% of the world’s population bears over 24% of the global disease burden, is home to only 3% of the global health workforce, and spends less than 1% of the world’s financial resources on health. In most developing countries, the health workforce is concentrated in the major towns and cities, while rural areas can only boast of about 23% and 38% of the country’s doctors and nurses respectively. The imbalances exist not only in the total numbers and geographical distribution of health workers, but also in the skills mix of available health workers. WHO estimates that 57 countries world wide have a critical shortage of health workers, equivalent to a global deficit of about 2.4 million doctors, nurses and midwives. Thirty six of these countries are in sub-Saharan Africa. They would need to increase their health workforce by about 140% to achieve enough coverage for essential health interventions to make a positive difference in the health and life expectancy of their populations. The extent causes and consequences of the health workforce crisis in Sub-Saharan Africa, and the various factors that influence and are related to it are well known and described. Although there is no “magic bullet” solution to the problem, there are several documented, tested and tried best practices from various countries. The global health workforce crisis can be tackled if there is global responsibility, political will, financial commitment and public-private partnership for country-led and country-specific interventions that seek solutions beyond the health sector. Only when enough health workers can be trained, sustained and retained in sub-Saharan African countries will there be meaningful socio-economic development and the faintest hope of attaining the Millennium Development Goals in the sub-continent.
PMCID: PMC3728573  PMID: 17617671
Health workforce; human resources for health; health worker; crisis; skills mix
10.  Is There a Statistical Relationship between Economic Crises and Changes in Government Health Expenditure Growth? An Analysis of Twenty-Four European Countries 
Health Services Research  2012;47(6):2204-2224.
Objective
To identify whether, by what means, and the extent to which historically, government health care expenditure growth in Europe has changed following economic crises.
Data Sources
Organization for Economic Cooperation and Development Health Data 2011.
Study Design
Cross-country fixed effects multiple regression analysis is used to determine whether statutory health care expenditure growth in the year after economic crises differs from that which would otherwise be predicted by general economic trends. Better understanding of the mechanisms involved is achieved by distinguishing between policy responses which lead to cost-shifting and all others.
Findings
In the year after an economic downturn, public health care expenditure grows more slowly than would have been expected given the longer term economic climate. Cost-shifting and other policy responses are both associated with these slowdowns. However, while changes in tax-derived expenditure are associated with both cost-shifting and other policy responses following a crisis, changes in expenditure derived from social insurance have been associated only with changes in cost-shifting.
Conclusions
Disproportionate cuts to the health sector, as well as reliance on cost-shifting to slow growth in health care expenditure, serve as a warning in terms of potentially negative effects on equity, efficiency, and quality of health services and, potentially, health outcomes following economic crises.
doi:10.1111/j.1475-6773.2012.01428.x
PMCID: PMC3523372  PMID: 22670771
Health economics; health care financing/insurance/premiums; comparative health systems/international health; health care organizations and systems
11.  The role of business in addressing the long-term implications of the current food crisis 
Before the onset of the current food crisis, the evidence of a severely neglected nutrition crisis was starting to receive attention. Increased food prices are having severe impacts on the nutritional status of populations. Our current food system has evolved over decades in a largely unplanned manner and without consideration for the complexity and implications of linkages between health, nutrition, agricultural, economic, trade and security issues. The underlying causes for the nutrition crisis include the above, as well as decades of neglect with regard to nutrition, and agricultural science (especially in emerging markets); a failure of governance with respect to the major players involved in nutrition, a weak response by government donors and Foundations to invest in basic nutrition (in contrast to growing support for humanitarian aspects of food aid), and a reluctance to develop private-public partnerships. The emergence of new business models that tackle social problems while remaining profitable offers promise that the long term nutrition needs of people can be met. Businesses can have greater impact acting collectively than individually. Food, retail, food service, chemical and pharmaceutical companies have expertise, distribution systems and customers insights, if well harnessed, could leapfrog progress in addressing the food and nutrition crises. While business can do lots more, its combined impact will be minimal if a range of essential government actions and policies are not addressed. Governments need to create innovative and complementary opportunities that include incentives for businesses including: setting clear nutritional guidelines for fortification and for ready-to eat products; offering agreements to endorse approved products and support their distribution to clinics and schools; eliminating duties on imported vitamins and other micronutrients; and providing tax and other incentives for industry to invest with donors in essential nutrition and agricultural research. Currently governments in developed countries provide a wide range of incentives to the pharmaceutical industry to develop medicated solutions to nutritional problems. We need equivalent effort to be given to the development of more sustainable agricultural and food based solutions. We now face a truly global set of interlinked crises related to food that affect all people. The same degree of urgency and high level leadership and partnership seen during the Second World War is required on a global basis. This time it will need to simultaneously address agricultural, environmental and health considerations with the aim being the attainment of optimal nutrition for all within a framework of sustainable development.
doi:10.1186/1744-8603-4-12
PMCID: PMC2631462  PMID: 19055848
12.  Effects of global financial crisis on funding for health development in nineteen countries of the WHO African Region 
Background
There is ample evidence in Asia and Latin America showing that past economic crises resulted in cuts in expenditures on health, lower utilization of health services, and deterioration of child and maternal nutrition and health outcomes. Evidence on the impact of past economic crises on health sector in Africa is lacking. The objectives of this article are to present the findings of a quick survey conducted among countries of the WHO African Region to monitor the effects of global financial crisis on funding for health development; and to discuss the way forward.
Methods
This is a descriptive study. A questionnaire was prepared and sent by email to all the 46 Member States in the WHO African Region through the WHO Country Office for facilitation and follow up. The questionnaires were completed by directors of policy and planning in ministries of health. The data were entered and analyzed in Excel spreadsheet. The main limitations of this study were that authors did not ask whether other relevant sectors were consulted in the process of completing the survey questionnaire; and that the overall response rate was low.
Results
The main findings were as follows: the response rate was 41.3% (19/46 countries); 36.8% (7/19) indicated they had been notified by the Ministry of Finance that the budget for health would be cut; 15.8% (3/19) had been notified by partners of their intention to cut health funding; 61.1% (11/18) indicated that the prices of medicines had increased recently; 83.3% (15/18) indicated that the prices of basic food stuffs had increased recently; 38.8% (7/18) indicated that their local currency had been devalued against the US dollar; 47.1% (8/17) affirmed that the levels of unemployment had increased since the onset of global financial crisis; and 64.7% (11/17) indicated that the ministry of health had taken some measures already, either in reaction to the global financing crisis, or in anticipation.
Conclusion
A rapid assessment, like the one reported in this article, of the effects of the global financial crisis on a few variables, is important to alert the Ministry of Health on the looming danger of cuts in health funding from domestic and external sources. However, it is even more important for national governments to monitor the effects of the economic crisis and the policy responses on the social determinants of health, health inputs, health system outputs and health system outcomes, e.g. health.
doi:10.1186/1472-698X-11-4
PMCID: PMC3094291  PMID: 21489284
13.  The Impact of Economic Crises on Communicable Disease Transmission and Control: A Systematic Review of the Evidence 
PLoS ONE  2011;6(6):e20724.
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.
doi:10.1371/journal.pone.0020724
PMCID: PMC3112201  PMID: 21695209
14.  Economic recession and health inequalities in Japan: analysis with a national sample, 1986–2001 
Objective
Little is known about whether economic crises widen health inequalities. Japan experienced more than 10 years of economic recession beginning in the 1990s. The question of whether socioeconomic-based inequality in self-rated health widened after the economic crisis was examined.
Design, setting and participants
Repeated cross-sectional survey design. Two pooled datasets from 1986 and 1989 and from 1998 and 2001 were analysed separately, and temporal change was examined. The study took place in Japan among the working-age population (20–60 years old). The two surveys consisted of 168 801 and 150 016 people, respectively, with about an 80% response rate.
Results
The absolute percentages of people reporting poor health declined across all socioeconomic statuses following the crisis. However, after controlling for confounding factors, the odds ratio (OR) for poor self-rated health (95% confidence intervals) among middle-class non-manual workers (clerical/sales/service workers) compared with the highest class workers (managers/administrators) was 1.02 (0.92 to 1.14) before the crisis but increased to 1.14 (1.02 to 1.29) after the crisis (p for temporal change = 0.02). The association was stronger among males. The adjusted ORs among professional workers and young female homemakers also marginally increased over time. Unemployed people were twice as likely to report poor health compared with the highest class workers throughout the period. Self-rated health of people with middle to higher incomes deteriorated in relative terms following the crisis compared with that of lower income people.
Conclusions
Self-rated health improved in absolute terms for all occupational groups even after the economic recession. However, the relative disparity increased between the top and middle occupational groups in men.
doi:10.1136/jech.2007.070334
PMCID: PMC2785845  PMID: 18791043
15.  A health care system in transformation: making the case for chiropractic 
There are a number of factors that have conspired to create a crisis in healthcare. In part, the successes of medical science and technologies have been to blame, for they have led to survival where lives would previously have been cut short. An informed public, aware of these technological advances, is demanding access to the best that healthcare has to offer. At the same time the burden of chronic disease in an increasing elderly population has created a marked growth in the need for long term care. Current estimates for expenditure predict a rapid escalation of healthcare costs as a proportion of the GDP of developed nations, yet at the same time a global economic crisis has necessitated dramatic cuts in health budgets. This unsustainable position has led to calls for an urgent transformation in healthcare systems.
This commentary explores the present day healthcare crisis and looks at the opportunities for chiropractors as pressure intensifies on politicians and leaders in healthcare to seek innovative solutions to a failing model. Amidst these opportunities, it questions whether the chiropractic profession is ready to accept the challenges that integration into mainstream healthcare will bring and identifies both pathways and potential obstacles to acceptance.
doi:10.1186/2045-709X-20-37
PMCID: PMC3552679  PMID: 23216921
Chiropractic; Healthcare transformation; Healthcare reform
16.  The true cost of the economic crisis on psychological well-being: a review 
The recent economic crisis has led to many negative consequences, not the least having to do with the mental health and well-being of the populations involved. Although some researchers say it is still too early to speak about a relationship between the economic crisis and a rise in mental health problems resulting in suicides, there is solid evidence for the existence of such a relationship. However, several moderating or mediating mechanisms can also play a role. The main reactions of most policy makers to the economic crisis are (severe) austerity measures. These measures seem to have, however, a detrimental effect on the mental health of the population: Just when people have the highest need for mental help, cost-cutting measures in the health care sector lead to a (substantial) drop in the supply of services for the prevention, early detection, and cure of mental health problems. Policy makers should support moderating mechanisms such as financial and psychological coping and acculturation and the role of primary health care workers in the early detection of suicidal thoughts, suicide attempts, and suicide in times of economic recession. Several examples show that the countries best off regarding the mental health of their populations during the economic crisis are those countries with the strongest social safety net. Therefore, instead of cutting back on health care and social welfare measures, policy makers should in the future invest even more in social protection measures during economic crises.
Video abstract
doi:10.2147/PRBM.S44732
PMCID: PMC4295900  PMID: 25657601
economic recession; mental health; suicide; social protection; austerity; review
17.  Health-income inequality: the effects of the Icelandic economic collapse 
Introduction
Health-income inequality has been the focus of many studies. The relationship between economic conditions and health has also been widely studied. However, not much is known about how changes in aggregate economic conditions relate to health-income inequality. Nevertheless, such knowledge would have both scientific and practical value as substantial public expenditures are used to decrease such inequalities and opportunities to do so may differ over the business cycle. For this reason we examine the effect of the Icelandic economic collapse in 2008 on health-income inequality.
Methods
The data used come from a health and lifestyle survey carried out by the Public Health Institute of Iceland in 2007 and 2009. A stratified random sample of 9,807 individuals 18–79 years old received questionnaires and a total of 42.1% answered in both years. As measures of health-income inequality, health-income concentration indices are calculated and decomposed into individual-level determinants. Self-assessed health is used as the health measure in the analyses, but three different measures of income are used: individual income, household income, and equivalized household income.
Results
In both years there is evidence of health-income inequality favoring the better off. However, changes are apparent between years. For males health-income inequality increases after the crisis while it remains fairly stable for females or slightly decreases. The decomposition analyses show that income itself and disability constitute the most substantial determinants of inequality. The largest increases in contributions between years for males come from being a student, having low education and being obese, as well as age and income but those changes are sensitive to the income measure used.
Conclusions
Changes in health and income over the business cycle can differ across socioeconomic strata, resulting in cyclicality of income-related health distributions. As substantial fiscal expenditures go to limiting the relationship between income and health, the business-cycle effect on equality, which has up until now not received much attention, needs to be considered.
doi:10.1186/1475-9276-13-50
PMCID: PMC4119249  PMID: 25063235
Concentration index; Decomposition; Health-income inequalities; Economic conditions; Crisis; Iceland
18.  A Framework and Methodology for Navigating Disaster and Global Health in Crisis Literature 
PLoS Currents  2013;5:ecurrents.dis.9af6948e381dafdd3e877c441527cba0.
Both ‘disasters’ and ‘global health in crisis’ research has dramatically grown due to the ever-increasing frequency and magnitude of crises around the world. Large volumes of peer-reviewed literature are not only a testament to the field’s value and evolution, but also present an unprecedented outpouring of seemingly unmanageable information across a wide array of crises and disciplines. Disaster medicine, health and humanitarian assistance, global health and public health disaster literature all lie within the disaster and global health in crisis literature spectrum and are increasingly accepted as multidisciplinary and transdisciplinary disciplines. Researchers, policy makers, and practitioners now face a new challenge; that of accessing this expansive literature for decision-making and exploring new areas of research. Individuals are also reaching beyond the peer-reviewed environment to grey literature using search engines like Google Scholar to access policy documents, consensus reports and conference proceedings. What is needed is a method and mechanism with which to search and retrieve relevant articles from this expansive body of literature. This manuscript presents both a framework and workable process for a diverse group of users to navigate the growing peer-reviewed and grey disaster and global health in crises literature. Methods: Disaster terms from textbooks, peer-reviewed and grey literature were used to design a framework of thematic clusters and subject matter ‘nodes’. A set of 84 terms, selected from 143 curated terms was organized within each node reflecting topics within the disaster and global health in crisis literature. Terms were crossed with one another and the term ‘disaster’. The results were formatted into tables and matrices. This process created a roadmap of search terms that could be applied to the PubMed database. Each search in the matrix or table results in a listed number of articles. This process was applied to literature from PubMed from 2005-2011. A complementary process was also applied to Google Scholar using the same framework of clusters, nodes, and terms expanding the search process to include the broader grey literature assets. Results: A framework of four thematic clusters and twelve subject matter nodes were designed to capture diverse disaster and global health in crisis-related content. From 2005-2011 there were 18,660 articles referring to the term [disaster]. Restricting the search to human research, MeSH, and English language there remained 7,736 identified articles representing an unmanageable number to adequately process for research, policy or best practices. However, using the crossed search and matrix process revealed further examples of robust realms of research in disasters, emergency medicine, EMS, public health and global health. Examples of potential gaps in current peer-reviewed disaster and global health in crisis literature were identified as mental health, elderly care, and alternate sites of care. The same framework and process was then applied to Google Scholar, specifically for topics that resulted in few PubMed search returns. When applying the same framework and process to the Google Scholar example searches retrieved unique peer-reviewed articles not identified in PubMed and documents including books, governmental documents and consensus papers. Conclusions: The proposed framework, methodology and process using four clusters, twelve nodes and a matrix and table process applied to PubMed and Google Scholar unlocks otherwise inaccessible opportunities to better navigate the massively growing body of peer-reviewed disaster and global health in crises literature. This approach will assist researchers, policy makers, and practitioners to generate future research questions, report on the overall evolution of the disaster and global health in crisis field and further guide disaster planning, prevention, preparedness, mitigation response and recovery.
doi:10.1371/currents.dis.9af6948e381dafdd3e877c441527cba0
PMCID: PMC3625621  PMID: 23591457
19.  Environmental Sanitation Crisis: More than just a health issue 
The global environmental sanitation crisis cannot be denied: well over a century after the sanitary revolution in 19th century Europe, 40% of the world’s population still lacks access to improved sanitation. Important lessons from the past must be applied today if the crisis is to be averted. Sanitation has suffered from a lack of prioritization for as long as it has remained the poor relation to water supply. The International Year of Sanitation 2008 provides an opportunity to separate the two and give sanitation the emphasis it requires. The economic argument for sanitation must be articulated and non-health incentives for improved sanitation exploited. Environmental sanitation results in a multitude of socio-economic benefits and can contribute positively to all the Millennium Development Goals. Community-led bottom-up approaches, rather than supply-led or technology-driven approaches, are most effective in increasing and sustaining access to sanitation but need to be implemented at scale. Targeted strategies for urban and school sanitation are also required. Evidence-based advocacy can help develop the political will that is now needed to ensure sufficient public sector investment, leadership, legislation and regulation to ensure that the fundamental human right of access to sanitation is realized.
PMCID: PMC3091339  PMID: 21572832
developing countries; environmental sanitation; preventive health
20.  Management of type 2 diabetes and its prescription drug cost before and during the economic crisis in Greece: an observational study 
Background
The aim of the present study is to examine the clinical indices related to cardiovascular risk management of Greek patients with type 2 diabetes, before and after the major economic crisis that emerged in the country.
Methods
In this retrospective database study, the medical records of patients with type 2 diabetes treated at three diabetes outpatient centers of the national health system during 2006 and 2012 were examined. Only patients with at least six months of follow-up prior to the recorded examination were included. The prescription cost was calculated in Euros per patient-year (€PY).
Results
A total of 1953 medical records (938 from 2006 and 1015 from 2012) were included. There were no significant differences in adjusted HbA1c, systolic blood pressure and HDL-C, while significant reductions were observed in LDL-C and triglycerides. In 2012, a higher proportion of patients were prescribed glucose-lowering, lipid-lowering and antihypertensive medications. Almost 4 out of 10 patients were prescribed the new incretin-based medications, while the use of older drugs, except for metformin, decreased. A significant increase in the adjusted glucose-lowering prescription cost (612.4 [586.5-638.2] €PY vs 390.7 [363.5-418.0]; p < 0.001) and total prescription cost (1306.7 [1264.6-1348.7] €PY vs 1122.3[1078.1-1166.5]; p < 0.001) was observed. The cost of antihypertensive prescriptions declined, while no difference was observed for lipid-lowering and antiplatelet agents.
Conclusions
During the economic crisis, the cardiovascular risk indices of Greek patients with type 2 diabetes being followed in public outpatient diabetes clinics did not deteriorate and in the case of lipid profile improved. However, the total prescription cost increased, mainly due to the higher cost of glucose-lowering prescriptions.
doi:10.1186/1472-6823-14-23
PMCID: PMC3946132  PMID: 24593679
Type 2 diabetes; Prescription cost; Economic crisis; Cardiovascular risk
21.  When families fail: shifting expectations of care among people living with HIV in Nairobi, Kenya 
Anthropology & Medicine  2014;21(2):136-148.
The availability of free antiretroviral treatment in public health facilities since 2004 has contributed to the increasing biomedicalization of AIDS care in Kenya. This has been accompanied by a reduction of funding for community-based care and support organizations since the 2008 global economic crisis and a consequent donor divestment from HIV projects in Africa. This paper explores the ways that HIV interventions, including support groups, home-based care and antiretroviral treatments have shaped expectations regarding relations of care in the low-income area of Kibera in Nairobi, Kenya, over the last decade. Findings are based on 20 months of ethnographic research conducted in Nairobi between January 2011 and August 2013. By focusing on three eras of HIV treatment – pre-treatment, treatment scale-up, and post-crisis – the authors illustrate how family and community-based care have changed with shifts in funding. Many support groups that previously provided HIV care in Kibera, where the state is largely absent and family networks are thin, have been forced to cut services. Large-scale HIV treatment programmes may allow the urban poor in Nairobi to survive, but they are unlikely to thrive. Many care needs continue to go unmet in the age of treatment, and many economically marginal people who had found work in care-oriented community-based organizations now find themselves jobless or engaged in work not related to HIV.
doi:10.1080/13648470.2014.924298
PMCID: PMC4200576  PMID: 25175290
HIV/AIDS; care; community-based organizations; social support; Kenya
22.  A Likelihood-Based Approach to Identifying Contaminated Food Products Using Sales Data: Performance and Challenges 
PLoS Computational Biology  2014;10(7):e1003692.
Foodborne disease outbreaks of recent years demonstrate that due to increasingly interconnected supply chains these type of crisis situations have the potential to affect thousands of people, leading to significant healthcare costs, loss of revenue for food companies, and—in the worst cases—death. When a disease outbreak is detected, identifying the contaminated food quickly is vital to minimize suffering and limit economic losses. Here we present a likelihood-based approach that has the potential to accelerate the time needed to identify possibly contaminated food products, which is based on exploitation of food products sales data and the distribution of foodborne illness case reports. Using a real world food sales data set and artificially generated outbreak scenarios, we show that this method performs very well for contamination scenarios originating from a single “guilty” food product. As it is neither always possible nor necessary to identify the single offending product, the method has been extended such that it can be used as a binary classifier. With this extension it is possible to generate a set of potentially “guilty” products that contains the real outbreak source with very high accuracy. Furthermore we explore the patterns of food distributions that lead to “hard-to-identify” foods, the possibility of identifying these food groups a priori, and the extent to which the likelihood-based method can be used to quantify uncertainty. We find that high spatial correlation of sales data between products may be a useful indicator for “hard-to-identify” products.
Author Summary
Response to foodborne disease outbreaks is complicated by globalization of our food supply chains. Rapid identification of contaminated products is essential to limit the damage caused by foodborne disease. Worldwide, foodborne disease outbreaks are responsible for $9B a year in medical costs and over $75B in economic losses. Yet relevant data required to accelerate the identification of suspicious food already exists as part of the inventory control systems used by retailers and distributors today. Combining this retail data with public health case reports has the potential to hasten outbreak investigations and provide public health investigators with better information on suspected products to test. This paper demonstrates the feasibility of the principle and efficiency of this approach. Based on these findings it can be concluded that in foodborne disease outbreaks retail data could be used to speed and target public health investigations and consequently reduce numbers of sick/dead people as well as reduce economic losses to the industry.
doi:10.1371/journal.pcbi.1003692
PMCID: PMC4080998  PMID: 24992565
23.  Evidence-Based Health Care Policy in Reimbursement Decisions: Lessons from a Series of Six Equivocal Case-Studies 
PLoS ONE  2013;8(10):e78662.
Context
Health care technological evolution through new drugs, implants and other interventions is a key driver of healthcare spending. Policy makers are currently challenged to strengthen the evidence for and cost-effectiveness of reimbursement decisions, while not reducing the capacity for real innovations. This article examines six cases of reimbursement decision making at the national health insurance authority in Belgium, with outcomes that were contested from an evidence-based perspective in scientific or public media.
Methods
In depth interviews with key stakeholders based on the adapted framework of Davies allowed us to identify the relative impact of clinical and health economic evidence; experience, expertise & judgment; financial impact & resources; values, ideology & political beliefs; habit & tradition; lobbyists & pressure groups; pragmatics & contingencies; media attention; and adoption from other payers & countries.
Findings
Evidence was not the sole criterion on which reimbursement decisions were based. Across six equivocal cases numerous other criteria were perceived to influence reimbursement policy. These included other considerations that stakeholders deemed crucial in this area, such as taking into account the cost to the patient, and managing crisis scenarios. However, negative impacts were also reported, in the form of bypassing regular procedures unnecessarily, dominance of an opinion leader, using information selectively, and influential conflicts of interest.
Conclusions
‘Evidence’ and ‘negotiation’ are both essential inputs of reimbursement policy. Yet, purposely selected equivocal cases in Belgium provide a rich source to learn from and to improve the interaction between both. We formulated policy recommendations to reconcile the impact of all factors identified. A more systematic approach to reimburse new care may be one of many instruments to resolve the budgetary crisis in health care in other countries as well, by separating what is truly innovative and value for money from additional ‘waste’.
doi:10.1371/journal.pone.0078662
PMCID: PMC3813690  PMID: 24205290
24.  Medical Supplies Shortages and Burnout among Greek Health Care Workers during Economic Crisis: a Pilot Study 
Greece has been seriously affected by the economic crisis. In 2011 there were reports of 40% reduction to public hospital budgets. Occasional shortages of medical supplies have been reported in mass media. We attempted to pivotally investigate the frequency of medical supplies shortages in two Greek hospital units of the National Health System and to also assess their possible impact on burnout risk of health care workers. We conducted a cross-sectional study (n=303) of health care workers in two Greek hospitals who were present at the workplace during a casually selected working day (morning shift work). The Maslach Burnout Inventory (MBI) was used as the measure of burnout. An additional questionnaire was used about demographics, and working conditions (duration of employment, cumulative night shifts, type of hospital including medical supplies shortages and their impact on quality of healthcare. The prevalence of emotional exhaustion, depersonalization and low personal accomplishment was 44.5%, 43.2% and 51.5%, respectively. Medical supply shortages were significantly associated with emotional exhaustion and depersonalization. This finding provides preliminary evidence that austerity has affected health care in Greece. Moreover, the medical supply shortages in Greek hospitals may reflect the unfolding humanitarian crisis of the country.
doi:10.7150/ijms.7933
PMCID: PMC3970095  PMID: 24688306
medical supplies shortages; burnout; Maslach Burnout Inventory
25.  Communications in Public Health Emergency Preparedness: A Systematic Review of the Literature 
During a public health crisis, public health agencies engage in a variety of public communication efforts to inform the population, encourage the adoption of preventive behaviors, and limit the impact of adverse events. Given the importance of communication to the public in public health emergency preparedness, it is critical to examine the extent to which this field of study has received attention from the scientific community. We conducted a systematic literature review to describe current research in the area of communication to the public in public health emergency preparedness, focusing on the association between sociodemographic and behavioral factors and communication as well as preparedness outcomes. Articles were searched in PubMed and Embase and reviewed by 2 independent reviewers. A total of 131 articles were included for final review. Fifty-three percent of the articles were empirical, of which 74% were population-based studies, and 26% used information environment analysis techniques. None had an experimental study design. Population-based studies were rarely supported by theoretical models and mostly relied on a cross-sectional study design. Consistent results were reported on the association between population socioeconomic factors and public health emergency preparedness communication and preparedness outcomes. Our findings show the need for empirical research to determine what type of communication messages can be effective in achieving preparedness outcomes across various population groups. They suggest that a real-time analysis of the information environment is valuable in knowing what is being communicated to the public and could be used for course correction of public health messages during a crisis.
During a public health crisis, agencies engage in a variety of communication efforts to inform the public, encourage the adoption of preventive behaviors, and limit the impact of adverse events. The authors conducted a systematic literature review to examine the extent to which this field of study has received attention from the scientific community. They describe current research in the area of communication to the public in public health emergency preparedness, focusing on the association between sociodemographic and behavioral factors and communication as well as preparedness outcomes. Their findings show the need for empirical research to determine what type of communication messages can be effective in achieving preparedness outcomes across various population groups.
doi:10.1089/bsp.2013.0038
PMCID: PMC3778998  PMID: 24041193

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