How Austerity Kills the Public Health System


By DAVID STUCKLER and SANJAY BASU, NYT

EARLY last month, a triple suicide was reported in the seaside town of Civitanova Marche, Italy. A married couple, Anna Maria Sopranzi, 68, and Romeo Dionisi, 62, had been struggling to live on her monthly pension of around 500 euros (about $650), and had fallen behind on rent.

Angus Greig

Because the Italian government’s austerity budget had raised the retirement age, Mr. Dionisi, a former construction worker, became one of Italy’s esodati (exiled ones) — older workers plunged into poverty without a safety net. On April 5, he and his wife left a note on a neighbor’s car asking for forgiveness, then hanged themselves in a storage closet at home. When Ms. Sopranzi’s brother, Giuseppe Sopranzi, 73, heard the news, he drowned himself in the Adriatic.

The correlation between unemployment and suicide has been observed since the 19th century. People looking for work are about twice as likely to end their lives as those who have jobs.

In the United States, the suicide rate, which had slowly risen since 2000, jumped during and after the 2007-9 recession. In a new book, we estimate that 4,750 “excess” suicides — that is, deaths above what pre-existing trends would predict — occurred from 2007 to 2010. Rates of such suicides were significantly greater in the states that experienced the greatest job losses. Deaths from suicide overtook deaths from car crashes in 2009.

If suicides were an unavoidable consequence of economic downturns, this would just be another story about the human toll of the Great Recession. But it isn’t so. Countries that slashed health and social protection budgets, like Greece, Italy and Spain, have seen starkly worse health outcomes than nations like Germany, Iceland and Sweden, which maintained their social safety nets and opted for stimulus over austerity. (Germany preaches the virtues of austerity — for others.)

As scholars of public health and political economy, we have watched aghast as politicians endlessly debate debts and deficits with little regard for the human costs of their decisions. Over the past decade, we mined huge data sets from across the globe to understand how economic shocks — from the Great Depression to the end of the Soviet Union to the Asian financial crisis to the Great Recession — affect our health. What we’ve found is that people do not inevitably get sick or die because the economy has faltered. Fiscal policy, it turns out, can be a matter of life or death.

At one extreme is Greece, which is in the middle of a public health disaster. The national health budget has been cut by 40 percent since 2008, partly to meet deficit-reduction targets set by the so-called troika —  the International Monetary Fund, the European Commission and the European Central Bank — as part of a 2010 austerity package. Some 35,000 doctors, nurses and other health workers have lost their jobs. Hospital admissions have soared after Greeks avoided getting routine and preventive treatment because of long wait times and rising drug costs. Infant mortality rose by 40 percent. New H.I.V. infections more than doubled, a result of rising intravenous drug use — as the budget for needle-exchange programs was cut. After mosquito-spraying programs were slashed in southern Greece, malaria cases were reported in significant numbers for the first time since the early 1970s.

In contrast, Iceland avoided a public health disaster even though it experienced, in 2008, the largest banking crisis in history, relative to the size of its economy. After three main commercial banks failed, total debt soared, unemployment increased ninefold, and the value of its currency, the krona, collapsed. Iceland became the first European country to seek an I.M.F. bailout since 1976. But instead of bailing out the banks and slashing budgets, as the I.M.F. demanded, Iceland’s politicians took a radical step: they put austerity to a vote. In two referendums, in 2010 and 2011, Icelanders voted overwhelmingly to pay off foreign creditors gradually, rather than all at once through austerity. Iceland’s economy has largely recovered, while Greece’s teeters on collapse. No one lost health care coverage or access to medication, even as the price of imported drugs rose. There was no significant increase in suicide. Last year, the first U.N. World Happiness Report ranked Iceland as one of the world’s happiest nations.

Skeptics will point to structural differences between Greece and Iceland. Greece’s membership in the euro zone made currency devaluation impossible, and it had less political room to reject I.M.F. calls for austerity. But the contrast supports our thesis that an economic crisis does not necessarily have to involve a public health crisis.

Somewhere between these extremes is the United States. Initially, the 2009 stimulus package shored up the safety net. But there are warning signs — beyond the higher suicide rate — that health trends are worsening. Prescriptions for antidepressants have soared. Three-quarters of a million people (particularly out-of-work young men) have turned to binge drinking. Over five million Americans lost access to health care in the recession because they lost their jobs (and either could not afford to extend their insurance under the Cobra law or exhausted their eligibility). Preventive medical visits dropped as people delayed medical care and ended up in emergency rooms. (President Obama’s health care law expands coverage, but only gradually.)

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The $85 billion “sequester” that began on March 1 will cut nutrition subsidies for approximately 600,000 pregnant women, newborns and infants by year’s end. Public housing budgets will be cut by nearly $2 billion this year, even while 1.4 million homes are in foreclosure. Even the budget of the Centers for Disease Control and Prevention, the nation’s main defense against epidemics like last year’s fungal meningitis outbreak, is being cut, by at least $18 million.

To test our hypothesis that austerity is deadly, we’ve analyzed data from other regions and eras. After the Soviet Union dissolved, in 1991, Russia’s economy collapsed. Poverty soared and life expectancy dropped, particularly among young, working-age men. But this did not occur everywhere in the former Soviet sphere. Russia, Kazakhstan and the Baltic States (Estonia, Latvia and Lithuania) — which adopted economic “shock therapy” programs advocated by economists like Jeffrey D. Sachs and Lawrence H. Summers — experienced the worst rises in suicides, heart attacks and alcohol-related deaths.

Countries like Belarus, Poland and Slovenia took a different, gradualist approach, advocated by economists like Joseph E. Stiglitz and the former Soviet leader Mikhail S. Gorbachev. These countries privatized their state-controlled economies in stages and saw much better health outcomes than nearby countries that opted for mass privatizations and layoffs, which caused severe economic and social disruptions.

Like the fall of the Soviet Union, the 1997 Asian financial crisis offers case studies — in effect, a natural experiment — worth examining. Thailand and Indonesia, which submitted to harsh austerity plans imposed by the I.M.F., experienced mass hunger and sharp increases in deaths from infectious disease, while Malaysia, which resisted the I.M.F.’s advice, maintained the health of its citizens. In 2012, the I.M.F. formally apologized for its handling of the crisis, estimating that the damage from its recommendations may have been three times greater than previously assumed.

America’s experience of the Depression is also instructive. During the Depression, mortality rates in the United States fell by about 10 percent. The suicide rate actually soared between 1929, when the stock market crashed, and 1932, when Franklin D. Roosevelt was elected president. But the increase in suicides was more than offset by the “epidemiological transition” — improvements in hygiene that reduced deaths from infectious diseases like tuberculosis, pneumonia and influenza — and by a sharp drop in fatal traffic accidents, as Americans could not afford to drive. Comparing historical data across states, we estimate that every $100 in New Deal spending per capita was associated with a decline in pneumonia deaths of 18 per 100,000 people; a reduction in infant deaths of 18 per 1,000 live births; and a drop in suicides of 4 per 100,000 people.

OUR research suggests that investing $1 in public health programs can yield as much as $3 in economic growth. Public health investment not only saves lives in a recession, but can help spur economic recovery. These findings suggest that three principles should guide responses to economic crises.

First, do no harm: if austerity were tested like a medication in a clinical trial, it would have been stopped long ago, given its deadly side effects. Each nation should establish a nonpartisan, independent Office of Health Responsibility, staffed by epidemiologists and economists, to evaluate the health effects of fiscal and monetary policies.

Second, treat joblessness like the pandemic it is. Unemployment is a leading cause of depression, anxiety, alcoholism and suicidal thinking. Politicians in Finland and Sweden helped prevent depression and suicides during recessions by investing in “active labor-market programs” that targeted the newly unemployed and helped them find jobs quickly, with net economic benefits.

Finally, expand investments in public health when times are bad. The cliché that an ounce of prevention is worth a pound of cure happens to be true. It is far more expensive to control an epidemic than to prevent one. New York City spent $1 billion in the mid-1990s to control an outbreak of drug-resistant tuberculosis. The drug-resistant strain resulted from the city’s failure to ensure that low-income tuberculosis patients completed their regimen of inexpensive generic medications.

One need not be an economic ideologue — we certainly aren’t — to recognize that the price of austerity can be calculated in human lives. We are not exonerating poor policy decisions of the past or calling for universal debt forgiveness. It’s up to policy makers in America and Europe to figure out the right mix of fiscal and monetary policy. What we have found is that austerity — severe, immediate, indiscriminate cuts to social and health spending — is not only self-defeating, but fatal.

America: Where It’s Easier to Get a Gun Than Good Mental Health Care


Gun violence is up. Access to good mental healthcare is down. What, exactly, are our priorities?

June 10, 2012  |

Photo Credit: Tony Webster

Last spring my younger sister Kathy jumped off a freeway bridge in Phoenix. For better or worse, she lived. Kathy made her first suicide gesture in high school, when she took a handful of, I think, aspirin in reaction to a bad haircut. At the time, she was already, obviously, mentally ill. In middle school, anorexia had drawn her down to a skeletal 38 pounds. Her hair fell out. Her sunken face took on a plastic texture from fat-soluble vitamins that her body couldn’t process. Force-feeding brought her back from the brink, but couldn’t heal her. In the years since, even during three pregnancies, she has never topped 100 pounds, nor has she ever been free of compulsions, body-loathing or debilitating bouts of depression.

Since that first handful of analgesics, Kathy has made an effort to die somewhere between 12 and 15 times: prescription pills, threatened jumps from an apartment balcony and a communications tower, an attempt at drowning, a car set on fire. Kathy is alive because even in the heart of Arizona’s Wild West no one will sell her a gun; a fact she finds immensely frustrating at times that her bipolar illness takes her into another trough of despair.

For three days, Seattle has been reeling, grieving a wave of senseless violence that left five dead, including a shooter who was, from his family’s description, bipolar like my sister. Mentally ill women are most likely to exit this world alone or try to take their children with them. Some men prefer to go out in a blaze of rage and blood. Either way, access to a gun makes the impulse more lethal. Firearms are two and a half times more effective than the next method of suicide, suffocation. According to Centers for Disease Control statistics for 2003-2007, gunshots represented only 3 percent of suicide attempts, but almost half of fatalities. So far this year, over 40,000 people in the U.S. have been shot. By December 31, we can expect to bury about 9,500, each dead at the hands of someone pulling a trigger. Guns were designed to be effective, efficient killing machines, and they work very well.

When someone kills – we ask why? It’s a worthy question. A part of the answer that haunts me (because it seems so preventable) is the way we choose as a society to prioritize our resources. We build for-profit prisons across the country, with lock-up room for minor drug offenders. But while prisons are growing, prevention and treatment services are disappearing.

As a psychologist, I used to have an outpatient mental health practice in Seattle. By the time I quit, it was almost impossible to get public mental health services for a person who hadn’t been diagnosed with a chronic mental illness or acute intent to harm. I told one desperate and suicidal young woman with no health insurance that she could get inpatient treatment if she was willing to go in front of a judge and swear that she intended to hurt herself or someone else. She disappeared, and I didn’t know for weeks if she was still alive. Relentless cuts in funding and services over the last 20 years mean that psychiatrists, psychologists and caseworkers are under constant pressure to pretend someone is more intact than they actually are.

The state of Arizona spent close to a million dollars last year putting Kathy back together after she fell 49 feet. By contrast, they spent a pittance, a few thousand on follow-up mental health assessment and treatment. Kathy’s car-on-fire incident was triggered by her SSI and Medicare being cut off because she had earned a couple hundred extra dollars working at Target over the holidays. Desperate to cut costs, the Social Security administrators decided that she wasn’t actually disabled–this is despite the fact that she has repeatedly ended up in restraints at state and county hospitals.

But even the best mental health treatment in the world won’t prevent some people from just losing it. There are going to be people who want to die. There are going to be people who want to kill. Most of the time the impulse passes. Whether someone dies before it does depends largely on the tools at hand.

I once traveled with a handful of young adventurers and a couple of fishermen in an open skiff from southern Belize to Honduras. In the middle of the night, we stopped on a small offshore island for hot drinks. There we were greeted by a wiry black man in his 60s. A deep scar ran across his face, from cheekbone to chin. Another deformed one arm. He was missing digits. He told us that as a young man he had been attacked with a machete.

I was fascinated and horrified by his graphic story, and one thought embedded itself permanently in my mind: It takes a lot of effort to kill someone with a machete. But with a gun, it takes very little.

Valerie Tarico is a psychologist and writer in Seattle, Washington and the founder of Wisdom Commons. She is the author of “Trusting Doubt: A Former Evangelical Looks at Old Beliefs in a New Light” and “Deas and Other Imaginings.” Her articles can be found at Awaypoint.Wordpress.com.

 

How bacteria behind serious childhood disease evolve to evade vaccines


London, Jan 30 (ANI): The study of genetics has provided surprising insights into why vaccines used in both the UK and US to combat serious childhood infections can eventually fail.

The study, which investigates how bacteria change their disguise to evade the vaccines, has implications for how future vaccines can be made more effective.

Pneumococcus (Streptococcus pneumoniae) causes potentially life-threatening diseases including pneumonia and meningitis. Pneumococcal infections are thought to kill around a million young children worldwide each year, though the success of vaccination programmes has led to a dramatic fall in the number of cases in countries such as the UK and US.

These vaccines recognise the bacteria by its polysaccharide, the material found on the outside of the bacterial cell. There are over ninety different kinds or ‘serotypes’ of the bacteria, each with a different polysaccharide coating.

In 2000, the US introduced a pneumococcal vaccine, which targeted seven of the ninety serotypes. This ’7-valent’ vaccine was extremely effective and had a dramatic effect on reducing disease amongst the age groups targeted.

Remarkably, the vaccine has also prevented transmission from young children to adults, resulting in tens of thousands fewer cases of pneumococcal disease each year. The same vaccine was introduced in the UK in 2006 and was similarly successful.

In spite of the success of the vaccine programmes, some pneumococcal strains managed to continue to cause disease by camouflaging themselves from the vaccine.

In research funded by the Wellcome Trust, scientists at the University of Oxford and at the Centers for Disease Control and Prevention in Atlanta studied what happened after the introduction of this vaccine in the US.

They used the latest genomic techniques combined with epidemiology to understand how different serotypes of the pneumococcus bacteria evolve to replace those targeted by the initial vaccine.

The researchers found bacteria that had evaded the vaccine by swapping the region of the genome responsible for making the polysaccharide coating with the same region from a different serotype, not targeted by the vaccine.

This effectively disguised the bacteria, making it invisible to the vaccine. This exchange of genome regions occurred during a process known as recombination, whereby one of the bacteria replaces a piece of its own DNA with a piece from another bacterial type.

“Imagine that each strain of the pneumococcus bacteria is a class of schoolchildren, all wearing the school uniform. If a boy steals from his corner shop, a policeman – in this case the vaccine – can easily identify which school he belongs to by looking at his uniform. But if the boy swaps his sweater with a friend from another school, the policemen will no longer be able to recognise him and he can escape. This is how the pneumococcus bacteria evade detection by the vaccine,” Rory Bowden, from the University of Oxford, said.

Bowden and his colleagues identified a number of recombined serotypes that had managed to evade the vaccine. One in particular grew in frequency and spread across the US from east to west over several years.

They also showed that during recombination, the bacteria also traded a number of other parts of the genome at the same time, a phenomenon never before observed in natural populations of pneumococcus.

This is of particular concern as recombination involving multiple fragments of DNA allows rapid simultaneous exchange of key regions of the genome within the bug, potentially allowing it to quickly develop antibiotic resistance.

The original 7-valent vaccine in the US has now been replaced by a 13-valent vaccine, which targets thirteen different serotypes, including the particular type which had escaped the original vaccine. In the UK, the 7-valent vaccine resulted in a substantial drop in disease overall.

This overall effect was a mixture of a large drop in frequency of the serotypes targeted by the vaccine with some growth in serotypes not targeted by the vaccine. The 13-valent vaccine was introduced in the UK in 2010.

“Childhood vaccines are very effective at reducing disease and death at a stage in our lives when we are susceptible to serious infections. Understanding what makes a vaccine successful and what can cause it to fail is important. We should now be able to understand better what happens when a pneumococcal vaccine is introduced into a new population. Our work suggests that current strategies for developing new vaccines are largely effective but may not have long term effects that are as successful as hoped,” Derrick Crook, Professor of Microbiology at the University of Oxford and Infection Control Doctor at the Oxford University Hospitals NHS Trust, said.

The study has been recently published in Nature Genetics.

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