Barreto, Maurício L.

Universidad Nacional de Lanús: Portal de revistas científicas de la UNLa "Arturo Peña Lillo"

Debate / DebateSaLUD COLeCtIVa. 2018;14(4):681-684. doi: 10.18294/sc.2018.1990681Salud Colectiva | Universidad Nacional de Lanús | ISSN 1669-2381 | EISSN 1851-8265 | doi: 10.18294/sc.2018.1990Austerity comes to Latin America: Lessons from the recent European experience on studying its effects on healthLa austeridad visita a América Latina: Aprendizajes de la reciente experiencia europea sobre el estudio de sus efectos en la saludMaurício L. Barreto1 1MD, PhD in Epidemiology, Senior Investigator, Center for Data and Knowledge Integration for Health, Fiocruz. Professor of Epidemiology, Institute of Collective Health, Universidade Federal da Bahia, Salvador, Bahia, Brazil. *doi: 10.18294/sc.2018.1990Discussion of: Spijker J, Gumà J. The effect of the eco-nomic crisis on health in Spain according to educational level and employment status: Does the duration of the crisis also matter? Salud Colectiva. 2018;14(4):655-670. doi: 10.18294/sc.2018.1297Until 2015, several Latin American coun-tries were in prosperous periods. For over a decade, progressive governments imple-mented social protection and economic de-velopment policies and strengthened the health and education systems, achieving high employment rates and significant increases in minimum wages. Those policies contributed to lessening the immoral social inequalities in these countries,(1) and the health effects were visible.(2) They accelerated positive health trends and were the primary reasons several Latin American countries reached the Millennium Development Goals, albeit behind schedule.(3) Since that time, changes in the political leadership in several Latin American countries resulted in the imple-mentation of policies that go against the people’s interests: plans of the global neo-liberal project. Given the well-consolidated scientific literature on the subject, particularly that based on recent European experiences, the conservative governments that are cur-rently in power and that have implemented austerity policies have triggered worry in the Latin American academic community about the harmful effects, and not improvements, in health.In recent times, the 2008 financial crisis marked the beginning of austerity measures in several European countries. Those mea-sures created a window of opportunity for studying the health effects of austerity, and extensive literature on this subject emerged over the years following the acute crisis pe-riod.(4) Beyond that, though, a vast body of literature exists describing the social determi-nants of health, and has consistently shown relationships between health and social, economic, political, and cultural factors.(5) For various European countries, particularly those with more conservative governments, the acute 2008 crisis was followed imme-diately by the implementation of austerity policies. Those measures created a unique opportunity for studying the health effects of austerity in developed countries, embedded in a complex political context and connected to broader field of research into the social de-terminants of health.Before commenting on such studies, it is necessary to understand that investigating population health determinants, particularly the effect of austerity, is not an easy task, and this could explain, in part, the variability of results reported thus far. While these studies have generally shown harmful health effects, this is not a consistent result across all studies. For instance, in Greece, where radical auster-ity measures have been taken, several stud-ies show harmful effects, but one concludes, “On the basis of the extant evidence, claims of a public health tragedy in Greece seem overly exaggerated.”(6) Spain is another sub-ject of several important studies; one recently estimated that 505,509 more deaths occurred than was expected during the 5-year period following the financial crisis.(7) However, this Barreto ML.SaLUD CoLeCtIVa. 2018;14(4):681-684. doi: 10.18294/sc.2018.1990682Salud Colectiva | Creative Commons Attribution-NonCommercial 4.0 International License | BY - NC result was a clear overestimation of the num-bers as the consequence of a gross method-ological error.(8,9)These studies were performed with the aim of finding the health effects of austerity. Investigators must infer the causal links be-tween the attribute (austerity policies) and the effect (changing health outcomes). Ex-perimental studies cannot be performed to investigate these effects. Therefore, they are typically observational study designs; a few are quasi-experimental.(10) However, it is well known that health is a complex and mul-tidetermined phenomenon  and health out-comes are expressed in muiltidimensional forms that must be measured carefully and with some difficulties. It is challenging to conduct an observational study where a spe-cific determinant (such as austerity policies) must be isolated in the midst of effects from other potential determinants, which must be adequately controlled. Additionally, auster-ity can affect a vast range of health outcomes (such as infant mortality, mental health, sui-cide, self-perceived health) obtained by the use various types of measures (such as mor-tality, morbidity, self-perception), with  data originated from a range of sources (such as registries, surveys, etc.). A significant por-tion of these studies focus on a time trend of the health outcomes after austerity mea-sures were implemented, but very often the studied health outcome presents itself on a background of temporal variations, upward or downward trends that confound associ-ations between an apparent trend and the studied effect. Reviews of empirical studies have contributed to a more realistic and critical account of overall findings as well as to the development of better frameworks regarding how austerity effects health oper-ate.(11,12) A recent review of a large number of studies performed in Europe found that most of those examining the health effects of the European financial crisis had a substan-tial risk of bias; therefore, those study results were to be cautiously interpreted. Some in-dicators appeared to be more sensitive than others, and some outcomes appeared earlier than others.(13)Spijker and Gumà(14) aimed to analyze differences in self-perceived health among participants according to socioeconomic pro-file and position occupied in the household. Self-perceived health was measured using population surveys completed before (2006) and after (2010 and 2014) the 2008 financial crisis. It is a measure that is available across European countries and has been used in sev-eral studies. A review of the studies of auster-ity and health in Europe found that 12 of those published in 2016 used this health outcome measure, and three were performed in Spain. Overall, they found “mixed results depend-ing on the country and group analyzed.”(13) This finding arouses caution when analyzing similar and specific results. Another consid-eration for any health measure is its behavior under various conditions. There is no doubt that self-perceived health is an important measure of individual health and an excel-lent predictor of future health problems and survival. However, it is less clear how sensi-tive it is to changing conditions over time. An important finding of the Spijker and Gumà(14) study was that, among disadvantaged men some time after the implementation of aus-terity measures, perceived health was worse than that among those who were better off. Therefore, inequality in self-perceived health increased as the austerity policies advanced over time.An essential point in this discussion, for Latin Americans, is to learn from recent Eu-ropean experience the best ways to present solid and convincing results about the harm-ful effects of austerity on the health of the Latin American population.(12) For instance, it is worth noting that the literature on Eu-ropean austerity and health is very consis-tent in that increases in certain health events (particularly mental health and suicide) are the first warning signs that austerity poli-cies are taking their toll. However, Brazil that has been under a conservative govern-ment implementing tight austerity measures since 2015, and the health effect recorded almost immediately was an increase in in-fant mortality. This outcome was showing a marked decreasing trend for several years Debate / DebateSaLUD COLeCtIVa. 2018;14(4):681-684. doi: 10.18294/sc.2018.1990683Salud Colectiva | Universidad Nacional de Lanús | ISSN 1669-2381 | EISSN 1851-8265 | doi: 10.18294/sc.2018.1990leading up to 2015, but in 2016, it not only stopped decreasing, but reversed, showing a small increase.(15) The 2017 mortality data is expected to show whether this reversion continued.Strategies and study designs must con-sider a framework that accounts for: a) the very unequal characteristics in Latin Amer-ican countries whereby despite decreas-ing observed trends in the previous period, social inequality rates continue to be very high; b) the presentation of morbidity and mortality patterns mixing poverty-related health problems (e.g., undernutrition, infant mortality, infectious diseases, etc.) and high levels of non-communicable diseases, men-tal health problems and violence; c) the un-derstanding of health as a multidetermined problem as a the background for conceptual-izing the chain of events by which austerity policies can affect the population’s health status  (such as food insecurity, breaks in so-cial protections, and unemployment) or the curative and preventive health services (such as decreasing coverage, increasing barriers to access, etc.).Studying the effects of the present cycle of austerity on health in Latin American coun-tries could be an opportunity to contribute to the existing literature (European in particular) on the topic, delving deeper into investiga-tions of the social determinants of health, but giving it the political flavor of the LA con-text. The most important goal is to produce reliable evidence that austerity measures im-plemented by the Latin American neoliberal governments are not only harmful to the way people live, but make them sicker and cut their lives short.  REFERENCEs1. De La O AL. Crafting policies to end poverty in Latin America: the quiet transformation. New York: Cambridge University Press; 2015.2. Rasella D, Aquino R, Santos CA, Paes-Sousa R, Barreto ML. Effect of a conditional cash transfer programme on childhood mortality: a nationwide analysis of Brazilian municipalities. Lancet. 2013;382(9886):57-64.3. MDG Progress Report of Latin America and the Ca-ribbean in 2015 [Internet]. MDG Monitor; 12 apr 2015 [cited 4 Aug 2018]. Available from: https://tinyurl.com/y8jff648. 4. Stuckler D, Basu S. The body economics: why austerity kills. New York: Basic Books; 2013.5. Marmot M. The health gap: the challenges of an une-qual world. London: Blomsbury; 2015.6. Tapia Granados JA, Rodriguez JM. Health, economic crisis, and austerity: a comparison of Greece, Finland and Iceland. Health Policy. 2015;119(7):941-953.7. Cabrera de León A, Rodríguez IM, Gannar F, Pe-drero García AJ, González DA, Rodríguez Pérez MDC, Brito Díaz B, Alemán Sánchez JJ, Aguirre-Jaime A. Aus-terity policies and mortality in Spain after the finan-cial crisis of 2008. American Journal of Public Health. 2018;108(8):1091-1098.8. Hernández-Quevedo C, Lopez-Valcarcel BG, Porta M. Short-term adverse effects of austerity policies on morta-lity rates: what could their real magnitude be? American Journal of Public Health. 2018;108(8):983-985.9. Salas J. Los 500.000 muertos por la austeridad en Es-paña que no existieron: un error estadístico provoca la publicación de un estudio que asegura que la crisis pro-vocó “más muertes que la Guerra Civil” [Internet]. El Pais; 18 jul 2018 [cited 3 Aug 2018]. Available from: https://tinyurl.com/y74jmeva. 10. Hessel P, Vandoros S, Avendano M. The differential impact of the financial crisis on health in Ireland and Greece: a quasi-experimental approach. Public Health 2014;128(10):911-919. 11. Stuckler D, Reeves A, Loopstra R, Karanikolos M, Mc-Kee M. Austerity and health: the impact in the UK and Eu-rope. European Journal of Public Health. 2017;27(Suppl 4):18-21.12. Schramm JMA, Sousa RP, Villarinho L. Políticas de austeridade e seus impactos na saúde: um debate em tem-pos de crises. Rio de Janeiro: Centro de Estudos Estratégi-cos da Fiocruz, Fiocruz; 2018.13. Parmar D, Stavropoulou C, Ioannidis JP. Health outco-mes during the 2008 financial crisis in Europe: systematic literature review. BMJ. 2016;354:i4588. doi: 10.1136/bmj.i4588.14. Spijke J,  Gumà J. The effect of the economic crisis on health in Spain according to educational level and em-ployment status: Does the duration of the crisis also mat-ter?  Salud Colectiva. 2018;14(4):655-670. doi: 10.18294/sc.2018.1297.15. Crise interrompe a queda da mortalidade infantil, aler-tam especialistas [Internet]. Sociedade Brasileira de Pe-diatria; 14 may 2018 [cited 4 Aug 2018]. Available from: https://tinyurl.com/ydb55mjw.BARRETO ML.SALUD COLECTIVA. 2018;14(4):681-684. doi: 10.18294/sc.2018.1990684Salud Colectiva | Creative Commons Attribution-NonCommercial 4.0 International License | BY - NC CITATIONBarreto ML. Austerity comes to Latin America: Lessons from the recent European experience on studying its effects on health. Salud Colectiva. 2018;14(4):681-684. doi: 10.18294/sc.2018.1990.This article was translated into Spanish by Vanessa Di Cecco with funds from the Subsidy for Scientifi c Publications (No. 1459/17) of the Comission of Scientifi c Research of the province of Buenos Aires.http://dx.doi.org/10.18294/sc.2018.1990This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

La austeridad visita a América Latina: Aprendizajes de la reciente experiencia europea sobre el estudio de sus efectos en la salud

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La austeridad visita a América Latina: Aprendizajes de la reciente experiencia europea sobre el estudio de sus efectos en la salud

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