Oxford Department of Sociology |
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My research integrates the sciences of public health with political economy and development economics. Currently I am focusing on three areas of population health and development: 1) Macro-social and -economic determinants of health, 2) Political Economy of Global Health, and 3) Comparative Healthcare Systems.
The first branch of research empirically evaluates the devastating mortality crisis that occurred after the collapse of the Soviet Union. More specifically, the role of economic processes, and their interactions with culture, firms and the state, is analyzed using quasi-experimental approaches; The second branch focuses upon the political economy of global health: understanding the current and changing roles of global institutions, states, NGOs, the private sector, civil society and the interactions among them for control of chronic and infectious diseases. The final branch seeks to model and analyze the effects of market forces on patient decision-making, medical errors, and access to and quality of healthcare.
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Background: Many low- and middle-income countries are not on track to reach the public health targets set out in the Millennium Development Goals (MDGs). We evaluated whether differential progress towards health MDGs was associated with economic development, public health funding (both overall and as percentage of available domestic funds), or health system infrastructure. We also examined the impact of joint epidemics of HIV/AIDS and noncommunicable diseases (NCDs), which may limit the ability of households to address child mortality and increase risks of infectious diseases. Methods and Findings: We calculated each country’s distance from its MDG goals for HIV/AIDS, tuberculosis, and infant and child mortality targets for the year 2005 using the United Nations MDG database for 227 countries from 1990 to the present. We studied the association of economic development (gross domestic product [GDP] per capita in purchasing-powerparity), the relative priority placed on health (health spending as a percentage of GDP), real health spending (health system expenditures in purchasing-power-parity), HIV/AIDS burden (prevalence rates among ages 15–49 y), and NCD burden (agestandardised chronic disease mortality rates), with measures of distance from attainment of health MDGs. To avoid spurious correlations that may exist simply because countries with high disease burdens would be expected to have low MDG progress, and to adjust for potential confounding arising from differences in countries’ initial disease burdens, we analysed the variations in rates of change in MDG progress versus expected rates for each country. While economic development, health priority, health spending, and health infrastructure did not explain more than one-fifth of the differences in progress to health MDGs among countries, burdens of HIV and NCDs explained more than half of between-country inequalities in child mortality progress (R2-infant mortality = 0.57, R2-under 5 mortality = 0.54). HIV/AIDS and NCD burdens were also the strongest correlates of unequal progress towards tuberculosis goals (R2 = 0.57), with NCDs having an effect independent of HIV/AIDS, consistent with micro-level studies of the influence of tobacco and diabetes on tuberculosis risks. Even after correcting for health system variables, initial child mortality, and tuberculosis diseases, we found that lower burdens of HIV/ AIDS and NCDs were associated with much greater progress towards attainment of child mortality and tuberculosis MDGs than were gains in GDP. An estimated 1% lower HIV prevalence or 10% lower mortality rate from NCDs would have a similar impact on progress towards the tuberculosis MDG as an 80% or greater rise in GDP, corresponding to at least a decade of economic growth in low-income countries. Conclusions: Unequal progress in health MDGs in low-income countries appears significantly related to burdens of HIV and NCDs in a population, after correcting for potentially confounding socioeconomic, disease burden, political, and health system variables. The common separation between NCDs, child mortality, and infectious syndromes among development programs may obscure interrelationships of illness affecting those living in poor households—whether economic (e.g., as money spent on tobacco is lost from child health expenditures) or biological (e.g., as diabetes or HIV enhance the risk of tuberculosis). Summary: Tuberculosis incidence appears to be amplified by mineral mining operations in southern Africa. A number of immediately-available measures to improve continuity of care for miners, change recruitment and compensation practices, and reduce the primary risk of infection may critically mitigate the negative association between mineral mining and tuberculosis. Abstract: What will the current economic crisis mean for the health of the people of Northern Ireland? We review the experience of three major economic crises in the 20th century: the Great Depression (1929), the Post-communist Depression (early 1990s) and the East Asian financial crisis (late 1990s). Available evidence suggests that health is at risk in times of rapid economic change, in both booms and busts. However the impact on mortality is exacerbated where people have easy access to the means to harm themselves and is ameliorated by the presence of strong social cohesion and social protection systems. On this basis, Northern Ireland may escape relatively unscathed in the short term but as every crisis also provides an opportunity, this is an appropriate time for the Northern Ireland Executive to reflect on whether they are making a sufficient investment in the long term health of their population. Abstract: In April 2009, the G20 countries committed US$750 billion to the International Monetary Fund (IMF),
which has assumed a central role in global economic management. The IMF provides loans to financially ailing countries,
but with strict conditions, typically involving a mix of privatization, liberalization, and fiscal austerity programs.
These loan conditions have been extremely controversial. In principle, they are designed to help countries balance their books.
In practice, they often translate into reductions in social
spending, including spending on public health and health care delivery. As more countries are being exposed to IMF policies,
there is a need to establish what we know and do not know about the IMF’s effects on global health. This article
introduces a series in which contributors review the evidence on the relationship between the IMF and public health
and discuss potential ways to improve the Fund’s effects on health. While more evidence is
needed for some regions, there is sufficient evidence to indicate that IMF programs have been significantly associated
with weakened health care systems, reduced effectiveness of health-focused development aid, and
impeded efforts to control tobacco, infectious diseases, and child and maternal mortality. Reforms are urgently needed
to prevent the current wave of IMF programs from further undermining public health in financially ailing countries and
limiting progress toward the health Millennium Development Goals.
Abstract: Large increases in food prices have occurred at many times and in many places throughout history. The recent increases differ in their global reach and degree of volatility. Between January 2006 and July 2008 global food prices rose by an average of 75%, causing an estimated 75 million additional people to become undernourished worldwide. We evaluate how several factors have contributed to rising food prices and analyse the potential consequences of these rises for food security and public health. As food prices are predicted to remain high for several years, we discuss policy responses that could help secure an affordable, healthy global food supply. Background: There is widespread concern that the present economic crisis, particularly its effect on unemployment, will adversely affect population health. We investigated how economic changes have affected mortality rates over the past three decades and identified how governments might reduce adverse effects. Methods: We used multivariate regression, correcting for population ageing, past mortality and employment trends, and country-specific differences in health-care infrastructure, to examine associations between changes in employment and mortality, and how associations were modified by different types of government expenditure for 26 European Union (EU) countries between 1970 and 2007. Findings: We noted that every 1% increase in unemployment was associated with a 0·79% rise in suicides at ages younger than 65 years (95% CI 0·16–1·42; 60–550 potential excess deaths [mean 310] EU-wide), although the effect size was non-significant at all ages (0·49%, ?0·04 to 1·02), and with a 0·79% rise in homicides (95% CI 0·06–1·52; 3–80 potential excess deaths [mean 40] EU-wide). By contrast, road-traffic deaths decreased by 1·39% (0·64–2·14; 290–980 potential fewer deaths [mean 630] EU-wide). A more than 3% increase in unemployment had a greater effect on suicides at ages younger than 65 years (4·45%, 95% CI 0·65–8·24; 250–3220 potential excess deaths [mean 1740] EU-wide) and deaths from alcohol abuse (28·0%, 12·30–43·70; 1550–5490 potential excess deaths [mean 3500] EU-wide). We noted no consistent evidence across the EU that all-cause mortality rates increased when unemployment rose, although populations varied substantially in how sensitive mortality was to economic crises, depending partly on differences in social protection. Every US$10 per person increased investment in active labour market programmes reduced the effect of unemployment on suicides by 0·038% (95% CI -0·004 to -0·071). Interpretation: Rises in unemployment are associated with significant short-term increases in premature deaths from intentional violence, while reducing traffic fatalities. Active labour market programmes that keep and reintegrate workers in jobs could mitigate some adverse health effects of economic downturns. Additional Web Appendix Background: During the early-1990s, adult mortality rates rose in most post-communist European countries. Substantial differences across countries and over time remain unexplained. Although previous studies have suggested that the pace of economic transition was a key driver of increased mortality rates, to our knowledge no study has empirically assessed the role of specific components of transition policies. We investigated whether mass privatisation can account for differences in adult mortality rates in such countries. Methods: We used multivariate longitudinal regression to analyse age-standardised mortality rates in working-age men (15–59 years) in post-communist countries of eastern Europe and the former Soviet Union from 1989 to 2002. We defined mass privatisation programmes as transferring at least 25% of large state-owned enterprises to the private sector within 2 years with the use of vouchers and give-aways to firm insiders. To isolate the effect of mass privatisation, we used models to control for price and trade liberalisation, income change, initial country conditions, structural predispositions to higher mortality, and other potential confounders. Findings: Mass privatisation programmes were associated with an increase in short-term adult male mortality rates of 12·8% (95% CI 7·9–17·7; p<0·0001), with similar results for the alternative privatisation indices from the European Bank for Reconstruction and Development (7·8% [95% CI 2·8–13·0]). One mediating factor could be male unemployment rates, which were increased substantially by mass privatisation (56·3% [28·3–84·3]; p<0·0001). Each 1% increase in the percentage of population who were members of at least one social organisation decreased the association of privatisation with mortality by 0·27%; when more than 45% of a population was a member of at least one social organisation, privatisation was no longer significantly associated with increased mortality rates (3·4% [95% CI –5·4 to 12·3]; p=0·44). Interpretation: Rapid mass privatisation as an economic transition strategy was a crucial determinant of differences in adult mortality trends in post-communist countries; the effect of privatisation was reduced if social capital was high. These findings might be relevant to other countries in which similar policies are being considered. Background: Ministers of health, donor agencies, philanthropists, and international agencies will meet at Bamako, Mali, in November, 2008, to review global priorities for health research. These individuals and organisations previously set health priorities for WHO, either through its regular budget or extra-budgetary funds. We asked what insights can be gained as to their priorities from previous decisions within the context of WHO. Methods: We compared the WHO biennial budgetary allocations with the burden of disease from 1994—95 to 2008—09. We obtained data from publicly available WHO sources and examined whether WHO allocations varied with the burden of disease (defined by death and disability-adjusted life years) by comparing two WHO regions—Western Pacific and Africa—that are at differing stages of epidemiological transition. We further assessed whether the allocations differed on the basis of the source of funds (assessed and voluntary contributions) and the mechanism for deciding how funds were spent. Findings: We noted that WHO budget allocations were heavily skewed toward infectious diseases. In 2006—07, WHO allocated 87% of its total budget to infectious diseases, 12% to non-communicable diseases, and less than 1% to injuries and violence. We recorded a similar distribution of funding in Africa, where nearly three-quarters of mortality is from infectious disease, and in Western Pacific, where three-quarters of mortality is from non-communicable disease. In both regions, injuries received only 1% of total resources. The skew towards infectious diseases was substantially greater for the WHO extra-budget, which is allocated by donors and has risen greatly in recent years, than for the WHO regular budget, which is decided on by member states through democratic mechanisms and has been held at zero nominal growth. Interpretation: Decision makers at Bamako should consider the implications of the present misalignment of global health priorities and disease burden for health research worldwide. Funds allocated by external donors substantially differ from those allocated by WHO member states. The meeting at Bamako provides an opportunity to consider how this disparity might be addressed. Additional Web Appendix with sources and details of WHO Budget Data Background: Previous studies have indicated that International Monetary Fund (IMF) economic programs have influenced health-care infrastructure in recipient countries. The post-communist Eastern European and former Soviet Union countries experienced relatively similar political and economic changes over the past two decades, and participated in IMF programs of varying size and duration. We empirically examine how IMF programs related to changes in tuberculosis incidence, prevalence, and mortality rates among these countries. Methods and Findings: We performed multivariate regression of two decades of tuberculosis incidence, prevalence, and mortality data against variables potentially influencing tuberculosis program outcomes in 21 post-communist countries for which comparative data are available. After correcting for confounding variables, as well as potential detection, selection, and ecological biases, we observed that participating in an IMF program was associated with increased tuberculosis incidence, prevalence, and mortality rates by 13.9%, 13.2%, and 16.6%, respectively. Each additional year of participation in an IMF program was associated with increased tuberculosis mortality rates by 4.1%, and each 1% increase in IMF lending was associated with increased tuberculosis mortality rates by 0.9%. On the other hand, we estimated a decrease in tuberculosis mortality rates of 30.7% (95% confidence interval, 18.3% to 49.5%) associated with exiting the IMF programs. IMF lending did not appear to be a response to worsened health outcomes; rather, it appeared to be a precipitant of such outcomes (Granger- and Sims-causality tests), even after controlling for potential political, socioeconomic, demographic, and health-related confounders. In contrast, non-IMF lending programs were connected with decreased tuberculosis mortality rates (-7.6%, 95% confidence interval,-1.0% to -14.1%). The associations observed between tuberculosis mortality and IMF programs were similar to those observed when evaluating the impact of IMF programs on tuberculosis incidence and prevalence. While IMF programs were connected with large reductions in generalized government expenditures, tuberculosis program coverage, and the number of physicians per capita, non-IMF lending programs were not significantly associated with these variables. Conclusions: IMF economic reform programs are associated with significantly worsened tuberculosis incidence, prevalence, and mortality rates in post-communist Eastern European and former Soviet countries, independent of other political, socioeconomic, demographic, and health changes in these countries. Future research should attempt to examine how IMF programs may have related to other non-tuberculosis–related health outcomes. In January, 2009, a new administration will assume power in Washington, DC, USA. Whichever of the current presidential candidates wins, US foreign policy will change direction. One element of this policy will be global health, a subject often characterised by controversy. The debate that will shape the next administration’s approach to global health has begun, including the decision by the US Institute of Medicine to update its 1997 report on US global-health priorities. What principles might inform this debate? Policy makers often reason by metaphors to boil down a set of complex policy tradeoffs into a few consistent strategies and principles. We suggest that there are at least five metaphors that can be applied to global health (table). These are global health as foreign policy, global health as security, global health as charity, global health as investment, and global health as public health... If privatisation ever had a significant impact on health, it would show up in the former Soviet Union. Compare Margaret Thatcher the “Great Privatiser”, who privatised roughly 30 state-owned companies during her 11-year tenure, to Boris Yeltsin’s regime, which under the guidance of Jeffrey Sachs and World Bank economists, privatised over 15 000 large state-owned companies in less than 2 years. Such an episode of privatisation as that seen in Russia during the early- to mid-90s remains unparalleled in both its scale and its scope. Not all former Soviet countries took such a radical approach to privatisation... |
Print:
Rise in TB is linked to loans from IMF, New York Times
Bank crises 'increase heart attacks', Financial Times, pg.3 (UK)
Why market crashes are a health hazard, MacLean's (Canada)
Could IMF loans be causing TB deaths? , Scientific American
Sick borrowing, Slate
Bank crises 'deadly' for health, BBC Online (UK)
IMF loans 'lead to TB deaths', New Scientist
Northern-Rock like crises bring heart attacks, Telegraph (UK)
Bank crises increase rate of heart attacks , Guardian (UK)
Scourge of the IMF, The Huffington Post
Crisis bancarias de infarto, El Mundo (Spain)
Rompen Bancos Corazones, El Porvenir (Spain)
Crisis bancarias podrían ocasionar la muerte de miles de personas, El Comercio (Peru)
Surges in heart attacks correlates with bank failures, SciDev Magazine
Financial Times Special Healthcare & the
Recovery: Painful cuts and trade-offs in prospect
TV:
Taking Money Matters to Heart, CNBC
Primetime Market Watch , CNBC
Curriculum Vitae Publications Web Annex Department of Sociology Christ Church Last Updated, 6th October 2009 |