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BMJ Is Collaborating With JSTOR To Digitize, Preserve and Extend Access To BMJ: British Medical Journal
BMJ Is Collaborating With JSTOR To Digitize, Preserve and Extend Access To BMJ: British Medical Journal
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_ANALYSIS
Response on bmj.com
"Programmesmust... be designed to prevent furthernegative social problems,or financialrisk.The programmesmust
clearlybenefit the people of the country.There should be no partialityamong citizens,whether employed or unemployed."
Monique JGrant-Coke,nursingprogramcoordinatorand assistant professor,Jamaica
O To submita rapid response,go to any articleon bmj.comand select "Respond to thisarticle"
social
and
health,
crises,
Budget
welfare
programmes
Governments
health
mayfeeltheyareprotecting
bysafeguarding
healthcare
yetDavid Stuckler,Sanjay Basu,
budgets,
3
andMartinMcKee arguethatsocialwelfarespendingisas
ifnotmoreso,forpopulation
health
important
The recessionof2008 has had profoundeconomic
consequences
formany
countries. How
and when
The new
government
has already
begun
expenditure
but by many
factors out
recently
1100
5 ? Hungary
1000
es,ovakia
fi
E Q.
- ? Poland
900
?
Czech
Republic
800.lre,and ?
Denmark
*
Portugal? United
Kingdom Finland
700
Luxembourg
Greece^ Irlands*
.?
fi
.? . ?
Germany
^
- Austna
A
*5
even
tomake largecuts inpublic expenditure,12
receive better education, have safe environments in
thoughtheUK's projectedunderlyingdebt, as a
1000
2000
4000
3000
5000
6000
shareofgrossdomesticproduct(GDP),is less than which toplay,andwho liveingood qualityhous
Social
more
are
to
than
it
has
those
per
power
thatofotherindustrialised
spending
capita
(purchasing
parity)
countries,
longer ing
likely growup healthy
thanmany othercountriesbeforeitis requiredto who do not. Adults in secure and safe employment,
Fig 11 Relation between social welfare spending and
refinanceloans (table1), and theactual deficitin receiving
wages above thelevelneededmerely to all cause mortality in 18 EU countries, 2000
are less likelytoadopthazardous lifestyles
less than expected.
2009-10 was considerably
survive,
orunhealthy
15 European Union countries forwhich compara
diets)and
drinking,
Leading economistshavewidely divergentviews (suchas smoking,
tivedata are available over thepast threedecades
aboutwhetherthecutswill aid orhindereconomic can expect to live longer.
4
of
this
evidence
for
the
to
Yet
the
wel
scant
the
attention
but
have
(Austria, Belgium,
Denmark,
France,
Finland,
implications
paid
recovery,3
of reductionsinhealthand social farestateare contested.Do theyimplytheneed for Germany, Greece, Ireland, Italy, Luxembourg, Neth
potentialeffects
a well functioning
on population
welfare statethatcan support erlands,Portugal,Spain, Sweden, and theUnited
health.5 We examine
expenditure
historicaldata forinsightsintohow lowerlevels people at all stagesof theirlives,activelyseeking Kingdom).10This covers 1980-2005, although
topromote
health.
ofpublic spendingmightaffect
wellbeing forall?Or is thewelfarestate mortalitydata forBelgiumwere available up to
out individualinitiative onlyl998.n
of
the
part
problem,driving
toproducea cultureofdependency
as
TheOECD definessocialwelfareexpenditure
and creativity
Wider view offhealth spending
What little
discussion therehas been abouthealth thatstiflestheemergenceofan improvedsociety? "theprovisionbypublic (andprivate)institutions
viewshave led toa politicaldebate ofbenefitsto,and financialcontributions
Thesedivergent
in the current economic
recession has focused
targeted
onwhether toringfenceNHS spending.6This isa
characterised
at,households and individualsinordertoprovide
by, on the one hand, calls for ever
narrow perspective
supportduring circumstanceswhich adversely
greater "efficiency savings,"8 which is increasingly
given the extensive evidence
seen as a euphemism
Country
Deficitas
% ofGDP
Gross debt
as a % of
GDP
Germany
US
-5.7_7215_6S)_
-11.0
83.2
France
-8.2
77.4
UK
-11.4
68.2~
Greece
Japan
Italy_-5.2
Portugal
-8.1_115.1
-9.8
insecurity.9
6.5_
12.8_
7.4_
_5.2
6.7
_
_6J_
This
includes
spending
education,
or
care, housing
dies), unemployment
217.7
Average maturity
ofgovernment
debt (years)
4.4
115.8
-8.8_77
forbudget
to pro
other, calls for "stronger social safety nets...
tect themost vulnerable in rich and poor countries"
orhelp the
What do the data show?
programmes(tomaintainemployment
One way to informthisdebate is to examine unemployedobtain jobs),and supportforpeople
All of thesecould plausibly
whether thereisa historicalassociationbetween with disabilities.71213
levelsof social spendingand population health affecthealth.Although theOECD has developed
data on social welfare
outcomes. We evaluated
standardiseddefinitions
and harmoniseddata col
across countries,
the
for
Eco
collected
lection to ensure comparability
Organisation
by
spending
nomic Cooperationand Development (OECD),10 we adjusted thedata furtherto takeaccount of
with age standardisedall cause mortalityin the purchasingpowerparityand inflation.Figure 1
77
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All use subject to JSTOR Terms and Conditions
ANALYSIS_
Table 31 Effect of $100 of income, social welfare spending, and healthcare spending on cause specific
(purchasing power parity in$ for2000)
mortality in 15 EU countries, 1980-2005
-4000
4000
2000
-2000
Deviationfrom
averagespendingon socialwelfarepercapita
country
Fig 21 Relation between deviation fromcountry
health)
averageofsocialwelfarespending(excluding
and all cause mortality in15 EU countries,1980-2005.
Each point represents a single country year value.
powerparity
2000) adjustedforpurchasing
Alcohol
related
Malignant
neoplasms
-0.21%
-0.034%
All cause
Covariate
Cardiovascular
disease
Suicide
Tuberculosis
$100 in incomepercepita
-0.14%**
(0.035)
(0.12)
(0.034)
(0.084)
(0.20)
(0.14)
-0.99%***
-2.80%***
-0.065%
-1.23%**
-0.62%
-4.34%**
(0.11)
(0.46)
(0.18)
(0.31)
(0.49)
(1.27)
-0.01%
0.97%
-0.82%
-0.28%
-3.15%
2.11%
(0.43)
(0.90)
(0.47)
(0.95)
(1.50)
(2.32)
No of country-years
320
319
319
0.773
0.535
0.239
0.716
R2
0.906
-0.31%**
0.19%
-0.59%***
319
319
318
0.901
a clear association
between
in 2000
and mortality
social welfare
across
EU coun
0.11%,
social welfare
overall are associated
spending
dummyvariables),reporting
(byincludingcountry
with reducedmortality fromthese conditions,
betweensocial Comparing social spending with healthcare
estimatesof thelongtermrelations
Given spending
theeffectisdue tospendingon areas other than
spendingand healthwithin each country.
health. Futureresearchshould lookat theeffect
ofdifferencesinsocial We recognise that correlation may not mean
thatthetiming
of theeffect
ofdifferent
typesof social spending(employment
spendingisuncertain,themethodwe used enabled causation; we also need to consider multicolin
us toaccount foranypotential laggedeffects(up earity(multiplevariables thathappen tochange versus housing for example). For now, this result
mean countryspecific together)and thepotential forundetected con
indicatesthatsome aspects ofpopulationhealth
toa decade) by estimating
our
are
more sensitive, in the short term, to spending
to
constrains
isolate
the
to
that
health.14
social
Figure founding
ability
spending
slopes relating
on
on
welfare
health.
in
of
each
social
social support thanon health care,although
effects
which
in
each
2,
country
spending public
point represents
Oneway toscreenforthisproblem isby compar a caveat is necessary as these countries have not
each year, shows a clear association between social
would not experienced changes inhealthcare fundingof
welfare spending and all cause mortalityafter ingmortalityfromcauseswhere there
adjustmentforany countryspecificfactors.Ifno plausiblybe a shorttermrelationbetweenhealth thescale thatmightbe expected toaffecthealth.
the maintenance
of social welfare
Nevertheless,
countrydeviated fromtheaverage socialwelfare and social spending, such as most cancers, with
we
zero.
a
diseases
where
would
seems
from
at
to
be
of
would
cluster
all
expect programmes
mortality
key determinant
points
spending,
to see changeswith spending, such as alcohol
be
future
health
that
should
taken
into
Themodels constructedshow thateach addi
population
account in ongoing economic debates.
tional$100 increase in socialwelfare spending relateddeaths. Our findingsare in linewith pre
has been associatedwitha 1.19% drop inall cause dictions(table3) supportingtheidea thatourfind
were spe
ourfindings
Implicationsforpublic health practice
ingsare not simplydue tomulticolinearity.
mortality(table2). Crucially,
In thecurrentdebate on spending cuts in the The delivery of public services in the UK is
cifictosocialwelfarespending(as definedabove);
there was no observable
UK, inwhich some politicianshave promised to recognised to be impeded by pervasive silo
protective effect associ
is
which
atedwith generalgovernment
spending,
understandable
or similar
could produce
an artefactual
association
Table 21 Effect of $100 of income, social welfare, and general government spending on all cause mortality for
15 EUcountries,
1980-2005(purchasing
powerparityin$ for2000)
Social welfare
Covariate
spending
$100 rise insocial welfare
spending (includinghealth care)
we
also
found
that a comparable
rise
over a sevenfold
greater
reduction
inmortality
-1.19%* (0.068)
-
320
R2
0.865
_Statisticalmodel_
Incomeand general
governmentspending
-0.80%*
(0.098)
Income
-0.28%*
- -0.27%
(0.041)
-0.24%* (0.050)
(0.15)
-0.11%* (0.025)
258
320
320
0.792
0.787
0.900
78
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All use subject to JSTOR Terms and Conditions
_ANALYSIS
of this fail
the consequences
cases,
were missed
problems
between
poor communication
because
several
of
agencies.
needs.
for complex
package
There
is
this problem,
each
encouraging
organisa
and
concentrating
One
Place
for
considerable
attracting
example
is the Total
attention
avenues
positive
programme,
together.
count
three elements:
Ithas
involved
The agencies
users).
primary
and welfare
employment
regional
also
included
and fire
agencies,
Some
organisations.
development
the non-governmental
sec
government
institutional
smaller
local
agencies
boundaries.20
initiatives
can work
across
across
sectors,
awards.21
3
4
5
6
7
8
12
13
14
15
17
18
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Is chronic
kidneydisease
bad medicine?
This week we publish several
letters in response
toa recent
BMJcolumnarguingthatchronic
disease (CKD)isa condition
witha
kidney
medicalised10% ofthepopulation.
Meanwhile,
discussionisthrivingon
doc2doc,BMJ
Group's
global online clinical community.
PieterKubben:"Manythingsfor
whichwe
used to say 'We don't know what
it is, so you'll
have to livewith it,'now require a 'label'
Industry interestmay be both a cause and a
consequence.
Attention-deficit/hyperactivity
disorder is another good example."
Tauseef Mehrali:
encounters
withpatientsfumingthat
nobody
toldthemtheyhad stagetwokidney
disease
forthemselves.
What's thefirst
of
thingIthink
when Ithink'renal
medicine'?Anotherspecialty
adulterated
willeventually
getCKD iftheyarenotgiven
orsubjectedtoexpensive
antibiotics
lifelong
studiessuggestthisis
monitoring.
Onlyrecent
not true."
Dr AGS: "Iwould
like to 'un-diagnose'
all people
ridiculous of
all istheeffect
incookedmeat has
Creatinine
on the estimated glomerularfiltration
rate.My
labelling; it is a
condition that affects many future treatment
decisions
of differentmedical
conditions."
a number of pendingtests.
Moreover,
the
have todealwithhigher
bloodpressure,higher
glycated hemoglobin,
high as before."
atbeat:"Iam a nephrologist
butmyopinion
"I rejecttheideaofCKDbeing
M.B.Ibrahim:
is scarce
bad medicine.True
evidence
branch ofmedicine
341 79
BMJ
110JULY
20101VOLUME
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inevery