Lancet Series examines the state of health in Europe

March 26th, 2013
Seven Series papers, led by Professor Martin McKee of the London School of Hygiene & Tropical Medicine, cover a diverse range of subjects, from how the financial crisis is affecting health in Europe, to whether children's health services are keeping pace with the changing landscape of child health.

Disparity between male life expectancy in eastern and western Europe now greater than 40 years ago

The first Series paper highlights successes and failures of health policy in Europe over the past 40 years, showing that political divisions of the 20th century remain apparent today in patterns of health in the region. While life expectancy in Western Europe has improved almost continuously during this period, progress in Eastern Europe has been erratic, with the disparity in male life expectancy between the two regions now greater than it was 40 years ago. In the former Soviet Union, poor economic progress, combined with failure to stem rising levels of infectious disease – particularly HIV / AIDS and tuberculosis (TB) – as well as dangerous alcohol and tobacco use in these countries, has contributed to life expectancies in this region lagging far behind western Europe, with the gap at 12 years for men, and 8 years for women. Although more successful public health policies in western Europe have contributed to fewer deaths from causes such as cardiovascular disease and road traffic accidents, there is no room for complacency – striking disparities in health still exist between different socioeconomic groups within countries, and the authors point out noteworthy failures in public health policy such as delays in acting on tobacco in Germany, Denmark, and Austria.

Public health efforts at risk of disruption and deregulation from EU law

The EU's formal legal responsibilities in health and health services might, at first glance, appear to be fairly limited in scope, but the second Series paper shows that the influence of EU law on health is often underestimated, and that EU law can sometimes be disruptive towards public health policies. Tensions between the EU's legal commitment to a free market and individual countries' efforts to manage public health effectively are of particular concern, with legislation governing the movement and trade of substances such as food, tobacco, and alcohol subject to strong influence from industry and a marked "pro-business" stance from EU lawmakers. According to the authors, "EU public health policies tend to combine actions that industry can tolerate, a great deal of talk and capacity building of NGOs, and disappointment for public health advocates who are aware of how much EU power goes unused."

Countries of the former Soviet Union face health crisis

Several countries in the Commonwealth of Independent States (CIS) of the former Soviet Union [1] have yet to recover the levels of health noted before the dissolution of the Soviet Union in 1991, and mortality rates in the CIS remain far in excess of those in Western Europe. Urgent action needs to be taken to improve public health in these regions, say the authors of the third Series paper, and health systems need to become less fragmented, more efficient, and the replacement of outdated treatment methods with modern evidence-based clinical practice accelerated. Hazardous drinking in these countries is thought to cause between 4 and 6 out of every 10 deaths in working age men, and a third of deaths in women of the same age, yet governments have largely failed to tackle the production and distribution of cheap alcohol, and where public health policies have been implemented (for example, in Russia), the authors say they have been marked by little ambition, poor engagement and excessive industry influence. Likewise, the accumulated burden of tobacco-related disease in men under 75 in the CIS is the highest in the world, and although public health efforts are improving, these will need to be accelerated if the gap in life expectancy between these regions and western Europe is to be narrowed.

[1] Azerbaijan, Armenia, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Russia, Tajikistan, Turkmenistan, Uzbekistan, and Ukraine

6000 children's lives could be saved annually with "achievable" improvements in child health services

Children's health services in Europe are not keeping pace with changing patterns in child health, say the authors of the fourth Series paper. While child survival has improved greatly in the last 30 years across the first 15 members of the European Union (EU15) [2], 6000 children's lives could be saved annually if all of the EU15 countries could match the performance of Sweden, the EU15 country with the lowest child mortality rates. This is an entirely achievable goal, say the authors, but will depend on child health services adapting to new challenges in child health, where non-communicable diseases such as asthma, musculoskeletal disorders, and neuropsychiatric disorders such as depression are increasingly common causes of disability and death in children. The broad consensus that many non-acute health services should be delivered in the community has not been acted on by most countries in the EU15, and the authors also highlight a worrying lack of specialist training in some countries – in the UK, a GP might receive no specific paediatric training beyond undergraduate level.

The authors also point out that the extent of child poverty and inequality in Europe – which directly affects health, not just in childhood but throughout life – is not always realised. For instance, in Sweden, just 1.3% of children live in deprived circumstances, whereas in Portugal, more than a quarter (27.4%) of children are thought to live in households that cannot afford to eat three meals a day. According to the authors, "Policy makers often seem reluctant to translate into policies the increasing evidence showing that the foundations of life-long health are built through greater investments in the early years of life…Until national and European governing bodies are willing to accept this challenge, the outlook for child health in Europe will remain uncertain."

[2] EU15 countries are Austria, Belgium, Denmark, Finland, France, Germany, Greece, Ireland, Italy, Luxembourg, Netherlands, Portugal, Spain, Sweden, and United Kingdom.

Migrant health threatened as progressive health policies disappear

The fifth Series paper examines the challenges of improving migrant health in Europe, where the proportion of migrant populations is growing. Immigration is politically controversial – even in countries such as Denmark, the Netherlands, and the UK, which have some of the lowest proportions of immigrants in Europe – but the authors suggest that the need for continued immigration into Europe, chiefly to address a shortfall in the working-age population in an ageing European society, is poorly recognised. Monitoring migrant health is extremely challenging, due to inconsistent, patchy data, and the diverse origins of the people who migrate to or within Europe. However, while research suggests that migrants generally arrive in a country in an above-average standard of health, they face a number of challenges in accessing health care, including language barriers, lack of awareness of services, and poverty. The problems faced by asylum seekers and undocumented migrants are particularly acute; in 2010, only five EU states offered this group access to any health care beyond emergency services, and nine EU countries effectively barred this group from access to any health care, including emergency services. Some countries, such as Spain, which formerly adopted progressive and inclusive policies for providing health care to migrants, have recently withdrawn these services, citing financial pressure engendered by the ongoing economic crisis. According to the authors, "Migrants, like everyone else, have a right to the highest attainable standards of physical and mental health. Yet even those rights enshrined in international conventions all too often remain confined to paper, because commitment to implementation is weak."

"Alarmist" concerns about ageing European society must not be used to justify welfare cuts

While Europe is undoubtedly an ageing population, with twice as many people over 65 than those under 15 expected by 2060, an ageing society does not present a fundamental threat to the European state, and must not be used as part of a political agenda to cut back on the welfare state, say the authors of the sixth Series paper. Projected increases in health expenditure due to ageing have been exaggerated, whereas other factors, such as technological developments, have a much larger effect on aggregate health care costs. Despite this, health systems in Europe will clearly need to adapt to an ageing population, and the authors suggest a number of ways in which health systems can become more "age-friendly", including improving coordination of care, addressing the ageing health workforce, and enabling older people to care for themselves for longer. The authors also point out that an ageing European population is likely to result in changing pension policies, and given established effects of the social determinants of health, radical new pension policies – such as differentiation of retirement age by socioeconomic group – might be "appropriate and even inevitable".

Public health voices must break their silence to combat ill effects of financial crisis on health

The effects of economic turbulence on health are poorly understood, despite having been researched for nearly 100 years, and while some studies have suggested that there may be some health benefits to a slowing economy, it appears that some adverse effects of the current financial crisis on public health in Europe are already becoming visible, for example through increased rates of suicide and mental health problems in countries affected by the crisis. In the final Series paper, the authors warn that strong social protection mechanisms are needed to mitigate these effects, yet austerity measures are already leading to a weakening of social protection in some countries, through reduced state funding and the threat of prescriptive EU-mandated health spending policies in countries which have undergone the most severe financial shocks.

According to the authors, "Policy decisions about how to respond to economic crises have pronounced and unintended effects on public health, yet public health voices have remained largely silent during the economic crisis…The Directorate-General for Health and Consumer Protection of the European Commission, despite its legal obligation to assess the health effects of EU policies, has not assessed the effects of the troika's drive for austerity, and has instead limited EU commentary to advice about how health ministries can cut their budgets. A small source of optimism is that European civil society organisations, including professional bodies, have spoken out about the adverse health effects of cuts to health and social spending. The question is whether anyone will listen."

Martin McKee, Professor of European Public Health at the London School of Hygiene & Tropical Medicine, said: "Europe has changed greatly in the past 40 years, and the immense differences in health care and life expectancy highlight this. While some countries have excelled, others have withdrawn services due to the financial crisis, failed to adapt to new health challenges, and lacked the will to implement public health policies around tobacco and alcohol. Policy makers must act now before children, migrants, and older people face a public health crisis, both in the UK and across Europe."*

According to a Lancet Comment accompanying the Series, "Europe is diverse in culture, attitudes, and historical roots and is perhaps becoming more so with changing national identities and increased migration. This diversity should be welcomed. What we should not tolerate is diversity in access to health and preventive care services, and in health outcomes."

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