Until 2015, several Latin American countries were in prosperous periods. For over a decade, progressive governments implemented social protection and economic development 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,¹1. De La O AL. Crafting policies to end poverty in Latin America: the quiet transformation. New York: Cambridge University Press; 2015. and the health effects were visible.²2. 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. They accelerated positive health trends and were the primary reasons several Latin American countries reached the Millennium Development Goals, albeit behind schedule.³3. MDG Progress Report of Latin America and the Caribbean in 2015 [Internet]. MDG Monitor; 12 abr 2015 [citado 04 ago 2018]. Disponible en: Disponible en: https://tinyurl.com/y8jff648 .
https://tinyurl.com/y8jff648... Since that time, changes in the political leadership in several Latin American countries resulted in the implementation of policies that go against the people’s interests: plans of the global neoliberal project. Given the well-consolidated scientific literature on the subject, particularly that based on recent European experiences, the conservative governments that are currently 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 measures 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 period.⁴4. Stuckler D, Basu S. The body economics: why austerity kills. New York: Basic Books; 2013. Beyond that, though, a vast body of literature exists describing the social determinants of health, and has consistently shown relationships between health and social, economic, political, and cultural factors.⁵5. Marmot M. The health gap: the challenges of an unequal world. London: Blomsbury; 2015. For various European countries, particularly those with more conservative governments, the acute 2008 crisis was followed immediately 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 determinants 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 austerity measures have been taken, several studies show harmful effects, but one concludes, “On the basis of the extant evidence, claims of a public health tragedy in Greece seem overly exaggerated.”⁶6. Tapia Granados JA, Rodriguez JM. Health, economic crisis, and austerity: a comparison of Greece, Finland and Iceland. Health Policy. 2015;119(7):941-953. Spain is another subject 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.⁷7. Cabrera de León A, Rodríguez IM, Gannar F, Pedrero García AJ, González DA, Rodríguez Pérez MDC, Brito Díaz B, Alemán Sánchez JJ, Aguirre-Jaime A. Austerity policies and mortality in Spain after the financial crisis of 2008. American Journal of Public Health. 2018;108(8):1091-1098. However, this result was a clear overestimation of the numbers as the consequence of a gross methodological error.⁸8. Hernández-Quevedo C, Lopez-Valcarcel BG, Porta M. Short-term adverse effects of austerity policies on mortality rates: what could their real magnitude be? American Journal of Public Health. 2018;108(8):983-985.^,99. Salas J. Los 500.000 muertos por la austeridad en España que no existieron: un error estadístico provoca la publicación de un estudio que asegura que la crisis provocó “más muertes que la Guerra Civil” [Internet]. El Pais; 18 jul 2018 [citado 03 ago 2018]. Disponible en: Disponible en: https://tinyurl.com/y74jmeva .
https://tinyurl.com/y74jmeva...

These studies were performed with the aim of finding the health effects of austerity. Investigators must infer the causal links between the attribute (austerity policies) and the effect (changing health outcomes). Experimental studies cannot be performed to investigate these effects. Therefore, they are typically observational study designs; a few are quasi-experimental.¹⁰10. 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. However, it is well known that health is a complex and multidetermined phenomenon and health outcomes are expressed in muiltidimensional forms that must be measured carefully and with some difficulties. It is challenging to conduct an observational study where a specific determinant (such as austerity policies) must be isolated in the midst of effects from other potential determinants, which must be adequately controlled. Additionally, austerity can affect a vast range of health outcomes (such as infant mortality, mental health, suicide, self-perceived health) obtained by the use various types of measures (such as mortality, morbidity, self-perception), with data originated from a range of sources (such as registries, surveys, etc.). A significant portion of these studies focus on a time trend of the health outcomes after austerity measures were implemented, but very often the studied health outcome presents itself on a background of temporal variations, upward or downward trends that confound associations 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 operate.¹¹11. Stuckler D, Reeves A, Loopstra R, Karanikolos M, McKee M. Austerity and health: the impact in the UK and Europe. European Journal of Public Health. 2017;27(Suppl 4):18-21.^,1212. Schramm JMA, Sousa RP, Villarinho L. Políticas de austeridade e seus impactos na saúde: um debate em tempos de crises. Rio de Janeiro: Centro de Estudos Estratégicos da Fiocruz, Fiocruz; 2018. 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 substantial risk of bias; therefore, those study results were to be cautiously interpreted. Some indicators appeared to be more sensitive than others, and some outcomes appeared earlier than others.¹³13. Parmar D, Stavropoulou C, Ioannidis JP. Health outcomes during the 2008 financial crisis in Europe: systematic literature review. BMJ. 2016;354:i4588. doi: 10.1136/bmj.i4588.
https://doi.org/10.1136/bmj.i4588...

Spijker and Gumà¹⁴14. Spijke J, Gumà J. The effect of the economic 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. aimed to analyze differences in self-perceived health among participants according to socioeconomic profile 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 several studies. A review of the studies of austerity 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 depending on the country and group analyzed.”¹³13. Parmar D, Stavropoulou C, Ioannidis JP. Health outcomes during the 2008 financial crisis in Europe: systematic literature review. BMJ. 2016;354:i4588. doi: 10.1136/bmj.i4588.
https://doi.org/10.1136/bmj.i4588... ⁾ This finding arouses caution when analyzing similar and specific results. Another consideration 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 excellent predictor of future health problems and survival. However, it is less clear how sensitive it is to changing conditions over time. An important finding of the Spijker and Gumà¹⁴14. Spijke J, Gumà J. The effect of the economic 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.⁾ study was that, among disadvantaged men some time after the implementation of austerity 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 European experience the best ways to present solid and convincing results about the harmful effects of austerity on the health of the Latin American population.¹²12. Schramm JMA, Sousa RP, Villarinho L. Políticas de austeridade e seus impactos na saúde: um debate em tempos de crises. Rio de Janeiro: Centro de Estudos Estratégicos da Fiocruz, Fiocruz; 2018. For instance, it is worth noting that the literature on European austerity and health is very consistent in that increases in certain health events (particularly mental health and suicide) are the first warning signs that austerity policies are taking their toll. However, Brazil that has been under a conservative government implementing tight austerity measures since 2015, and the health effect recorded almost immediately was an increase in infant mortality. This outcome was showing a marked decreasing trend for several years leading up to 2015, but in 2016, it not only stopped decreasing, but reversed, showing a small increase.¹⁵15. Crise interrompe a queda da mortalidade infantil, alertam especialistas [Internet]. Sociedade Brasileira de Pediatria; 14 may 2018 [citado 04 ago 2018]. Disponible en: Disponible en: https://tinyurl.com/ydb55mjw .
https://tinyurl.com/ydb55mjw... The 2017 mortality data is expected to show whether this reversion continued.

Strategies and study designs must consider a framework that accounts for: a) the very unequal characteristics in Latin American countries whereby despite decreasing 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, mental health problems and violence; c) the understanding of health as a multidetermined problem as a the background for conceptualizing the chain of events by which austerity policies can affect the population’s health status (such as food insecurity, breaks in social 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 countries could be an opportunity to contribute to the existing literature (European in particular) on the topic, delving deeper into investigations of the social determinants of health, but giving it the political flavor of the LA context. The most important goal is to produce reliable evidence that austerity measures implemented by the Latin American neoliberal governments are not only harmful to the way people live, but make them sicker and cut their lives short.

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