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Health inequalities, the financial crisis, and infectious disease in Europe (ECDC, October 7 2013, excerpts)

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  • Health inequalities, the financial crisis, and infectious disease in Europe (ECDC, October 7 2013, excerpts)

    [Source: European Centre for Disease Prevention and Control (ECDC), full PDF document: (LINK). Excerpts.]


    Health inequalities, the financial crisis, and infectious disease in Europe

    This report of the European Centre for Disease Prevention and Control (ECDC) was coordinated by lead authors Jonathan Suk, Anastasia Pharris and Jan Semenza.

    Contributing authors: Teymur Noori, Tek-Ang Lim, Andreas Sandgren, Irina Dinca & Svetla Tsolova.

    An earlier version of this report was commissioned by the European Centre for Disease Prevention and Control (ECDC), coordinated by Jan Semenza and produced by Gunnilla Lonnberg.

    Suggested citation: European Centre for Disease Prevention and Control. Health inequalities, the financial crisis, and infectious disease in Europe. Stockholm: ECDC; 2013.

    Stockholm, October 2013

    ISBN 978-92-9193-503-1

    doi 10.2900/90716

    Catalogue number TQ-02-13-403-EN-N

    © European Centre for Disease Prevention and Control, 2013

    Reproduction is authorised, provided the source is acknowledged


    Social inequalities in Europe, both between and within Member States, can have serious consequences for health. Health inequalities among socially disadvantaged and advantaged EU citizens are at odds with the EU principles of solidarity, fairness, and equal opportunity for all. In 2009, the Commission of the European Communities recognised the need to act on these inequalities and described specific steps to be taken in the communication entitled: ‘Solidarity in Health: Reducing Health Inequalities in the EU’ [1]. The Commission proposed to advance the understanding of what interventions work best to reduce health inequalities and how to translate these insights into practice, to monitor the status of health inequalities and to improve the knowledge of successful strategies to reduce them. In accordance with this communication, the European Centre for Disease Prevention and Control (ECDC) has prioritised work on health inequalities in relation to infectious disease. There are systematic and avoidable differences in infectious diseases between social groups that differ by variables such as income, education, occupation, etc. Poor and more disadvantaged individuals tend to suffer from a higher disease burden and are more likely to experience illness and disability as a result.

    The economic recession that started in late 2007 resulted in budgetary constraints for many governments and has also adversely impacted many individuals, particularly members of vulnerable groups, such as the Roma, migrants, and unemployed youth. ECDC is committed to address these challenges and aims to find evidence-based strategies and best practices that can be enacted by Member States to measure and ameliorate health inequalities in their countries. Such insights are particularly important during times of economic duress; they can potentially help minimise adverse health outcomes from budget cuts and the discontinuation of public health programs. This report summarises some of the work done by ECDC in this field and describes on-going and planned work in this area.

    Certainly, measuring and tackling health inequalities in relation to infectious disease is no small task – but it is essential if we are to meet the European principles of social solidarity and aspirations for population health.

    Marc Sprenger, Director


    According to its founding Regulation, ECDC's mission is to identify, assess and communicate current and emerging threats to human health posed by infectious diseases [2]. During 2012 and 2013, in recognition of widening health inequalities and the challenges faced by Members States brought about by the economic crisis, ECDC placed strategic emphasis on addressing health inequalities as related to infectious disease prevention and control in Europe.

    This report summarises the importance of addressing health inequalities by identifying key areas for attention from health professionals and policy makers. It presents key findings from previous ECDC meetings and activities, alongside other important studies, which collectively make a convincing case that socio-economic determinants have a substantial impact on infectious disease control in Europe. Based on these findings, this report then outlines the ECDC strategy for addressing health inequalities in the coming years.

    1. Background

    1.1. Health equality: a European priority

    Health is a fundamental universal right. In Europe, the 1992 Maastricht Treaty guarantees social protection, fights against social exclusion, and protects human health, and Article 129 of this Treaty includes Public Health as an activity area at the EU level. The Lisbon Treaty (the Charter of Fundamental Rights of the EU), meanwhile, establishes that everyone has the right of access to preventative healthcare [3].

    Social stratification exacerbates ill health. Differences in income, education and social status lead to differing living and working conditions which, in turn, result in certain exposures that can impair health. In recent years, however, it has been observed that health inequalities continue to persist within EU Member States. To further prioritise this issue, the European Commission issued a Communication on ‘Solidarity in Health: Reducing Health Inequalities in the EU’ in 2009 suggesting, among other activities: assessing the impact of EU policies on health inequalities; collecting data on the size of inequalities in the EU; meeting the needs of vulnerable groups; and reviewing successful strategies aimed at reducing them.

    Similarly, the European Parliament adopted the resolution ‘Reducing health inequalities in the EU’ (2011) to highlight the need to improve data and knowledge (including measuring, monitoring, evaluation, and reporting), to build support for reducing health inequalities, and to act promptly to meet the needs of vulnerable groups.

    It is not simply health inequalities, but also specific vulnerable groups that have become focal points for activity. Targeted EU-initiatives have also focused upon children, Roma, and migrants, as well as other vulnerable groups. In 2011, for example, the Commission developed ‘An EU Framework for National Roma Integration Strategies up to 2020’ [4].

    Healthcare is one of four key integration goals in this strategy.

    The issue of migration and its implications for public health, meanwhile, was put on the European agenda during the Portuguese Presidency of the Council of the EU in 2007. The conference ‘Health and migration in the EU: Better health for all in an inclusive society’, in Lisbon in June 2007, led to Council Conclusions on Health and Migration in the EU, adopted by the Council of the EU in December 2007, which highlighted the link between the health of migrants and that of all EU citizens [5]. The Council Conclusion recommended that the European Commission support action through the Programme of Community Action in the Field of Health 2008–2013 and invited Member States to integrate migrant health into national policies and to facilitate access to healthcare for migrants. The Conclusion also called on ECDC to produce a comprehensive report on migration and infectious diseases in the EU, focusing on tuberculosis (TB), HIV and vaccine-preventable diseases, in order to inform policy and public health responses.

    Moving forward, the European Commission growth strategy for 2020 discusses directions towards inclusive growth highlighting issues of social inclusion, workforce capacities, reducing loss to labour market from death, disease and disability and moving towards smart growth where health is seen as wealth [6]. Building upon past activities in the area of health inequalitiesi [7] and consistent with the Commission’s growth strategy, the Directorate General for Health and Consumers proposed the EU Health Strategy for 2014–2020, ‘Health for Growth’, which highlights the importance of targeting key health determinants as well as preparing for cross-border health threats [8]. However, in light of the continuing economic difficulties in some European countries, health inequalities are also best seen in the context of government budget shortfalls and potential public health program cuts.

    1.2. Health inequalities, infectious disease, and the financial crisis in Europe

    The financial crisis in Europe started in late 2007 and continues to influence many of the key social determinants of health in Europe, both through changes to living conditions and to public spending.

    Even before the current financial crisis, it had been noted that a social gradient in health existed both globally and throughout the EU, through which lower life expectancies and poorer health were associated with lower socioeconomic status and/or lower education [9, 10]. The financial crisis substantially lowered economic growth rates in the EU and drove up unemployment rates. In some cases, these changes were drastic. As has been reported elsewhere, Eurostat data demonstrate that the mean EU decrease in GDP in 2009 was 4.5%, with the worst individual case was 17.7% in Latvia [11]. Although GDP growth rates started to rebound in 2010 and 2011, the mean EU GDP rate decreased again in 2012 by 0.4% [12]. Meanwhile, unemployment increased dramatically in 2008, with examples including 9% in Ireland, 12% in Spain and Estonia, 13% in Latvia and 14% in Lithuania [11]. With lower economic growth and higher unemployment, it is unsurprising that the financial crisis appears to have increased income inequality in many countries (Figure 1, 2). In 2013, the Organisation for Economic Cooperation and Development (OECD) noted that the number of people living in poverty increased in most OECD countries between 2007 and 2010. Moreover, as the OECD notes, ‘income inequality increased by more in the first three years of the crisis to the end of 2010 than it had in the previous twelve years [13]. Such numbers demonstrate that the need to pay attention to social inequalities, and the disparate health outcomes that they lead to, is greater today than it has been in many years.


    There is accumulating evidence that the financial crisis is impacting the spread of infectious disease and Member States ability to prevent or respond to infectious diseases. In 2009, ECDC launched a project aimed at assessing the potential impact of this crisis. A systematic literature review found examples of changes in disease transmission patterns and treatment availability in times of economic hardship [14]. In addition, public health experts were surveyed for their thoughts on possible effects of the crisis on preventive and disease control programs [15]. Services for vulnerable and hard-to-reach groups were reported to be particularly at-risk. Respondents also reported that governments were likely to cut public spending which would lead to less investment in health services.

    Some of these predictions have already come true. In the last five years in many EU countries public spending had been reduced, affecting resource allocation for public health prevention [16]. Meanwhile, a large outbreak of HIV among people who inject drugs (PWID) that began in Athens in 2011 has been linked, anecdotally, to the financial crisis, increased unemployment and increased injecting drug use [17]


    In sum, health inequalities are present within the EU/EEA, they exist across a social gradient [18], and recent evidence, as noted above, suggests that the financial crisis has widened inequalities in many EU Member States. A pertinent question that can be asked is to what extent are health inequalities important for infectious disease prevention and control?

    A systematic literature review conducted by ECDC has revealed that health inequalities for various infectious diseases can be identified in each EU Member State [19]. ECDC has also demonstrated strong associations between income inequalities and rates of tuberculosis [20, 21]. This evidence, although incomplete, will be further discussed in sections 2 and 3, for it informs the ECDC strategy on health inequalities (section 4).

    The financial crisis has and continues to influence many of the key social determinants of health in Europe, both through changes to living conditions and to public spending. It remains to be seen whether long-term effects of the financial crisis will continue to impact infectious diseases in Europe, but history suggests that identifying key social determinants, addressing health inequalities, and engaging vulnerable groups are and will be important activities for European public health in the coming years.

    2. Social determinants and infectious diseases in Europe

    2.1 Structural, intermediary and individual determinants

    Infectious diseases, like many other health issues, can be seen as both an indicator and product of the structure of a society. In Europe, the most recent centuries and decades have yielded substantial improvements in nutrition, housing, and basic hygiene, including cleaner water and better food handling that have helped to curtail many of the infectious diseases that once plagued Europe. Yet those who live and work in suboptimal conditions or lack, for whatever reason, adequate access to healthcare, may not fully benefit from these societal advances. One way of viewing health inequalities is to consider the structural, and intermediary factors (determinants) that affect health (Figure 3). Structural issues refer to those that might be expected to affect large swathes of society, such as national levels of wealth (often measured as GDP per capita), the distribution of income, levels of higher education or employment rates. These structural factors influence the extent to which social inequalities, and thus health inequalities, persist. Other examples of structural determinants could include the equitable or inequitable distribution of societal benefits among minority groups, which might determine the extent to which these groups are particularly vulnerable to specific disease outcomes. Slightly more proximal to individuals, intermediary determinants, such as safety standards for housing and at work, affect people’s lifestyles, exposures to disease, and overall well-being.

    Structural and intermediary may overlap, creating situations in which some groups might face multiple vulnerabilities. Thus wider social and public contexts (societal wealth and its distribution, socioeconomic stratification, welfare policies, housing, healthcare organisation, etc.) influence the health status of individuals and of populations.


    To demonstrate the multifaceted and complex ways in which the various structural, and intermediary determinants affect vulnerability to infectious disease, consider the examples from Table 1. A surprisingly wide range of infectious diseases, and different vulnerable groups, collectively demonstrate that in each and every EU/EEA Member State, health inequalities related to infectious disease can be identified. The examples are many, including lower vaccination coverage among socially deprived families; a strong correlation between syphilis and unemployment; higher incidence of disease among immigrants; or socioeconomic deprivation as a risk factor for meningococcal disease.

    In order to elaborate upon some of the determinants discussed here, the following sections, will provide a few concrete examples of the ways in which specific social determinants have been shown to affect infectious disease rates in Europe. Those that are discussed at length are by no means meant to be viewed of as exhaustive, but rather as illustrative examples.

    Table 1. Selected examples of infectious diseases impacted by social determinants in Europe, 1999–2010 (adapted from Semenza JC 2010)

    [Infection - Health endpoint - Social determinants and site of study – Ref]
    • Campylobacter - Intestinal disease - Pakistani community at greater risk of infection than White community in England. - [22]
    • Clostridium botulinum - Progessive bulbar palsy, diplopia, dysarthria, and a positive electromyography (EMG) test - Injecting heroin drug users at risk, Dublin, Ireland. - [23]
    • Common childhood pathogens - Infectious/parasitic diseases - High infection rates found in children in a lower socioeconomic area in Romania (Moldova) - [24]
    • Cytomegalovirus (CMV) - infectious mononucleosis, with fever, and mild hepatitis; congenital abnormalities - Low socioeconomic status and social environment risk factor for CMV seroprevalence and congenital CMV infection in Helsinki, Finland. - [25]
    • Bacillus anthracis - Inflammation or abscesses related to sites of heroin injection; death - Outbreak among (predominantly) people who inject drugs in Scotland - [26]
    • Drug-related infections and co-infections - Number of major health consequences - Marginalised (Roma or homeless) people who inject drugs suffer risks from injecting and sexual behavior risks, as well as from poor hygienic living and injecting conditions in Budapest, Hungary - [27]
    • Flaviviridae (Arbovirus) transmitted by ticks - Tick-borne encephalitis (TBE) - Socio-economic factors influence transmission of TBE in Central and Eastern European countries. - [28]
    • Herpes simplex virus type 1 (HSV1) and 2 (HSV2) - Significant morbidity, and HSV2 is considered a risk factor for HIV transmission - HSV1 seroprevalence increase with age among people of Turkish and Moroccan origin, men who have sex with men, and individuals with low educational level in Amsterdam, Netherlands. - [29]
    • Neisseria meningitidis (meningococcus) - Meningococcal disease - Parental smoking and unfavorable socioeconomic circumstances among children in the Czech Republic. - [30]
    • Rubella - Terminations and congenital rubella syndrome (CRS) - Low socioeconomic status associated with low rubella seropositivity in Dogankent Health Center, in Turkey. - [31]
    • Hepatitis A - Acute infectious disease of the liver - Outbreak in Lomnička, a village in the eastern part of Slovakia among the Roma population associated with low socio-economic conditions. - [32]
    • Hepatitis B - Malignant and non-malignant liver disease - Immigrant women in Greece significant higher prevalence. - [33]
    • Influenza - Vaccine coverage - Lower vaccine uptake in socio-economically deprived populations in Britain. - [34]
    • Methicillin-resistant Staphylococcus aureus (MRSA) - Postoperative infection - Patients from the most deprived areas at higher infection risk than those from the least deprived areas in England. - [35]
    • Neisseria meningitidis – Meningitis - Association with area deprivation of socio-economic environment in England. - [36]
    • Sexually transmitted diseases (STI) – STI - High-risk sexual behavior among immigrant groups in Amsterdam. - [37]
    • Toxoplasmosis - Encephalitis and congenital malformations - Migrants in Northern Italy not correctly monitored for toxoplasmosis during pregnancy, which precludes timely application of preventive measures. - [38]
    • Puumala virus (PUUV) – Nephropathia epidemica, a mild form of hemorrhagic fever with renal syndrome (HFRS)


    i For more information see the EC Directorate-General for Health and Consumer’s website where information on projects from 2003 till 2009 can be retrieved -