title: Economic downturns, universal health coverage, and cancer mortality in high-income and middle-income countries, 1990-2010: a longitudinal analysis.
abstract: BACKGROUND
  The global economic crisis has been associated with increased unemployment and reduced public-sector expenditure on health care (PEH). We estimated the effects of changes in unemployment and PEH on cancer mortality, and identified how universal health coverage (UHC) affected these relationships.
  
  
  METHODS
  For this longitudinal analysis, we obtained data from the World Bank and WHO (1990-2010). We aggregated mortality data for breast cancer in women, prostate cancer in men, and colorectal cancers in men and women, which are associated with survival rates that exceed 50%, into a treatable cancer class. We likewise aggregated data for lung and pancreatic cancers, which have 5 year survival rates of less than 10%, into an untreatable cancer class. We used multivariable regression analysis, controlling for country-specific demographics and infrastructure, with time-lag analyses and robustness checks to investigate the relationship between unemployment, PEH, and cancer mortality, with and without UHC. We used trend analysis to project mortality rates, on the basis of trends before the sharp unemployment rise that occurred in many countries from 2008 to 2010, and compared them with observed rates.
  
  
  RESULTS
  Data were available for 75 countries, representing 2.106 billion people, for the unemployment analysis and for 79 countries, representing 2.156 billion people, for the PEH analysis. Unemployment rises were significantly associated with an increase in all-cancer mortality and all specific cancers except lung cancer in women. By contrast, untreatable cancer mortality was not significantly linked with changes in unemployment. Lag analyses showed significant associations remained 5 years after unemployment increases for the treatable cancer class. Rerunning analyses, while accounting for UHC status, removed the significant associations. All-cancer, treatable cancer, and specific cancer mortalities significantly decreased as PEH increased. Time-series analysis provided an estimate of more than 40,000 excess deaths due to a subset of treatable cancers from 2008 to 2010, on the basis of 2000-07 trends. Most of these deaths were in non-UHC countries.
  
  
  CONCLUSIONS
  Unemployment increases are associated with rises in cancer mortality; UHC seems to protect against this effect. PEH increases are associated with reduced cancer mortality. Access to health care could underlie these associations. We estimate that the 2008-10 economic crisis was associated with about 260,000 excess cancer-related deaths in the Organisation for Economic Co-operation and Development alone.
  
  
  BACKGROUND
  None.
authors.affiliation: Faculty of Medicine, Imperial College London, London, UK. Electronic address: maruthappu@post.harvard.edu.
authors.forename: Mahiben
authors.initials: M
authors.lastname: Maruthappu
authors.affiliation: Institute for Mathematical & Molecular Biomedicine, King's College London, London, UK; Department of Research Oncology, King's College London, London, UK; PILAR Research and Education, Cambridge, UK.
authors.forename: Johnathan
authors.initials: J
authors.lastname: Watkins
authors.affiliation: Department of Research Oncology, King's College London, London, UK.
authors.forename: Aisyah Mohd
authors.initials: AM
authors.lastname: Noor
authors.affiliation: The Economist, London, UK.
authors.forename: Callum
authors.initials: C
authors.lastname: Williams
authors.affiliation: Cancer Epidemiology Unit, University of Oxford, Oxford, UK; Faculty of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates.
authors.forename: Raghib
authors.initials: R
authors.lastname: Ali
authors.affiliation: Kings Health Partners, Integrated Cancer Centre, Guy's Hospital Campus, King's College London, London, UK.
authors.forename: Richard
authors.initials: R
authors.lastname: Sullivan
authors.affiliation: World Health Organization, Geneva, Switzerland; University of Bern, Bern, Switzerland.
authors.forename: Thomas
authors.initials: T
authors.lastname: Zeltner
authors.affiliation: Harvard School of Public Health, Harvard University, Boston, MA, USA.
authors.forename: Rifat
authors.initials: R
authors.lastname: Atun
mesh_terms: D000328:Adult; D000368:Aged; D019049:Developed Countries / Q000191:economics / Q000706:statistics & numerical data*; D003906:Developing Countries / Q000191:economics / Q000706:statistics & numerical data*; D057172:Economic Recession; D005260:Female; D005102:Health Expenditures; D006801:Humans; D007182:Income; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D009026:Mortality / Q000639:trends; D009369:Neoplasms / Q000401:mortality*; D017150:Public Sector; D015996:Survival Rate; D014478:Unemployment; D019472:Universal Health Insurance