Social Programmes Save Lives... and Could Save Many More

Global social epidemiology looks at how the current crises are affecting the health of the most vulnerable and which social programmes can help the most.

We live in a world facing more than one crisis at a time: the COVID-19 pandemic, international conflicts, economic instability and climate change, to name a few. This complex poly-crisis is already being paid for by the poorest, who see their deprivation worsen and their health deteriorate, and who may even die as a result of the lack of social protection.

It is not new that the circumstances in which people are born and live are crucial to their health, but there has been a dearth of research assessing the precise impact of these social determinants, especially in times of recession. Additionally, it was necessary to assess which anti-poverty policies were most effective in improving health outcomes. Since 2020, the Health Impact Assessment group at ISGlobal, led by Davide Rasella, and now also the recently established Global Social Epidemiology Network, which the group facilitates, have been working on both of these issues.

Learning from the past: Brazil

Rasella's team's analysis quantifies the health consequences of economic downturns and the benefits of poverty alleviation programmes at precisely those sensitive times when they tend to be withdrawn in favour of austerity measures. They have calculated, for example, that so-called conditional cash transfers, which give money to low-income families provided that their children attend school or medical check-ups, have prevented more than 700,000 child deaths in Mexico, Brazil and Ecuador over the past 20 years. Moreover, their research showed that primary health care has saved the lives of more than 300,000 children in four Latin American countries over the past two decades.

Similarly, the combined effect of two major national programmes in Brazil (conditional cash transfers plus social pensions) has reduced child mortality by 13-16% in recent years. And, if we also take into account the implementation of primary health care in Brazil, the results of a fourth study suggest that the combination prevented 1.46 million deaths between 2004 and 2019, especially among children under five and adults over 70.

Social programmes that change lives

Evidence is mounting that improving people’s living conditions is a highly effective way to fight disease and death. Cash transfers enable families to buy more and better food, hygiene products and medicines, improve their shelter and avoid having to work when they are sick. They also improve health because they are conditional on meeting certain health and education requirements.

Diseases such as HIV/AIDS and tuberculosis follow a similar pattern to infant mortality. A recent study showed that Brazil's Bolsa Familia cash transfer programme more than halved the number of new HIV/AIDS cases and deaths among the poorest. Another study also found a positive effect of Bolsa Familia on tuberculosis incidence and mortality. In both studies, the poorer the beneficiary, the greater the impact of the programme on reducing TB incidence and mortality.

Brazil is an excellent case study because it has developed one of the largest social assistance strategies in recent decades, but there are about thirty conditional cash transfer programmes in Latin America that have great potential to mitigate the health impact of the current polycrisis.

A new branch of social epidemiology

If social epidemiology is the branch of epidemiology that studies the impact of social determinants of health and health inequalities, the area of global social epidemiology promoted by Rasella and his team aims to address these in the context of our globalised world.

They have established a Global Social Epidemiology Network (GSEN) and created a large database that brings together data from different levels and sources, covering 72 million people and 189 countries over more than forty years (1990-2022). By combining its hundreds of demographic, socio-economic and health variables, the GSEN aims to analyse in detail the impact of both economic crises and social protection.

Data to inform decisions

One of the first studies published found that a 1% increase in the overall coverage of social and labour protection programmes was associated with a 0.19% reduction in suicide rates, particularly among the youngest (10-24 year olds). Scaling up these programmes would therefore be a good strategy for tackling suicide in low- and middle-income countries at a time of multiple global crises.

The ultimate goal of all this work is to understand what has worked in the past in order to anticipate scenarios and assess what interventions might work better now and in the future. We already knew that poverty, lack of education and social inequalities affect health, but now it is time to propose solutions and bridge the gap between research and policy so that decision-makers have the information they need. This is important because they have the power to affect the health of millions of people.