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Public Health in Europe: Power, Politics, and Where Next?


Health policy in Europe is at a crossroads. Longstanding challenges, such as persisting social and geographical inequalities, ageing populations, and rising burdens of chronic diseases, are being compounded by new, global threats, such as pandemic influenza and crises in the world’s financial markets. Significant improvement in the health of Europe’s population has been driven by factors both inside and outside the health sector. Key obstacles to improving population health in Europe result from underlying failures to overcome political and economic issues, including those shaping healthcare financing and delivery systems. How can the public health community respond to these challenges? This paper discusses three examples of how power and politics have shaped the world in which public health works. The focus on individual risk factors diverts attention from underlying determinants, such as the dominance of the market in healthcare, and the political decision to favour a rapid transition from communism in the 1990s. Effective public health policy requires addressing these political forces, seeking to understand the dominant paradigms, how they have been defined and shaped, and how they might be changed. Their effects are often subtle but powerful, shaping the language that is used, the assumptions that are made, and the rules that are implied. We can formulate key policy options to help improve health outcomes by reshaping the critical forces that affect public health risk factors among those populations currently most burdened by significant disease in Europe today.


  1. 1.

    Van Doorslaer E, Koolman X. Explaining the differences in income-related health inequalities across European countries. Health Econ. 2004;13:609–28.

  2. 2.

    Judge K, Platt S, Costongs C, Jurczak K. Health inequalities: a challenge for Europe. Discussion paper. London: UK Presidency of the EU; 2006. Available from URL: (Accessed 11 April, 2010).

  3. 3.

    Mackenbach J. Health inequalities: Europe in profile. Erasmus: EU Commission; 2006. Available from URL: (Accessed 11 April, 2010).

  4. 4.

    Albreht T, McKee M, Alexe DM, Coleman MP, Martin-Moreno JM. Making progress against cancer in Europe in 2008. Eur J Cancer. 2008;44:1451–6.

  5. 5.

    Zatonski W, Didkowska J. Closing the gap: Cancer in Central and Eastern Europe (CEE). Eur J Cancer. 2008;44:1425–37.

  6. 6.

    Mackenbach J, Stirbu I, Roskam AJ, Schaap MM, Menvielle G, Leinsalu M, et al. Socioeconomic inequalities in health in 22 European countries. N Engl J Med. 2008;358:2468–81.

  7. 7.

    European Roma Rights Centre. Ambulance not on the way. Budapest: ERRC; 2006. Available from UEL: European Roma Rights Centre. Ambulance not on the way. (Accessed 11 April, 2010).

  8. 8.

    Kósa Z, Széles G, Kardos, L, Kósa K, Németh R, Országh, et al. A comparative health survey of the inhabitants of the Roma settlements in Hungary. Am J Public Health. 2007;97:853–9.

  9. 9.

    Rechel B, Blackburn CM, Spencer NJ, Rechel B. Access to health care for Roma children in Central and Eastern Europe: findings from a qualitative study in Bulgaria. Int J Equity Health. 2009;8:24.

  10. 10.

    Wedel J. Collision and collusion: the strange case of Western aid to Eastern Europe. New York: PalgraveTM; 2001.

  11. 11.

    Stuckler D, King L, McKee M. Mass privatisation and the post-communist mortality crisis. Lancet. 2009;373:399–407.

  12. 12.

    Cornia GA, Paniccia R (editors). The mortality crisis in transitional economies: New York: Oxford University Press, USA; 2000.

  13. 13.

    Deaton A. Health, inequality and economic development. J Econ Lit. 2003; XLI:113–58.

  14. 14.

    Omran AR. The epidemiologic transition: a theory of the epidemiology of population change. Milbank Mem Fund Q. 1971;29:509–38. Available from URL: pdf (Accessed 11 April, 2010). Public Health in Europe 237

  15. 15.

    Fries JF. Aging, natural death and the compression of morbidity. Bull World Health Org. 2002;80:245–50. Available from URL: pdf/bwho/v80n3/v80n3a12.pdf (Accessed 11 April, 2010).

  16. 16.

    Stuckler D. Population causes and consequences of leading chronic diseases: a comparative analysis of prevailing explanations. Milbank Q. 2008;86:273–326. Available from URL: (Accessed 1 April, 2010).

  17. 17.

    World Health Organization. Statistical Information System (WHOSIS). Geneva: World Health Organization; 2009. Available from URL: whosis/en/ (Accessed 11 April, 2010).

  18. 18.

    McKee M. Solidarity in a unified Europe. Eur J Public Health. 2008;18:2–4. Available from URL: 18/1/2 (Accessed 11 April, 2010).

  19. 19.

    Blanchflower D. Cameron’s dud options. Guardian News and Media Limited 2009 October 9. Available from URL: (Accessed 11 April, 2010).

  20. 20.

    Brittan S. A cool look at the current deficit hysteria. Financial Times 2009 October 1. Available from URL: (Accessed 11 April, 2010).

  21. 21.

    Easterly W. The white man’s burden. Lancet. 2006;367:2060.

  22. 22.

    Stuckler D, Basu S. The International Monetary Fund’s effects on global health: before and after the 2008 financial crisis. Intl J Health Serv. 2009;39:771–81.

  23. 23.

    Weisbrot M, Ray R, Johnston J, Cordero JA, Montecino JA. IMF-supported macroeconomic policies and the world recession: a look at forty-one borrowing countries. Washington (DC): Center for Economic Policy Research (CEPR); 2009. Available from URL: imf-supported-macroeconomic-policies-and-the-world-recession/ (Accessed 1. April, 2010).

  24. 24.

    Jolly, D. Latvian health official resigns over cuts. in New York Times (New York, 2009). June 17. Available from URL: 06/18/business/global/18lat.html?_r=1 (Accessed 11 April, 2010).

  25. 25.

    Starr P. The social transformation of American medicine. New York: Basic Books; 1982.

  26. 26.

    Snow J. On the supposed influence of offensive trades on mortality. Lancet. 1856;68:95–7.

  27. 27.

    McKeown T. The role of medicine: dream, mirage or nemesis. In: Mackay L, Soothill K, Melia K, editors. Classic Texts in Health Care. Oxford: Butterworth-Heinemann; 1998.

  28. 28.

    Blower S, McLean AR, Porco TC, Small PM, Hopewell PC, Sanchez, et al. The intrinsic transmission dynamics of tuberculosis epidemics. Nat Med. 1995; 1:815–21.

  29. 29.

    Harvey D. A brief history of neoliberalism. Oxford: Oxford University Press; 2007.

  30. 30.

    Castells M. The rise of the network society. Second ed. Oxford: Wiley-Blackwell;.

  31. 31.

    Commission on Social Determinants of Health. Closing the gap in a generation: health equity through action on the social determinants of health. Final report of the Commission on Social Determinants of Health. Geneva: World Health Organization; 2008. Available from URL: (Accessed 11 April, 2010).

  32. 32.

    World Bank. Investing in health. Washington (DC): World Bank; 1993. Available from URL: (Accessed 11 April, 2010).

  33. 33.

    Giovanni AC, Jolly R, Stewart F. (editors) Adjustment with a human face. Vol 1. Protecting the vulnerable and promoting economic growth. Oxford: Clarendon Press; 1987.

  34. 34.

    Kim JY, Millen JV, Irwin A, Gershman J. Dying for growth: global inequality and the health of the poor. Monroe (Me): Common Courage Press; 2000.

  35. 35.

    Acemoglu D, Johnson S, Robinson J. Disease and development in historical perspective. J Eur Econ Assoc. 2003;1:397–405.

  36. 36.

    Cochrane A, St Leger AS, Moore F. Health service ‘input’ and mortality ‘output’ in developed countries. J Epidemiol Community Health. 1978;32:200–5.

  37. 37.

    Andreev EM, Nolte E, Shkolnikov VM, Varavikova E, McKee M. The evolving pattern of avoidable mortality in Russia. Int J Epidemiol. 2003;32:437–46.

  38. 38.

    Rutstein DD, Berenberg W, Chalmers TC, Child CG 3rd, Fishman AP, Perrin EB. Measuring the quality of medical care: a clinical method. New Engl J Med. 1976; 294:582–8.

  39. 39.

    Charlton JR, Hartley RM, Silver R, Holland WW. Geographic variation in mortality from conditions amenable to medical intervention in England and Wales. Lancet. 1983;1:691–6.

  40. 40.

    Holland WW. European Community Atlas of Avoidable Death. Oxford: Oxford University Press; 1988.

  41. 41.

    Nolte E, McKee M. Does health care save lives? Avoidable mortality revisited. London: Nuffield Trust; 2004.

  42. 42.

    Nolte E, McKee CM. Measuring the health of nations: updating an earlier analysis. Health Aff. 2008;27:58–71.

  43. 43.

    Rose R. What is lesson-drawing? J Publ Pol. 1991;11:3–30.

  44. 44.

    Doll R, Hill AB. Lung cancer and other causes of death in relation to smoking: a second report on the mortality of British doctors. Br Med J. 1956;2: 1071–81.

  45. 45.

    US Surgeon General. The reports of the Surgeon General: the 1964 report on smoking and health; 1964. Bethesda (MD): National Institutes of Health; 1964. Available from URL: (Accessed 11 April, 2010). Public Health in Europe 239

  46. 46.

    Joossens L, Raw M. Progress in combating cigarette smuggling: controlling the supply chain. Tob Control. 2008;17:399–404.

  47. 47.

    Joossens L, Raw M. Turning off the tap: the real solution to cigarette smuggling. Int J Tuberc Lung Dis. 2003;7:214–22.

  48. 48.

    Subramanian SV, Jones K, Kaddour A, Krieger N. Revisiting Robinson: The perils of individualistic and ecologic fallacy. Int J Epidemiol. 2009;38:342–60.

  49. 49.

    Durkheim E. Suicide. Glencoe (IL): Free Press; 1951.

  50. 50.

    Selvin H. Durkheim’s suicide and problems of empirical research. Am J Soc. 1958;63: 607.

  51. 51.

    Diez-Roux AV. Bringing context back into epidemiology: variables and fallacies in multilevel analysis. Am J Public Health. 1998;88:216–22.

  52. 52.

    Susser M, Susser E. Choosing a future for epidemiology: II: From black box to Chinese boxes and ec-epidemiology. Am J. Public Health. 1996;86674-7.

  53. 53.

    Susser M, Susser E. Choosing a future for epidemiology: I: Eras and paradigms. Am J Public Health. 1996;86:668–73.

  54. 54.

    Rothman KJ, Adami HO, Trichopoulos, D. Should the mission of epidemiology include the eradication of poverty? Lancet. 1998;352:810–3.

  55. 55.

    Mackenbach JP. Politics is nothing but medicine at a larger scale: reflections on public health’s biggest idea. J Epidemiol Community Health. 2009;63:181–4.

  56. 56.

    Foucault, M. 1980: Truth and power. In Gordon, C., editor, Power/knowledge: selected interviews and other writings, 1972–1977, New York: Pantheon Books, 1980.

  57. 57.

    Smith R. The big idea [Editor’s choice]. BMJ.1996;312.

  58. 58.

    World Health Organization. The world health report 2000: health systems: improving performance. Geneva: World Health Organization; 2000.

  59. 59.

    Gatta G, Capocaccia R, Coleman MP, Gloeckler Ries LA, Hakulinen T, Micheli A, et al. Toward a comparison of survival in American and European cancer patients. Cancer. 2000;89:893–900.

  60. 60.

    Xu K, Evans DB, Carrin G, Aguilar-Rivera AM, Musgrove P, Evans T. Protecting households from catastrophic health spending. Health Aff. 2007; 26:972–83.

  61. 61.

    McKee M, Nolte E. Responding to the challenge of chronic disease: ideas from Europe. Clin Med. 2004;4:336–42.

  62. 62.

    NHANES. National Health and Nutrition Examination Survey. Atlanta: Centers for Disease Control and Prevention; 2008 Available from URL: (Accessed 11, April 2010).

  63. 63.

    Arrow KJ. Uncertainty and the welfare economics of medical care. Am Econ Rev. 1963; [reprinted WHO Bull World Health Organ. 2004;82:141–149.] Available from URL: (Accessed 11 April, 2010).

  64. 64.

    Krugman P. Why markets can’t cure healthcare. New York Times. 2009 July 25. Available from URL: (Accessed 11 April, 2010).

  65. 65.

    Atun RA, McKee M. Is the private finance initiative dead? It may have failed in the United Kingdom, but that won’t stop it being exported. BMJ. 2005;331: 792–3.

  66. 66.

    McKee M, Edwards N, Atun R. Public-private partnerships for hospitals. Bull World Health Organ. 2006;84:890–6. Available from URL: (Accessed 11 April, 2010).

  67. 67.

    Sachs J. Accelerating privatization in Eastern Europe: the case of Poland. A Working Paper. World Bank Annual Conference on Development Economics; 199. April 25-26th; 1991.Washington (DC). Available from URL: 9464337/default/WP92.pdf+Sachs+J.+Accelerating+privatization+in+Eastern +Europe:+the+case+of+Poland.+A+Working+Paper.+World+Bank (Accessed 1. April, 2010).

  68. 68.

    Lieberman IW, Kopf DJ. Privatization in transition economies: the ongoing story. Amsterdam: Elsevier; 2008.

  69. 69.

    Pomer M. Introduction.(p 5). In: Klein L, Pomer M. The new Russian transition gone awry. Stanford; Stanford University Press; 2001.

  70. 70.

    Naughton B. Growing out of the plan: Chinese economic reform, 1978–1993. New York (NY): Cambridge University Press; 1996.

  71. 71.

    Hertz N. The role we can play in shaping globalization global challenge for Maastricht University: Speech on the occasion of the Opening Ceremony of the Academic Year 2005–2006. Available from URL: noreena+hertz&meta=&rlz=1R2GGLL_en&aq=f&aqi=&aql=&oq=&gs_rfai= (Accessed 14 April, 2010).

  72. 72.

    Adeyi O, Chellaraj G, Goldstein E, Preker A, Ringold D. Health status during the transition in Central and Eastern Europe: development in reverse? Health Policy Plan. 1997;12:132–45.

  73. 73.

    De Melo M, Gelb A. A comparative analysis of twenty-eight transition economies in Europe and Asia. Post-Soviet Geography and Economics. 1996;37:265–85.

  74. 74.

    De Melo M, Denzier C, Gelb A, Tenev S. Circumstances and choice: The role of initial conditions and policies in transition economies. World Bank Econ Rev. 2001;15:1–31.Available from URL: content/abstract/15/1/1 (Accessed 11 April, 2010).

  75. 75.

    King L, Sznajder A. The state-led transition to liberal capitalism: neoliberal, organization, world-systems, and social structural explanations of Poland’s economic success. Am J Socio. 2006;112:751–801.

  76. 76.

    King L. Shock privatization: the effects of rapid large scale privatization in enterprise restructuring. Polit Soc. 2003;31:3–30.

  77. 77.

    Stuckler D, King LP, Basu S. International Monetary Fund programs and tuberculosis outcomes in post-communist countries. PLoS Med. 2008;5:e143.

  78. 78.

    Tragakes E, Lessof, S. Health care systems in transition. In: Tragakes E, editor. Health care systems in transition: Russian Federation. Copenhagen: European Observatory on Health Systems and Policies; 2003.

  79. 79.

    Davis C. Reforms and performance of the medical systems in the transition states of the former Soviet Union and Eastern Europe. Int Soc Secur Rev. 2001;54:7–56.

  80. 80.

    Tulchinsky TH, Varavikova EA. Addressing the epidemiologic transition in the former Soviet Union: strategies for health system and public health reform in Russia. Am J Public Health. 1996;86:313–20.

  81. 81.

    Balabanova D, Falkingham, J, McKee, M. Winners and losers: the expansion of insurance coverage in Russia in the 1990s. Am J Public Health. 2003;93:2124–30.

  82. 82.

    Balabanova D, McKee M, Pomerleau J, Rose R, Haerpfer C. Health service utilization in the former soviet union: evidence from eight countries. Health Serv Res. 2004;39:1927–50.

  83. 83.

    McKee M, Britton A. The positive relationship between alcohol and heart disease in Eastern Europe: potential physiological mechanisms. J R Soc Med. 1998; 91:402–407.

  84. 84.

    McKee M, Nolte E. Lessons from health during the transition from communism. BMJ. 2004;329:1428–9.

  85. 85.

    McKee M, Suhrcke M. Commentary: health and economic transition. Int J Epidemiol. 2005;34:1203–6.

  86. 86.

    McKee M. Alcohol in Russia. Alcohol and Alcoholism. 1999;34:824–829.

  87. 87.

    McKee M, Pomerleau J, Robertson A, Pudule I, Grinberga D, Kadziauskiene K, et al. Alcohol consumption in the Baltic Republics. J Epidemiol Community Health. 2000;54:361–6.

  88. 88.

    Perlman F, Bobak, M. Assessing the contribution of unstable employment to mortality in posttransition Russia: prospective individual-level analyses from the Russian longitudinal monitoring survey. Am J Public Health. 2009;99: 1818–25.

  89. 89.

    Stuckler D, Basu S, Suhrcke M, Coutts A, McKee M. The public health impact of economic crises and alternative policy responses in Europe: an empirical analysis. Lancet. 2009;374:315–23.

  90. 90.

    Gil A, Polikina O, Koroleva N, McKee M, Tomkins S, Leon DA. Availability and characteristics of non-beverage alcohols sold in 17 Russian cities in 2007. Alcohol Clin Exp Res. 2009;33:79–85.

  91. 91.

    King L, Hamm P, Stuckler D. Rapid large-scale privatization and death rates in ex-communist countries: an analysis of stress-related and health system mechanisms. Int J Health Serv. 2009;39: 461–89.

  92. 92.

    Gilmore AB, Radu-Loghin C, Zatushevski I, McKee M. Pushing up smoking incidence: plans for a privatised tobacco industry in Moldova. Lancet. 2005; 365:1354–9.

  93. 93.

    Gilmore AB, McKee M. Moving East: how the transnational tobacco industry gained entry to the emerging markets of the former Soviet Union - part I: establishing cigarette imports. Tob Control. 2004;13:143–50.

  94. 94.

    Gilmore A, Fooks G, McKee M. The International Monetary Fund and tobacco: a product like any other? Int J Health Serv. 2009;39:789–93.

  95. 95.

    Haines MR, Kantor S. Births, deaths and New Deal relief during the Great Depression. Rev Econom Stat. 2007;89:1–14.

  96. 96.

    Stuckler D, Basu S, Suhrcke McKee M. The health implications of financial crisis: a review of the evidence. Ulster Med J 2009;78:142–5.

  97. 97.

    World Health Organizaztion. Health Impact Assessment (HIA). Available from URL: (Accessed 11 April, 2010).

  98. 98.

    Virchow R. Der Armenarzt. Medicinske Reform. 1848;18:125–27.

  99. 99.

    Rose G. Sick individuals and sick populations. Bull World Health Organ. 2001.79:32–8.

  100. 100.

    National Institute of Health. NIH Director’s Pioneer Award. Washington (DC). Available from URL: (Accessed 1 April, 2010).

  101. 101.

    Wellcome Trust Strategic Awards. Available from URL: (Accessed 14 April, 2010).

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Correspondence to David Stuckler PhD, MPH.

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Stuckler, D., Basu, S. & McKee, M. Public Health in Europe: Power, Politics, and Where Next?. Public Health Rev 32, 213–242 (2010).

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Key Words

  • Europe
  • Public Health
  • political economy
  • social determinants
  • medical care