>> please let us know about book fairs and be festivals in your area, and we'll add them to our list. e-mail us at booktv@c-span.org. >> next on booktv, dr. sanjay basu reports on the correlation between health and economic issues and talks about the rise in rates of things like heart disease, suicide and hiv as a result of government cuts in social and health spending. this is about 0 minutes. -- 40 minutes. [applause] >> thank you. well, thanks for coming. i'm going to talk for about 30 minutes or so about some data, and what i'll present to to you is data discussing why we might think about the recession not just in terms of stock markets and economic growth and debts and deficits, but really in terms of our health and the

public health more generally. and to do so i'll present what i found initially as somewhat of a confusing puzzle. and that was perhaps best capture inside this old "usa today" newspaper clipping, but it's been repeated a few times in a variety of different outlets. and that is this notion could recession be good for you? the headline confused me at first. i had assumed that during recessionary periods or people's health insurance would be lost, they would stop paying for medications, become depressed, turn to alcohol. and yet this and other news stories were paced on a -- based on a series of studies that suggested that during recessionary periods such as the great depression, unemployment spikes were associated with improvements in life expectancy which i found really confusing. what i want to do is present what i would argue one solution to apparent puzzle, and in presenting the solution i think

we can gain some insights into why we might be asking some of the wrong questions when we correlate the recession to a lot of different things. what i'll do is, first, talk a little about how we might learn from so-called natural experiments, when very similar communities to these states, whole countries experience the same or very similar recessions and decided to take very different policy avenues, very different strategies and response and ended up in very different places in terms of public health. ultimately, the goal will be to say something about what the role is of safety nets and answer that ultimate question that seems most apart right now which is can we afford social safety nets. and, of course, are they effective? and if so, which kinds? so let me return to that puzzle, that conundrum about why during recessionary periods people seem to have found increased life expectancy. perhaps if we are going to learn from any major recession, the

great depression is the best template we can have. and during the great depression, in fact, there were numerous reports of death rates dropping around the country which seems streakingly odd quinn t at the same time there were bread lines and hoovervilles and some of the other features we learn about with regard to the great depression. so one possibility might be just that the that atistics are -- statistics are biased, right? maybe they're just keeping track of people who are insured and those people who are very bad off during the great depression were just the uninsured. but it turns out that the public health service -- what's now become moan as cdc and other industries -- went around and cub and even among up insured they found the same declines in overall death rates. and some of the clues were present in that third headline from "the new york times" back in 1933, that traffic accidents had dropped for the first time in history.

indeed, if you were to look at indicators of the recessioning such as overall gdp or state income on the left and overall death rates on the right, they also look like mirror images of one another. death rates falling at the same time that recession hit. so this serves as a pretty good example of why it can be dangerous to look at such aggregate level data. in fact, if you look across states with the highest gas prices and the lowest unemployment were pre-ralph nader days. and hidden behind that decline in traffic are probably a lot more important things going on with people's health. perhaps the most obvious to explain is the dramatic spike in citizen rates -- in suicide rates that was hidden beneath the traffic accident deaths.

traffic accidents are such a large part of death that their decline masked these other increases taking place at the same time producing in this correlation between rising life expectancy and changes in the unemployment rate. but here i think is another important lesson which is that suicide rates can't increase universeally across the country. in fact, suicide rates and simply alcohol rates and other rates of decides that -- diseass that are clearly associated with people becoming unemployed only increased in certain areas more than others and in some places actually declined. so that's the sort of natural experiment where we can start to analyze why these variations seem to be occurring. one of the most important, in my opinion, was that between states that decided to implement major parts of the new deal and states that didn't. particularly in states that had rapid reintegration programs so

that the newly unemployed could get back to work rather rapidly, one didn't see the spikes in suicide rates or new alcoholism, although alcoholism was also affected by prohibition at time. the other interesting thing is dramatic declines in infectious diseases in some of these stays, particularly tuberculosis in programs that provided rapid rehousing but not in states that avoided rehousing. so we begin to see the beginning of a hoi post sis that maybe some big aggregate death rates are affected beconfounders, but behind this is some other story. but to really try to answer a story about what might be happening between social policy responses to recession and ultimate public health outcomes, we'd have to look at much more details data. and so while the great depression has these big scale kind of average-level data from pretty rough data resources, we

have to rook through more modern recessions in order to come up with the answers to this question. so i'll look at three recessions, the collapse of the ussr, the russian mortality crisis as it's often called where very similar countries, otherwise similar populations all had an economic recession at the same time and had very different outcomes. i'll look at the east asian economic crisis which had roots very similar to our own recent crisis in terms of having a reality bubble, and then, of course, our current great recession. so looking first at russia, during the collapse of the soviet union, a vast array of populations all experienced recession around the same time a, right? as the ussr collapsed. but otherwise demographically-similar populations ended up having very different population outcomes. and what was particularly weird was that a number of

demographers from france and russia and a number of countries were all on serving the same trend which is that you'd expect that in bad be times the people who would hurt the most would be the very young like infants and the very old. but what is really strange about the russian crisis is nearly the opposite happened. young, robust russian men had huge spike in their death rates. which was rather confusing. and there were a variety of theories about what might be happening. maybe the russians had been kind of faking their data before the collapse of the soviet union. they were often amplifying the number of young men around in order to impress people about the size of their potential army, and that turned out, it turned out they had fudged the numbers in that context. but some independent demographers had been worried about this, so in france, france had sort of been secretly keeping track of the russian young male population for this

very reason, you know, well before our current nsa surveillance. the french demographers were the form of surveillance during the cold war and, in fact, confirmed this giant spike had actually happened. and what was particularly dramatic about the spike is that, again, kind of like the suicide rates in the great depression, it doesn't occur everywhere. it only curred in a few cities and counties and states. one saw this dramatic variation which amounts to several million people in locations in russia that underwent what has been called shock therapy or mass privatization or dramatic austerity. so here was the idea that russia needed to get back on track and enter into the global marketplace. and the concern was if the government had too many obligations, it would go into too much debt, you'd get up nation, and then it would never really recover a stable economy. so the recommendations of a large group of people were to

dramatically cut social programs that had been previously in existence when the ussr was still intact. these programs included things like rapid job reentry programs, childcare, a variety of housing programs and in particular a major alcohol prevention program. but not everyone agreed. countries like belarus, to toland, a couple others decided this was going to be a bad idea. and so they sort of refused to follow this advice. while russia and a couple others sort of went whole hog. and in that setting we found a massive divergence between those countries that experienced this dramatic decline in life expectancy particularly among young men and those who new orleans refused shock therapy among whom the life expectancy and death rates were essentially flat even though they were very hard times. and so we end up sort of seeing again just like in the great depression that depressions don't necessarily manifest in

bad public health outcomes. it could be a matter of policy choices. the same pattern emerged again in the east asian crisis. the origins are not very different from the origins of our recent crisis. east asia had a massive housing bubble and the context of great enthusiasm that it was going to be the technology end center of the future. and so many buildings were being built in thailand, for example, that bang congress could house five times its population in terms of number of empty apartments that were being built prior to the crisis. but like every price bubble, the supply was greatly outstripping true value and what was really going on. so eventually, investors pulled out in the context of this big currency crisis, and the same thing happens r happened as what happened during our current recession which is we, essentially, ended up with a giant bursting of the stock

market in the area. no one could get loans because all the money has dissipated from the system. and the idea, there was a great debate about what to do in in this context. the international monetary fund at time which was the sort of lender of last resort, it's the major international wang that often helps -- bank that helps countries in tough situations, said, look, we don't want you guys going into inflation. we want you to cut down your spending dramatically in order that you don't have major government obligations, and you preserve the value of your currency. and you should a lot of protests, malaysia and, essentially, south korea refused to do that while their neighbors, again, kind of went into it wholeheartedly. and the same kind of natural experiment emerged. one saw the spikes in suicide and alcohol rates but also in the number of infectious decides in those countries undergoing

the austerity. remember, at this time hiv had entered into east aiz rah in a -- asia in a big way, and these were the years where thailand was being viewed as a model for prevention programs. if one of the programs that were cut was the hiv prevention program in thailand, and one saw a huge spike in subsequent infectious decide rates that as people with untreated hiv were getting all sorts of second dare infections. the malaysian experience, however, was essentially flat. and what was particularly ironic was that malaysia and south korea actually recovered first which was quite surprising because they had spent more. and this really emphasizes one of the major policy lessons, the idea has often been either you will spend be and maintain your safety net, or you will recover faster. either you will go into inflation, bad things will

happen, or you need to cut down now in order for the future. and be this was shown as somewhat of a false dichotomy. why was that? the answer was really written in the 1950s and only recently reiterated which is that when countries are in these sorts of liquidities crises, that means businesses can't get the loans they need to maintain their staff, expand and continue their business, essentially the government needs to do the opposite of what households need to do. as a household, if you have debt, one should pay off the debt. there's no doubt about that. you don't want to be continuing to accrue interest and having to owe people more and more. yet governments need to do precisely the opposite ford to actually grow the economy -- in order to actually grow the economy out of its current debt, you these to have stimulus. but not just in the form be of stimulus for banks to loan to

others, but also to safety nets as the poor are up those who spend the vast proportion of their income. and as i'll show you when we get to the united states, we'll see that a lot of safety nets actually preserve the business cycle and help us grow out of short-term debts to pay off longer-term debts. ..

but a smaller population about a million people, particularly young man, who either had trouble finding work or were unable to maintain work have started frequent imaging can usually the assertions within the population. among those young men busy emergency room visit, emergencies and other alcohol related harm. on average, you see a decline in overall drinking rates. this really going on behind that decline is that two american phenomenon and again shows the danger of using these african statistics. similarly can receive fast emergencies within europe while people are commenting your puny universe or recession, in fact that is not true. everyone talking about greece, but before we talk about greece,

everyone is talking about iceland and then we forgot about iceland. iceland was the first country to experience the first part of the recession. relative to the size of the economy experienced the largest recession economic case three. it invested in u.s. mortgage-backed securities. based the district and they recovered what greece has not. the political economic is quite different. nor is it restricted by the politics of the e.u. but iceland did this rather dramatic. they say we been recommended by the imf and others to undergo short-term deficit, maintain currency can reduce your obligations as you can recover faster. and actually number of ministers including the health minister resigned and would eliminate

their universal health system and embrace the show safety net, a rather dramatic move for a politician. for the first time since 1944, iceland is something rather incredible and had a countrywide vote. they use social media and other things to have a constitutional amendment or two ago to you though. you move that was 800% of gdp, they subvert a small group of people in charge of a something have invested all their money and mortgage-backed securities and is lost. we have two options. one is to cut social safety net obligations and use government taxpayer money to rapidly pay back all the foreign creditors. the other option is to do a loan repayment program, payback slowly over time while preserving their safety net at home. most people understandably voted for the second one.

when we investigated subsequent effects on iceland's public health, everything was essentially flat. in fact, some indicators for improved like sleep quality, but there is absolutely no increase in suicides, how close is the among four different groups of scientific investigators. there's only one in week 52 for the recession, a sudden spike in respiratory emergency room visits. when we investigate what happened, and turns of the volcano erupted and i pretty much nothing to do with the reception. i can't pronounce the name of the volcano. a lot of confidence. greece went a very different route. so greece underwent this idea that it must be able to help us quickly get out of this recession. they quickly cut the public health by a tremendous degree,

but ultimately ended up having higher public health spending, which has confused a lot of people. it's not confusing if you look at the time trend. short-term cuts resulted in so many complications they end up having to pay much more than the epidemics. for example someone said a 40% to 50% unemployment rate, a new truck hits the market for major events of methamphetamine. at the same time as the new exchange programs were cut, and once all this genetic tenfold rise in drug use related hav and action, which then resulted in subsequent spending to take care of the hav. similarly, the malaria epidemic has broken out for the first time in decades in the mosquito spray was cut. but of course cost 10 times more than it does to present and we see the same thing unfold. it was quite embarrassing for the state department which had a

conundrum because they had to issue a warning to american travelers about taking prophylaxis to western american country which increases problems for a trade agreement. and now we see the same kind of trend in the u.s. dates. in the u.s., alcoholism and suicide, we see spikes outdraw, but they are very heterogeneous, not across all cities, counties and states. similar cities which face massive unemployment, and other cities we spikes and others they don't. it seems to relate strongly to a set of social programs to talk about. those social programs are the answers major question, which is why unemployment is and always correlate to suicide rates. develop and test correlation not causation and that's precisely the point in why we went to investigate and correlations don't occur.

for example, unemployment rates very closely or followed by suicide rate is shown on the left. in places like sweden and finland, despite a large recession what i did some baking crisis, suicide rates begin to decline. so how do we explain this? what are they doing or is it that the swedish church is so robust? my swedish friends like to think that, but it's not true. it turns out we investigate a slew of different programs people were exposed to. one set of program seems to be particularly if at preventing these recession he associated mental health related and other health related problems and it's not in spite of my being a physician. i have to admit it has nothing to do with health care. it's something called act labor market programs. these programs are part keratin part stick. when someone comes near the unemployed, taking unemployment check, but only on the position

that they ruled this program. and here is the stick part, the program involves a person with everything from job retraining to actively working with their firms churros are required to participate still the same part-time employment in the integrate them into the workforce. it turns out that preemptive spending on this program's results an economic stimulus and ends up paying for itself and downstream costs, but then is a question of what is safe it is the swedish? maybe it's like the european thing. a number of us have worked on these multisite randomized controlled trials in the u.s., including recently in the city of detroit, where people are randomized seating standard programs cannot go off can get benefits, good luck to you. are the effective labor market

program. all of the cities now in four different continents, the same missiles had been found of reducing health outcomes, negative health outcomes as a side effect of what is ultimately an economic job stimulus program. we were seen this implemented across the u.s. much of the u.s. economic recovery seemed to correspond to stimulus, where is their pure country, the u.k., which i recession under which posterity program and yesterday clipped their recovery and now they are starting into triple digit session. this ended for us around the time of the sequester when we started flat enough in terms of a recovery. on the same time they issued a major policy document in public statement from its chief economist, which basically amounted to 400 pages a set of

hoops. in this fascinating document if you get through. but it's not just the following penalty phase previously during the current crisis is based on an assumption about one number. that assumption is for every dollar of government spending, how many dollars do you get to? the imf and others have assumed the number was about .5 and a footnote to an earlier document, you can find a reason is because it's a nice round number for and that's about it. four different groups including us actually calculated inside during recessions, how many dollars do you get that? when you invest in food stamps, how much do you plan to in the economy came back in terms of net job growth, business growth in overall gdp? multiplier is greater.

you got $1.70 for every dollar you invest. these were groups that workgroups to watch each other ended up at the same number. the irony is germany has figured this out a while ago. by recommending greece to hundred posterity, they calculated this number called the fiscal multiplier for themselves and decided to undergo stimulus internally while recommending the opposite for greece. and we had the first ones to figure out either. texas figured out during the savings and loan crisis, california and massachusetts helped bell of texas, which native texan politician has remembered. so we have seen this manifesting notice changes in governments pending during the recession have correlated to the changes in recovery over time across a number of countries. of course this begs the question of are we going to spend forever? fiscal multiplier is often go

below one. in 1997 would've been a good time to cut back on a variety of government ending. it argues for a data-driven roach in deciding when to undergo spending increases and what to spend on good food stamps are a good example. a number of people have concerts at any you do a safety net program, welfare will be permanent and people will be cheating the system and so on. there's been very good studies. one by the editor of the american journal of economics that founder is essentially no data to support these notions. in fact, quite a bit of data to support the opposite. i'm food stamps and general welfare of sense, people, not as the economy recovers and furthermore, the multipliers on programs that food stamps are particularly high because of people eligible are often not spending on other things when

they are unable to get food stamps. this is classic dilemma in public health where people can spend on their heating or spend on food. during periods where they are able to get food stamps, other spending is able to stimulate to much more than what the foodstamp expenditure costs. even if he didn't care about public health is a pure content, that result is a deficit reduction. i will say that it is however important to recognize that if difficult to find funding during a recessionary period. medicaid and other programs are classically programs where you have less of a tax base during the recessionary. because more people are unemployed. so how are you going to find safe as we need them the most? is there a better way as well? some of us have been working on international initiative, which

the goal is to simultaneously fund for tapes of programs we need when we have the least amount of money and at the same time, also discourage the things that led for a recession. we on a risky investment led to a recession. very few of us participate in risky investments. i doubt any of you went without a mortgage-backed security or so on. so the idea is to place a small fee, .005% of which is based on the old idea of the tobin tax on the highest risk commodity, does that the hedge funds and others are participating in the uri don't put our entire incomes. the cc was small, poorly transact hundreds of millions of dollars and subfreezing on the order of 5 billion or more due to the list of market volatility encourages heavy transactions.

naturally because of this mechanism, put the money will naturally increase during the highest risk to the feeds are undergoing the net with the most money to put in a safety net pool vice versa. the reason i would argue for such a system as well but maybe in a unique time, it actually not that unique. if you look at periods of recession, certainly over the last several years, we haven't had a recession this arch, but we've had many recessions. it's actually somewhat surprising when we are not in a recession if you look at the number of crashes taking base in the last few decades. my favorite is the tequila crisis of 1995. but it strikes me that we have price bubbles in a variety of commodities all the time. i will end by saying that essentially what i've learned

from understanding this data if you were to adopt the position's mantra do no harm and apply it to your social and economic policy, we may be better buffering people against economic shocks them with quite a bit dated to understand to understand what the best in terms of safety nets and that they reap for us. i will conclude by offering this quote. i noticed on, long, but it's worth going through, a speech from robert kennedy back in 1968. he says our gross national product now is over $800 billion a year. that gross national product if we should judge the united states of america, that gross national product counts air pollution and cigarette advertising to clear our highways of carnage. they counts special locks for doors and shows for people who break them. they counts destruction of the loss of her wonder in chaotic sprawl. it counts napalm and nuclear warhead and are cars for the

police to fight the rising niceties. they counts of television programs which glorify violence coming at the gross national product does not allow the hope of her children, quality of education or jury of you. it is include beauty of poetry or strength of marriages or intelligence of our public debate or the integrity of public officials. it measures neither wit nor courage, neither of us do our learning, neither compassion or devotion to country. it measures everything insured except that which makes life worthwhile and i can tell us everything about america and that's where we are proud that we are americans. i will end with that in thing for many people who worked on the data and the analysis i talked about, particularly david stuck her at oxford and take any questions you may have.

but i saw a book review today. i have not seen the book you don't assure you think what about the hospital of new orleans. ensure you are aware of the situation. i wonder how you increase onto that in light of what you have told us. just to give some context. the hospital of new orleans -- as the number of situations going on with health care new orleans similar to detroit. a number of locations around the country are suffering from such extensive deficits and debt that hospitals are closing among the safety net groups and among some private hospitals, we see cherry-picking phenomenon, which is alluded to both during the recession and since. i didn't talk a lot about health

care and health care insurance and how they suspect they carried recessionary. but i will say there were these really interesting studies in many teen 90s. the portion of health we could bifurcate everyone in the universe health care insurance, if i read had a fantastic doctor in perfect surgery and so would, how much could we improve u.s. health care? studies without commenting particularly on the hospital, where i don't have the details of their financial situation, but from what i understand, especially if everyone had perfect health care, we could buy between 15% and 20% of preventable deaths, which is really though. so the question is where did the rest come from and why do we talk so much about the social phenomenon?

the rest comes from how much we smoke or drink or exercise in the quality of the diet we can make you as much as is going on at the u.s. health care system, quite a bit base to be addressed is what is going on in our neighborhoods and communities to understand what's driving across the united states. >> here we go. i have actually two questions. one has to first of all i appreciate your data-driven information because it seems like we like that so much. when it is very black and white, it seems that people can't dispute it sometimes. but i was with some friends

today and i mentioned i was coming to this tonight and this one friend who is chairman of mary to a french man and spends a lot of time in france was railing about for you and what france has been doing, how one in four workers are government workers and how people want their pictures to be paid, but grants doesn't have the money to do it, et cetera, et cetera. i'm curious what you would say to that and then i have one more question. >> there's a lot of concern about the so-called world fair in the idea that i supplication results in huge problems in terms of paying pensions and so on. a number of people believed the same for the classic detroit. the data essentially don't show that. to summarize briefly, france bases of race better than

germany. but the cultural myth that is fair is so strong that it's very hard to dispute. similarly with germany greece episode, a lot of people are blaming greek workers in the premise everybody's working for the government. they're not working hard, just getting the payroll. there's a very common surveys uses the same survey across european countries to sample how hard people work, go go to overwrite it places on the couch and their businesses. the greeks did quite a bit higher than nejdra nance prior to the recession. so it's difficult when you've you have cultural myth perpetuating themselves. the concern i understand is that the government has a degree of inefficiency that private markets can cure, but that is based on ricardo's theory of contrarian advantage, which has some assumptions.

this assumption is that have perfect competition that we are in some settings under full employment in the capital doesn't fly across borders. all of which are violated under basically our entire global economy. so it's hard. i do not model for a living, but ricardo said clearly this is a model in the model can only apply when assumptions are violated. >> my second question has to do with is there anyone in washington d.c. at the sydney and a choir in and wanted to know more about what you are doing? >> many people as -- besides myself, i don't want to make it seem like a one-man show. there's a lot of people for whom this is old hat to be honest. the difficulty is that a lot of discussion about deficits and debt is really unintuitive. the standard macroeconomic prices government needs to spend

the site of short-term deficits. that is really unintuitive. it makes it easier soundbite to say we are in bad times, therefore we could cut back for a household, not a government and it's very hard to go through keynesian economic reasoning and political speech. that being said, very many folks who do want data-driven approach to our safety net. the best interest who would like to have a dramatic reduction are very compelling. do you mind just speaking into the microphone? >> in your or sampler card is assumptions or deal the sun

click >> are buried in footnotes. it's actually i think if you're interested in these issues with ricardo and comparative advantage, personal report to the group oxfam that was published in 2003. if you look at chapter two of that report, it was a major trade report. they discuss in great detail what the data are regarding trade agreement, the assumptions upon which trade should improve, which countries are true, which countries it seems to be violated and how drawn out off the last two decades. so i would recommend that reading. it is cited in the book in a chapter there that is one of the best chapters i've seen in terms of laying it all out and revisiting the original papers in space-time. okay, thank you.

[applause] >> judges are like umpires. umpires don't make the rules, they apply them. the role of an umpire to judge is critical. they make sure everybody plays by the rules, but it is a limited role. nobody ever went to a ballgame to see the umpire. the >> that came across as a statement sort of like jurisprudence that all the judges did was sit there and see whether the statute was within the strike zone or outside the strike zone. that suggested that the job of the justice was relatively mechanical. at least that's what the metaphor came across. when professor how good was questioned, she said yes, you don't want the justices to be the focus. you want the law to be the focus. but when the justices make a decision, the law is not always as clear as the overall coming

right down through the strike zone and there's always -- or very frequently some degree of judgment that is involved in determining whether the statute is constitutional or not. >> here are some of the books that are published in the 299 or a tv psychic ear as he. in february, untrue untrue

>> writing my memoirs was difficult in a way because journalists are unfamiliar with the word i. we are used to writing about others, not ourselves. i remember telling the "washington post" when i started to write the book that it wouldn't sell because it had no sex in that.

>> i think the most important thing the president can do to help the united states is to put a plan in place to keep the economy growing. if the economy doesn't grow, it's kind of a sophisticated concept for you, but if the economy doesn't grow, it's hard to make a living. so the main job of a president is to have the economic plan that helps keep economic growth alive. and so the major job is to keep the peace. >> up an extra in the 2013th president roosevelt, susan dunn discusses her book, "1940: fdr, wilkie, lindbergh, hitler- the election amid the storm" this annual festival is hosted by the frequently roosevelt presidential library and museum in height or come in york.

this is about 45 minutes. >> good afternoon, everyone. welcome to the afternoon session of the tee and into was about reading festival. .clark, supervisory archivist curator frank d. roosevelt library and i can't seem spent 10 years. it's the 10 anniversary of the building that allows us to host this event every year. this is one of my favorite bands because they get to showcase what we do in the archives of the roosevelt library, which is great writers and historians that the person you're about to your network. before we get started, a couple housekeeping matters. the first is will everyone please take etcher cell phones, pagers, thanks to pete that muscle imbalance and turn them off so that our program is an interactive. the second thing is i want to thank c-span for being here broadcasting this event