Health and the Great Depression: a reply to

et al In their response to my letter,1 Stuckler et al2 refer to cancer outcomes and the Great Depression as if I were suggesting a link between them. But this is to muddle the issue. What I said is that cancer mortality decreased during the Great Depression of the early 1930s. It is not correct, as it was maintained in the paper that I criticised, that ‘[c]onsistent with longer-term patterns commonly referred to as ‘epidemiologic transition, ’ chronic non-communicable dis-eases and injuries tended to rise during the Great Depression.’3 Second, Stuckler et al2 say they found ‘that the mechanisms linking economic changes to infectious diseases are complex and time-varying, but we cannot identify a plausible mechanism by which the Great Depression might have caused a decline in deaths due to pneumonia. ’ Since they cannot ‘identify ’ the mechanism, they deny what is shown by the statistical evidence. It is important to remember, however, that understanding of causal pathways often lags behind the identification of associa-tions. The lack of an explanatory mechan-ism does not negate the fact that oscillations of respiratory disease mortality appear strongly correlated with oscillation