Potentially positive systemic economic and political changes may entail large transitional health costs. These have often been underestimated ex-ante and are often neglected ex-post by incumbent governments. With the aim of drawing lessons for future transformations and the actions of policymakers, the paper reviews six past and current episodes of political, economic, and social transformation that were expected to generate greater political freedom, economic prosperity, and individual wellbeing, but that instead generated substantial increases in death rates, particularly among low-income groups.
The paper presents a taxonomy of causal factors behind the mortality crises that followed potentially positive political and economic reforms which were expected to move certain countries from a low social equilibrium to a higher one. The taxonomy of factors responsible for the discrepancy between ex-ante expectations and ex-post outcomes includes:
- the unexpected effects of rural-urban migration combined with an inelastic supply of public infrastructure;
- political reforms carried out in the absence of adequate administrative, legal, and redistributive institutions;
- the introduction of economic reforms under conditions of incomplete or distorted markets and institutions;
- and the unchecked contact between socio-economic groups characterised by different disease profiles.
The impact of the lack of democratic institutions is also explored when data allow.
Particular attention is placed on the transition to the market economy and liberal democracy of the former European communist countries. Between 1990 and 2014, the transition generated an aggregate excess of 17 million deaths, of which only a modest portion was due to population ageing. Despite its magnitude and a growing number of studies, the ‘transition mortality crisis’ has attracted limited attention from national authorities and international agencies. When it has been acknowledged, it has often been attributed to past shocks or irrelevant factors, thereby retarding the introduction of an adequate policy response. Unless actively managed by incumbent governments, the transition from a low to a high socio-economic equilibrium may therefore generate large health and social costs.
 The author would like to thank Luca Bortolotti and Bruno Martorano for helping with the data compilation and analysis, as well as Matti Pohyola, Vladimir Popov, and Vladimir Schkolnikov for sharing research in this field and for providing comments on an initial version of this paper. The usual caveats apply.
 Section 2 of this paper draw in part on Cornia (2004) and Cornia and Paniccia (2000).