Evidence from previ ous reces sions Effects on health

There is a substan tial body of research explor ing how chan ging economic condi tions affect health. In a review, Catalano et al. (2011) iden ti fied pro- and coun ter cyc lical asso ci ations between health outcomes and changes in the economy. Some of the strongest evid ence relates to increases in the frequency and sever ity of mental and beha vi oural disorders asso ci ated with job loss, includ ing suicide.¹ Importantly, there is evid ence that it is not only job loss itself but the fear of job loss that adversely affects mental health (Reichert and Tauchmann 2011).

For other health outcomes, the impact of economic down turns varies by age, sex, histor ical period, the analyt ical methods employed, the indic at ors used to measure economic change, and the depth of the reces sion. Creating a coher ent summary of the evid ence is further complic ated by discip lin ary differ ences in the liter at ure most frequently cited and in concep tu al iz a tions of caus al ity. The econom ics liter at ure takes little account of the public health liter at ure, on the whole, and emphas izes empir ical asso ci ations, often looking at overall mortal ity rather than mortal ity by cause. In contrast, the public health liter at ure seeks to identify whether there are plaus ible biolo gical mech an isms for what is observed (Stuckler et al. 2014).

In a series of papers, Ruhm and Tapia Granados (Tapia Granados 1991, 2005a, 2005b; Ruhm 2000, 2003, 2008; Gerdtham and Ruhm 2006; Tapia Granados and Ionides 2008; Tapia Granados and Diez Roux 2009) show that in high- income coun tries deaths (mortal ity) tend to rise during periods of economic growth² and fall as the economy slows down, with suicides a notable excep tion.

Road traffic deaths have shown a pro- cyclical pattern in rela tion to economic changes, with decreased road traffic deaths coin cid ing with growth in

unem ploy ment due to a drop in the volume of trans port and the number of jour neys made (Ruhm 2000; Tapia Granados 2005a; Stuckler et al. 2009a).

As a result, some have argued that reces sions improve health, perhaps because the reduced oppor tun ity cost of leisure time allows people to engage in health- enhan cing activ it ies such as exer cise; having less income lowers food, alcohol and tobacco intake; there is less employ ment in hazard ous working condi tions; and lower levels of work- related stress. Positive beha vi-oural changes such as reduc tions in overall alcohol consump tion have been repor ted during reces sions (Ruhm 1995; Freeman 1999; Dee 2001), mainly among indi vidu als who remain in employ ment; increases in alcohol intake have been repor ted among people who lose their jobs and among already heavy drink ers.

However, research based on more recent reces sions does not find that reces sions posit ively affect mortal ity (Huff Stevens et al. 2011; Ruhm 2013;

Tekin et al. 2013) and many indi vidual- level studies from a wide range of high- income coun tries find an asso ci ation between becom ing unem ployed and increased mortal ity (Martikainen and Valkonen 1996; Osler et al. 2003; Gerdtham and Johannesson 2005; Martikainen et al. 2007; Economou et al. 2008; Eliason and Storrie 2009; Sullivan and von Wachter 2009; Lundin et al. 2010; Montgomery et al. 2013; Mustard et al. 2013). A system atic review finds that unem ploy ment is asso ci ated with a signi fic antly increased risk of all- cause mortal ity in men and women of working age; those in the early and middle stages of their career were at partic u larly high risk and the asso ci ation was signi fic ant in the short and longer term, suggest ing that stress and negat ive effects on beha viour asso-ci ated with job loss persist even after work is resumed (Roelfs et al. 2011).

Prolonged unem ploy ment in early adult hood in men has also been asso ci ated with accel er ated prema ture ageing (Ala- Mursula et al. 2013).

The imme di ate impact of reces sion on mental health is mostly reflec ted in greater risk of mental and beha vi oural disorders such as alcohol abuse and suicides among those who become unem ployed or face finan cial diffi-culties (Wahlbeck and McDaid 2012). Debts, inad equate income and mort gage payment prob lems are asso ci ated with psycho lo gical distress and increased mental disorders, partic u larly depres sion (Brown et al. 2005; Taylor et al. 2007;

Jenkins et al. 2008), while unem ploy ment, espe cially long- term unem ploy ment (Janlert and Hammarstrom 1992; Dee 2001; Mossakowski 2008), and finan cial strain (Shaw et al. 2011) are asso ci ated with heavy drink ing. A large study of the experience of European countries over three decades found that a rapid (defined as more than three percentage points) rise in unemployment levels in one year was asso ci ated with a signi fic ant increase in deaths from alcohol abuse in people aged under 65, indic at ing that the short- term negat ive effects of unem ploy ment give rise to major psycho lo gical distress (Stuckler et al. 2009a).

A recent system atic review and meta- analysis found a strong asso ci ation between long- term unem ploy ment and suicide and attemp ted suicide, which is partic u larly marked within five years of job loss, but persists after this period (the average follow- up time was eight years) (Milner et al. 2013). Suicides have tended to rise rapidly follow ing severe economic crises, driven primar ily by rises in unem ploy ment (Catalano et al. 2011). In their analysis of mortal ity in the European Union (EU) between 1970 and 2007, Stuckler et al. (2009a)

Figure 6.1 Association (Spain) and lack of asso ci ation (Sweden) between unem ploy ment and suicide during reces sion, 1980–2005 Source: Stuckler et al (2009a).

found that two coun tries – Finland and Sweden – managed to decouple suicides from rising unem ploy ment in the early 1990s (Figure 6.1). The authors attrib ute this to the pres ence of strong social protec tion mech an isms, in partic u lar active labour market programmes. However, even in Sweden, where suicides did not increase during the reces sion, unem ployed men were at higher risk of suicide in the five years after the reces sion (Garcy and Vagero 2013). In Finland, suicides were not asso ci ated with unem ploy ment during the down turn, but increased as the economy grew; this was asso ci ated with an increase in average levels of alcohol consump tion among men (Hintikka et al. 1999).

Another recent system atic review and meta- analysis found that perceived job insec ur ity was asso ci ated with higher incid ence of coron ary heart disease (CHD)³ (Virtanen et al. 2013). In addi tion, a cohort study from Sweden found that middle- aged men who became unem ployed for longer than 90 days had a signi fic antly higher risk of hospit al iz a tion for CHD over the next eight years, adjust ing for known CHD risk factors (Lundin et al. 2014).

Research using data from the German Socioeconomic Panel found that unem-ploy ment worsened the mental health of people who lose their jobs and of their spouses, suggest ing that the public health costs of unem ploy ment are under es-tim ated because they do not usually account for poten tial impact on family members (Marcus 2013). When looked at over the life course, economic condi-tions at birth influ ence cognit ive func condi-tions later in life (after 60); being born during a reces sion is negat ively asso ci ated with numer acy, verbal fluency, recall abil it ies and overall cognit ive abil it ies in old age (Doblhammer et al.

2013). Similar effects have been observed in rela tion to expos ure to reces sions during early and middle adult hood (Leist et al. 2014).

Although the avail able evid ence mainly shows that unem ploy ment and finan-cial insec ur ity increase the risk of mental health prob lems and to some extent cardio- vascu lar disease, there is a lack of consist ent evid ence on their effects on many other health outcomes. However, in spite of complex it ies related to the differ ent methods used in the studies described in this section, and their compar-ab il ity, the evid ence suggests that economic down turns adversely affect infant mortal ity. Studies from the United States have shown that mortal ity from unin ten tional injur ies and Sudden Infant Death Syndrome increased during reces sions, a finding attrib uted to parents spend ing less time and effort monit-or ing chil dren (Bruckner and Catalano 2006; Bruckner 2008).

A system atic review has found evid ence of increased risk of commu nic able disease outbreaks during reces sion, attrib uted to factors such as higher rates of contact with those who have infec tions among people in poorer living circum stances, barri ers to access ing treat ment and lower rates of complet ing courses of treat ment (Suhrcke et al. 2011). The review iden ti fied high- risk groups (includ ing migrants, home less people and prison inmates) as partic u-larly vulner able conduits of epidem ics during reces sions.

In summary, evid ence from previ ous reces sions indic ates that the scale and nature of the impact on popu la tion health varies, although a common finding is that health outcomes gener ally worsen in people who become unem ployed.

Unemployment is the strongest predictor of adverse health outcomes in reces-sions and mental health is partic u larly sens it ive to economic changes. Trends in overall mortal ity are not affected by reces sion, but specific causes of death are:

144 Economic Crisis, Health Systems and Health in Europe

suicides tend to increase and road traffic acci dents tend to fall. In a reces sion, risk beha viours such as alcohol consump tion and smoking may decline overall due to reduc tions in dispos able income, but increase among people who binge- drink or are unem ployed. Changes in other health indic at ors vary depend ing on a country’s response to reces sion.

Three points are worth high light ing. First, we should be cautious when extra-pol at ing from studies examin ing normal swings in the economic cycle to large- scale crises such as the current crisis in Europe. Box 6.1 summar izes the health effects of two major twen ti eth- century crises and finds evid ence of negat ive effects on health. Second, a clear research finding is that economic changes do not have the same effect on the whole popu la tion: improve ments for some may mask adverse effects on others, espe cially on more vulner able groups of people.

Third, negat ive health effects can be mitig ated by public policy actions, as we set out in the follow ing para graphs.

Box 6.1 Major economic crises in the twen ti eth century

Research on the health of Americans during the Great Depression found that while suicides rose, overall mortal ity fell, driven by a decrease in infec tious diseases and road- traffic acci dents (Fishback et al. 2007). (Stuckler et al. 2011b). Two major policies played a role in mitig at ing the impact of the Great Depression: Prohibition, which preven ted a surge in alcohol- related deaths, and the New Deal, which included stim u lus programmes that created jobs and enhanced social protec tion (Stuckler and Basu 2013).

The break- up of the USSR was followed by economic collapse in the newly independent states (Sachs 1994; Wedel 2001), which had major consequences for popu la tion health across the region, with mortal ity increases of up to 20 per cent in some coun tries. Deaths were mainly concen trated in men of working age: male life expect ancy fell by between four and seven years. The avail ab il ity of cheap alcohol and its surrog ates played a central role in the rise of mortal ity in the region, partic u larly in the Russian Federation (Leon et al. 2009). However, it was not just the drink ing habits of some of the population that led to the sudden rise in deaths among younger men. Declines in life expect ancy were greatest in coun tries exper i en cing the most rapid pace of trans ition (Stuckler et al.

2009c) brought on by radical privat iz a tion policies and unem ploy ment, a finding mirrored in differ ent parts of the Russian Federation and across the former Soviet Union (Walberg et al. 1998). To some extent, adverse consequences were mitig ated in coun tries with high levels of member ship in trade unions, reli gious groups and sports clubs – a widely used marker of strong informal social protec tion mech an isms.

Mitigating negat ive effects on health

The negat ive effects of reces sion can be mitig ated by govern ment policies already in place and those intro duced in response to an economic shock.

Protective factors include the pres ence of formal social safety nets, partic u larly active labour market programmes and programmes target ing the most vulner-able groups of people (Stuckler et al. 2009b); informal protec tion mech an isms, such as member ship of trade unions, reli gious groups and sports clubs (Stuckler et al. 2009c); and coun ter cyc lical public spend ing on social protec tion, includ ing health (Marmot et al. 2012). An analysis of public spend ing in OECD coun tries over 25 years showed that each US$100 increase in public spend ing on social protec tion⁴ per person per year was asso ci ated with a 1 per cent reduc tion in overall mortal ity and a 2.8 per cent reduc tion in deaths related to social circum stances (for example, alcohol- related deaths)⁵ (Figure 6.2) (Stuckler et al. 2010). Recent research in the United States also suggests that between 1968 and 2008, more gener ous state unem ploy ment benefit programmes moder ated the rela tion ship between unem ploy ment rates and suicide (Cylus et al. 2014).

A recent review iden ti fies access ible and respons ive mental health services as being key to support ing people during diffi cult times; it high lights the role of advice centres and legal restric tions on high- interest loan compan ies in helping to reduce other wise unman age able debts (Wahlbeck and McDaid 2012). A large body of evid ence from model ling studies (Purshouse et al. 2010; Lhachimi et al.

2012) and exper i ence from Canada show that a 10 per cent increase in minimum alcohol pricing is asso ci ated with a 32 per cent decrease in alcohol- related

Figure 6.2 Relation between devi ation from country average of social welfare spend-ing (exclud spend-ing health) and all- cause mortal ity in 15 EU coun tries, 1980–2005

Source: Stuckler et al (2010).

146 Economic Crisis, Health Systems and Health in Europe

deaths (Zhao et al. 2013). This suggests that stricter alcohol control policies can prevent those already at risk from damaging them selves further.