Fast track — ArticlesThe public health effect of economic crises and alternative policy responses in Europe: an empirical analysis
Introduction
Many commentators have expressed concern that the present economic downturn will adversely affect public health as a result of job losses, contributing to mental health or addiction problems, the adoption of less healthy lifestyles (such as increased consumption of cheap food with little nutritional value, or smoking as a response to stress), and poor disease management resulting from overburdened health-care services or delays seeking care for patients who are concerned about additional costs. WHO has warned that “it should not come as a surprise that we continue to see more stresses, suicides and mental disorders”; “the poor and vulnerable will be the first to suffer”; and “defending health budgets” will become more difficult.1, 2
Yet many analysts have argued that overall health might not be affected by economic downturns; indeed, some argue that a recession could lead to health gains. Studies undertaken in high-income countries have suggested that mortality has tended to fall when the economy slows down and conversely rise when the economy speeds up.3, 4, 5, 6, 7 These effects vary substantially for different age groups,8 sexes, and diseases,9, 10 and the results are somewhat sensitive to the indicators used to measure economic change.11, 12, 13, 14 Although Catalano and Bellows15 have noted the counterintuitive nature of these findings, it has been postulated that recessions lead people to engage in fewer unhealthy, so-called affluent activities (overconsumption of food and alcohol) and spend more time in health-promoting activities (eg, walking instead of driving), which has led some to speculate that a recession might make you healthier.16, 17 Which view of the effect of economic downturns on public health is best supported by empirical data?
Existing published work on the relation between economic trends and public health offers only an incomplete understanding of the present economic situation. Most previous studies have not analysed the effects of recession per se on health, but instead have assessed the static effects of routine peaks and troughs in total economic output (gross domestic product [GDP]) or GDP per person. These measures can ascertain whether death rates are relatively high when GDP is relatively low, but do not assess whether death rates rise after GDP falls, as in a recession. Other studies have recorded trends in mortality during periods of recession, but have not corrected for possible confounding variables.18 One study has shown that a serious financial crisis, as opposed to common economic fluctuations during the business cycle, does adversely affect health generally, although the specifics are unclear.13
Furthermore, although GDP might be the most widely used measure of the state of the economy, it is distant from the everyday experience of individuals, especially since it relates to the average income of a country and does not comment on inequality within countries. Instead, examination of measures such as unemployment or consumer confidence could be more relevant to capture the economic turmoil and insecurity faced by the population during periods of economic uncertainty. Of all the possible economic measures, unemployment is the most widely available indicator of economic difficulty, and previous research has shown that fluctuations in employment are more closely associated with short-term changes in health than are other economic indicators.5 Although decreases in GDP are generally connected with rises in unemployment, the strength of this association varies greatly across countries and over time, reflecting factors such as fiscal responses to recession and employment legislation. Poor and vulnerable members of the population are most sensitive to unemployment, and could be missed by GDP that measures a country's average income. To overcome these gaps in our knowledge, we assessed the effects of significant financial events on mortality with measures of employment, examining causes of death at different ages and in both men and women. We also checked the robustness of our findings to other economic indicators, such as GDP per person, hours worked, and alternative measures of unemployment.
A crucial question is how to respond to any recorded effect of economic change on public health.15 Growing evidence suggests that countries have different health responses to exogenous shocks. For example, in countries emerging from communism in Europe in the early 1990s, the adverse consequences of rapid economic reforms were reduced in countries in which many people were members of social organisations, such as trade unions, religious groups, or sports clubs.19 Similarly, the Asian economic crisis seemed to have few health consequences in Malaysia, but far more significant consequences in Indonesia and Thailand; Malaysia's rejection of World Bank advice to reduce health expenditures, as opposed to Thailand and Indonesia's adoption of this advice, probably contributed to the different outcomes in these countries.20 Other research has suggested that the adverse health effects of economic fluctuations might be reduced when there are high levels of social protections.7 Individual-level studies have shown that the health effect of social programmes varies greatly by the type of social programme and, in some cases (such as with youth opportunity schemes), could be adverse.21, 22 Although these individual-level studies provide a hypothesis that governments might be able to reduce any potential negative effects of economic downturns on population health, the specific scope and scale of social programmes need to be understood since they relate to protecting health during economic turmoil.
Much of the previous work assessing the association between countries' economic cycles and public health outcomes has been limited to individual countries, such as Finland,23 Germany,24 the USA,5 Japan,6 Spain,25 and Denmark.26 To understand whether, and under what circumstances, increased unemployment might be linked to worse health outcomes across populations, and what social programmes may mitigate these effects, we extended our analysis to a large international dataset for mortality and employment, encompassing 26 European Union (EU) countries from 1970 to 2007. To assess the plausibility of our statistical observations within populations, we calculated the expected effect of employment changes on mortality, on the basis of the effect sizes reported previously in studies of individual countries. We also examined trends in deaths from different causes to assess the biological plausibility of reported statistical trends—eg, changes in death rates from neoplasms are unlikely to be attributable to short-term events in view of the typically lengthy delay between exposure to carcinogens such as tobacco and death from lung cancer, whereas deaths from events such as suicide can occur rapidly after the onset of changed economic circumstances.
Section snippets
Data collection
Age-standardised and age-specific mortality data were taken from the WHO European Health for All database (basic and mortality database versions, respectively). Mortality rates were age-standardised by the direct method, according to the European Standard Population.27 Official unemployment data were taken from the International Labour Organisation (ILO) Key Indicators of the Labour Market, which defines unemployment as all people who were without work yet available for or seeking employment.
Results
Figure 1 shows the results of 29 regression models of different diseases for 26 EU countries between 1970 and 2007 (on average more than 550 country-years). After correcting for population ageing, past employment and mortality trends, and country-specific differences in surveillance, we noted that every 1% rise in unemployment rates was associated with a 0·79% rise in suicides at ages younger than 65 years (95% CI 0·16–1·42; 60–550 potential excess deaths [mean 310] EU-wide) and a 0·79% rise in
Discussion
We have shown that rapid and large rises in unemployment were associated with short-term rises in suicides in working-age men and women and in homicides; adverse health effects on suicides were mitigated when investments in active labour market programmes were high (>$190 per head). Rapid increases in unemployment were also associated with short-term reductions in road-traffic fatalities. We noted no consistent evidence across the EU that all-cause mortality rates increased or decreased when
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