CommentaryWill the recession be bad for our health? It depends
Introduction
The recent financial and economic crisis has raised major concerns in the public health community that death, illness and disability will rise in both rich and poor countries across the globe, and that the operation of health systems will be compromised both by increased demand for treatment and reduced health budgets. Such fears are supported by, among others, a wealth of epidemiological evidence on the strong and positive associations at the level of the individual between lower income, unemployment and poor health (Catalano & Bellows, 2005; Clark & Oswald, 1994; McKee-Ryan, Song, & Wanberg, 2005; Murphy & Athanasou, 1999; Gallo, Bradley, & Dublin, 2004). The idea that the financial crisis will harm health also reflects the findings of the Commission on Social Determinants of Health published in 2008 (Marmot, Friel, & Bell, 2008), as argued in a recent article in the British Medical Journal (Marmot & Bell, 2009).
Several researchers, however, argue the opposite: recession might actually improve health, at least in the short run. Research in the USA and Europe finds pro-cyclical worsening of mortality during expansions and improvement during recessions, with recession associated with lower road-traffic injuries and alcohol-related deaths and hospital admissions (Gerdtham & Ruhm, 2006; Ruhm, 2008; Tapia-Granados and Lonides, 2008). These studies have led some commentators to speculate, perhaps slightly with ‘tongue in cheek’, that “Good News: Recession may make you healthier!”(Bougerol, 2009) and that “recession may be a lifestyle blessing in disguise” (Cohen, 2009).
This commentary aims to elucidate this seemingly contradictory evidence with a summary of the existing evidence on the actual and potential impact of recessions on health, in order to distil some lessons as to the expected health effects of the current crisis and as to how policy should respond, if at all. We find that the relationships involved are complex, but that some of the complexity may be reduced by highlighting a set of factors on the causal chain that influence the direction and magnitude of the resulting health effects.
Section snippets
What does the existing evidence tell us?
In order to structure the diverse evidence base, spanning multiple disciplines and limiting potential for a quantitative systematic meta-analysis, we reviewed a limited set of seven factors and interactions putatively on the causal chain, including differential exposure, vulnerability, protective factors, levels, distribution, outcomes and their temporality, that are likely to matter when trying to answer the overarching question of whether and, if so, how recessions affect health.
Individual vs aggregate relationships
According to the International Labour Organization, the global economic crisis had led to an additional 22 million people unemployed worldwide in 2009 alone, with a particularly pronounced increase in developed economies and the European Union (ILO, 2011). Individual level primary epidemiological research that has analysed the health effects of unemployment and country or state level ‘ecological’ research that focuses on the relationship of macroeconomic indicators such as unemployment may
Poor countries vs rich countries
The above discussion has focused on rich countries, characterised (1) by populations whose average level of wealth may serve as a “cushion” against any income shocks and (2) by social safety nets that provide formal insurance mechanisms (if to varying degrees across countries). In poor countries, with large shares of the population living in or close to abject poverty, any aggregate income shock is likely to push many people below subsistence levels. A further cut in available resources and
Average health effects vs health equity effects
The bulk of the studies on the health effects of recessions (or of economic upturns) has focused on population averages, mainly due to constraints in the available data. This is a potentially important shortcoming, as it is very likely that the health of different subgroups of the population will respond differently to a given economic crisis. If the net effect of those responses is an improvement or no change in health in the population on the whole, this may lead policymakers to infer that no
“Normal” fluctuations vs “severe” crises
A difficulty with interpreting historical data is that the majority of the existing studies at country level do not actually evaluate “recession” per se, but rather base their analyses on routine fluctuations in gross domestic product (Ruhm, 2003, 2006; Tapia Granados, 2008). Economy-health relationships during ‘steady-state’, or normal, business-cycle peaks and valleys may differ substantially from those occurring under exceptional market circumstances, as in an acute financial crisis.
Short term vs long term effects
It is plausible that there is a difference between the short and the long term effects of a crisis. In particular, one might think that any potentially existing short-term positive health effects of a crisis could be more than outweighed by adverse long term health effects. Risks of cancer from a rise in tobacco use as a coping response to stress would require decades to manifest as lung-cancer, although ischaemic heart disease deaths could rise rapidly. Thus, it is important to identify the
Crisis with and without a “welfare state”
It is often assumed that social welfare systems will protect against economic downturn. Our review suggests this hypothesis has not yet been demonstrated universally in the literature.
Gerdtham and Ruhm (2006) looked at the potential role of social expenditures as a way to mitigate possible harmful health effects of economic upturns in OECD countries. They found that the effects are particularly harmful for countries with weak social insurance systems (as proxied by public social expenditure as
Concluding remarks
This commentary addresses the question of whether the current economic crisis will be harmful to the health of populations in rich and poor countries. Our answer, based on a preliminary review of the evidence discussed in this commentary, is: “It depends!”. We tentatively identified a number of key issues that likely play a critical role in the significance and direction of any resulting health consequences.
Based on our review, for high-income countries, if past experience is any guide, it
Acknowledgements
The authors gratefully acknowledge financial support from the European Observatory on the Social Situation at the London School of Economics and from the European Centre for Health Assets and Architecture. MS also gratefully acknowledges partial support from the Centre for Diet and Activity Research (CEDAR), a UKCRC Public Health Research Centre of Excellence.
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