Social Science & Medicine 74 (2012) 647e653
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Social Science & Medicine
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Commentary
Will the recession be bad for our health? It depends
Marc Suhrcke a, *, David Stuckler b, c
a
University of East Anglia, Norwich Medical School, Health Economics Group, Norwich NR4 7TJ, UK
University of Cambridge, UK
c
London School of Hygiene & Tropical Medicine, UK
b
a r t i c l e i n f o
Article history:
Available online 4 January 2012
Keywords:
Economic recession
Health
Health determinants
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; McKeeRyan, 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 alcoholrelated 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
* Corresponding author. Tel.: þ44 1603 59 3536; fax: þ44 1603 59 3604.
E-mail address: [email protected] (M. Suhrcke).
0277-9536/$ e see front matter Ó 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.socscimed.2011.12.011
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.
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
648
M. Suhrcke, D. Stuckler / Social Science & Medicine 74 (2012) 647e653
level ‘ecological’ research that focuses on the relationship of
macroeconomic indicators such as unemployment may inform us
about what the health effects of such trends may be.
Both approaches provide seemingly contradictory predictions.
At the risk of slight over-simplification, the former suggests health
would deteriorate with increasing unemployment (and hence in
a recession), while the latter tends to suggest the opposite: if
anything, health improves during recessions. We briefly summarise
each of the two perspectives in turn and discuss their compatibility.
Individual level evidence
A large body of research has documented the detrimental effects
of unemployment on health at the individual level. For instance,
studies on unemployment and mortality in Britain in the 1970s and
1980s showed that unemployed people had a mortality rate 20%e
25% higher than average for people of the equivalent socioeconomic group (Bethune, 1997; Moser, Goldblatt, Fox, & Jones, 1990).
Beyond the UK, Stern (1983), Creed (1998), and Ungváry, Morvai,
and Nagy (1999) review the existing evidence of the various
pathways through which unemployment affects individual health.
They find that unemployment is detrimental to the individual’s
standard of living and financial resources. Restricted financial
resources can lead to poor nutrition and restriction to access to
health care when needed. As Martikainen and Valkonen (1996 and
1998) indicate, this may cause increased physical morbidity and
mortality. Martikainen and Valkonen (1996) show that individuals
who experience unemployment exhibit greater mortality rates
compared to their employed counterparts, after controlling for
demographic and socioeconomic indicators. Furthermore, Morris,
Cook, and Shaper (1994) show that not only unemployment
experience, but also the duration of unemployment spells, increase
the risk of mortality after controlling for potential confounders
such as age, race, marriage, income, and occupational class.
More generally, other individual level analysis has repeatedly
shown the detrimental health effects of low socioeconomic status
and position, proxied by low income, poor education, lower-skilled
jobs or indeed unemployment. Lower socioeconomic status, is
associated with worse physical health (Blakely, Lochner, & Kawachi,
2002; Ecob and Davey-Smith, 1999; Grundy & Holt, 2000; Wagstaff,
Paci, & Joshi, 2001), lower emotional and psychological health
(Everson, Maty, & Lynch, 2002; Theodossiou, 1998), and increased
risk of mortality (Gardner & Oswald, 2004; Goldman, Korenman, &
Weinstein, 1995; Van Rossum, Van de Mheen, & Mackenbach,
2000).
Aggregate level analysis
This entire body of rather robust and consistent individual level
evidence would lead one to conclude that a recession that is typically characterised by a significant increase in unemployment
would be expected to also harm health at the aggregate, national
level. Such a conclusion was drawn from work by Brenner (1975,
1977, 1979) and Brenner and Mooney (1982), who used aggregate
time series data.
Brenner’s work, however, has been severely criticised (e.g.
Wagstaff, 1985), mainly on the grounds of omitted variable bias,
structural instability of the relationships, lag-misspecifications and
data inconsistencies.
Later work (Gerdtham & Johannesson, 2005; Neumayer, 2004;
Ruhm, 2000, 2003, 2006, 2008; Tapia Granados, 2005, 2008) that
also used aggregate data over time for a range of high income
countries, has effectively turned the Brenner Hypothesis up-sidedown by showing that negative deviations from the long term
per capita GDP trend are closely associated with reductions in
a wide range of cause-specific mortality rates (with the notable
exception of suicide rates that consistently accelerate in recessions). So-defined “recessions” would accordingly seem to be ‘good’
for overall health, at least in the short run..
The contrasting results between the individual level and the
aggregate level evidence appear puzzling at first sight, but can be
reconciled upon closer inspection. They are consistent with
a scenario in which those that do fall into unemployment during
a recession are indeed likely to suffer worse health. At the population health level, however, this effect appears to be more than
compensated by improvements in the average health of the rest of
the population.
Ruhm and others argue that during recessions health improves
as individuals both improve their dietary habits and reduce lifestyle
habits detrimental to health (e.g. Ruhm, 2000). Reasons include an
increase in leisure time augmenting the possibility of health
enhancing activities such as exercise; a decrease in exposure to
hazardous working conditions, physical exertion and in working
hours; and a reduction in individuals taking risks and indulging in
activities such as smoking drinking and excessive eating of high fat
diets due to lower incomes.
However, a minority of recent studies, applying similar techniques to Ruhm (2000), but using Swedish (Gerdtham &
Johannesson, 2005; Svensson, 2007) and European data
(Economou, Nikolaou, & Theodossiou, 2008), did not find such a procyclical relationship between the business cycle and mortality.
Further below we discuss briefly some of the factors that may
help account for part of the observed differential health response
across countries.
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 hence in consumption in an under-nutrition setting seems very likely to be health and possibly life-threatening in poor countries, while the same
income shock may be health-enhancing in a rich country situation
of ‘over-nutrition’. Thus, health impacts depend crucially on how
households cope with sudden losses of income.
Such predictions are indeed widely confirmed by the existing
literature. In a recent review of the evidence on the effects of
recessions on human capital across a range of income strata,
Ferreira and Schady (2009) find that in richer countries (e.g. the US)
child health and education outcomes are counter-cyclical: they
improve during recessions. In poorer countries, mostly in Africa and
low-income Asia, the outcomes are pro-cyclical: infant mortality
rises, and school enrolment and nutrition fall during recessions. In
the middle-income countries of Latin America, the picture is more
nuanced: health outcomes are generally pro-cyclical, and education
outcomes counter-cyclical.
However, not all studies on the health effects of economic crises
in developing countries detect harmful health effects. When
comparing the effects of the East Asian crisis in Indonesia, Thailand
and Malaysia, Hopkins (2006) finds that while the crisis was
associated with (short-lived) increases in the mortality rate in the
former two countries, there was little apparent impact on health in
Malaysia. Hopkins attributes this differential impact to the fact that
the Indonesian and Thai government followed the World Bank
prescription for adjustment, which included a cut-back in
M. Suhrcke, D. Stuckler / Social Science & Medicine 74 (2012) 647e653
government spending at a time when there were significant job
losses, while Malaysia chose its own path to adjustment. If this is
a correct assessment, this already raises the importance of the
policy response to a crisis in possibly mitigating (or not) the health
effects (see below).
Thus, there do appear to be different aggregate health responses
to recessions in the rich vs the poor countries. In the current
recession, overall, those rich countries more deeply integrated in
the global banking system’s centres were more exposed to toxic
debts and the ensuing financial meltdown, whereas the economies
of poor countries, after experiencing an initial export shock,
appeared to rebound more rapidly. However, poor countries are
more vulnerable to economic shocks overall, so that a crisis of
similar magnitude would likely do more economic damage in poor
than in rich countries. This means, that for a global recession, health
differences between poor and rich countries are expected to widen.
649
policies, such as social protection, appear to make a difference to
the income inequality effect of a given recession. For instance, the
reason why income inequality remained remarkably stable during
the economic crisis that hit the Scandinavian countries in the early
1990s has been partly attributed to those countries’ generous
levels of welfare support (Aaberge, Bjorklund, & Janitti, 2000).
However Aaberge et al point out that increased welfare benefits
during the crisis do not fully account for the stability in the income
distribution. Also, a recession such as the one experienced in
Scandinavian countries may have adverse long term distributional
repercussions. First, many unemployed workers might suffer from
human capital losses that will reduce their future earnings. Also,
the crises were costly for the public sector and resulted in budget
deficits. Perhaps the reductions in transfer programmes that were
motivated by these budget deficits will turn out to have larger
effects on income inequality than the rise in unemployment per se
(Aaberge et al., 2000).
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 specific action is needed to
counter the health effects. Upon closer inspection, however, there
may well be a good reason for intervention, if the health of specific
groups is at risk or if health inequities would be rising during
recessions.
Edwards (2008) examined mortality by individual characteristics during 1980s and 1990s using the U.S. National Longitudinal
Mortality Survey. Overall, individuals with extremely low education
(and presumably very low wages and wealth) were at risk of
declining health during periods of rising unemployment. Those
with a high school degree or more, who presumably have some
buffer-stock savings and better prospects of avoiding long-term
unemployment, benefited during recessions, perhaps from
working less hard or being exposed to less pollution. Those that
made up the middle socioeconomic groups tended not to be
affected (health-wise) by the recession. Similar evidence of unequal
impacts of recession come from other parts of the world. Kondo,
Subramanian, and Kawachi (2008) examined the impact of the
long lasting economic crisis in Japan during the 1990s on health
inequalities between socioeconomic groups using two repeated
cross-sectional surveys: from 1986 to 1989 and from 1998 to 2001.
Perhaps surprisingly, self-rated health improved in absolute terms
for all occupational groups even after the economic recession.
However, disaggregated analyses, controlling for confounding
factors, showed health inequalities had widened.
In contrast, other findings caution the extent to which unambiguous predictions can be made. Valkonen et al. (2000) document
the evolution of inequalities in mortality (by occupational category)
in Finland in the 1980s e a period of economic boom e and in the
1990s e over a severe and prolonged recession. While health
mortality inequalities widened in both periods, the increase in
health inequalities was markedly smaller during the recession of
the 1990s than in the 1980s.
Clearly, more research is needed to understand the health
equity implications of recessions (and economic upturns). In order
to develop at least a more informed hypothesis as to the expected
health equity consequences for the current economic crisis, it is
perhaps worthwhile to begin by understanding the past impact of
recessions on the distribution of incomes per se, Government
“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 ‘steadystate’, or normal, business-cycle peaks and valleys may differ
substantially from those occurring under exceptional market
circumstances, as in an acute financial crisis. Although studies
have evaluated routine “business cycles”, they have yet to test
properly the theory that “recession” may adversely affect a society’s health. If the current economic crisis is indeed comparable to
the Great Depression, the existing research provides limited
relevance for forecasting the effects of the current crisis (Catalano,
2009).
In a first attempt to assess whether a “substantial” economic
downturn makes any difference compared to a smaller economic
downturn, we have looked at the effects of (1) a 1% increase in
unemployment rates compared (see Fig. 1a) to (2) a >3% increase in
unemployment (see Fig. 1b) in 26 EU countries over the period
1971e2006. The overall health indicators e all cause-morality and
life expectancy e do not appear to be affected. However, some of
the cause-specific mortality rates do appear to be affected by the
severity of the crisis. For instance the size and (sometimes) the
significance of the increase in suicide rates, homicides, alcohol
poisoning, psychiatric disorders, liver cirrhosis and ulcers all tend
to be greater in the context of “massive” increases in
unemployment.
Evidently, these preliminary conclusions require further examination. One interesting avenue of further research would be to
code recessions more properly as well as to distinguish different
types of “recessions”.
Physical vs mental health
Another important dimension of the health consequences of
crisis is physical and mental health. It is unlikely that effects of
economic shocks would be similar across disease types. Notably, as
shown in the above figures, the main causes linked to significant
short-term effects all reflect psychological problems, providing
support to the notion that mental health is especially likely to be
harmed during the course of a recession. Ultimately the potential
differential impact on physical vs mental health should be examined with the help of longitudinal micro data rather than through
aggregate mortality statistics.
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M. Suhrcke, D. Stuckler / Social Science & Medicine 74 (2012) 647e653
a
Cause of Death
Country-Years
Effect
Size (95% CI)
External Causes
Suicide
Suicide (0-64)
Homicide
Drug Abuse
Alcohol Poisoning
Accidents
Drowning
Poisoning
Ill-Defined Causes
Transport Accidents
Falls
Cardiovascular Disease
Cardiovascular Disease (0-64)
Ischaemic Heart Disease
Cerebrovascular Disease
Psychiatric Disorders
Liver Cirrhosis
Ulcer
Neoplasms
Lung Cancer
Alzheimer
Diabetes
Diabetes (15-44)
Maternal Mortality
Infant Mortality
Infectious Diseases
Respiratory Infections
Tuberculosis
All-Cause
662
657
657
496
261
203
516
506
504
611
515
516
662
662
660
662
490
662
514
662
661
500
655
499
584
671
660
511
462
521
-0.25 (-0.68, 0.18)
0.49 (-0.04, 1.02)
0.79 (0.16, 1.42)
0.79 (0.06, 1.52)
-3.75 (-7.67, 0.17)
0.81 (-5.93, 7.54)
-0.45 (-0.88, -0.02)
-0.16 (-1.34, 1.04)
-0.09 (-1.90, 1.73)
-1.48 (-3.51, 0.54)
-1.39 (-2.14, -0.64)
0.11 (-0.42, 0.65)
0.03 (-0.25, 0.30)
0.13 (-0.16, 0.42)
0.31 (-0.15, 0.77)
-0.16 (-0.45, 0.14)
-0.71 (-3.47, 2.05)
0.12 (-0.78, 1.02)
0.24 (-0.44, 0.91)
0.04 (-0.07, 0.16)
0.05 (-0.14, 0.24)
0.12 (-1.71, 1.96)
0.54 (-0.33, 1.40)
0.46 (-1.68, 2.60)
-0.17 (-3.06, 2.73)
-0.06 (-0.59, 0.47)
-0.31 (-1.18, 0.56)
1.89 (0.02, 3.76)
0.18 (-0.58, 0.94)
0.05 (-0.19, 0.29)
-6 -4 -2
0
Decreases MR
2
4
6
Increases MR
Percentage Change
Fig. 1a. Associations of a 1% rise in unemployment with Age-standardised mortality rates. b. Associations of a Mass rise (>3%) in unemployment with Age-standardised mortality
rates. Source: adapted from Stuckler et al. (2009). Notes: Coefficients are presented from 29 regression models. Error bars are 95% confidence intervals based on robust standard
errors clustered by country. Data are from the World Health Organization European Health for All Database 2008 Edition (HFA-MDB).
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 lungcancer, although ischaemic heart disease deaths could rise
rapidly. Thus, it is important to identify the links of the economic
consequences of recession to specific behaviour changes and the
temporality of their effects on specific health outcomes. However,
few studies have examined the difference between short and long
term effects in great detail, a methodologically challenging task,
and those studies that have done so, find mixed results.
Ruhm (2000), for instance, has indirectly provided an answer to
the question when he looked at the differential health response to
economic booms, which he showed to be health damaging in the
short run. At the same time though he points out that if growth is
long lasting, then the short-term effect will be partially or fully
offset. By contrast, Tapia Granados (2005), after careful analysis
finds the closest statistical association between current economic
fluctuations and current mortality changes, at least in the US data
he examined. In our analysis we found that the bulk of mortality
increases linked to crisis occurred in the contemporary period.
There is also some evidence from the current crisis that suicide risk
increased in anticipation of economic shocks (Stuckler, Sanjay,
Suhrcke, Coutts, & McKee, 2011), consistent with evidence that
fear of job loss may be worse for health than actual unemployment
(Perlman & Bobak, 2009).
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
a share of GDP).
While the overall average health impact of recessions at least in
high income countries may be positive, we have earlier pointed out
the fairly consistent finding of the adverse mental health effect of
economic crises, as evidenced by the surge in suicide rates. Would
M. Suhrcke, D. Stuckler / Social Science & Medicine 74 (2012) 647e653
651
b
Cause of Death
Country-Years
Effect Size (95% CI)
External Causes
Suicide
Suicide (0-64)
Homicide
Drug Abuse
Alcohol Poisoning
Accidents
Drowning
Poisoning
Ill-Defined Causes
Transport Accidents
Falls
Cardiovascular Disease
Cardiovascular Disease (0-64)
Ischaemic Heart Disease
Cerebrovascular Disease
Psychiatric Disorders
Liver Cirrhosis
Ulcer
Neoplasms
Lung Cancer
Alzheimer
Diabetes
Diabetes (ages 15-44)
Maternal Mortality
Infant Mortality
Infectious Diseases
Respiratory Infections
Tuberculosis
All-Cause
662
678
678
496
261
203
516
506
504
629
515
516
662
662
660
662
490
683
514
662
661
500
677
499
584
684
660
511
462
521
0.72 (-2.99, 4.44)
3.93 (0.48, 7.38)
4.45 (0.65, 8.24)
5.98 (-2.98, 14.90)
-19.80 (-40.60, 0.95)
28.00 (12.30, 43.70)
-0.02 (-3.88, 3.83)
-2.84 (-10.90, 5.23)
0.11 (-5.96, 6.19)
3.92 (-12.55, 20.39)
-4.18 (-8.52, 0.17)
5.42 (-0.18, 11.00)
-1.10 (-3.65, 1.45)
0.14 (-2.70, 2.99)
-0.60 (-4.31, 3.10)
-2.05 (-5.93, 1.84)
1.81 (-18.20, 21.80)
4.39 (-3.94, 12.72)
3.66 (-3.68, 11.00)
0.25 (-0.75, 1.24)
-1.07 (-2.53, 0.40)
-6.80 (-25.90, 12.30)
6.78 (-3.39, 17.14)
-8.54 (-20.50, 3.46)
1.14 (-24.60, 26.90)
1.17 (-1.77, 4.11)
0.92 (-6.16, 8.00)
3.23 (-4.60, 11.10)
1.97 (-5.91, 9.85)
0.64 (-1.59, 2.86)
-30 -20 -10 0
10 20 30
Decreases MR
Increases MR
Percentage Change
Fig. 1b. Associations of a Mass Rise (>3%) in Unemployment with Age-Standardised Mortality Rates. Source: adapted from Stuckler et al. (2009). Notes: Coefficients are presented
from 29 regression models. Error bars are 95% confidence intervals based on robust standard errors clustered by country. Data are from the World Health Organization European
Health for All Database 2008 Edition (HFA-MDB).
there then be a role for some form of welfare policy to alleviate any
potentially adverse mental health effects?
According to recent findings by Stuckler, Sanjay, Suhrcke, Coutts,
and McKee (2009), such a mitigating effect does appear to exist, in
a sample of European Union countries analysed for the time period
1970-2007. The study reported that for every US$10 higher
investment in active labour market programmes, there was
a 0.038% lower effect of a 1% rise in unemployment on suicide rates
in people younger than 65 years (95% CI 0$004e0$071, p ¼ 0$028).
When this spending was greater than US$190 per head per year
(adjusted for purchasing power parity), a 3% rise in unemployment
was estimated to have no significant adverse effect on suicide rates
(Stuckler et al., 2009, p.7). More research is clearly needed to
examine this preliminary result, preferably using individual-level
data.
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 appears unlikely that the recession will have
major negative effects on overall population health indicators, such
as all cause mortality or life expectancy. The majority of evidence at
national level suggests that the effects may even be positive on
average in the short-term, likely resulting from a reduction in roadtraffic fatalities outweighing increases in suicides. Nevertheless, the
health of population groups particularly hard hit in economic
terms, e.g. through lay-offs, is likely to suffer in absolute and/or
relative terms (compared with wealthier groups), potentially
leading to widening health inequities. It is also likely that specific
diseases and cause-specific mortality rates will rise, such as suicide
rates, reflecting a significant harmful mental health effect associated with the recession.
In low-income countries, by contrast, it is likely that the global
economic crisis does pose a severe threat to overall population
health, as people can hardly cushion themselves through their own
accumulated wealth, nor can they expect wide-ranging social
protection support. In middle-income countries, there may well be
no effect in any direction. However, while several countries remain
exposed to volatility in food prices and currency fluctuations, the
direct consequences of the economic crisis were mainly borne out
in a short-term export reduction and most emerging economies
have recovered more quickly than those in the global North.
Overall, differences in health between rich and poor countries may
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M. Suhrcke, D. Stuckler / Social Science & Medicine 74 (2012) 647e653
well increase in the current recession as a result of differential
vulnerability in the latter.
Because much of the existing evidence focuses on the health
effects of ‘normal’ business cycle fluctuations, the actual transferability of those findings to the current, much more than
ordinary fluctuation may indeed be limited. One might speculate
that the true negative health effects of a recession only materialise with a time lag, possibly more than compensating any
immediate beneficial health effects. This is, however, not widely
confirmed by those (few) studies that did consider the issue. To
summarise a broad conceptual framework, our findings suggest
that economic crises have the greatest potential adverse effects
on health when: i) economic changes are rapid; ii) social
protection and cohesion are weak; and iii) drugs and alcohol are
widely available.
The potential foci of policy could be:
a. In high income countries: to prevent health from deteriorating
in groups that are at risk of harm to health, such as the
unemployed or other lower socioeconomic groups, and to
prevent specific health risks from arising in recessions, e.g.
psychological health problems.
b. In low-income countries: to protect the health of the general
population health from suffering, particularly among those
below or near the poverty line (of which there will be many).
How precisely this could be done is a critical question for further
research. Some of the literature argues that social protection and
more generally “the welfare state” could be one e admittedly very
loosely defined e way of mitigating the harmful effects of recessions (as well as of economic booms).
If it is true that in high income countries, overall mortality
behaves pro-cyclically, then an alternative, possibly highly controversial view would be that the average welfare gain resulting from
a health improvement during the recession could be seen as a way
to compensate the welfare loss associated with the economic
decline, in the same way as the welfare loss of worsening health in
an economic boom would be compensated by the welfare gains
resulting from economic growth. Irrespective of the magnitude of
these effects, in the current period of austerity in Europe, there is
a need to maintain a focus on the multiple losers of the crisis, not
only on those who were recipients of the benefits of fiscal stimulus
(mainly the financial sector) (Stuckler, Basu, & McKee, 2010). If
there are reasons for interventions in high income countries, they
may have to relate to specific health conditions (e.g. mental health)
and/or specific socioeconomic groups whose health may suffer
disproportionately.
Lastly, our findings help disentangle the effects of economic
crises from government responses. In some of the countries that
were worst-affected by the ongoing crisis of 2008, it appears
that austerity policies may be resulting in a set of independent and
much greater adverse effects on health than the economic crisis per
se; indications from Greece of significant rises in HIV, homicides,
suicides, prostitution, and heroin use are sufficient cause for
concern and immediate action (Kentikelenis et al., 2011).
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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