CommentaryEconomic crises: Some thoughts on why, when and where they (might) matter for health—A tale of three countries
Introduction
That we have been in the midst of a global economic crisis since 2008, should surprise no one. However, there is less agreement as to the potential downstream and future effects of a crisis that has led to both personal and societal pain, trillions of dollars of wealth lost, near collapse of some governments, dangerously high levels of unemployment in some places, and a palpable sense to many that this crisis will leave an imprint on future generations.
In what follows, I will ask if it is reasonable to expect that this imprint will extend to the health of populations, how health may be affected, and whether we can expect that the impacts on health will be felt equally across countries. I acknowledge at the outset, that there no clear answers. In the absence of clear data-driven signposts, I will provide a framework for exploring the potential health implications of economic crises. I will be focusing on three wealthy countries, Sweden, the United Kingdom, and the United States, but we should recognize that the effects will be more extreme among those poor countries that are already highly vulnerable.
Even in these three wealthy countries, the extent of the economic downtown was extensive, with 2–5% declines in real annual GDP (IMF, 2010) in 2008–2009, and official unemployment rates in 2009 rising to 10.2% in the United States, and to around 8% in the United Kingdom and Sweden (OECD, 2010). A “bubble” in housing prices, felt in many countries for a variety of reasons, led to families losing their homes in staggering numbers—just under 4 million foreclosures in 2009 in the US (Reuters, 2010), and a 57% increase in foreclosures in England and Wales from 2007 to 2009 (Ministry of Justice, 2010). Interestingly, this did not happen in Sweden. While this is probably due to very different policies regarding home mortgage debt in Sweden, compared to the US and the UK, it highlights that social and economic policies that differ between countries may lead to differing impacts of economic crises on health.
The conventional view is that individual and population health are co-determined by genetics, behavior, and medical care. Thus we might expect modest effects of economic crises on health, although as we shall see the direction of the putative impact on health is not unambiguous. An alternate and broader view is shown in Fig. 1 (adapted from Kaplan, Everson, & Lynch, 2000), and nicely summarized in the final report of the WHO Commission on the Social Determinants of Health (CSDH, 2008). This perspective emphasizes that the health of individuals and populations is determined by a wide range of factors ranging from social and economic policies to biology, operating over the life course, so there are many points at which economic crises might impact health.
We can identify many health determinants that could be impacted by economic crises, although in some cases the direction of the impact is ambiguous. A partial list of these candidate pathways that may theoretically link economic crises and health is shown in Table 1, with ‘−’ indicating pathways that may produce detriments to health and ‘+’ suggesting potential benefits to health.
Unemployment (perhaps even anticipation of unemployment) has economic, psychosocial, and behavioral effects. Income and wealth can surely fall for many during economic crises, either due to unemployment, under-employment, or decreased social spending. However, there may be compensatory increases in savings. Educational attainment can also be influenced by economic crises, again perhaps in opposite directions. On the one hand, students in higher education may need to leave school to support themselves. On the other hand, students may prolong their education as jobs get harder to find. Economic crises may also lead to decreased public spending on education. Economic crises may also affect neighborhood conditions, although the directions of these effects are unclear. Increased stressors associated with unemployment and increased poverty may lead to increased violence, and these may combine with cutbacks in public spending on public infrastructure to cause declines in neighborhood quality. However, if, in times of shared economic stress, people in some communities are able to bond together and help each other more, some positive social determinants may be strengthened. Psychological distress may increase as meeting the demands of a difficult economy takes its toll. Risky behaviors such as smoking and over consumption of alcohol may increase or they may decrease, depending on the relative strengths of their use as coping or escape mechanisms vs. the countervailing impact of the price sensitivity of consumption. The impact of economic crises on health care will likely vary according to the relative importance of public vs. market mechanisms for funding of health care, but in either case there are possible effects. Increased demands on public resources may lead to decreases in access or quality of care where public funding predominates. Where access to health care is primarily funded through employment-related mechanisms or personal funds and/or through co-payment, access and quality of care may also suffer. Access to adequate housing also suffers during economic crises as foreclosures take their toll, and as stocks of subsidized or publicly-financed housing fall behind population needs. Finally, civil society may decline as inequality, marginalization, and fragmentation increase, although there may be countervailing forces that bring people together as well.
Thus, there are reasons to believe that economic crises could have a substantial impact on important determinants of health. Below I have reviewed selected examples of research suggesting that these determinants have an impact on health in each the three countries. For the purpose of this discussion, I will focus on five of the above determinants for which there is considerable evidence of a health impact: employment, income and wealth, education, neighborhood quality, and health care.
Section snippets
Impact of unemployment on health
In a cohort from the British Household Survey that was followed for 10 years, men and women who were unemployed had over a two-fold risk of developing a limiting illness subsequent to being unemployed, and unemployed men were 60% less likely to recover than men who were not unemployed (Bartley, Sacker, & Clarke, 2004). In Sweden, male and female workers displaced from their jobs were 20–40% more likely to have alcohol-related hospitalizations, and men were at increased risk of hospitalizations
Impact of income and wealth on health
While there are few studies in Britain that have examined this association (the majority preferring measures of occupational social class), Chandola (2000) reports findings for the British Household Panel Survey showing a strong non-linear association between weekly income and risk of death from 1991 to 1997. The association is much stronger among those who are poorer than in those who have higher incomes. Wolfson, Kaplan, Lynch, Ross, and Backlund (1999) also report a rather similar, strongly
Impact of education on health
Better education is known to be associated with better health. In the United States, twenty-five year-old college graduates can expect to live five years longer than those who have not completed high school (Ergerter, Braveman, Sadegh-Nobari, Grossmn-Khan, & Dekker, 2009). Stroke mortality in England and Wales is more than twice as high among those with lower education compared to those with higher education (Avendano et al., 2004). In Sweden there is a strong, and graded, association between
Neighborhood quality and health
In England and Wales, rates of death increase smoothly as level of neighborhood deprivation (measured by the Carstairs Index) increases (Romeri, Baker, & Griffiths, 2006). Median family income at neighborhood level was strongly associated with 16-year death rates in a large cohort in the United States (Smith, Neaton, Wentworth, Stamler, & Stamler, 1996), and those living in the lowest quartile of neighborhood income compared to the highest quartile in Stockholm, had 2–2.5 times higher risk of
Availability of health care and health
Of most relevance here are studies that indicate an association between financial crises and changes in routine and non-emergency treatment. Research by Lusardi, Schneider, and Tufano (2010) shows that those in the United States who reported decreases in financial assets during the current economic crises were almost four times as likely to report a decrease in the use of routine and non-emergency treatment compared to those who did not report financial losses, while there was no such affect in
Might we expect economic crises to have differential effects in the three countries?
While a variety of important determinants of health operate similarly in Sweden, the United Kingdom, and the United States, there are reasons for expecting that economic crises might not have the same effect in these countries. Variations in social spending between the three countries are substantial, and social spending effects many of the health determinants we have been considering. Immervoll (2009) examined the percent of GDP spent on nine categories of social spending in the three
Importance of a life course perspective
The importance of a life course perspective on chronic diseases is now well recognized (Kuh & Ben-Shlomo, 1997), but it has seldom been used in thinking about the impact of economic crises on health. While we have little data to turn to, given what is known about sensitive periods to both biological and social determinants of later health (Ben-Shlomo & Kuh, 2002) it is reasonable to think that the impacts of economic crises may not be seen until years later. Similarly, economic crises may lead
Summary
Economic crises can have important effects on a wide variety of determinants of individual and population health, and these effects may be played out over the life course. However, social and economic policies have the potential to mitigate at least some of the potential negative health effects of economic crises, and the substantial variation in these policies across countries suggests that the impact of economic crises may vary between countries. We know much less about this than we need to.
Acknowledgments
Support provided by National Institutes of Health (AG031358, HSSN276200800013C).
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