1. Economic recession and health: Good, bad or ugly for health? Professor Clare Bambra International Meeting of Indicators of Economic Recession and Health 12 th October, 2010.

2. ∂ Overview What is a recession? Debate Good: mortality and health behaviours. Bad: morbidity and suicide, unemployment. Ugly: inequalities and safety nets. Summary

3. ∂ What is a recession?  How to measure recession?  Rising u/e?  Decreasing or negative GDP?  Falling house prices?  Repossessions?  Inflation?  How long does it last (e.g. negative growth of 2 or more quarters)?  Local v national measures?  Lag time in terms of health?

4. ∂ Media and popular opinion Growth good Recession bad What about health? http://www.youtube. com/watch?v=kK3jkl pQPAM&feature=rel atedhttp://www.youtube. com/watch?v=kK3jkl pQPAM&feature=rel ated

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6. ∂ Mortality Consensus: Economic growth, not recession that is detrimental to mortality: Brenner USA (1971, 1982, 1987) and Bunn Australia (1979) found a negative relationship between recession and all cause/ CHD mortality. Methodological errors (Gravelle et al, 1981). Graham et al, (death rates in the USA,1972-1991) - a 1% increase in the unemployment rate reduced death rates by 4.6 per 100,000. Ruhm (2000) - a1% reduction in unemployment rates in the USA increased cardiovascular disease mortality by 0.75%. Ruhm (1995) - one standard deviation increase in the unemployment rate associated with 3% reduction in daytime fatal accidents (from 23.0 to 18.9 per 100,000) and 7% for night time accidents (from 4.16 to 4.04 per 100,000). Neumayer’s (2004) Germany, Tapia Granados (2005) Spain, (2008) Sweden. Stuckler et al Europe (2009) found no association between increased unemployment and all cause mortality.

7. ∂ Health behaviours (1) Tobacco consumption decreases during economic recession: Ruhm (2000) a 1% increase in local unemployment = a reduction of at least 1% in the number of smokers Reduced consumption amongst heaviest smokers Novo et al (2000) - reductions in tobacco amongst those aged under 21 during a period of recession

8. ∂ Health behaviours (2) Recession decreases alcohol consumption: Ruhm (1995) USA: increases in levels of local (state) unemployment were associated with reductions in alcohol consumption. Decreases in alcohol consumption amongst the heaviest drinkers, lower spirits USA, Sweden (Ruhm and Black, 2002; Johansson et al, 2006). Increase in the local unemployment rate of 1% was found to lower the consumption of spirits by 1.1% compared to 0.4 % for beer and wine (Ruhm and Black, 2002). Johansson et al (2006) also found alcohol consumption to rise in line with increases in economic growth.

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10. ∂ Morbidity Various studies show deteriorations in morbidity: Psychological ill health increases: including distress and dissatisfaction (Tausig, 1999), sleep difficulties and psychosomatic complaints (Hyyppi and Alanen, 1997), depression and anxiety (Hagquist et al, 2000), and mental health (Solantaus et al, 2004). Limiting long term illness and self- reported general health, decline during economic recessions (Leeni and Berntsson, 2001).

11. ∂ Suicide Suicides increase amongst men: Stuckler et al, Europe (2009) - increased unemployment, increased suicides amongst men and women aged under 65, with the greatest effect seen for men aged 30-44 and women aged 15-29. A 1% increase in the unemployment rate was associated with a 0.79% (95% CI 0.16 to 1.42) rise in suicides amongst those aged under 65. Gerdtham and Johannesson (2005) Sweden - suicide increased amongst men (but not women) to significantly increase in times of economic recession in Sweden Tapia Granados (2005) reporting a similarly gendered finding for Spain. Ruhm (2000) also reported these results for the USA as whilst suicides amongst women were only weakly related or unrelated to economic change, suicide rates amongst men escalated during economic downturns.

12. ∂ Unemployment Unemployment increases and has a negative effect on health: Unemployment is associated with an increased likelihood of poor mental health (2x) and suicide (10x), higher rates of all cause and specific causes of mortality (2x), self reported health and limiting long term illness (2x), and, in some longitudinal studies, a higher prevalence of risky health behaviours (particularly amongst young men), including problematic alcohol use (2x) and smoking (3x). The negative effects extend to families and the wider community. For example, figures from a 1984 study suggested that for every “2000 men seeking work 2 (1.94), and among their wives 1 (0.98), will die each year as a result of unemployment” (Moser et al, 1984). Recession weakens the association between unemployment and health e.g. Finnish study found OR 2.11 mortality in a period of low unemployment v OR1.35 in high unemployment (Martikainen and Valkonen, 1996).

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14. ∂ Inequalities Few studies have examined the effects of recessions on health inequalities A Japanese study found that recession increased relative occupational inequalities in self-rated health amongst men by 16% (Kondo et al, 2008) A Finnish study found that the recession slowed down the trend towards increased inequalities in mortality (Valkonen et al, 2000) A series of studies of morbidity in Finland, Norway, Sweden and Denmark concluded that there were no significant effects of the 1990s recession on health inequalities in these countries (Lahlema et al, 2002). The effects of recessions on health inequalities is unclear and underexplored.

15. ∂ Safety nets Health effects of recessions vary by welfare state: Gerdtham and Ruhm (2006), 23 OECD countries - countries with low social expenditure had larger fluctuations in mortality than those with more generous provision. Hopkins (2006), Asian economic crisis - public expenditure important in mitigating the health effects of economic crises Stuckler et al (2009), Europe - ALMP can reduce the effects of recessions on suicide: every $10 per person per year reduced the effect of unemployment increases on suicides by 0.038%, expenditure of $190 per person per year (as in Scandinavia), meant that increases in the unemployment rate did not increase suicide rates. Bambra and Eikemo (2009) – relationship between unemployment and health varies by welfare state

16. ∂ Summary: Good? Bad? Ugly! All cause mortality decreases Health behaviours improve Morbidity increases Unemployment increases (but association with poor health decreases) Effects on health inequalities unclear Public expenditure mediates the negative health effects of recessions Policy implications: cash not cuts Research implications: Need to examine effects on socio-economic and geographic health inequalities, more comparisons by welfare state.