1. Does the crisis make us sick? About the economic and social determinants of health Aaron Reeves University of Cambridge asr45@cam.ac.uk

2. Thanks to... Martin McKee LSHTM Sanjay Basu UCSF Chris Meissner University of California Davis David Stuckler University of Cambridge

3. Austerity and the economic crisis Recession -> – Increased suicide – Decline in traffic accidents Austerity -> – Increased rates of infectious disease – Increased suicide rates

4. Suicide

5. Impact of 1% rise in unemployment on mortality Source: Stuckler et al 2009 Lancet Suicide

6. Rising Suicides - 9 out of 10 countries suicides rose Source: Stuckler et al 2011 Lancet - About 3400 excess suicides New member statesOld member states

7. Infection

8. New HIV cases in Greece Note: Data on HIV, hep b and hep c are collected in 3 sentinel surveillance sites where these patterns have been confirmed 10-fold rise in HIV from injection drug use Source: Paraskevis and Hatzakis 2011

9. Are these inevitable? Social Protection austerity Health care austerity Austerity and economic growth

10. Social protection austerity

11. Social welfare expenditure “the provision by public (and private) institutions of benefits to, and financial contributions targeted at, households and individuals in order to provide support during circumstances which adversely affect their welfare.” Includes spending related to: – family support programmes (such as preschool education, child care, and maternity or paternity leave), – old age pensions and survivors benefits, – health care, – housing (such as rent subsidies), – unemployment benefits, – active labour market programmes (to maintain employment or help the unemployed obtain jobs), and support for people with disabilities.

12. Social Protection Change: 2007-2010 Social spending up Increase unemployment benefits Decrease disability benefits increase decrease Countries with no social protection spending data: Belgium, Iceland, Romania, and Switzerland.

13. Spain and Sweden

14. Social Protections Help… Each 100 USD greater social spending reduced the effect on suicides by: - 0.38%, active labour market programmes Spending> 190 USD no effect of unemployment on suicide Source: Stuckler et al 2009 Lancet

15. Source: Stuckler D et al. BMJ, 2010, 340. Relation between deviation from country average of social welfare spending (excluding health) and all-cause mortality in 15 EU countries, 1980–2005

16. Healthcare austerity

19. Healthcare austerity: Greece Source: EU-SILC: Kentikelenis et al., 2011, Health effects of financial crisis, The Lancet 2011; 378:1457-1458)

20. Cost of heath care and utilization “Reductions in routine care today might lead to undetected illness tomorrow and reduced individual health and well-being in the more distant future.” Source: Lusardi A et al. The economic crisis and medical care usage. Harvard Business School, 2010. Med copayment High copayment Low copayment

21. New HIV cases in Greece Note: Data on HIV, hep b and hep c are collected in 3 sentinel surveillance sites where these patterns have been confirmed 10-fold rise in HIV from injection drug use Source: Paraskevis and Hatzakis 2011

22. Healthcare austerity

23. Spain Mental Health Crises - 1.7-fold greater risk of depression in unemployed Source: Gili, et al 2012 JECH - 3.0-fold greater risk in mortgage payment problems Prevalence Change, 2006 to 2010

24. Austerity, fiscal multipliers, and Economic growth

25. Fiscal Multipliers: The effect of public spending on the economy Govt spending (+£1) Or Austerity (-£1) Fiscal Multiplier How that investment or reduction effects economy? >1 Increased Growth (GDP) <1 Reduced Growth (GDP)

27. Austerity and economic growth

28. Key conclusions Recession -> poorer health Austerity -> Increased suicide, heart disease mortality, infectious disease Not inevitable – Social protection – Health care – Public expenditure (e.g. Health and social protection) fosters economic growth

30. Data ‘In marked contrast to financial data, some of which are available instantaneously and others, such as economic growth, within a few weeks, data on mortality in many countries are delayed by several years’ (McKee et al., 2012) Even now the full extent of the crisis on health is obscured by lack of available data.