What happened? GDP per capita (2007=1) What happened to health? The health effects of a financial crisis: epidemiology on a large scale

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1 The health effects of a financial crisis: epidemiology on a large scale Martin McKee Hong Kong, August 216 What happened? GDP per capita (27=1) Germany United States United Kingdom Spain Greece What happened to health?

2 Suicides in old and new EU Member States: 27= We estimate that the Great Recession is associated with at least 1, additional economic suicides between 28 and EU members before May 24 EU members since May 24 Deaths on the roads Reversal in long term decline in unmet need 3 25 deaths/1, Hungary Lithuania Netherlands Reeves A, McKee M, Stuckler D. The attack on Universal Health Coverage in Europe: recession, austerity, and unmet needs. Eur J Publ Health 216 Suicides in England Each 1% increase in the number of unemployed men was significantly associated with a 1.4% (.5% to 2.3%) increase in male suicides. About two fifths of the recent increase in suicides among men (increase of 329 suicides, 126 to 532) during the 28-1 recession can be attributed to rising unemployment. Increase in unmet medical need in Portugal, by economic status, 21 to 212 Barr B, Taylor-Robinson D, Scott-Samuel A, McKee M, Stuckler D. Suicides associated with the recession in the UK: a time-trend analysis. BMJ 212: 345 doi: /bmj.e5142 2

3 A question of priorities Health of all Greeks worsened during austerity after 21 However, impact of job loss on chance of reporting worse health much greater during austerity Pre-austerity Austerity Financial data Instantaneous Mortality data Within the decade Country Iceland 29 Ireland 21 France 211 Estonia 211 Belgium 212 Last year of mortality data (June 216) Epidemiological issues Another source? Data availability & accuracy Defining exposure What is a financial crisis or a recession? Understanding causality in complex situations Causal pathways Time lags Understanding effect modifiers What makes things worse What makes things better Natural experiments Multi-disciplinarity What is the treatment? Cyclical trends in search activity for suicide and depressionrelated terms, with peaks in autumn and winter months, and a trough in summer months Significant association with suicides among: age group year old women (older women tend to overdose so search for details, men tend to hang themselves) Beware incentives to distort data Benford slaw on the distribution of the first significant digit in a collection of numerical data Data availability & accuracy P (d) P(d) log 1 ([d + 1]/d) d 3

4 Benford slaw applied to EU 27 and Greek financial statistics (average 133 observations/ country/ year) P (d).15 P(d) P(d) EU27 P(d) Greece NBER definition a significant decline in [the] economic activity spread across the country, lasting more than a few months, normally visible in real GDP growth, real personal income, employment, industrial production, and wholesale-retail sales d Source: Rauch, Göttsche, Brähler, & Engel, 211 Defining and interpreting exposure The need for a multidisciplinary approach Recession: a definition A rule of thumb... a decline in the seasonally and calendar adjusted real gross domestic product (GDP) in at least two successive quarters Julius Shiskin, NY Times 1974 Who is publishing? Different disciplines Systematic search of Web of Science for literature on recessions and health 461 articles & 14,41 cited documents Network analysis of cocitation pattern by disciplines, journals and backgrounds of the authors Stuckler D, Reeves A, Karanikolos M, McKee M. The health effects of the global financial crisis: can we reconcile the differing views? A network analysis of literature across disciplines. Health Econ Pol Law 215; 1:

5 Few reading each other s work Koch s Postulates Economics Medicine Public health Psychiatry The microorganism must be isolated from a diseased organism and grown in pure culture. The cultured microorganism should cause disease when introduced into a healthy organism. The microorganism must be reisolated from the inoculated, diseased experimental host and identified as being identical to the original specific causative agent. Addiction Cause and effect Bradford Hill s criteria of causality Strength of association Consistency Specificity Temporal relationship Biological gradient Experiment Analogy Biological plausibility Coherence A fair experiment Population Timing When might we expect to see an effect? Control Intervention 3 5

6 Age-standardised rate per 1, 6 3 Some effects occur almost instantly: Injuries, poisoning and violence mortality (excluding acute alcohol poisoning) Russia: Men aged 3-59 Mortality rate Alcohol consumption Per capita consumption litres pure alcohol/year Mechanisms 31 Smoking and lung cancer in British men A lagged effect Cigarettes per year per capita Source : HOAB and Wald Cigarettes per capita per year Lung cancer mortality rate Age-standardised mortality rate per million Data for men aged We used longitudinal data to evaluate the impact of housing payment problems on health status among home-owners and renters in 27 EU states Multi-level and fixed-effects models applied to a retrospective cohort drawn from the EU-SILC data Sample of employed persons without housing arrears in base year 28, followed through to 21 (n=45,457 persons, 136,371 person-years) Multi-variate models tested impact of transitioning into housing arrears on self-reported health Arrears associated with a significant deterioration in health of renters but not owners, after adjusting for individual fixed effects Effect independent of and greater than the impact of job loss for the full sample Magnitude varied across countries largest adverse associations in Belgium, Austria, and Italy. Time Some things we can predict A change in drinking pattern can have an impact almost at once Some things are more difficult Smoking rates today predict lung cancer mortality years in the future We can only expect to detect effects with short lags Many other effects will be lost in the noise Why have rates of homelessness claims in England risen since 21? We used variations in rates across local authorities to test the impact of economic downturns and budget cuts. Using cross-area fixed effects models of data from 323 UK local authorities between 24 and 212, we evaluated associations of changes in statutory homelessness rates with economic activity, unemployment, and local and central government expenditure. Each 1% fall in economic activity was associated with an increase of.45 homelessness claims per 1 households Increasing rates of homelessness also strongly linked with government reductions in welfare spending Disaggregating types of welfare expenditure, we found that strongest associations with reduced homelessness claims were spending on social care, housing services, discretionary housing payments and income support for older persons. 33 6

7 Effect modifiers Are there things that might protect people from economic crises? Social support, friends, marriage Welfare systems Are there things that might worsen the effects of economic crises? Easy access to harmful substances Lack of protection (e.g. Breakdown of law and order) Suicide Rate Something can be done... Active Labour Market Programmes Below Median Spending < 1 per capita Unemployment Rate The impact of a 1% increase in unemployment on mortality Cause of Death External Causes Suicide Suicide (-64) Homicide Drug Abuse Alcohol Poisoning Accidents Drowning Poisoning Ill-Defined Causes Transport Accidents Falls Cardiovascular Disease Cardiovascular Disease (-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 Country-Years Suicide Transport accidents Effect Size (95% CI) -.25 (-.68,.18).49 (-.4, 1.2).79 (.16, 1.42).79 (.6, 1.52) (-7.67,.17).81 (-5.93, 7.54) -.45 (-.88, -.2) -.16 (-1.34, 1.4) -.9 (-1.9, 1.73) (-3.51,.54) (-2.14, -.64).11 (-.42,.65).3 (-.25,.3).13 (-.16,.42).31 (-.15,.77) -.16 (-.45,.14) -.71 (-3.47, 2.5).12 (-.78, 1.2).24 (-.44,.91).4 (-.7,.16).5 (-.14,.24).12 (-1.71, 1.96).54 (-.33, 1.4).46 (-1.68, 2.6) -.17 (-3.6, 2.73) -.6 (-.59,.47) -.31 (-1.18,.56) 1.89 (.2, 3.76).18 (-.58,.94).5 (-.19,.29) Suicide Rate Something can be done... Active Labour Market Programmes Above Median Spending > 1 per capita Unemployment Rate Decreases MR Increases MR Stuckler et al..lancet 29; 374: Percentage Change Association (Spain) or lack (Sweden) of unemployment and suicides Unemployment red, suicides - blue Multivariate statistical models used to evaluate changes in suicide rates in 2 EU countries from Male suicide increases were significantly associated with each percentage point rise in male unemployment, by.94%, and indebtedness, by.54%. Spending on active labour market programmes (.26%) and high levels of social capital (.48%) moderated the unemployment suicide association. There was no interaction of the volume of anti-depressant prescriptions, monetary benefits to unemployed persons or total social protection spending per capita. Active labour market programmes and social capital were estimated to have prevented 54 and 21 male suicides, respectively, arising from unemployment in the countries studied Stuckler et al..lancet 29; 374: European Journal of Public Health 214; 25:

8 Employment protection policies may counteract labour market inequalities between healthy and unhealthy people, but additional programmes are likely needed to protect vulnerable groups during severe recessions. Natural experiments Housing benefit and mental health Data on household food insecurity for 21 EU countries (24 212) from Eurostat 215 edition and OECD Cross-national first difference models used to evaluate how rising unemployment and declining wages related to changes in prevalence of food insecurity and role of social protection expenditure in modifying observed effects. Economic hardship strongly associated with greater food insecurity, with each 1 percentage point rise in unemployment associated with estimated.29 percentage point rise in food insecurity Each $1 decrease in annual average wages associated with.62 percentage point increase in food insecurity Prev Med 216: 89:44-5 In April 211 the UK government reduced financial support for lowincome persons renting private-sector housing (mean reduction ~ 1,22 per year) Data from UK Annual Population Survey (repeated quarterly crosssectional survey) Analysis of renters in private sector intervention group receiving housing benefit (n = 36,859) control group not receiving housing benefit (n = 142,25). Main outcome binary measure of self-reported mental health problems Reeves A, Clair A, McKee M, Stuckler D. Reductions in housing benefit increases symptoms of depression in low-income UK households. Am J Epidemiol (in press) Change in food insecurity associated with 1% increase in unemployment Rising unemployment and falling wages are strong statistical determinants of increasing food insecurity, but at high levels of social protection, these associations could be prevented Change in probability of selfreported depression before & after April 211 Housing benefit and mental health Non recipients Housing benefit recipients Extrapolating these findings, ~ 26, (95% CI: 14, to 38,) people newly experienced depressive symptoms in association with cuts to housing benefit Reeves A, Clair A, McKee M, Stuckler D. Reductions in housing benefit increases symptoms of depression in low-income UK households. Am J Epidemiol (in press) 8

9 National minimum wage and mental health UK government implemented minimum wage legislation in 1999, increasing hourly wages to 3.6 We used longitudinal data from the British Household Panel Survey to compare otherwise similar persons: Intervention, who moved up to the minimum wage Controls, who were likely unaffected because their wages were between 1% and 11% of the eligibility threshold their firms did not increase wages to meet the threshold Assessed the probability of mental ill-health using 12 item General Health Questionnaire (GHQ-12) The intervention group, whose wages rose above the minimum wage, experienced lower probability of mental ill-health compared with both controls Improvement represented.37 of a standard deviation, comparable to the effect of anti-depressants (.39 of a standard deviation) on depressive symptoms. The role of mass privatisation Mass privatisation programmes associated with an increase in short-term adult male mortality rates of 12 8% Unemployment rates increased substantially by mass privatisation (56 3%) Each 1% increase in the percentage of population who were members of at least one social organisation decreased the association of privatisation with mortality by 27%; When more than 45% of a population was a member of at least one social organisation, privatisation was no longer significantly associated with increased mortality rates Reeves A, McKee M, Mackenbach J, Whitehead M, Stuckler D. Introduction of a national minimum wage reduced depressive symptoms in low-wage workers: a quasi-natural experiment in the UK. Health Econ 216: doi: 1.12/hec.3336 National minimum wage and mental health On the effect of mass privatisation in the former USSR polemic that will not withstand epidemiological scrutiny Don t they know that the most important reason for poor health in Russia is diet Real data Life expectancy at birth, in years As seen by The Economist 53 Data torture Not everyone will agree Interpreting every result as confirming your hypothesis Lack of biological plausibility Failure to report number of comparisons made Dropping subjects without justification Inappropriate classification of exposure and disease 9

10 Greek Tragedy - 4% rise in homelessness - 5% increase in unmet medical needs - 4% increase in infant mortality - 3% rise in stillbirths - 6% rise in suicides Source: Kentikelenis A, Karanikolos M, Papanicolas I, Basu S, McKee M, Stuckler D. Health effects of financial crisis: omens of a Greek tragedy. Lancet 214 One percentage point increase in unemployment increased likelihood of food bank opening in subsequent year by 1.8 (95% CI 1.2 to 1.14) Each 1% cut in central government spending on welfare benefits in local authority increased odds of a food bank opening within two years by 1.6 (95% CI 1.25 to 2.3). Each 1% increase in the rate of benefit sanctions associated with significant increase of.9 percentage points (95% CI.1 to.17) The growth of foodbanks Denialism Denialism is characterized by: 1. Conspiracy -Suggesting opponents have an ulterior motive for their position or are part of a conspiracy. 2. Cherry picking -Selecting an anomalous critical paper supporting their idea, or using outdated, flawed, and discredited papers in order to make their opponents look like they base their ideas on weak research. 3. False Experts -Paying an expert in the field, or another field, to lend supporting evidence or credibility; bypassing the peer review process. 4. Moving the Goalpost -Dismissing evidence presented in response to a specific claim by continually demanding some other (often greater) piece of evidence. Denialists use the absence of complete and absolute knowledge to prevent the implementation of sound policies, or the acceptance of an idea or theory. 5. Other Logical Fallacies -Usually one or more of false analogy, straw man, red herringor quote mining, and even plain liesand insults. Source: Loopstra et al BMJ 215 Source: Diethelm, PA and McKee, M (29)."Denialism: what is it and how should scientists respond?". European Journal of Public Health 19(1): 2 4 Reasons? not able to manage their finances (Michael Gove, Education Minister) [Food bank use can] become a habit (Paul Maynard, Conservative MP) food from a food bank is by definition a free good and there s almost infinite demand (Lord Freud, Conservative minister) have more money to spend on alcohol, cigarettes (Councillor Steward (Conservative)) Trussell Trust is Scaremongering (Iain Duncan Smith, Work & Pensions minister) Treatment 1

11 Red = reduced spending Real choices Blue = increased spending Protect health, education, and social protection spending Reeves A, Basu S, McKee M, Meissner C, Stuckler D. Does investment in the health sector promote or inhibit economic growth? Globalization Health. 213; 9(43). Source: ONS % we re all in this together Increase in income in UK, Private FTSE Inflation sector directors workers Increase in income in USA, All private sector 27 CEOs % 1 5 Natural Experiment: stimulus versus austerity and then Natural Experiment: stimulus versus austerity Olivier Blanchard, Chief Economist of the IMF has recalculated the fiscal multiplier the impact of additional spending on GDP growth Larger than previously thought about 1.6 So maybe increased government spending would actually make things better? 11

12 What can we do? Thank you for your attention Have we been here before? How to solve a slump: "A solid majority of economists" agree: The government borrows more and invests the cash either in building schools and hospitals or in providing benefits and tax cuts This boosts demand and generates employment This can be paid for by borrowing wartime UK government ran "astronomical budget deficits", while "the rate of interest has shown no rise since the beginning of 194 If it becomes too costly to keep on top of the national debt then ministers should raise more funds, not by taxing ordinary pay or spending, which would slow the economy, but with a levy on idle wealth A booming economy and healthy profits would be good for the "leaders of industry", but they will never support such government intervention The main sources of resistance are "so-called 'economic experts' closely connected with banking and finance" and "big business". Michał Kalecki, 1942 So what should we prioritise to maintain health? Active labour market interventions: public employment programmes (welfare to work) training and skills development programmes for youth transitioning from school to work programmes to get the unemployed back to work programmes to provide employment for disabled people support for people with low level mental health And don t forget that health services are major employers they do good by employing people as well as by treating them 12