Suhrcke Stuckler Ssmdf

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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, UKb University of Cambridge, UKc London School of Hygiene & Tropical Medicine, UK

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 nancial 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 epidemio-

logical evidence on the strong and positiveassociations at the level

of the individual between lower income, unemployment and poor

health (Catalano & Bellows, 2005;Clark & Oswald, 1994; McKee-

Ryan, Song, & Wanberg, 2005;Murphy & Athanasou, 1999; Gallo,

Bradley, & Dublin, 2004). The idea that the nancial crisis will

harm health also reects the ndings 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 inthe USA and Europe nds pro-cyclical worsening of mortality

during expansions and improvement during recessions, with

recession associated with lower road-trafc injuries and alcohol-

related 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

healthier!(Bougerol, 2009) and that recession may be a lifestyle

blessing in disguise(Cohen, 2009).

This commentary aims to elucidate this seemingly contradictory

evidencewith a summary of the existing evidence on the actual and

potential impact of recessions on health, in order to distil somelessons as tothe expected healtheffectsof thecurrentcrisis andas to

how policy should respond, if at all. We nd 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

inuence 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 tomatter 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 unem-

ployed 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* Corresponding author. Tel.: 44 1603 59 3536; fax: 44 1603 59 3604.

E-mail address:[email protected](M. Suhrcke).

Contents lists available atSciVerse ScienceDirect

Social Science & Medicine

j o u r n a l h o m e p a g e : w w w . e l s e v i e r . co m / l o c a t e / s o c s ci m e d

0277-9536/$e see front matter 2011 Elsevier Ltd. All rights reserved.

doi:10.1016/j.socscimed.2011.12.011

Social Science & Medicine 74 (2012) 647e653
mailto:[email protected]://www.sciencedirect.com/science/journal/02779536http://www.elsevier.com/locate/socscimedhttp://dx.doi.org/10.1016/j.socscimed.2011.12.011http://dx.doi.org/10.1016/j.socscimed.2011.12.011http://dx.doi.org/10.1016/j.socscimed.2011.12.011http://dx.doi.org/10.1016/j.socscimed.2011.12.011http://dx.doi.org/10.1016/j.socscimed.2011.12.011http://dx.doi.org/10.1016/j.socscimed.2011.12.011http://www.elsevier.com/locate/socscimedhttp://www.sciencedirect.com/science/journal/02779536mailto:[email protected]


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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-simplication, 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 briey summarise

each of the twoperspectives 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 socioeco-

nomic group (Bethune, 1997;Moser, Goldblatt, Fox, & Jones, 1990).

Beyond the UK,Stern (1983),Creed (1998), andUngvry, Morvai,

and Nagy (1999) review the existing evidence of the various

pathways through which unemployment affects individual health.

They nd that unemployment is detrimental to the individuals

standard of living and nancial resources. Restricted nancialresources can lead to poor nutrition and restriction to access to

health care when needed. AsMartikainen and Valkonen (1996and

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-skilledjobs 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 typi-

cally characterised by a signicant increase in unemploymentwould 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.

Brenners work, however, has been severely criticised (e.g.

Wagstaff, 1985), mainly on the grounds of omitted variable bias,

structural instability of the relationships, lag-misspecications 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-side-

down by showing that negative deviations from the long term

per capita GDP trend are closely associated with reductions in

a wide range of cause-specic mortality rates (with the notable

exception of suicide rates that consistently accelerate in reces-

sions). So-dened recessions wouldaccordingly seem to be goodfor overall health, at least in the short run..

The contrasting results between the individual level and the

aggregate level evidence appear puzzling at rst 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 pop-

ulation 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 tech-

niques to Ruhm (2000), but using Swedish (Gerdtham &Johannesson, 2005; Svensson, 2007) and European data

(Economou, Nikolaou, & Theodossiou,2008),did not ndsuchapro-

cyclical relationship between the business cycle and mortality.

Further below we discuss briey some of the factors that may

help account for part of the observed differential health response

across countries.

Poorcountries vs rich countries

The above discussion has focused on rich countries, charac-

terised (1) by populations whose average level of wealth may serve

as a cushionagainst 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 ofthe 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 consump-

tion 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 conrmed 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) nd 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 andlow-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) nds 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

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government spending at a time when there were signicant 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 systems centres were more exposed to toxic

debts and the ensuing nancial 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 fora global recession, health

differences between poor and rich countries are expected to widen.

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 differentsubgroups of the population will respond differently to a given

economic crisis. If the net effect of those responses is an improve-

ment or no change in health in the population on the whole, this

may lead policymakers to infer that no specic 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 specic

groups is at risk or if health inequities would be rising during

recessions.

Edwards (2008)examined mortality by individual characteris-

tics 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 somebuffer-stock savings and better prospects of avoiding long-term

unemployment, beneted 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 ndings caution the extent to which unam-

biguous 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 boome 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

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, 200 0).

However Aaberge et al point out that increased welfare benets

during the crisis do not fullyaccountfor thestability 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

decits. Perhaps the reductions in transfer programmes that were

motivated by these budget decits will turn out to have larger

effects on income inequality than the rise in unemployment per se

(Aaberge et al., 2000).

Normal uctuations vs severecrises

A difculty with interpreting historical data is that the majority

of the existing studies at country level do not actually evaluaterecessionper se, but rather base their analyses on routine uc-

tuations in gross domestic product (Ruhm, 2003, 2006; Tapia

Granados, 2008). Economy-health relationships during steady-

state, or normal, business-cycle peaks and valleys may differ

substantially from those occurring under exceptional market

circumstances, as in an acute nancial crisis. Although studies

have evaluated routine business cycles, they have yet to test

properly the theory that recessionmay adversely affect a soci-

etys 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 rst 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) t o ( 2 ) a>3% increase in

unemployment (see Fig. 1b) in 26 EU countries over the period

1971e2006. The overall health indicatorse all cause-morality and

life expectancye do not appear to be affected. However, some of

the cause-specic mortality rates do appear to be affected by the

severity of the crisis. For instance the size and (sometimes) the

signicance 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 exam-

ination. 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 gures, the main causes linked to signicant

short-term effects all reect 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 exam-

ined with the help of longitudinal micro data rather than through

aggregate mortality statistics.

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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 lung-

cancer, although ischaemic heart disease deaths could riserapidly. Thus, it is important to identify the links of the economic

consequences of recession to specic behaviour changes and the

temporality of their effects on specic 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, nd 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

nds the closest statistical association between current economicuctuations 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 nding of the adverse mental health effect of

economic crises, as evidenced by the surge in suicide rates. Would

External CausesSuicideSuicide (0-64)

HomicideDrug AbuseAlcohol PoisoningAccidentsDrowningPoisoningIll-Defined CausesTransport AccidentsFallsCardiovascular DiseaseCardiovascular Disease (0-64)Ischaemic Heart DiseaseCerebrovascular DiseasePsychiatric DisordersLiver CirrhosisUlcerNeoplasmsLung Cancer

AlzheimerDiabetesDiabetes (15-44)Maternal MortalityInfant MortalityInfectious DiseasesRespiratory InfectionsTuberculosis

All-Cause

Cause of Death

662657657

496261203516506504611515516662662660662490662514662661500655499584671660511462521

Country-Years

-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)

Size (95% CI)Effect

Decreases MR Increases MR

0-6 -4 -2 2 4 6

Percentage Change

a

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: Coefcients are presented from 29 regression models. Error bars are 95% condence 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).



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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 uctuations, the actual trans-

ferability of those ndings to the current, much more than

ordinary uctuation may indeed be limited. One might speculate

that the true negative health effects of a recession only materi-

alise with a time lag, possibly more than compensating any

immediate benecial health effects. This is, however, not widely

conrmed by those (few) studies that did consider the issue. To

summarise a broad conceptual framework, our ndings 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 specic health risks from arising in recessions, e.g.

psychological health problems.

b. In low-income countries: to protect the health of the generalpopulation 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 statecould be onee admittedly very

loosely dened e way of mitigating the harmful effects of reces-

sions (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 contro-

versial 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 inan 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 benets ofscal stimulus

(mainly the nancial sector) (Stuckler, Basu, & McKee, 2010). If

there are reasons for interventions in high income countries, they

may have to relate to specic health conditions (e.g. mental health)

and/or specic socioeconomic groups whose health may suffer

disproportionately.

Lastly, our ndings 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 andmuch greater adverse effects on health than the economic crisisper

se; indications from Greece of signicant rises in HIV, homicides,

suicides, prostitution, and heroin use are sufcient cause for

concern and immediate action (Kentikelenis et al., 2011).

Acknowledgements

The authors gratefully acknowledge nancial 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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