Intended for healthcare professionals

Feature European Healthcare

Greek economic crisis: not a tragedy for health

BMJ 2012; 345 doi: (Published 27 November 2012) Cite this as: BMJ 2012;345:e7988

Re: Greek economic crisis: not a tragedy for health

When signs of worldwide economic crisis appeared in 2007, Greece was affected as much as any country globally. The next year, Greece entered the most serious socioeconomic downturn in the country’s modern history. Compared with a 2008 GDP of €233.2 billion, Greece’s GDP in 2013 plunged to €182.1 billion, a staggering 21.9% decrease.1 While the tremendous toll of the crisis on employment has received considerable attention,1 a second important victim has been the Greek health-care system. Financial crisis can pose great threats to health,2 and IMF programs have been strongly related with weakened health care systems.3 Major structural problems in the Hellenic health care system had already been accumulating for over a decade,4 and these were dramatically compounded by the economic crisis. Between 2009 and 2011, the Ministry of Health undertook restructuring measures that reduced total Ministry of health expenditures by 18.2%; an additional 6.2% budget cuts were implemented in 2012.5 Due to these measures, public hospital budgets were reduced by 20%;5 370 specialist units were either merged or closed down; public hospital beds were reduced by nearly 6%; hiring of new physicians was markedly curtailed; and nurse-to-patient ratios were substantially reduced.6,7 Further worsening matters, since the beginning of the crisis more than 4,000 medical doctors have emigrated due to massive cuts in wages, overtime remuneration, and other benefits.8 Simultaneously, rates of private health insurance have declined, admissions to public hospitals have increased, and admissions to private hospitals have decreased.9,10 Furthermore, although Greece has secured cheaper prices for many generic and patented drugs, access for patients has decreased due to widespread drug shortages as companies turn to markets with higher profits,11,12 increased copayments for prescription drugs,8 and lower relative affordability due to reduced personal incomes.13
The crisis has also directly increased the demand for health care. Self-reported general health in Greece has deteriorated during the period of the economic crisis.14,15 Mental health has particularly declined, including increases in suicidal ideation, attempted suicides, and completed suicide rates, which are now at record highs.16-19 The prevalence of major depressive disorders has more than doubled from 2008 to 2011, with people facing serious economic problems being most at risk.20,21
Economic factors also play an important role in the evolution of crime trends. In the European Union, each 1% rise in unemployment was associated with a 0.79% rise in homicides below age 65.22 Consistent with this, the homicide mortality rate in Greece has significantly increased during the crisis period.23
Rates of several communicable diseases have also increased. An HIV outbreak among intravenous drug users occurred in 2011 and worsened in 2012, increasing the total number of HIV infections reported in Greece from 530 in 2010 to 826 in 2011 and 1,001 in 2012.24 Insufficient provision of preventive services has been an important contributor to increased HIV transmission.25 Furthermore, many previously rare or absent infections have also now been reported, including malaria in 2011 and 2012,26,27 West Nile virus in 2010-201226,28,29,30 and rabies in 201231. The causes of these outbreaks of communicable diseases in the era of economic crisis can be multiple: higher rates of infectious contact under poorer living circumstances, illegally migrating populations that have a different disease epidemiology in their country of origin; reduced treatment availability and lower quality of the public health system resources; and poorly funded or ineffective public health interventions.26,32
The economic crisis and its effects on health do not spare any age groups. Prior reports have seen that financial crisis and unemployment are linked to cardiovascular morbidity and mortality.33,34 Consistent with this, recent data suggest that the prolonged financial crisis has led to higher incidence of myocardial infarction in Messinia, especially among older individuals.35 At the other end of the age spectrum, rates of stillbirth, infant and child mortality in Greece have also increased during the crisis.36 The latter may partly relate to fewer childhood immunizations due to the financial situation.37 Furthermore, births and marriages have markedly decreased over the crisis period further worsening the Greek demographic problem.38
Interestingly, consistent with prior reports in other countries,6,39,40 deaths and injuries from road traffic accidents have fallen in Greece as drivers have switched to less expensive means of transport or reduced their overall travel.41 Furthermore, consistent with findings in Iceland,42 two recent nationwide reports find that smoking prevalence in Greece has started to decrease. With the financial crisis as well as an increased cigarette excise tax, cigarette consumption has declined to 2,197 cigarettes/ person in 2011, a 21.4% decrease compared with 2007.43 Especially amongst young adults smoking prevalence has fallen, from 48% in 2006 to 35% in 2010.44 Yet, these improvements in road traffic injuries and smoking were unable to offset the remarkable declines in the capacity of the public health care system and the substantial increases in mental illness, cardiovascular and other chronic conditions, infectious disease, crime, and poor overall health. In 2011–12 there was an increase in mortality amongst people >55 years (about 2,200 excess deaths).45
In sum, the unprecedented economic crisis in Greece has brought with it a humanitarian crisis in health. The financial crisis has reduced the supply of health care, while simultaneously increasing demand across many areas. Kakouli et al have recently proposed a series of actions for the Greek government to help the collapsing public health system stand on its feet,8 whereas Stuckler and McKee had previously discerned that Greece’s National Health care system was under threat and asked for the political and financial solidarity of the Europeans.25 European civil society and professional organizations have stated that “indiscriminate reductions in health and social services today will both lead to late detection of illness and higher long-term costs and take away the much needed support that people in Europe need to be resilient and emerge quickly from the economic crisis”.46 Yet, unfortunately, until now neither the Greek government nor the EU have responded to these calls. Policy makers, both domestic and foreign, must recognize and prioritize these issues in order to design and implement policies necessary to protect the detoriating health status of the population.  
1. Statistical Issues. Hellenic Statistical Authority, 2013. (Accessed 02/05/2013, at
2. Horton R. The global financial crisis: an acute threat to health. Lancet 2009;373:355-6.
3. Stuckler D, Basu S. The International Monetary Fund's effects on global health: before and after the 2008 financial crisis. Int J Health Serv 2009;39:771-81.
4. Economou C. Greece: Health system review. Health Syst Transit 2010;12:1-177, xv-xvi.
5. Budget Ministry of Health 2012: Tables - Objectives. 2013. (Accessed 15/08/2013, at
6. Karanikolos M, Mladovsky P, Cylus J, et al. Financial crisis, austerity, and health in Europe. Lancet 2013;381:1323-31.
7. Kalafati M. How Greek healthcare services are affected by the Euro crisis. Emerg Nurse 2012;20:26-7.
8. Kakouli T. "Troika" mandated austerity and the emerging healthcare crisis in Greece: an open letter to the Greek government. BMJ 2013;346:f2807.
9. Kondilis E, Giannakopoulos S, Gavana M, Ierodiakonou I, Waitzkin H, Benos A. Economic crisis, restrictive policies, and the population's health and health care: the Greek case. Am J Public Health 2013;103:973-9.
10. Karamanoli E. Debt crisis strains Greece's ailing health system. Lancet 2011;378:303-4.
11. Karamanoli E. Greece's financial crisis dries up drug supply. Lancet 2012;379:302.
12. Panic in Greek pharmacies as hundreds of medicines run short. The Guardian, 2013. (Accessed 07/05/2013, at
13. Davlouros P, Gizas V, Stavrou K, Raptis G, Alexopoulos D. DES thrombosis related to antiplatelet therapy noncompliance: A consequence of the Greek financial crisis. Int J Cardiol 2013;168:4497-9.
14. Kentikelenis A, Karanikolos M, Papanicolas I, Basu S, McKee M, Stuckler D. Health effects of financial crisis: omens of a Greek tragedy. Lancet 2011;378:1457-8.
15. Zavras D, Tsiantou V, Pavi E, Mylona K, Kyriopoulos J. Impact of economic crisis and other demographic and socio-economic factors on self-rated health in Greece. Eur J Public Health 2013;23:206-10.
16. Economou M, Madianos M, Theleritis C, Peppou LE, Stefanis CN. Increased suicidality amid economic crisis in Greece. Lancet 2011;378:1459.
17. Economou M, Madianos M, Peppou LE, Theleritis C, Patelakis A, Stefanis C. Suicidal ideation and reported suicide attempts in Greece during the economic crisis. World Psychiatry 2013;12:53-9.
18. Fountoulakis KN, Koupidis SA, Grammatikopoulos IA, Theodorakis PN. First reliable data suggest a possible increase in suicides in Greece. BMJ 2013;347:f4900.
19. Michas G. Suicides in Greece: a light at the end of the tunnel. BMJ 2013;347:f6249.
20. Madianos M, Economou M, Alexiou T, Stefanis C. Depression and economic hardship across Greece in 2008 and 2009: two cross-sectional surveys nationwide. Soc Psychiatry Psychiatr Epidemiol 2011;46:943-52.
21. Economou M, Madianos M, Peppou LE, Patelakis A, Stefanis CN. Major depression in the era of economic crisis: a replication of a cross-sectional study across Greece. J Affect Disord 2013;145:308-14.
22. Stuckler D, Basu S, Suhrcke M, Coutts A, McKee M. The public health effect of economic crises and alternative policy responses in Europe: an empirical analysis. Lancet 2009;374:315-23.
23. Michas G, Varytimiadi A, Micha R. The Greek financial crisis and homicide rates: another reason to worry. J Epidemiol Community Health 2013;67:1073.
24. HIV/AIDS Surveillance in Greece. Hellenic Centre of Disease Prevension and Control, 2012. (Accessed 08/05/2013, at
25. Stuckler D, McKee M. There is an alternative: public health professionals must not remain silent at a time of financial crisis. Eur J Public Health 2012;22:2-3.
26. Bonovas S, Nikolopoulos G. High-burden epidemics in Greece in the era of economic crisis. Early signs of a public health tragedy. J Prev Med Hyg 2012;53:169-71.
27. Epidemiological Surveillance Report on Malaria in Greece. Hellenic Centre for Disease Prevention and Control, 2012. (Accessed 07/05/2013, at
28. Report on the epidemic of West Nile Virus in Greece, 2010. Hellenic Centre for Disease Prevention and Control, 2013. (Accessed 07/05/2013, at
29. Report on the epidemic of West Nile Virus in Greece, 2011. Hellenic Centre for Disease Prevention and Control, 2013. (Accessed 07/05/2013, at
30. Report on the epidemic of West Nile Virus in Greece, 2012. Hellenic Centre for Disease Prevention and Control, 2013. (Accessed 07/05/2013, at
31. Information on Rabies. Hellenic Centre for Disease Prevention and Control, 2013. (Accessed 07/05/2013, at
32. Suhrcke M, Stuckler D, Suk JE, et al. The impact of economic crises on communicable disease transmission and control: a systematic review of the evidence. PLoS One 2011;6:e20724.
33. Brenner MH. Economic changes and heart disease mortality. Am J Public Health 1971;61:606-11.
34. Dupre ME, George LK, Liu G, Peterson ED. The cumulative effect of unemployment on risks for acute myocardial infarction. Archives of Internal Medicine 2012:1-7.
35. Makaris E, Michas G, Micha R, et al. Greek socio-economic crisis and incidence of acute myocardial infarction in Southwestern Peloponnese. Int J Cardiol 2013;168:4886-7.
36. Michas G, Varytimiadi A, Chasiotis I, Micha R. Maternal and child mortality in Greece. Lancet 2014;383:691-2.
37. Mammas IN, Theodoridou M. Financial crisis and childhood immunization: when parents disagree. Acta Paediatr 2012.
38. Michas G, Papadopoulos S, Micha R. Austerity in Greece not only kills but also curtails births and marriages. BMJ 2013;347:f6639.
39. Fishback PV, Haines MR, Kantor S. Births, Deaths, and New Deal Relief during the Great Depression. Review of Economics and Statistics 2007;89:1-14.
40. Stuckler D, Basu S, Suhrcke M, Coutts A, McKee M. Effects of the 2008 recession on health: a first look at European data. Lancet 2011;378:124-5.
41. Michas G, Micha R. Road traffic accidents in Greece: have we benefited from the financial crisis? J Epidemiol Community Health 2013;67:894.
42. McClure CB, Valdimarsdottir UA, Hauksdottir A, Kawachi I. Economic crisis and smoking behaviour: prospective cohort study in Iceland. BMJ Open 2012;2.
43. Alpert HR, Vardavas CI, Chaloupka FJ, et al. The recent and projected public health and economic benefits of cigarette taxation in Greece. Tob Control 2013.
44. Filippidis FT, Vardavas CI, Loukopoulou A, Behrakis P, Connolly GN, Tountas Y. Prevalence and determinants of tobacco use among adults in Greece: 4 year trends. Eur J Public Health 2012.
45. Vlachadis N, Vrachnis N, Ktenas E, Vlachadi M, Kornarou E. Mortality and the economic crisis in Greece. Lancet 2014;383:691.
46. Open letter to the European Council. EU leaders must focus on sustainable equitable Europe that fosters, and is sustained by, a healthy population. European Public Health Alliance, 2012. (Accessed 15/08/2103, at

Competing interests: No competing interests

12 April 2014
George Michas
Research Associate
Renata Micha, Dariush Mozaffarian
Agricultural University of Athens
Iera Odos 75, Athens, Greece