Recessions are harmful to healthBMJ 2016; 354 doi: https://doi.org/10.1136/bmj.i4631 (Published 06 September 2016) Cite this as: BMJ 2016;354:i4631
- Ben Barr, senior clinical lecturer in applied public health1,
- David Taylor-Robinson, senior clinical lecturer in public health2
- 1Department of Public Health and Policy, University of Liverpool, Liverpool L69 3GB, UK
- 2Department of Public Health and Policy, The Farr Institute@HeRC, Liverpool, UK
- Correspondence to:
The 2008 economic crisis led to rising unemployment, homelessness, and poverty—all important determinants of health. Government debt increased, as public money was used to prevent the collapse of the financial system, and many governments then cut public services to reduce this debt. But what has been the effect of all of this on health?
In a linked systematic review in The BMJ, Parmar and colleagues1 find that most studies investigating the 2008 recession in Europe show it was associated with adverse health outcomes. These findings were strongest for suicides and mental health problems. They find less evidence that the recession had a negative effect on self reported health, mortality, and health behaviours, and conclude that there was a high risk of bias in most of the studies reviewed.
Assessing the health effects of recessions is challenging. Firstly, the exposure of interest is poorly defined. The 2008 recession involved multiple economic processes, extending over at least 10 years, which could all negatively affect health.2 3 4 5 6 7 8 9 In the UK, house repossessions started increasing in 2005, unemployment rose in 2008, and wages fell from 2009 to 2015 (fig 1⇓). Secondly, there are multiple lag times between these exposures and health outcomes. Some health effects—especially those on mental health picked up in the new review—can occur rapidly, even before increases in unemployment, for example, due to threat or anticipation of job loss2 3 or increases in household debt.4 5 Other effects resulting from adverse exposure in childhood might not become evident until the children of the recession become adults.6 7
Investigating the effect of macroeconomic processes on health inevitably relies on the kind of observational studies included in the systematic review by Parmar and colleagues. These studies are never going to meet the validity criteria applied to clinical studies and they will often have only sufficient power to detect comparatively large effects that have a relatively short lag time, such as those related to mental health. Given previous evidence for the damaging health effects of unemployment and poverty, it is very likely that, in the absence of mitigating policies, the increase in these factors during recessions leads to adverse health outcomes.
Although governments might not be able to prevent recessions, their response is a matter of political choice, which has important consequences for health. Governments can mitigate the harmful effects of recession, stimulate growth, manage problems with public finances, or they can exploit the crisis to push through policies that would be politically unacceptable at other times.8 It is therefore critical to distinguish between the health effects of recessions and the effect of different policy responses to recession.
Initially, the UK government responded to the crisis by increasing public spending in 2009 to stimulate growth and protect vulnerable groups, such as unemployed young people.9 14 In 2010, the Conservative led coalition government reversed this approach, implementing austerity policies to reduce the public deficit by cutting public expenditure,15 particularly spending on welfare benefits and local government.16 17 These austerity policies have disproportionately affected more disadvantaged groups.17 18 19 20 21 and occurred some time after the initial recession (fig 1⇑).
But what evidence is there for the health effects of alternative policy responses? Some of the studies in the review by Parmar and colleagues specifically investigate the direct effect of the recession, whereas others also report the negative health effects of austerity measures that were implemented in response. The implementation of austerity measures in England coincided with a further rise in suicides from 2011 that followed the initial increase in suicides in the 2008 recession (fig 1⇑). Other observational studies not included in the review by Parmar and colleagues also indicate that welfare reforms and austerity measures implemented after the 2008 crisis have adversely affected health.22 23 24 Several studies also indicate that adequate welfare policies can mitigate some of the harmful effects of recession.25 26 27 28
Although this evidence on policy responses might be good enough to inform action, it could be improved. Robust prospective evaluation could take place before these policies are widely implemented. This rarely happens, however, because testing policies can be seen as politically risky.29 For example, since the 2008 recession, the UK has embarked on one of the largest transformations of its welfare system since its establishment, without any prior evidence of the potential health effect of these changes or any plans to evaluate these effects.
With the possibility of another recession in post-Brexit Britain, Parmar and colleagues’ helpful review shows that recessions can harm health. Doctors need to advocate for social and welfare policies that are informed by the evidence available and evaluated for their health effects, so that they protect people during crises rather than creating further health problems.
Competing interests: We have read and understood the BMJ policy on declaration of interests and declare the following interests: none.
Provenance and peer review: Commissioned, not externally peer reviewed.