The Role of Social Determinants in Tackling Health Objectives in a Context of Economic Crisis
Public Health Reviewsvolume 35, Article number: 9 (2013)
The impact of the economic crisis on health through its social determinants has the greatest effect on disadvantaged, low income households as they are more vulnerable to falls in income and are more likely to suffer the employment effects of an economic crisis. They are subject to exclusionary processes that lead to worse health both in the short and long term.
The health impacts of an economic crisis include an increase in suicides, homicides and cardiovascular mortality, a fall in road traffic accidents, and worse infectious disease and mental health outcomes. Those who become unemployed have a greater risk of poor health than the employed, while employees may be affected by the rise in insecure and temporary work and a greater effort-reward imbalance. As the cost of living rises faster than incomes, more households fall below a minimum income necessary to live a healthy life. There are higher levels of poverty, greater income inequalities and more households with debt problems or other financial difficulties. Lower incomes lead to more homelessness and fuel poverty. All of these factors are associated with worse physical and mental health.
Health inequalities are likely to widen following an economic crisis, though policy responses can help to mitigate the impacts. Higher levels of social spending are associated with better health outcomes and reduced inequalities, whereas research suggests that austerity measures do not have positive health effects. Health equity impact assessments should be carried out on all policies. Specific policy areas covered in the recommendations include universal health coverage, active labour market programmes, a fairer tax system, homelessness prevention, housebuilding, debt relief and fuel poverty measures. Local interventions can also do much to improve daily living conditions, through improving public services and resilience to financial and other shocks.
Commission on Social Determinants of Health. CSDH Final Report: Closing the gap in a generation: health equity through action on the social determinants of health. Geneva: World Health Organization; 2008.
The Marmot Review Team. Fair society, healthy lives: strategic review of health inequalities in England post-2010 (The Marmot Review). London: The Marmot Review Team; 2010.
Stuckler D, Basu S. The Body Economic: Why Austerity Kills. London: Allen Lane; 2013.
Stuckler D, Basu S, McKee M. Public health in Europe: power, politics, and where next? Public Health Rev. 2010;32:213–42.
van den Berg GJ, Lindeboom M, Lopez M. Inequality in individual mortality and economic conditions earlier in life. Soc Sei Med. 2009;69:1360–7.
Stuckler D, Basu S, Suhrcke M, Coutts A, McKee M. The public health effect of economic crisis and alternative policy responses in Europe: an empirical analysis. Lancet. 2009;374:315–23.
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.
Suhrcke M, Stuckler D, Suk JE, Desai M, Senek M, et al. The impact of economic crises on communicable disease transmission and control: a systematic review of the evidence. PLoS One, 2011;6:e20724.
Stuckler D, Meissner CM, King LP. Can a bank crisis break your heart? Global Health. 2008;4:1.
Brenner MH. Mortality and the national economy: a review, and the experience of England and Wales, 1936–76. Lancet. 1979;314:568–73.
Davalso ME, French ML This recession is wearing me out! Health-related quality of life and economic downturns. J Ment Health Policy Econ. 2011; 14: 61–72.
Gili M, Roca M, Basu S, McKee M, Stuckler D. The mental health risks of economic crisis in Spain: evidence from primary care centres, 2006 and 2010. Eur J Public Health. 2013;23:103–8.
Evans-Lacko S, Knapp M, McCrone P, Thornicroft G, Mojtabai R. The mental health consequences of the recession: economic hardship and employment of people with mental health problems in 27 European countries. PLoS One. 2013;8:e69792.
International Labour Office. Global employment trends: recovering from a second jobs dip. Geneva: ILO; 2013.
Bethune A. Unemployment and mortality. In Drever F, Whitehead M (editors) Health Inequalities. London: Stationary Office; 1997. pp. 156–67.
Bartley M, Sacker A, Clarke P. Employment status, employment conditions, and limiting illness: prospective evidence from the British household panel survey 1991–2001. J Epidemiol Community Health. 2004;58:501–6.
Paul KI, Moser K. Unemployment impairs mental health: meta-analyses. J Vocat Behav. 2009;74:264–82.
Milner A, Page A, LaMontagne AD. Long-term unemployment and suicide: a systematic review and meta-analysis. PLoS One. 2013;8:e51333.
European Commission Directorate-General Health and Consumers, Directorate-General for Communication. Attitudes of Europeans towards tobacco. Special Eurobarometer 385. European Commission: May 2010.
Dupre ME, George LK, Liu G, Peterson ED. The cumulative effect of unemployment on risks for acute myocardial infarction. Arch Intern Med. 2012;172:1731–7.
Gallo WT, Teng HM, Falba TA, Kasl SV, Krumholz HM, Bradley EH. The impact of late career job loss on myocardial infarction and stroke: a 10 year follow up using the health and retirement survey. Occup Environ Med. 2006; 63:683–7.
Sullivan D, von Wächter T. Job displacement and mortality: An analysis using administrative data. Quart J Econ. 2009;124:1265–306.
Eliason M, Storrie D. Job loss is bad for your health — Swedish evidence on cause-specific hospitalization following involuntary job loss. Soc Sei Med. 2009;68:1396–406.
International Labour Office. Global employment trends for youth 2013: a generation at risk. Geneva: ILO; 2013.
Crawford C, Duckworth K, Vignoles A, Wyness G. Young people’s education and labour market choices aged 16/17 to 18/19. London: Department for Education; 2011.
Zeytinogla IU, Seaton MB, Lillevik W, Moruz J. Working in the margins women’s experiences of stress and occupational health problems in part-time and casual retail jobs. Women Health. 2005;41:87–107.
Natti J, Kinnunen U, Makikangas A, Mauno S. Type of employment relationship and mortality: prospective study among Finnish employees in 1984–2000. Eur J Public Health. 2009;19:150–6.
Voss M, Nylen L, Floderus B. Unemployment and early cause-specific mortality: a study based on the Swedish twin registry. Am J Public Health. 2004;94: 2155–61.
Vahtera J, Kivimäki M, Pentti J, Linna A, Vistanen M, et al. Organisational downsizing, sickness absence and mortality: 10-town prospective cohort study. BMJ. 2004;328:555–60.
Quinlan M, Bohle P. Overstretched and unreciprocated commitment: reviewing research on the occupational health and safety effects of downsizing and job insecurity. Int J Health Serv. 2009;39:1–44.
Brockner J, Greenberg J. The impact of layoffs on survivors: an organizational justice perspective. In: Carroll JS (editor) Applied Social Psychology and Organizational Settings. Hillsdale: Lawrence Erlbaum Associates; 1990. pp. 45–75.
Artacoz L, Benach J, Borrell C, Cortes I. Social inequalities in the impact of flexible employment on different domains of psychosocial health. J Epidemiol Community Health. 2005;59:761–7.
OECD. Crisis squeezes income and puts pressure on inequality and poverty: new results from the OECD Income Distribution Database. OECD; 2013.
Glennester H, Bradshaw J, Lister R, Lundberg O. Reducing the risks to health: the role of soical protecyion. Report of the Social Protection Task Gorce for the Strategic Review of Health Inequalities in England Post 2010. London: Centre for Analysis of Coial Exclusion, London School of Economics; June 2009.
Dyson A, Hertzman C, Roberts H, Tunstill J, Vaghri Z. Childhood development, education and health inequalities. Report of task group. Submission to The Marmot Review; 2009.
Hirsch D, Spencer N. Unhealthy lives: intergenerational links between child poverty and poor health in the UK. London: End Child Poverty; 2008.
Solantaus T, Leinonen J, Punamaki RL. Children’s mental health in times of economic recession: replication and extension of the family economic stress model in Finland. Dev Psychol. 2004;40:412–29.
Nagarajan S. Impact of global financial crisis on remittances flows to Africa. Development Research Department. Development Research Brief Number 4. Tunisia: African Development Bank; 2009. Available from URL: http://www.afdb.org/fileadmin/uploads/afdb/Documents/Financial-Information/Impact%20of%20Global%20Financial%20Crisis%20on%20Remittances%20Flows%20to%20Africa.pdf (Accessed 26 June 2013).
O’Hara S, Ivlevs A, Gentile M. The impact of global economic crisis on remittances in the Commonwealth of Independent States. Eurasian Geography Econ. 2009;50:447–63.
Wilkinson R, Pickett K. The Spirit Level: Why Equality is Better for Everyone. London: Penguin books; 2009.
Taylor MP, Pevalin DJ, Todd J. The psychological costs of unsustainable housing commitments. Psychol Med. 2007;37:1027–36.
Consumer Credit Counselling Service. Survey reveals high human cost of debt problems — press release. CCCS; 21 July 2010. Available from URL: http://www.cccs.co.uk/Portals/O/Documents/media/pressreleases/Human-impact-of-debt-survey-press-release.pdf (Accessed 26 June 2013).
Jenkins R, Bhugra D, Bebbington P, Brugha T, Farrell M, et al. Debt, income and mental disorder in the general population. Psychol Med. 2008;38:1485–93.
Meltzer H, Bebbington P, Brugha T, Farrell M, Jenkins R. The relationship between personal debt and specific common mental disorders. Eur J Public Health. 2012;23:108–13.
Fondeville N, Ward T. Homelessness during the crisis. Research note 8/2011. Social Situation Observatory — Income distribution and living conditions 2011. European Commission, Employment, Social Affairs and Inclusion; November 2011.
Burki T. Tackling tuberculosis in London’s homeless population. Lancet. 2010; 376:2055–6.
Homeless Link. The health and wellbeing of people who are homeless: evidence from a national audit. London: Homeless Link; 2010.
Morrison DS. Homelessness as an independent risk factor for mortality: results from a retrospective cohort study. Int J Epidemiol. 2009;38:877–83.
Geddes I, Bloomer E, Allen J, Goldblatt P. The health impacts of cold homes and fuel poverty. London: The Marmot Review, Team & Friends of the Earth; 2011.
Edwards R. Who is hurt by procyclical mortality? Soc Sei Med. 2008;67:2051–8.
Dorling D, Thomas B. Geographical inequalities in health over the last century. In: Graham H (editor). Understanding Health Inequalities. 2nd edition. Buckingham: Open University Press; 2009.
Kondo N, Subramanian SV, Kawachi I, Takeda Y, Yamagata Z. Economic recession and health inequalities in Japan: analysis with a national sample, 1986–2001. J Epidemiol Community Health. 2008;62:869–75.
Reinhart C, Rogoff K. Growth in a time of debt. Am Econ Rev: Papers Proceedings. 2010;100:573–8.
Blackstone B, Karnitschnig M, Thomson R. Europe’s banker talks tough. The Wall Street Journal. 24 February 2012. Available from URL: http://online.wsj.com/news/articles/SB 10001424052970203960804577241221244896782 (Accessed 16 Januaruy 2014).
Krugman P. End this Depression Now! New York and London: WW Norton & Company; 2013.
Stiglitz JE. Freefall: America, Free Markets and the Sinking of the World Economy. New York and London: WW Norton & Company; 2010.
Dahl E, van der Wei KA. Educational inequalities in health in European welfare states: a social expenditure approach. Soc Sei Med. 2013;81:60–9.
Stuckler D, Basu S, McKee M. Budget crises, health, and social welfare programmes. BMJ. 2010;340:3311.
Bambra C. Going beyond The three worlds of welfare capitalism: regime theory and public health research. J Epidemiol Community Health. 2007;61:1098–102.
Marmot M, Allen J, Bell R, Bloomer E, Goldblatt P. WHO European review of social determinants of health and the health divide. Lancet. 2012;380:1011–29.
Browne J, Hood A, Joyce R. Child and Working-Age Poverty in Northern Ireland from 2010 to 2020. IFS Repost R78. London: Institute for Fiscal Studies; 2013.
Stevis M, Talley I. IMF concedes it made mistakes on Greece. The Wall Street Journal. 5 June 2013. Available from URL: http://online.wsj.com/article/SBl0001424127887324299104578527202781667088.html (Accessed 26 June 2013).
Shelter. Value for money in housing options and homelessness services. London: Shelter; 2010.
Eurostat. Unemployment rates by education. 2010. Brussels: Eurostat; 17 August 2010.
Bradshaw J. Social Exclusion, Vulnerability & Disadvantage Task Group background paper 3: child poverty in the WHO European Region. Copenhagen: WHO Regional Office for Europe; 2012.