Health effects of the financial crisis: lessons from Greece.

Remarkably, 8 years after the onset of the global fi nancial crisis, the consequences for health are still being debated, even in Greece, the country most severely aff ected by the economic downturn. There can be few better indications of the low priority accorded to health within governments than the diff erence between the concerted eff orts dedicated to understanding the state of the economy and the apparent scarcity of concern about the health of populations. Economists are still divided about the causes of the crisis and how to respond to it, although many view austerity as a mistake; however, at least an active debate is taking place in the political arena, generating extensive coverage in the media. By contrast, with a few exceptions, the health consequences have been largely ignored. There are several possible reasons for this scant discussion of health consequences of the recession. First, health issues rarely attract much political or media attention unless they threaten privileged elites. For example, the emergence of SARS in east Asia posed a clear threat to the global business community and thus an immediate, coordinated response occurred. By contrast, many months passed before the world paid any attention to the emergence of Ebola virus in west Africa. Only in the past decade have global leaders accepted the need to respond to the increased burden of non-communicable diseases in low-income and middle-income countries, whereas the horrendous toll of death and disability from road traffi c accidents in those countries remains largely unacknowledged. Second, despite impressive progress in improving data collection, encouraged by the Global Burden of Disease project, we still do not have timely data on mortality from many countries. Consequently, although fi nancial data were available within days or weeks of the onset of the fi nancial crisis, several years passed before corresponding mortality data were published. This delay keeps the eff ect on health from getting onto the political agenda, and reinforces its low priority. Because of the diffi culty in obtaining data about what was happening to health in Greece, dismissal of the early signs of a crisis was easy. In 2011, echoing many reports by journalists, we reported what we considered to be “omens of a Greek tragedy”, describing a rising unmet need for health care, increasing suicides, and an HIV outbreak among injecting drug users. Yet others dismissed our concerns, arguing, for example, that “there is no evidence that it has aff ected health” or that budget cuts were “a positive result of improvements in fi nancial management effi ciency”. In 2015, Tapia Granados and Rodriguez argued that “claims of a public health tragedy in Greece seem overly exaggerated”. Several of these analyses drew on studies suggesting that economic recessions might benefi t health, although other researchers, including us, have argued that the situation is rather more complicated, depending on how governments respond, with both positive and negative consequences. Ioannis Laliotis and colleagues’ study in The Lancet Public Health does much to resolve the argument about what has happened in Greece. Laliotis and colleagues provide a comprehensive overview of changes in mortality by cause of death and age, tracking change over more than a decade. Overall mortality continued to decline after the onset of the fi nancial crisis, but at a slower pace than before the crisis (p<0·0001). Those aged older than 75 years experienced more negative eff ects (p<0·0001) than did those aged 20–34 years, in whom mortality trends improved (p<0·0001). Deaths from traffi c accidents declined faster after compared with before the onset of the crisis (p<0·0001), whereas deaths from suicides increased after the onset of the crisis (p=0·002). Laliotis and colleagues’ fi ndings highlight the crucial importance of national context in understanding the response to a fi nancial crisis. First, path dependency plays a major part. Many examples now exist of how deaths from road traffi c injuries fall during a recession, but cannot fall substantially in countries such as the UK or the Netherlands where they are already very low. Powerful cultural determinants of suicide rates have long been recognised, refl ecting factors such as religious belief, the stigma attached to self-harm, and social support networks, so that a small rise, in absolute terms, equates to a large relative increase. Rates have always been low in Greece. Second, the eff ect of a fi nancial crisis will depend on the measures taken in response to it. Governments have substantial discretion as to how they respond, although, in the case of Greece, the discretion is exercised not by the national government but by the Troika, Published Online November 4, 2016 http://dx.doi.org/10.1016/ S2468-2667(16)30016-0