Health effects of the financial crisis: lessons from Greece
Authors: Martin McKee, David Stuckler
Journal: The Lancet Public Health (2016)

Remarkably, 8 years after the onset of the global financial crisis, the consequences for health are still being debated, even in Greece, the country most severely affected by the economic downturn. There can be few better indications of the low priority accorded to health within governments than the difference between the concerted efforts 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;1Krugman P End this depression now. WW Norton, New York2012Google Scholar 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.2Shiffman J A social explanation for the rise and fall of global health issues.Bull World Health Organ. 2009; 87: 608-613Crossref PubMed Scopus (152) Google Scholar 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.3Moon S Sridhar D Pate MA et al.Will Ebola change the game? Ten essential reforms before the next pandemic. The report of the Harvard-LSHTM Independent Panel on the Global Response to Ebola.Lancet. 2015; 386: 2204-2221Summary Full Text Full Text PDF PubMed Scopus (313) Google Scholar 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,4Beaglehole R Bonita R Horton R et al.Priority actions for the non-communicable disease crisis.Lancet. 2011; 377: 1438-1447Summary Full Text Full Text PDF PubMed Scopus (1190) Google Scholar whereas the horrendous toll of death and disability from road traffic 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 financial data were available within days or weeks of the onset of the financial crisis, several years passed before corresponding mortality data were published. This delay keeps the effect on health from getting onto the political agenda, and reinforces its low priority. Because of the difficulty 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.5Kentikelenis A Karanikolos M Papanicolas I Basu S McKee M Stuckler D Health effects of financial crisis: omens of a Greek tragedy.Lancet. 2011; 378: 1457-1458Summary Full Text Full Text PDF PubMed Scopus (448) Google Scholar Yet others dismissed our concerns, arguing, for example, that "there is no evidence that it has affected health"6Liaropoulos L Greek economic crisis: not a tragedy for health.BMJ. 2012; 345: e7988Crossref PubMed Scopus (32) Google Scholar or that budget cuts were "a positive result of improvements in financial management efficiency".7Polyzos N Health and the financial crisis in Greece.Lancet. 2012; 379: 1000Summary Full Text Full Text PDF PubMed Scopus (19) Google Scholar In 2015, Tapia Granados and Rodriguez8Tapia Granados JA Rodriguez JM Health, economic crisis, and austerity: a comparison of Greece, Finland and Iceland.Health Policy. 2015; 119: 941-953Summary Full Text Full Text PDF PubMed Scopus (77) Google Scholar 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 benefit health,9Ruhm CJ Are recessions good for your health? National Bureau of Economic Research.http://www.nber.org/papers/w5570Date: 1996Google Scholar although other researchers, including us,10Stuckler 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: 315-323Summary Full Text Full Text PDF PubMed Scopus (972) Google Scholar have argued that the situation is rather more complicated, depending on how governments respond, with both positive and negative consequences. Ioannis Laliotis and colleagues' study11Laliotis I Ioannidis JPA Stavropoulou C Total and cause-specific mortality before and after the onset of the Greek economic crisis: an interrupted time-series analysis.Lancet Public Health. 2016; (published online Nov 4.)http://dx.doi.org/10.1016/S2468-2667(16)30018-4Summary Full Text Full Text PDF PubMed Scopus (76) Google Scholar 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 financial crisis, but at a slower pace than before the crisis (p<0·0001). Those aged older than 75 years experienced more negative effects (p<0·0001) than did those aged 20–34 years, in whom mortality trends improved (p<0·0001). Deaths from traffic 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' findings highlight the crucial importance of national context in understanding the response to a financial crisis. First, path dependency plays a major part. Many examples now exist of how deaths from road traffic 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, reflecting 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 effect of a financial crisis will depend on the measures taken in response to it. Governments have substantial discretion as to how they respond,12Reeves A Basu S McKee M Marmot M Stuckler D Austere or not? UK coalition government budgets and health inequalities.J R Soc Med. 2013; 106: 432-436Crossref PubMed Scopus (62) Google Scholar although, in the case of Greece, the discretion is exercised not by the national government but by the Troika, comprising the European Commission, European Central Bank, and International Monetary Fund. By contrast with other countries, where the income of pensioners was largely protected, this was a particular target in Greece, were many people were able to retire at relatively young ages. Consequently, that pensioners seem to have been most affected is not surprising. As Laliotis and colleagues note, this relative disadvantage experienced by older people was also the case in the UK, where changes to the welfare system adversely affected low-income pensioners, coinciding with rising mortality.13Loopstra R McKee M Katikireddi SV Taylor-Robinson D Barr B Stuckler D Austerity and old-age mortality in England: a longitudinal cross-local area analysis, 2007–2013.J R Soc Med. 2016; 109: 109-116Crossref PubMed Scopus (76) Google Scholar By contrast, in the crisis that followed the breakup of the Soviet Union, people of working age were most affected.14Shkolnikov V McKee M Leon DA Changes in life expectancy in Russia in the mid-1990s.Lancet. 2001; 357: 917-921Summary Full Text Full Text PDF PubMed Scopus (260) Google Scholar Perhaps the most important finding of this study, and one that has received inadequate attention in published work on the financial crisis thus far, is the increase in deaths due to adverse events during medical treatment (p<0·0001). This increase corresponds with accounts by journalists of the many problems facing the Greek health-care system,15Daley S Greeks reeling from health care cutbacks.The New York Times (New York, NY). Dec 26, 2011; (accessed Oct 31, 2016).http://www.nytimes.com/2011/12/27/world/europe/greeks-reeling-from-health-care-cutbacks.htmlGoogle Scholar as well as the growing evidence of an unmet need for care noted previously. This study should serve as a warning to politicians. Major cuts to health care cost lives. Unfortunately, there is little evidence that they are listening. We declare no competing interests. Total and cause-specific mortality before and after the onset of the Greek economic crisis: an interrupted time-series analysisMortality trends have been interrupted after the onset of compared with before the crisis, but changes vary by age, sex, and cause of death. The increase in deaths due to adverse events during medical treatment might reflect the effects of deterioration in quality of care during economic recessions. Full-Text PDF Open AccessGreece—the cost of recoveryThe worst wildfires in a decade have engulfed parts of Greece, leaving scores of people dead and injured. "We will do whatever is humanly possible", said Greek Prime Minister Alexis Tsipras. Emergency services across the country have been mobilised. A national state of emergency has been declared. European nations are urgently coming to Greece's assistance. These immediate actions are welcome, appropriate, and proportionate. But they are in stark contrast to the international response to Greece's long-term health crisis. Full-Text PDF Open Access