Dying to work: the health consequences of economic recession
Authors: James Macinko, Cesar Victora
Journal: The Lancet Global Health (2019)

In the The Lancet Global Health, Thomas Hone and colleagues1Hone T Mirelman AJ Rasella D et al.Effect of economic recession and impact of health and social protection expenditures on adult mortality: a longitudinal analysis of 5565 Brazilian municipalities.Lancet Glob Health. 2019; 7: e1575-e1583Summary Full Text Full Text PDF PubMed Scopus (40) Google Scholar relied upon econometric methods to assess associations between unemployment and adult mortality in 5565 Brazilian municipalities. The authors did a longitudinal analysis with data obtained from Brazilian Government sources to assess changes in state unemployment level and mortality in adults (aged ≥15 years) in Brazil between 2012 and 2017. Mortality data were stratified by age, sex, and race. Hone and colleagues assessed the interaction between recession and changes in mortality and whether this relationship was affected by levels of municipal social protection and health-care expenditure. During this 5-year period, when the country faced an important economic recession, an increase in the unemployment rate of 1 percentage-point was associated with a 0·50 increase per 100 000 population per quarter (95% CI 0·09–0·91) in all-cause mortality, resulting in 31 415 excess deaths (29 698–33 132). This association was observed mainly among black or mixed race (pardo) Brazilians (0·46 increase [95% CI 0·15–0·80] per 1 percentage-point increase in the unemployment rate), men (0·67 [0·22–1·13]), and individuals aged 30–59 years (0·43 [0·16–0·69]), but not among women, white men, young individuals (aged 15–29 years), or older individuals (aged ≥60 years). Additionally, the authors concluded that municipalities with greater investments on health and social protection programmes were largely spared from the fatal consequences of unemployment. Hone and colleagues used a robust research design and buttressed their arguments through an impressively thorough set of alternative specifications and sensitivity tests. Four important strengths of their study set it apart from much of the existing literature. First, the study had a time-series design, whereas many of the existing studies are cross-sectional. Second, the objective nature of the mortality outcome contrasts with many of the existing studies, which rely on self-reported data. Third, the study did a thorough exploration by cause of death and demographic subgroups, whereas much of the literature is restricted to aggregate effects. And lastly, the study's explicit assessment of the modifying role of social and health expenditures contrasts with many existing studies, which discuss social spending as a potential buffer, but fail to operationalise and test its effects. The relationship between unemployment and health outcomes is complex. Different health conditions might be affected in different ways through complex and overlapping pathways that even include mortality reductions for some conditions.2Burgard SA Kalousova L Effects of the Great Recession: health and well-being.Annu Rev Sociol. 2015; 41: 181-201Crossref Scopus (63) Google Scholar In this sense, Hone and colleagues' findings might represent just the tip of the iceberg. Increased morbidity, particularly from mental health and substance use disorders including alcohol abuse,3Frasquilho D Matos MG Salonna F et al.Mental health outcomes in times of economic recession: a systematic literature review.BMC Public Health. 2016; 16: 115Crossref PubMed Scopus (164) Google Scholar, 4de Goeij MC Suhrcke M Toffolutti V van de Mheen D Schoenmakers TM Kunst AE How economic crises affect alcohol consumption and alcohol-related health problems: a realist systematic review.Soc Sci Med. 2015; 131: 131-146Crossref PubMed Scopus (133) Google Scholar is likely to have occurred, but was not reflected in mortality data. Moreover, the possibility of intergenerational effects should not be discounted or underappreciated.5Chen WY On the relationship between economic conditions around the time of birth and late life cognitive abilities: evidence from Taiwan.Econ Hum Biol. 2016; 22: 126-139Crossref PubMed Scopus (12) Google Scholar In reviewing the impact of several previous large economic crises (the Great Depression, the post-communist depression, and the East Asian financial crisis), Stuckler and colleagues6Stuckler D Basu S Suhrcke M McKee M The health implications of financial crisis: a review of the evidence.Ulster Med J. 2009; 78: 142-145PubMed Google Scholar point out that "the impact on mortality is exacerbated where people have easy access to the means to harm themselves and is ameliorated by the presence of strong social cohesion and social protection systems." This point is supported by Hone and colleagues' demonstration of the mitigating effects of investments in Brazil's main health and social protection programmes: its conditional cash transfer programme (Bolsa Familia) and its national health service, the Unified Health System. Brazil is unique among middle-income countries in the way it has devoted resources to improving health and data infrastructure since the early 1990s. In fact, this study is only possible because of the availability of high-quality, publicly accessible data on almost all deaths that take place in such a large country. Disaggregation by ethnicity, on the basis of the skin colour system adopted in Brazil, was essential for adding an equity dimension to Hone and colleagues' analyses. Many other countries probably have been affected even more severely than Brazil by the changes in the global economy, but without the availability of timely and high-quality statistics, such an effect could be impossible to detect or attribute. Nevertheless, these health risks are real and should not be ignored. The human cost of macroeconomic shocks should feature more prominently when national and international strategies are developed to help combat such economic downturns. The present economic and political crises in Brazil started in 2014, and led to increased unemployment that persists today.7Dweck E Vianna MT Barbosa CA Discussing the role of fiscal policy in a demand-led agent-based growth model.EconomiA. 2019; (published online March 26.)DOI:10.1016/j.econ.2019·03·004Crossref Scopus (4) Google Scholar, 8Neri M The escalation of inequality—what was the impact of the crisis on income distribution and poverty. Fundação Getúlio Vargas, Rio de Janeiro2019Google Scholar The response of the last two governments to this situation led to a constitutional amendment in 2016, which restricted the growth of health-care and education spending in the country for a 20-year period.9Souza LEPFd Barros RDd Barreto ML et al.The potential impact of austerity on attainment of the Sustainable Development Goals in Brazil.BMJ Glob Health. 2019; 4e001661Crossref PubMed Scopus (13) Google Scholar This is a situation in which Hone and colleagues' work is most relevant going forward. Brazil faces a worst-case scenario in which, in defence against man-made financial disasters that led to high unemployment, the response has been to erode social protections that have been shown to buffer populations from such unnatural disasters.10Doniec K Dall'Alba R King L Austerity threatens universal health coverage in Brazil.Lancet. 2016; 388: 867-868Summary Full Text Full Text PDF PubMed Scopus (21) Google Scholar Contrary to what was expected by its proponents, the 2016 bill has flatly failed to lead to meaningful economic growth.8Neri M The escalation of inequality—what was the impact of the crisis on income distribution and poverty. Fundação Getúlio Vargas, Rio de Janeiro2019Google Scholar Furthermore, ongoing bills to reshape the country's retirement benefit schemes towards a tributary reform threaten some of the pillars of the Brazilian welfare state. After two decades of consistent reduction in income inequality, the Gini index started to increase in 2016,8Neri M The escalation of inequality—what was the impact of the crisis on income distribution and poverty. Fundação Getúlio Vargas, Rio de Janeiro2019Google Scholar and the situation of the chronically underfunded Unified Health System has become even more serious.11Castro MC Massuda A Almeida G et al.Brazil's unified health system: the first 30 years and prospects for the future.Lancet. 2019; 394: 345-356Summary Full Text Full Text PDF PubMed Scopus (137) Google Scholar The article by Hone and colleagues could not have been timelier. Whether Brazil as a nation will manage to take on board the accumulating evidence of the consequences of these failed policies and reverse such crucial trends before even more lives are unnecessarily lost remains to be seen. We declare no competing interests. Effect of economic recession and impact of health and social protection expenditures on adult mortality: a longitudinal analysis of 5565 Brazilian municipalitiesThe Brazilian recession contributed to increases in mortality. However, health and social protection expenditure seemed to mitigate detrimental health effects, especially among vulnerable populations. This evidence provides support for stronger health and social protection systems globally. Full-Text PDF Open Access