Ending the fairy tales
Authors: None The Lancet Global Health
Journal: The Lancet Global Health (2019)

At the UN Climate Summit last month, Greta Thunberg delivered an impassioned speech to world leaders, exhorting them to wake up and face reality: “We are at the beginning of a mass extinction” she said, and “all you can talk about is money and fairy tales of eternal economic growth. How dare you?” Greta has a way with words and her message is often on point. Last month, the Global Preparedness Monitoring Board, an independent body convened by the World Bank Group and WHO to monitor and advocate for global health emergency preparedness, released its first annual report, “A world at risk”. Unsurprisingly, it is a chilling read. The main message is that under the pressure of trends that include climate change, “the world is at acute risk for devastating regional or global disease epidemics or pandemics that not only cause loss of life but upend economies and create social chaos”—and the world is not ready. The seven recommendations call for commitment, coordination, and increased investment in preparedness. The main arguments centre around country vulnerabilities in terms of economic loss. A global influenza pandemic of the scale of the one that occurred in 1918 could cause an estimated 50 to 80 million deaths, but it would also cost about US$3 trillion, causing South Asia's GDP to drop by 2% and sub-Saharan Africa's by 1·7%, potentially erasing years-worth of economic growth. The ensuing recession could then reverberate across economies, reducing productivity and increasing unemployment. The negative effects of recession, and unemployment in particular, on health have been documented. Impacts on overall mortality are less clear, but studies done mostly in high-income countries have shown that mortality sometimes declines during economic downturns, as occupational and other accidents tend to decrease, reduced manufacturing activity leads to improved air quality, and less time spent at work means more time for healthy activities. In this issue of The Lancet Global Health, Thomas Hone and colleagues present the results of a longitudinal analysis of data from 5565 Brazilian municipalities during the 2014–16 recession, which show that adult mortality increased by 8% in the period around the recession. A 1 percentage point increase in unemployment rate was associated with a 0·50 increase in all-cause mortality per 100 000 population per quarter, mainly due to cancer and cardiovascular diseases, especially among black or mixed race Brazilians, men, and individuals of working age. In municipalities with high expenditure on health and social protection programmes, there was no significant increase in recession-related mortality. What this study shows is that in a middle-income country, when economic growth is suddenly reversed, there is a negative and unequal effect on mortality, but that effect can be mitigated. Unfortunately, when it comes to predicting catastrophes, economists seem as powerless as epidemiologists. The parallels are quite remarkable: it is not a matter of if, but when the next recession/pandemic will occur, but the capacity to predict and respond is currently very low in both cases. In the Financial Times last month, Robin Harding equates the next global economic downturn to “a traumatic and unlooked-for event, more like a sudden outbreak of a new disease than the annual onset of flu”. But beyond the unpredictability of macroeconomic trends, the obvious point is that just as a pandemic and its economic impacts are inevitable, eternal economic growth is indeed a fairy tale, so health and social protection (let's call them universal health coverage) are essential mechanisms to consider. And as James Macinko and Cesar Victora mention in a linked Comment in this issue, maybe the human cost of macroeconomic shocks should also become an integral consideration in national and international economic strategies. Maybe, as suggested by Alan Donnelly and Ilona Kickbusch in the Financial Times last month, WHO should appoint a chief economist to ensure that the interdependency of health and the economy is fully integrated and understood. And as they add, international bodies that regulate the global financial system, such as the Financial Stability Board, should probably also recognise the importance of, document, and address the economic impact of disease (and, surely, the health impact of economic cycles). Maybe then, within a more resilient, equitable, and responsive global economy where the protection of human health and its planetary correlates would come first, talking about money and economic growth would finally become unessential, and like Greta, the world could concentrate on what really matters: human lives, and the future of their planet. 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 AccessDying to work: the health consequences of economic recessionIn the The Lancet Global Health, Thomas Hone and colleagues1 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. Full-Text PDF Open Access