Brendan and Dermot Walsh on health and austerity

Dermot and Brendan Walsh have just published a provocative comment in the British Medical Journal on the link between health and austerity  [http://www.bmj.com/content/346/bmj.f4140/rr/651853].

Momentary relief from the deliberations on Anglo!

The comment reads:

Ireland is – after Greece – the country where the post 2008 structural adjustment programme, aka austerity, has been proportionately most severe. Yet there are few indications that this has had a significant adverse effect on basis health indicators.

The crude death rate in 2012 was 6.3 per 1,000 compared with 6.4 in pre-austerity 2007. The suicide rate in 2012 was 12.8 per 100, 000 in 2012 compared with 13.2 in 2007. Admission rates for depressive disorders fell to 117 per 100, 000 in 2012 from 138 in 2007. The percentage distribution of self-assessed health status did not change between 2007 and 2010 (the latest available year).

Overall there is a striking lack of evidence that the major austerity programme implementd since 2007, and the concomitant trebling of the inemployment rate, has had a significant deleterious effect on the health of the Irish population. This evidence needs to be given due weight in international assessments of the impact of economic policies on public health.

Comments

comments

35 thoughts on “Brendan and Dermot Walsh on health and austerity”

  1. I do not buy it!

    Measurement and the missing variables and the simplistic objectification of the human – perhaps!

  2. Wealthy people can afford better health care than poor people. Austerity creates more poor people.
    The return of the soft landing economists who failed to spot the greatest property bubble in the history of mankind.

  3. It’s too early to tell.

    It seems depression has to become chronic to have a record of it.

    Who is scoring increased addictions and family breakdowns?

    According to the WHO, the suicide rate among males in Ireland in 2011 was 19 per 100,000; 6 in Greece and 12 in Spain.

    Eurostat puts the Irish suicide rate for males at 16.1 in 2007, 19.7 in 2009 and 17.4 in 2010. The totals were 10.3, 12.3 and 10.9.

    So there was a big jump in Ireland between 2007 and 2009.

    The lowest suicide rates in 2010 were recorded in Greece (2.9 deaths per 100 000 inhabitants) and Cyprus (3.8), and relatively low rates – of less than 7.5 deaths per 100 000 inhabitants – were also recorded in Italy (2009), Spain, the United Kingdom and Malta. The death rate from suicide in Lithuania (28.5) was approximately three times the EU-27 average, while rates in Hungary (21.7) were around double the average.

    Maybe some countries underreport?

    The US Centers for Diseas Control asked in a study: Who Tends to be Most Depressed?

    This study found the following groups to be more likely to meet criteria for major depression:

    persons 45-64 years of age
    women
    blacks, Hispanics, non-Hispanic persons of other races or multiple races
    persons with less than a high school education
    those previously married
    individuals unable to work or unemployed
    persons without health insurance coverage

    Similar patterns were found among persons with “other depression” with the two following exceptions: adults aged 18-24 years were most likely to report “other depression” as were Hispanics (instead of other non-Hispanics).

  4. Irish mortality rates were heavily class driven before the crash . I’m not surprised there isn’t much to show since then. The most important stuff has been iterating away for years.

    http://www.cso.ie/en/media/csoie/census/documents/Mortality_Differentials_in_Ireland.pdf

    “The life expectancy at birth of males living in the most deprived areas in the State was 73.7 years in 2006/2007 compared with 78 years for those living in the most affluent areas (see Background Notes for a description of the deprivation
    methodology used). The corresponding figures for females were 80 and 82.7. The differential between female and male life expectancy (6.3 years) was greatest in the most deprived areas.
    Life expectancy at birth is greatest according to the affluence of the area in which the person lived at the time of the 2006 census. This relationship applied for both males and females at ages 0, 20, 35 and 65 years (see Table 1). Social class was also a powerful predictor of life expectancy with male
    professional workers having a life expectancy at birth of 81.4 years, 6.1 years
    higher than their unskilled counterparts. Male managerial and technical workers
    had the second highest life expectancy (79.8 years) followed by skilled manual
    workers (78.7 years). The situation for females was broadly similar with
    professional workers having the highest life expectancy (86 years) and unskilled workers the lowest (81 years).
    Life expectancy was also correlated with educational attainment. For a 35 year
    old male who had completed his full time education, life expectancy increased
    from 41.3 years for those educated to primary level only to 44.5 years for those with a secondary education to 46.9 years for those with a third level education.
    The corresponding figures for 35 year old females were 45.6, 48.5 and 50.4 years, respectively. The differential between female and male life expectancy was greatest for those educated to primary level only (4.3 years).”

    @ Michael

    WHO suicide numbers are not particularly useful – it comes down to the local culture and how doctors report the deaths. There is very little consistency across countries.

    Even in Ireland the number of suicides reported is, more than likely, an underestimate.

  5. I don’t know that counting sick and dead persons is exactly the way to go about describing a severely depressed economy. Morbid curiosity perhaps.

    But those making the decisions (and who are being implicitly criticized) will summon up their PR Panzer Grenadiers to rubbish any findings.

    What might be more useful (and with the possibility of checking the validity of the data) would be to count the number of now shuttered wholesale and retail premises, workshops, showrooms, etc. Do it on a quarterly basis. Bit tedious. A tad less ghoulish.

  6. Self-assessed health data are now available for 2011 (in SILC). It is an ordinal, categorical variable, so making year on year comparisons is difficult, but data seem to show that health inequality has been falling since about 2010, with no clear trend in the level of health. Note that by this I mean “pure” health inequality as opposed to the distribution of health with respect to income or some other measure of resources. With regard to the latter, there seems to be a weakening of the correlation between health and income poverty. For more detail see http://www.ucd.ie/t4cms/WP13_05.pdf .

  7. Alcohol consumption has trended steadily downwards throughout the crash. Perhaps the lack of money to spend on drink has outweighed the lack of money to spend on health 🙂

  8. The Eurostat data I see, go only until 2010, before any serious benefit cutting started anywhere, and one should be aware, that what the coroners put onto a death certificate is probably significantly biased by culture.

    In crime statistics there have been similar mismatches.

  9. I think ‘Michael Hennigan – Finfacts’ is correct in saying that it is too early to tell what impact the recession has had on the general health of the population. It is very possible that there are important lag features at play here.

    It is also true that these measures are limited. For example while inpatient admissions for depressive disorders are down it may be the case that community-based care demand has increased and/or the reliance on prescription medication has increased. Inpatient admissions has been steadily decreasing over time as a result of general shifts in psychiatric care.

    In regard to the crude death rates and suicide rates, it is worth noting that these rates have also been decreasing over time. Furthermore, the recession has changed the underlying demography of the country: with more emigration of young people and less immigration of people from Central and Eastern Europe.

    Finally, a simple ‘Google Trends’ analysis gives a little insight into the lives of people in Ireland over the period of the economic recession. Search terms like “anxiety”, “worry”, and “pain” have all steadily increased since 2007.

  10. beyond that,

    what to make of the persistently higher numbers for the “filthy rich” Norway and Switzerland, with current account surpluses north of 10% GDP?

    Liechtenstein, huugh, 3 times above average, do they count dead mailbox companies too? A little cynic, I know.

  11. Agree with both Michael and Peter re lags. We know that very traumatic events like famines etc have long-lasting effects. Clearly our recession has not been in that league of disaster, but negative shocks to the health (mental and physical) of children for example can have effects down the road.

  12. In addition to my point above regarding the general downward trend in inpatient admissions for depressive disorders, it should be noted that this decrease in admissions seems to be driven by a reduction in ‘re-admissions’ rather than a decrease in ‘new admissions’ (most recent available data is 2011).

    The frequency of ‘new admissions’ has increased since 2007, and now accounts for a greater proportion of overall inpatient activity than in 2007. (The rate per 100,000 might need a word of caution – if it changed sharply in 2012 due to new census figures then it would represent more of a statistical artifact rather than a true reflection of normal population growth over time).

    So, to me, it seems that the gross figure points toward disease management improvements in psychiatry (the reduction in ‘re-admissions’) rather than a causal effect of the economic recession. While the absolute increase in ‘new admissions’ remains an issue that might actually be well explained by the economic recession itself.

  13. I find it curious that people try explain away results that don’t suit their prior views. While the “too early to tell” view may be correct, how do you know when it’s not too early, when you find an effect?
    A recent paper in PLoSOne looks at suicide in 29 European countries, including Ireland. Their focus is on anti depressants (which seem to work) but they find unemployment and GDP have no effect. It would have been useful if they disaggregated: Walsh&Walsh in their ESR paper find some effect for young males. The latter paper takes account of the under-reporting of suicide.

    http://www.plosone.org/article/fetchObject.action?uri=info%3Adoi%2F10.1371%2Fjournal.pone.0066455&representation=PDF

  14. As more waves of Growing Up in Ireland become available there may be some useful evidence there – not sure if any analysis has been done yet on the second wave of 9 year old cohort which might throw some light on effect of recession on children.

  15. @KD I have an open mind on the issue but the arguments in favour have already been made so I believe that is why you are finding the arguments against here.

  16. Interesting piece. A couple of points I would add:

    1) The findings on physical health, as the authors are aware, are not unusual in the literature. The idea that recessions might have some positive short-run health effects has been backed up by a lot of papers

    2) As commentator Robert Sweeney points out, there is a big literature on deleterious effects of poorly planned “forced” migration. It is certainly worth thinking more about this.

    3) As Kevin has pointed out, results of macroeconomic determinants of the suicide rate are very mixed. Suicide is a very complex variable and a basic glance at the Irish trend would make one cautious about making any conclusive statements about aggregate linkages.

    4) On the other hand, there is absolutely no doubt that unemployment impacts negatively on psychological distress. This has been shown many times in so many different research designs. This is not inconsistent with the idea that a country experiencing a big increase in unemployment would not neccesarily experience a big decrease in average life satisfaction or other measures of welfare. If, for example, 200000 extra people were rendered unemployed from an adult population of over 3 million, then a sample survey isn’t going to register a big change in the overall mean of any measure of well-being. For example, on life satisfaction a typical ‘penalty’ from unemployment is usually something in the order of 1-2 points on a 10-point scale. This is psychologically very significant but scaled up will not register as a big dip in overall life satisfaction. If we are taking a more Rawlsian view then looking at the welfare of those most severely hit by the changes will be better than looking just at averaged adjustment.

    5) Overall, the authors are correct to contest exaggerations of the health and psychological impacts. But it would be a big mistake to rule out effects that are very plausible but hard to measure with their data. Peter is correct that a glance at google trends data shows very large increases in search terms associated with mental health problems. However, this data is by no means reliable enough yet to make policy conclusions. Studies that zeroed in more on the effects of recession most likely to cause mental health problems (unemployment, debt servicing problems, forced migration) will be needed before putting an estimate on overall effects and distribution of those effects.

  17. David, the 2nd wave of the infant cohort is available not the older group, available publicly that is. Because they are the same age you can’t identify an age effect from a year effect but you might get something from the cross section variation e.g health as a function of labour market status.
    The Eurobarometer has some sort of happiness question and I vaguely recall someone (BMW, CoG?) looking at the time variation.

  18. Kevin, what I had in mind is that I think GUI has information on “shocks” which hit the family, shocks which could be plausibly linked to the recession e.g. a parent loses their job. You could look at those families which received such a shock between wave 1 and wave 2 and see if this has affected child health, given that there is a wide range of child health measures in GUI. That approach should not need to separate an age from year effect, I think.

  19. It is surely remarkable that the Irish birth rate is still one of the highest among the OECD countries, despite which the infant mortality rate has remained below four per thousand live births, one of the lowest in the world. The maternal death rate has also remained among the lowest in the world. No evidence in these numbers of the public health ‘disaster’ that the BMJ warns of.

  20. It is the long term mental and physical health (and life span) of the younger cohorts growing up under austerity that will be the most interesting thing.

    I wonder do we have any other metrics available for the last few years that might give us a better idea of the long term effects? Things like maternal mortality rates, birth weights, height and educational achievements of children in different income groups at various ages and so on.

  21. David O Donnell, there is plenty of that “realistic, complex stuff” out there. For example: http://ideas.repec.org/p/ucd/wpaper/201222.html

    http://ideas.repec.org/p/ucn/wpaper/201214.html

    http://ideas.repec.org/p/ucd/wpaper/201212.html

    These are just three examples, all published. Check the websites of UCD Economics, the Geary Institute, ESRI, and any of the conferences in the last few years which have used the Growing Up in Ireland data. Where the data is available it is being used to produce and publish research in the areas Shay mentions.

  22. @David Madden

    That is some interesting stuff, I wish I had time to fully digest it.

    I wonder if twenty years from now we will see that the drop in incomes during the European component of the global financial crisis was temporarily beneficial for the health of adults (less consumption, better health, a la the second world war experience with rationing in the UK) but bad for the generations born during it (more newborns under the 2500g limit)?

  23. @David Madden

    Ta for that.

    I was being a little tongue in cheek there and am fully aware of attempts at that complex stuff, within its ontological limits, which includes more than three variables …

    UCC also produced some real stuff on the health and life chances of the Irish Traveller Community … a much neglected group.

  24. @Shay Begorrah

    The maternity hospitals publish data on birth weights in the their annual reports.
    I have the reports from the Rotunda Hospital to hand. The number of babies born in this hospital – which serves some of the poorest areas of the country- increased from 8456 in 2007 to 10547 in 2011, but the proportion of births under 2500g fell:

    2007 7.5%
    2008 6.9%
    2009 6.3%
    2010 6.7%
    2011 6.7%

  25. Shay, my guess is that in 20 years time there will be more low birthweight babies, but that will be because the technology to keep them alive will be better, so more of them will survive to birth.

    Like Liam says, the literature on the short run effects of recession on physical health is mixed with some evidence of positive effects. There is certainly evidence of a link between unemployment and mental health, but maybe the effect is too small to pick up in large scale surveys, or perhaps the effect is less when the increase in unemployment is generalised than when it is local. The loss in self-esteem is less if you are not the only one.

    This has been a good thread with lots of interesting points made. But having read the piece by the Walshes and the original editorial in the BMJ to which they were responding, I think they were just pointing out that, so far, the link between austerity and adverse health outcomes has not been evident in the Irish case. Thus it would be a mistake to automatically assume such a link exists (as the BMJ editorial seems to suggest).

    DOD, I kind of guessed you were being tongue in cheek (and no offence taken) but thought it no harm to give some references to the contrary. Even if only to remind readers of the blog that there is some worthwhile applied micro research going on, as well as all the macro/banking stuff that gets most of the attention here.

  26. If you are looking at many outcomes (different health conditions by age groups by sex) then you need to think about the Multiple Comparison Problem since the probability of getting at least one false positive rises.
    If you have a strong faith (sorry, prior) that austerity is bad for health then with a little torturing of the data you can probably find it.
    On a different note, it would be interesting to know the macro effects on educational attainment. A priori it could go either way: credit constraints vs. safe havens.

  27. Interesting paper on effects of unemployment in Spain on their babies health.

    (http://research.barcelonagse.eu/tmp/working_papers/702.pdf)

    “we find that babies are born healthier when the local unemployment rate is high”

    “the main result survives the inclusion of parents fixed-effects”

    “[..] women do not appear to engage in significantly healthier behaviors during recessions (in terms of exercise, nutrition, smoking and drinking). However, they are more likely to be out of work. Maternal employment during pregnancy is in turn negatively correlated with babies’ health.”

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