JAMA Forum: How the Economy Affects Health

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In the long term, growing economies are associated with longer and healthier lives. In the short term, that may not be the case—economic booms can boost mortality rates and busts can reduce them. There are many theories why, and some evidence to suggest the health system may have something to do with it.

Historically, long-run improvements in health have been tied to economic growth through 3 broad mechanisms: better nutrition, enhancements in public health infrastructure (such as sanitation and cleanliness of water supply), and more effective medical technology (such as antibiotics and vaccines). The results of many studies exhibit this familiar wealth-health connection, both across nations and within them. Citizens of nations with higher average incomes tend to live longer and, despite that, experience fewer years of disability. Women in higher-income nations have lower rates of anemia. Babies born in those countries have higher birth weights.

Within countries, people with higher incomes also tend to live longer. Children growing up in wealthier households are healthier. Infant and childhood mortality, as well as childhood illness rates, are lower. Lives lengthened in Japan after its economic booms in the 1960s and 1970s. Lifespans fell during the Great Depression. A recent study of US recessions and mortality from 1993 to 2012 by Sarah Gordon, MS, and Benjamin Sommers, MD, PhD, also found that a slowing economy is associated with greater mortality. According to their work, lower income and greater poverty are more strongly associated with higher mortality rates than is the unemployment rate.

Effects of Economic Expansions

Still, there is also a substantial body of research that in the short run, economic expansions can be detrimental to health. Or, conversely, recessions can improve the health of some. During the Great Recession of 2007–2012, unemployment spiked, but to different degrees in different countries. Exploiting this, one study of Europe found a 1 percentage point increase in the unemployment rate associated with a half percent decline in the mortality rate. A similar relationship has been observed at other periods, both in Europe and in the United States. The effect in the United States translates into about 13 000 fewer deaths for every 1 percentage point increase in the unemployment rate.

How can wealth improve health while slowing economies reduce mortality? Broadly speaking, the relationship between economic conditions and health is context dependent, can vary over time, and can be different in the short-term vs long-term. It can change due to the nature of the economy (such as agrarian vs industrial vs service). The depth of recessions and the strength of economic surges also play a role. Finally, the composition of the population is relevant, since different types of individuals are susceptible to the effects of economic changes to different degrees.

One theory is that during economic booms, an industrial economy produces more air pollution, which exacerbates certain diseases and increases mortality. One study found that the unemployment rate increase of the Great Recession was associated with reduced mortality for respiratory illnesses, cardiovascular disease, and heart conditions, which are all sensitive to air pollution. By one estimate, two-thirds of the short run, mortality-increasing effect of a strong economy can be attributed to air pollution.

Driving is another source of mortality that is affected by economic conditions in the short run. When the economy slows, people drive less (such as less driving to and from work and also fewer goods transported), and, consequently, there are fewer deaths due to automobile accidents. In addition, according to a study by Vikram Maheshri, PhD, and Clifford Winston, PhD, MSc, those who do drive during recessions tend to be safer drivers. According to automobile insurance data they analyzed, drivers with characteristics of higher risk—with a prior accident, over age 60, or who lived with no more than one other person—reduce the miles they drive during recessions more than other drivers.

Who is affected?

It’s important to recognize that the financial effects of a shrinking or growing economy—employment and reduced income—can accrue to different people than its health effects. This is demonstrated in an intriguing study by Ann Stevens, PhD, Douglas Miller, PhD, Marianne Page, PhD, and Mateusz Filipski, PhD. They found that increases in mortality during strong economic conditions are concentrated among the elderly, particularly older women living in nursing homes. One mechanism for this phenomenon is that employment levels in skilled nursing facilities—particularly for nursing staff—go down when the unemployment rate falls. This might occur because nurses who would otherwise work in those facilities are able to find better jobs elsewhere, or their other household members are able to gain employment. Moreover, it may be the case that during economic expansions, the nursing staff that facilities are able to retain are of lower quality. Since quality is positively correlated with nursing home staff levels, this connection between employment rates and nursing home mortality is plausible.

These findings are consistent with several other studies. For example, one study that also found increased mortality concentrated in the elderly during strong economic conditions showed that it is driven by deaths from cardiovascular, respiratory, and degenerative brain diseases, as well as infections. Another recent study that lends credibility to the findings examined nurses’ employment and patient outcomes in Denmark after the government introduced a federally funded parental leave program in 1994. The program led to a 12% reduction in nurse employment followed by 13% increase in nursing home mortality for residents 85 years or older.

These studies help reconcile the facts that higher incomes are broadly good for health but booming economies can increase mortality. Both things can be true if the people who experience mortality effects during a robust economy generally differ from those who enjoy financial gain. Think of it this way: my gains from a strong economy may be good for me and my family in the long run, but, in the short run, your grandparents may be harmed.







Categories: Health Policy, The JAMA Forum

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