Apr 30 2014
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Harvard School of Public Health Special Report: The Financial Crisis as a Public Health Crisis

“Five years after the Great Recession officially came to an end, the United States has yet to fully recover from the economic devastation sparked by the collapse of an $8 trillion housing bubble and the ensuing turmoil that saw global financial systems teetering on the brink of collapse. But while the economic costs of the downturn have drawn the lion’s share of attention, the damage to our bodies could end up far surpassing the damage to our bank accounts.”

Those are the opening lines of a new special report from the Harvard School of Public Health (HSPH), “Failing Economy, Failing Health: The Great Recession’s Toll on Body and Mind,” detailing how poverty and inequality resulting from the economic maelstrom pulled down so many—and what that will mean for public health in the long term.

“Health is a long-run thing, but the methods we use to analyze current data only estimate short-term effects,” says SV Subramanian, HSPH professor of population health and geography. “It may take awhile for the health impact of the Great Recession to kick in, but once it does, it could be dramatic.”

The data is strong on the links between employment and health—people who are unemployed, underemployed or laid off are less healthy and don’t live as long. 

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A 2009 study found that in the 12 months after men lost their jobs in mass layoffs, they saw their chances of dying nearly double. While over time the risk lessened it was still significant two decades later. Another study that same year found that losing a job when a business shuts its doors increases the odds of fair or poor health by 54 percent among workers with no preexisting health conditions while also increasing the risk of new health conditions by 83 percent. The stress of the situation, according to the researchers, heightens the odds of stress-related conditions such as stroke, hypertension, heart disease, arthritis, diabetes and psychiatric problems.

Yet another study, this one in 2010, found that about 4 in 10 Americans with heart disease or diabetes and 1 in 5 with cancer said the stress of the Great Recession made it more difficult to manage their illnesses.

What’s more complex is unearthing the pathways behind why this is the case. The HSPH article outlines some of the mechanisms by which unemployment affects health.

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Effects of Stress

“‘Stress’ is such a simple word. It rolls off the tongue,” said Michelle Williams, Stephen B. Kay Family Professor of Public Health and chair of the School’s Department of Epidemiology. “The challenge is to pin down its biological consequences.”

Study after study has linked stress to physical and mental problems. The biological effects of stress include:

  • Higher risk of heart disease and hypertension
  • Acute sleep deprivation, which alters the body’s immune and hormone-secreting systems
  • Depressed mood or anxiety
  • Unhealthy behaviors such as overeating, smoking, and alcohol use
  • Increased frequency and severity of upper respiratory infections
  • Decreased response to vaccines
  • Shortened telomeres (the protective caps at the ends of chromosomes), which are associated with accelerated aging and early death
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Ability to Pay for Health Care

The link between joblessness and poor health outcomes is especially troubling because for many Americans the loss of a job also means the loss of the ability to pay for health care at all. The Affordable Care Act may change that, but for now its long-term effects remain unknown, while for the hundreds of thousands of people who lost their job during the financial collapse the legislation came too late. According to the Harvard report, the public health effects of the Great Recession were stronger than they might have been had the collapse occurred in other parts of the worlds.

“If you look at countries with strong social safety nets, it’s not as dire for people who are out of work,” said Laura Kubzansky, Professor of Social and Behavioral Sciences. “It’s unpleasant, but it doesn’t set up this cascade of catastrophe in the way that it can in this country, where the only net people have once unemployment runs out is frequently their family and savings.”

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Lack of Stable Housing and Its Spreading Impact

That ongoing mental and physical trauma that can come with job loss is further intensified by the loss of a home—and more than 13 million American households were foreclosed on between 2008 and 2013. And it’s not just the people who lost their homes who were affected. There is “spillover” effect when a home is foreclosed, with a 2013 study finding that living near foreclosed homes may increase a person’s chances of being overweight.

Using housing and medical data on 2,078 participants in Massachusetts from 1987 to 2008, the researchers found that living within 100 meters of a foreclosed home was associated with a higher BMI of 0.2 units, or approximately 1.3 pounds of additional weight in a 5-foot-6-inch person. This was the case even for the residents who did everything “right” and were able to make their mortgage payment each month.

“It’s easy to think ‘You’re the kind of person who let your home go into foreclosure, so you are also more likely to be the kind of person who gains weight. You’re irresponsible!’” said Mariana Arcaya, Yerby Postdoctoral Research Fellow at Harvard’s Pop Center and the study’s author. “Spillover effect reveals harmful structural forces in the larger economy.”

Arcaya attributes the weight gain in these communities most strongly to stress over declining property values. Other possible explanations for this increase include people simply not wanting to spend as much time outdoors in a community with rundown, boarded-up houses, or even that they might not feel safe outside. Whatever the cause, HSPH experts believe the effects of the foreclosure crisis will continue to be felt for a long time.

“Health is not something that can be miraculously revived overnight,” said Kasisomayajula “Vish” Viswanath, professor of health communication. “Even if foreclosures go down, even if people manage to regain a foothold in mainstream society, the consequences will be long-lasting.”

Then there are other potential impacts of mass foreclosures. In May 2007 the city of Bakersfield, Calif. saw its first cases of the mosquito-borne West Nile virus. At first unable to explain the cause during a year that was considered low risk for the disease that can lead to fatal brain damage, the answer ultimately came when aerial photos determined that approximately one in six of the swimming pools, Jacuzzis and birdbaths in the images were overrun with green fuzz. Investigators found more than 4,000 infected mosquito larvae in 31 neglected pools—and almost all of the homes had either “For Sale” or “Bank-Owned Foreclosure” signs in their yards.

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Furthering Disparities

Public health officials continue to find more and more data suggesting that extreme income inequality is a significant factor when it comes to poor health. The income wealth gap in the United States—which was already wide and expanding—was further increased during the Great Recession. While many of facets of the economy have since recovered or are recovering, a 2013 study found that during the recovery years from 2009 to 2012 the top 1 percent if income earners saw 95 percent of the income gains. During those three years the average income of the top 1 percent of Americans grew by 31.4 percent, while the bottom 99 percent saw their incomes grow by only 0.4 percent.

This economy inequity is further exacerbated by the stress of social comparison—also known as “Keeping up with the Joneses”—which can lead to stress-related shame.

“Americans think you can just be like Bill Gates or Warren Buffett, but data on social mobility say just the opposite,” said Ichiro Kawachi, chair of the school’s Department of Social and Behavioral Sciences. “When people try hard and fail—which happens a lot during economic recessions—they end up blaming themselves,” adding, “We were already one of the most unequal societies—and we just became more unequal, thanks to the Great Recession. And the more unequal a society is, the worse its average health measures tend to be.”

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Lack of Sustainable Solutions

In addition to working to understand the effects of economic hardship, public health officials must also work to set it in place a system to reduce the effects of future economic downturns, according to Kubzansky.

“What are the resources that would mitigate the impact of stress?” she asked in the report. “What are the assets that enable people to meet life’s demands in a hardier way? Wouldn’t it be great if we knew the answers and put some proven protections in place before the next recession?”

Part of that means determining the structural and social arrangements that impact public health. Public health has known for a long time how strong social support from family, friends, neighbors, co-workers, pets and even governments and organizations can positively impact physical wellbeing and longevity. Kubzansky herself, along with other researchers, are now studying whether positive psychological factors and emotional states can reduce the risk of coronary heart disease, while another study has tied optimism to a slower rate of atherosclerotic progression.

“What drives resilience in some individuals? What leaves others more vulnerable?” asked Williams. “Those are the public health questions we need to answer.”

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Inadequate Data

Public health knows that it can’t see and understand the whole board until it first sees and understands all the contributing factors. That means a need for better data, which “natural experiments” such as the Great Recession can help provide. For example, Williams said during such events public health should track sensitive indicators of population health worth such as birth weights, infant death rates, management of chronic illnesses such as diabetes, psychological distress, engagement with health services—measures that help paint the picture of a community’s overall quality of life.

“If the data are not there, you don’t know the problem exists,” said Nancy Krieger, professor of social epidemiology. She reflected on 1933 public health study of 10-cities to evaluate the health impact of the Great Depression, which found details about health outcomes, wages, unemployment, diet, food insecurity, alcohol consumption, state of mind and other facts.

“What they found was very interesting,” said Krieger. “Some of the people who did psychologically worst were those who had previously been OK, if not somewhat affluent, and ended up suddenly being poor; they didn’t know how to handle it.”

A similar approach to understand disease trends and health inequities is needed now to better understand the long-term public health consequences of the Great Recession.

While the public health community understands all these facts, convincing the American people is still a potentially difficult proposition, according to the report. “The idea that people can collectively act to change things cuts against the American myth of self-sufficient individuals who pull themselves up by their bootstraps,” said Krieger. “Linking economics to health, and suggesting that there’s a social production of disease, is not the mainstream analysis—even as it’s very common in other countries.”

According to Viswanath, the public health community needs to implement an “activist agenda” in order to shift the national focus to the link between economic health public health.

“We are fixated on the upstream factors—the recession and its direct economic costs,” he said. “But the downstream factors—the terrible impact on health—are already far along.”

 

>>Bonus Links:

  • Stable Jobs = Healthier Lives infographic from NewPublicHealth
  • “How Does Employment, or Unemployment, Affect Health?” from the Robert Wood Johnson Foundation
  • “Mobilizing Communities Toward Better Health, Income and Education: Q&A With United Way's Brian Gallagher” from NewPublicHealth
  • “More Jobs For Better Health: NewPublicHealth Q&A with Mark Pinsky” from NewPublicHealth
  • “How Job Insecurity, The Decline in 'Good' Jobs, and an Uncertain Safety Net Affect Health” from Human Capital
  • “Recession Likely Cause of Drop in Doctor Visits, Prescription Medications” from Human Capital
  • “The Reverberating Impact of Low Wages” post from NewPublicHealth

Tags: Health disparities, Housing, Poor and economically disadvantaged, Poverty, Public policy, Research