Friday July 10 2009
BBC News has warned that we should “expect suicides” and even an increase in the murder rate as the economic downturn continues. The report follows research into how economic change has influenced death rates in 29 European countries over the past 30 years.
This in-depth study has analysed a large quantity of data on economic factors and death rates in the EU across a 30-year period. The study found no consistent evidence that a rise in unemployment increased overall death rates across the EU population. However, there was an association between rising rates of unemployment and a rise in suicide levels among people under the age of 65. The study also analysed the relationship between unemployment, social welfare measures and mortality. However, it provided no information on people’s overall health, health behaviour or quality of life during an economic downturn.
While the suicide findings may not be that surprising, the study is useful because it gives an indication of the ways that mass unemployment might affect mortality, and it identifies the influence that social protection policies can potentially have in neutralising these effects.
Where did the story come from?
The research was carried out by Dr David Stuckler and colleagues at Oxford University, the London School of Hygiene and Tropical Medicine, University of California San Francisco, and other institutions in the UK and Europe. Funding was provided by the Centre for Crime and Justice Studies of King’s College, London, and the Wates Foundation. The study was published in the peer-reviewed medical journal The Lancet.
What kind of scientific study was this?
This was a modelling study (also known technically as an ecological study) designed to investigate how economic changes affected mortality rates in the EU from 1970 to 2007. The authors also tried to identify possible ways in which governments can help to reduce these effects, such as introducing social programmes.
To assess this, age-standardised and age-specific mortality data was obtained from the World Health Organisation’s database, European Health for All. Unemployment details on people who were unemployed or seeking work were taken from the International Labour Organisation (ILO) Key Indicators of the Labour Market report, which covers 26 European Countries over different focus years.
Information on gross domestic product (GDP – total annual economic output of a nation), measured in US$, was taken from the 2008 World Bank World Development Indicators report. Figures for social expenditure were obtained from the OECD Health Data 2008 edition. This is expenditure related to:
- health (e.g. hospital inpatient care, medication, etc.),
- family (child costs, support of dependants),
- housing (rent payments or benefits given to support housing),
- unemployment (redundancy payments and early pensions), and
- active labour market programmes (money directed towards improving beneficiaries’ prospects of finding employment or to otherwise increase their earning capacity, including public employment services, youth training programmes, etc).
The researchers used statistical models to see how changes in employment affected change in mortality rates, and how the relationship between these two factors was altered once different types of government expenditure were taken into account.
They noted significant changes in unemployment levels by assessing periods when there was deviation in the average rate of change in unemployment, rather than change in average level from one time to the next. They also looked at mass unemployment (periods when there is a rise of 3% or more in a financial year), which is generally rare in EU countries.
Associations between rises in unemployment and age-standardised mortality rates were adjusted to account for the influence of population ageing, past employment and mortality trends, and country-specific differences in surveillance.
The researchers also supplemented their research by looking at previous studies from individual countries and how their mortality data was affected by unemployment levels. This was to see whether the effect sizes they had calculated were plausible.
They also looked at trends in deaths from different causes to see whether the statistical trend in mortality in the wake of economic change could be biologically plausible. For example, suicide deaths may occur rapidly after a change in economic circumstances, but deaths from cancer (if they could be directly or indirectly influenced by economic events) are likely to occur some considerable time after an economic change.
What were the results of the study?
Between 1970 and 2007, 26 EU countries were assessed, providing more than 550 country-years of data. The observations revealed that for every 1% increase in unemployment level there was a 0.79% rise in the suicide rate among people aged under 65 years (95% confidence interval 0.16 to 1.42%). Within EU countries, this would potentially mean 60 to 550 excess deaths (average 310 across the EU). However, there was no significant effect on suicide when they looked at all age groups combined (0.49%; 95% CI 0.04 to 1.02).
Additionally, a 1% rise in unemployment was associated with a 0.79% rise in the homicide rate (95% CI 0.06 to 1.52), equivalent to potentially three to 80 extra homicides (average 40 across the EU). Conversely, a 1% rise in unemployment was associated with a 1.39% decrease in the rate of deaths from road-traffic accidents (95% CI 0.64 to 2.14), equivalent to 290 to 980 fewer deaths (average 630 across the EU).
Unemployment had no effect on any other causes of death, including cardiovascular disease, cancer, liver disease, diabetes, and infectious disease.
When the authors looked at the effect of mass unemployment (more than a 3% rise), the increase in suicide rate among those aged under 65 years was 4.45% (95% CI 0.65 to 8.24). This was potentially 250-3220 excess deaths across the EU.
In addition, there was a 28% increase in deaths from alcohol abuse (95% CI 12.30 to 43.70) 1550 to 5490 excess deaths across the EU. However, these were the only significant relationships found. There was no link between mass unemployment and homicides, accidental deaths or other medical causes of death.
When the authors carried out separate analyses of males and females between 1980 and 2007, there was no relationship between a 1% rise in unemployment and all-cause death for either sex. Overall, there was a significant increase in suicides for women but not men, although the effect was inconsistent across age ranges for both sexes.
Social Spending Programmes
For active labour market programmes, an increased investment of $10 per person reduced the effect of unemployment on suicides by 0.038% (95% CI 0.004 to 0.071% decrease). Other economic measures included a 1% rise in hours worked per week, 1% rise in GDP per head, 1% rise in the percentage of underemployment, and reduced suicide rates. But these changes were not significant.
What interpretations did the researchers draw from these results?
The researchers conclude that economic downturns and rises in unemployment are associated with significant short-term increases in suicides and homicides among people of working age. However, these effects on suicide can be reduced through active labour market programmes that aim to keep workers in their jobs.
What does the NHS Knowledge Service make of this study?
This in-depth study has analysed a large quantity of economic and mortality data from within the EU across a 30-year period. It found no consistent evidence across the EU that a rise in unemployment increased death rates from any cause. However, when broken down by age group there was a tendency for people under the age of 65 to be more affected by rising rates of unemployment, particularly a rise in suicide levels. The research also found that some social programmes could mitigate the effects of an economic downturn.
A few points when considering the implications of this study:
- The researchers noted that within different populations there was a variable effect of economic crises on mortality, and this might partly be due to different levels of labour protection and social protection services across European countries. As the authors note, this information was unavailable for a number of countries assessed, particularly those in central and eastern Europe. This lack of information may have confounded some of the apparent associations.
- This high-level data analysis cannot examine the complex and detailed effect that economic change can have within subgroups in an individual country. Certain population groups may be more affected by financial downturns, and it may be most useful to know how their death rate is affected.
- The study has only examined the effects of unemployment on mortality. It is not able to provide information on the more detailed health status of populations during an economic crisis. The study cannot provide information on the overall health, health behaviour and quality of life of the population (employed or unemployed) during economic strife.
- Unemployment figures were partly based on numbers of people registering for benefits. There is a possibility that countries vary in the proportion of unemployed people who will, or can, register for benefits, which may affect the data. The researchers tried to take this into account in their analysis.
- Additionally, because this study has specifically examined the effects of unemployment, it does not support the suggestion in the news that ill-health is caused by people in an economic recession buying cheaper, unhealthier foods in response to rising prices.
- Lastly, the research has examined only the short-term effects in the years immediately following an economic change. Long-term effects are unclear from this analysis.
Despite these limitations, the study is valuable in giving an indication of the mortality effects that a change in employment during an economic downturn can have. Importantly for further research, it highlights the potential role that certain social protection policies could play in reversing this.