Can a troubled economy actually improve public health?
By By Susan Brink
|Los Angeles Times Staff Writer|
Aug 25, 2008 | 12:00 AM
AS MORE people watch their home equity erode, put off retirement because their nest eggs are taking a dive, and bike or bus to work to save gas money, many are thanking their lucky stars that they still have a job to commute to.
Unstable times breed worry and stress, so there should be worry and stress aplenty right now. Nearly 8 in 10 Americans believe the country is headed in the wrong direction, according to a Gallup poll in August, and with the national unemployment rate up to 5.7% in July -- make that 7.3% in California -- millions of gainfully still-employed people who thought they were safe and secure might fear a Dickensian poorhouse closing in on them.
You'd think that the health of the nation would suffer as well, what with emotional stress and less money for medical appointments, gym memberships and healthful food. And in certain ways, health does worsen in times of economic uncertainty. Medical science has accumulated a solid body of research showing that poverty and unemployment lead to higher rates of obesity and more cases of diabetes, asthma, kidney disease, cardiovascular disease, some cancers -- the list goes on.
But strange as it may seem, bad times can also be good for health. Forget individual health for a minute. This is about the macro picture, the health of entire societies. And there statistics show that as economics worsen, traffic accidents go down, as do industrial accidents, obesity, alcohol consumption and smoking. Population-wide, even deaths from heart disease go down during recessions.
"Deaths go down when unemployment goes up," says Christopher J. Ruhm, professor of economics at the University of North Carolina at Greensboro, who for the last few years has been publishing counterintuitive and controversial papers on the economy and health. Put total mortality numbers on a spreadsheet, he's found, and the population's physical well-being improves as just about every measure of economic health dips.
No one -- certainly not Ruhm -- is arguing that recessions are good. For unemployed individuals and for people who fear financial disaster -- relentlessly forecast in headlines and top-of-the-hour newscasts -- the outcome is mixed. Mental health worsens even for the vast majority who maintain their jobs, as the onslaught of bad news causes anger, anxiety and depression. And prenatal problems increase, leading to more miscarriages and higher infant mortality rates.
But even as people are worrying more, they're smoking, drinking and driving less, reducing their risks of heart disease, liver disease and car crashes. People who have lost jobs likely cut back because of lost income, whereas those still employed may be cutting back as they stare down inflation and stagnant incomes.
Some may take better care in order to look better to their bosses, says Ralph Catalano, economist at the School of Public Health of UC Berkeley. "They look around and think, 'I better cool it,' " he says. "Those people may be getting healthier."
Forewarned is forearmed. The research into the effects of tough times can show worried workers which reactions are helpful and which ones make things worse. Economists look at national trends, but real people can buck those trends -- maybe by taking a lesson from their grandparents.
"We know from the old days, 50 to 100 years ago, that people who were less well off actually did better," says Dr. C. Noel Bairey Merz, director of the preventive and rehabilitative cardiac center at Cedars-Sinai Medical Center. "They were working as laborers, they ate rice and beans, and they couldn't afford cigarettes."
Doing better, in other words, means following the advice of every public health agency in the world: exercise, eat healthful food and don't smoke.
Deaths from some diseases, such as cancer, seem to be unaffected by the ups and downs of the economy, studies generally find. That's probably in part because it takes years or decades for cancer to form -- too long a lag to be clearly tied to a temporary downturn or economic upswing.Also, the majority of cancer deaths are among people older than 65, most likely out of the workforce and less susceptible to the cost-cutting whims of an employer.
But deaths, overall, do decrease when times turn bad, Ruhm has found from studying the stats of the U.S. as well as the 23 developed nations of the Organisation for Economic Co-operation and Development, matching them to economic shifts.
To put the economic fluctuations in perspective: Ruhm notes in a May 2000 paper in the Quarterly Journal of Economics that in 1990, 1.5 million Americans older than 65 died from all causes, as well as 145,000 people 25 to 44.
Based on his calculations, a rise in unemployment of one percentage point would have predicted 2,900 fewer deaths among the young adults. It would have spared, for a while at least, 4,900 seniors. Both groups gain, but among the young -- who are far less likely to die -- the percentage of saved lives is greater: 2% versus 0.3%.
The more that a cause of death affects primarily young people (traffic accidents, for example), the greater the effect of a shifting economy, Ruhm says. "Some dimensions of health respond more or less quickly."
Researchers have found good news in bad times for a number of diseases, specifically illnesses most affected by lifestyle changes.
* Heart disease is at the top of that list. In a March 2006 report for the National Bureau of Economic Research, Ruhm looked at federal mortality statistics from 1979 to 1998, comparing periods of higher and lower employment rates as a measure of economic conditions. He found a percentage-point reduction in unemployment was associated with a 0.75% rise in heart disease deaths -- about 3,900 additional deaths a year. The finding held across all age groups.
One of Ruhm's theories is that in hard economic times, fewer jobs mean fewer factories spewing pollution. "Short-term changes in pollution have been tied to heart attacks," he says.
Indeed, according to the American Heart Assn., for every 10 micrograms per cubic meter increase in particulate matter in the air, a 3.4% increase in heart attack rates can be expected. Although elderly people are most vulnerable, pollution can also trigger sudden heart attacks in younger people who have cardiovascular disease or risk factors such as high blood pressure, diabetes, high cholesterol or a smoking habit.
Ruhm also looked at data from 1987 to 2000 collected by the Centers for Disease Control and Prevention in the world's largest telephone survey tracking health risk behaviors. He found that three of the risk factors linked to heart disease -- smoking, obesity and a sedentary lifestyle -- drop during recessions.
He quantified the drop, and found that a one-point increase in the unemployment rate reduces the prevalence of smoking by 0.6%, the obesity rate by 0.3% and physical inactivity by 1.8%. These may not look like big changes, but they represent a trend toward better behavior that could easily have health consequences, Ruhm believes.
Why these drops? It could be that when times are bad, some unemployed people use their increased free time to exercise more. And those who are still employed feel more urgently motivated to take care of the things still under their control. "The first thing is awareness that not everything [good times and good health] goes in the same direction," he says. "It's an individual thing. You can control some of it."
* Traffic accidents go down when fewer people are working. It makes sense, because fewer people are on the road commuting. In a November 2002 report for the National Bureau of Economic Research, Ruhm looked at statistics from 23 developed nations including the United States and extrapolated from them that if 1% more people have jobs, motor vehicle accidents will go up by 2.1%. "Risky activities, such as driving, increase in good economic times," he says.
With gas around $4 a gallon, that particular risky behavior will likely drop further. The Department of Transportation reported in March that Americans drove 4.3% less that month, or 11 billion fewer miles, than they did in March 2007.
And just as Ruhm might have thought, the federal department reported this month that deaths from motor vehicle accidents reached the lowest level in more than a decade, from 41,059 in 2006 to 39,459 in 2007.
* People drink less. That is to say, people who already drink, do less of it. Using CDC data and alcohol sales statistics, Ruhm found that existing drinkers cut back, and the heaviest drinkers cut back the most. Light drinkers, he found, actually upped the amount they drank just a little. He speculates, in a July 2002 paper in the Journal of Health Economics, that however much economic stress may send people to the bottle, the impulse is offset by money worries and a need to spend less on alcohol.
* Healthful living improves. This is the nuts and bolts of Ruhm's argument -- one he draws from those CDC survey data on health risk behaviors. He hasn't merely found that smoking declines, weight is lost and leisure-time physical activity rises during economic downturns. He's also found that the people who make the biggest changes are, fortunately, the ones who need it the most. He sees the highest drop in tobacco use among heavy smokers, the greatest weight reduction in the severely obese, and the most increase in exercise among people who were completely inactive.
"Health behaviors have a strong effect"on physical well-being, he says. And the effect he found was not just on death rates. He found that when unemployment went up one percentage point, it meant a 1.5% fall in the prevalence of medical problems and a 1.6% decrease in days people reported spending in bed.
These economic studies are from epidemiology -- research examining trends among whole populations. There's a lot of room for individual variation, enough for everyone -- the working worried and the wounded unemployed -- to make their own choices.
Take alcohol, for example. In rough times, some people imbibe less, while others find some solace in the bottle. "When there are stressful times, some people will respond by drinking more as a way of coping," says C. David Dooley, professor of psychology and social behavior at UC Irvine. And other people, in an effort to retain their jobs or save money, cut back. Dooley says this has been documented in several of his studies, in which he uses large-scale survey data asking about employment security and drinking habits.
And just because heart disease overall goes down when times are bad, individuals have the power to go either way. Some people worry their way into a heart attack, and it's there that a tweak in attitude could make all the difference. Instead of just fretting when watching coworkers get pink slips, they might opt to start straightening up their own act -- figuring that a workplace that tolerated bad personal habits in good times might be more choosy when budgets get tight.
People could, theoretically, minimize the effect of economic stress on their hearts, says Merz of Cedars-Sinai. It's the usual advice: Exercise more. Eat better. Relax. Meditate. Save some money by quitting smoking.
And public support for the effort would help. "If we actually played our cards right, put bike racks all over the city, helped people be more physically active, we could mobilize this [economic downturn] for the country and make it good for the heart," Merz says.
It's no surprise, Ruhm says, that when human-resources staffers give advice to the people they're about to lay off, they don't talk only about buffing up the old résumé.
"One of the things they'll tell you is to eat well and exercise. And if you feel better physically, you'll feel better mentally," he says. "One of the possible things going on is that when times are bad, people are actively doing those things to protect their health."
Ruhm's findings have been duplicated by others. For example, Eric Neumayer, a London economist studying the people of Germany, found lower rates of heart disease, stroke, pneumonia, influenza and motor vehicle accidents during recessions.
Still, Ruhm's findings remain controversial. Catalano, the UC Berkeley economist, doesn't buy all of it. "I think the evidence is that the net effect of a bad economy is that health gets worse," he says.
Catalano's body of research shows that hard times affect pregnancy in the same way that a hurricane or a flood does -- which is to say, negatively. And he's found that the least controversial result from research on a bad economy and health is that mental health declines (see related stories).
"It depends on which illness you're studying," he says. Stress from any source is linked to a lot of bad health outcomes, including high blood pressure and depression. "Some part of the population is getting sicker," he says
But even skeptics agree on a few positive effects of a downturn. People who hang onto their jobs when unemployment goes up start drinking less and fighting less and take fewer risks -- probably in an attempt to remake themselves into ideal employees. "They find ways to cover themselves," Catalano says. "They come to work every day. They drink less because they don't want to be absent."
In other words, they start behaving better. It can serve them well.