Health effects of financial crisis: omens of a Greek tragedy
2011; Elsevier BV; Volume: 378; Issue: 9801 Linguagem: Inglês
10.1016/s0140-6736(11)61556-0
ISSN1474-547X
AutoresAlexander Kentikelenis, Marina Karanikolos, Irene Papanicolas, Sanjay Basu, Martin McKee, David Stuckler,
Tópico(s)Health disparities and outcomes
ResumoGreece has been affected more by the financial turmoil beginning in 2007 than any other European country. 15 years of consecutive growth in the Greek economy have reversed. In adults, unemployment has risen from 6·6% in May, 2008, to 16·6% in May, 2011 (youth unemployment rose from 18·6% to 40·1%),1Hellenic Statistical AuthorityUnemployment rate at 16·6% in May 2011. Hellenic Statistical Authority, Piraeus2011Google Scholar as debt grew between 2007 and 2010 from 105·4% to 142·8% of gross domestic product (GDP; €239·4 billion to €328·6 billion) compared with the average change in the EU-15 (the 15 countries that were EU members before May 1, 2004) from 66·2% to 85·1% of GDP in this same period (€6·0 trillion to €7·8 trillion).2EurostatEuro area and EU27 government deficit at 6·0% and 6·4% of GDP respectively. Eurostat, Luxembourg2011Google Scholar Greece's options were limited, since its Government ruled out leaving the Euro, precluding them from one of the most common solutions in such circumstances: devaluation. To finance its debts, Greece had to borrow €110 billion from the International Monetary Fund and Eurozone partners, under strict conditions that included drastic curtailing of government spending. Whereas other countries in Europe (eg, France, Germany) now show signs of economic recovery, the crisis continues to evolve in Greece; industrial production fell by 8% in 2010.3Hellenic Statistical AuthorityThe production index in industry recorded a decline of 8·0% in March 2011 compared with March 2010. Hellenic Statistical Authority, Piraeus2011Google Scholar Richard Horton4Horton R Offline: Looking forward to some surprises.Lancet. 2011; 377: 2164Summary Full Text Full Text PDF Scopus (3) Google Scholar has asked whether anyone is looking at the effect of the economic crisis on health and health care in Greece, in light of the adverse health effects of previous recessions.5Stuckler D Basu S Suhrcke M Coutts A McKee M The public health effect of economic crises and alternative policy responses in Europe: an empirical analysis.Lancet. 2009; 374: 315-323Summary Full Text Full Text PDF PubMed Scopus (1013) Google Scholar Here, we describe changes in health and health care in Greece on the basis of our analysis of data from the EU Statistics on Income and Living Conditions,6EurostatCross-sectional European Union statistics on income and living conditions (EU-SILC), 2007 and 2009 users' database. European Commission, Eurostat, Luxembourg2011Google Scholar which provide comparable cross-sectional and longitudinal information on social and economic characteristics and living conditions throughout the EU. In Greece, representative samples of 12 346 and 15 045 respondents were recruited in 2007 and 2009, respectively, by use of consistent methods, of which a total of 26 489 had complete sociodemographic data (see webappendix p 1 for more details). We also drew on reports from medical research institutes, health prefectures, and non-governmental organisations (NGOs). These reports include epidemiological indicators, data on hospital admissions, and reports on mental health problems and the status of vulnerable groups. Compared with 2007—ie, before the crisis—2009 saw a significant increase in people reporting that they did not go to a doctor or dentist despite feeling that it was necessary (odds ratio 1·15, 95% CI 1·02–1·30 for doctors' visits; 1·14, 1·01–1·28 for dentists' visits [figure, webappendix p 2–3]), after correcting for differences in survey respondents including age, sex, marital status, educational attainment, and urban or rural residence. The main reasons for not seeking medical care did not seem significantly linked to an inability to afford care (0·87, 0·74–1·02), but to long waiting times (1·83, 1·26–2·64), travel distance to care (2·50, 1·35–4·63), waiting to feel better (1·93, 1·26–2·96), and other reasons not captured by the survey (1·54, 1·05–2·27; webappendix p 4). Since Greece's universal public health-care system entitles citizens and those with social insurance to visit general practitioners (GPs) free of charge and to attend outpatient clinics of hospitals for €0–5, these noted reductions in access probably reflect supply-side problems: there were about 40% cuts in hospital budgets,7Telloglou T Interview with Minister of Health Andreas Loverdos.in: Papahelas A Telloglou T Papaioannou S Folders. Skai TV, Greece2011Google Scholar understaffing, reported occasional shortages of medical supplies, and bribes given to medical staff to jump queues in overstretched hospitals.8Telloglou T Kakaounaki M Three weeks and one night on duty.in: Papahelas A Telloglou T Papaioannou S Folders. Skai TV, Greece2011Google Scholar Although people were less likely to visit GPs and outpatient facilities, there was a rise in admissions to public hospitals of 24% in 2010 compared with 2009,9Liakopoulou T Since last year private hospitals are in trouble while NHS is doing better.Kathimerini. June 12, 2011; Google Scholar and of 8% in the first half of 2011 compared with the same period of 2010.10Polyzos N ESY.net: Presentation of the Secretary General of the Ministry of Health and Social Solidarity. Ministry of Health and Social Solidarity, Athens2011Google Scholar Major private health providers, although comprising a smaller proportion of care delivery than public providers, were also hit by pressure on personal budgets and registered losses after the onset of the crisis. A 2010 study reported a 25–30% decline in admissions to private hospitals.11HellastatSector study: health services. Hellastat, Athens2010Google Scholar There are signs that health outcomes have worsened, especially in vulnerable groups. We noted a significant rise in the prevalence of people reporting that their health was "bad" or "very bad" (1·14, 1·02–1·28; figure). Suicides rose by 17% in 2009 from 2007 and unofficial 2010 data quoted in parliament mention a 25% rise compared with 2009.12Avgenakis E Question: dramatic increase in the number of suicides due to the economic crisis and rumors on the operation of networks of usurers and blackmailers. Reference number: 16171. Hellenic Parliament, Athens2011Google Scholar The Minister of Health reported a 40% rise in the first half of 2011 compared with the same period in 2010.13Loverdos A Response to question by Member of Parliament, reference number: 56885. Ministry of Health and Social Solidarity, Athens2011Google Scholar The national suicide helpline reported that 25% of callers faced financial difficulties in 201014Katsadoros D, Bekiari E, Karydi K, et al. Suicide help line 1018: characteristics of callers for January-December 2010. 21st Panhellenic Conference of Psychiatry; Athens, Greece; May 5–7, 2011.Google Scholar and reports in the media indicate that the inability to repay high levels of personal debt might be a key factor in the increase in suicides.15Tsimas P Erevna. Mega TV, Greece2011Google Scholar Violence has also risen, and homicide and theft rates nearly doubled between 2007 and 2009.16Carassava A Crime casts long shadow over Athens.Los Angeles Times. May 31, 2011; Google Scholar, 17Krug EG Mercy JA Dahlberg LL Zwi AB The world report on violence and health.Lancet. 2002; 360: 1083-1088Summary Full Text Full Text PDF PubMed Scopus (1735) Google Scholar, 18Sundquist K Theobald H Yang M Li X Johansson SE Sundquist J Neighborhood violent crime and unemployment increase the risk of coronary heart disease: a multilevel study in an urban setting.Soc Sci Med. 2006; 62: 2061-2071Crossref PubMed Scopus (163) Google Scholar The number of people able to obtain sickness benefits declined (0·61, 0·38–0·98) between 2007 and 2009, probably owing to budget cuts, and further reductions to access and the level of benefits are to be expected once austerity measures are fully implemented (webappendix p 5).6EurostatCross-sectional European Union statistics on income and living conditions (EU-SILC), 2007 and 2009 users' database. European Commission, Eurostat, Luxembourg2011Google Scholar A significant increase in HIV infections occurred in late 2010. The latest data suggest that new infections will rise by 52% in 2011 compared with 2010 (922 new cases versus 605), with half of the currently observed increases attributable to infections among intravenous drug users.19Paraskevis D, Hatzakis A. An ongoing HIV outbreak among intravenous drug users in Greece: preliminary summary of surveillance and molecular epidemiology data. EMCDDA Early Warning System, 2011.Google Scholar Data for the first 7 months of 2011 show more than a 10-fold rise in new infections in these drug users compared with the same period in 2010.20Paraskevis D Nikolopoulos G Tsiara C et al.HIV-1 outbreak among injecting drug users in Greece, 2011: a preliminary report.Eurosurveillance. 2011; 16: 19962Google Scholar The prevalence of heroin use reportedly rose by 20% in 2009, from 20 200 to 24 100, according to estimates from the Greek Documentation and Monitoring Centre for Drugs. Budget cuts in 2009 and 2010 have resulted in the loss of a third of the country's street-work programmes;21EKTEPNAnnual report on the state of the drugs and alcohol problem. Greek Documentation and Monitoring Centre for Drugs, Athens2010Google Scholar one survey of 275 drug users in Athens in October, 2010, found that 85% were not on a drug-rehabilitation programme.21EKTEPNAnnual report on the state of the drugs and alcohol problem. Greek Documentation and Monitoring Centre for Drugs, Athens2010Google Scholar Many new HIV infections are also linked to an increase in prostitution (and associated unsafe sex).22EKTEPNReport of the ad hoc expert group of the Greek focal point on the outbreak of HIV/AIDS in 2011. Greek Documentation and Monitoring Centre for Drugs, Athens2011Google Scholar An authoritative report described accounts of deliberate self-infection by a few individuals to obtain access to benefits of €700 per month and faster admission onto drug substitution programmes.22EKTEPNReport of the ad hoc expert group of the Greek focal point on the outbreak of HIV/AIDS in 2011. Greek Documentation and Monitoring Centre for Drugs, Athens2011Google Scholar These programmes offer access to synthetic opioids and can have waiting lists of 3 years or more in urban areas. Another indicator of the effects of the crisis on vulnerable groups is increased use of street clinics run by NGOs. Until recently, these clinics mainly catered to immigrants, but the Greek chapter of Médecins du Monde estimates that the proportion of Greeks seeking medical attention from their street clinics rose from 3–4% before the crisis to about 30%.23Karatziou D Society in humanitarian crisis.Kyriakatiki Eleftherotypia. July 24, 2011; Google Scholar Despite many adverse signs, there are some indications of improvement. There have been marked reductions in alcohol consumption24HellastatSector study: alcoholic beverages. Hellastat, Athens2010Google Scholar and, according to police data, drink-driving has decreased.21EKTEPNAnnual report on the state of the drugs and alcohol problem. Greek Documentation and Monitoring Centre for Drugs, Athens2010Google Scholar These trends were not artifacts of reduced detection owing to budget cuts in the police force, since police checks remained the same and more drivers were screened in 2009 than 2008. Overall, the picture of health in Greece is concerning. It reminds us that, in an effort to finance debts, ordinary people are paying the ultimate price: losing access to care and preventive services, facing higher risks of HIV and sexually transmitted diseases, and in the worst cases losing their lives. Greater attention to health and health-care access is needed to ensure that the Greek crisis does not undermine the ultimate source of the country's wealth—its people. Eurostat has no responsibility for the results and conclusions of this letter, which are those of the authors. We declare that we have no conflicts of interest. Download .pdf (.4 MB) Help with pdf files Supplementary webappendix Mental health care—the economic imperativeCountries at all stages of economic development have been hit by the global financial downturn. Some have been affected (and continue to be affected) more than others. Greece is one such country, and three letters in The Lancet today describe some of the negative health consequences of the debt crisis in this population. These include worrying effects on mental health such as increased rates of suicide attempts and suicide itself. Full-Text PDF Greek financial crisis and child mental healthDuring the past few years, the percentage of Greek children living in poverty or social exclusion has been on the rise as a result of the financial crisis. Although several reports1–3 showed that depression and suicide rates have increased in adults in Greece, no relevant studies exist in child and adolescent populations. It is well known that poverty is a distal risk factor for children's mental health and development. The psychological stress associated with poverty has proximal effects, such as harsh parenting, and distal ones, such as children's antisocial behaviour and other mental health problems. Full-Text PDF COPD patients trapped in the financial crisis in rural CreteThe global economic crisis has badly affected health and health care in Greece, described in the literature as having the omens of a Greek tragedy.1 Increased fuel taxes have led to a rise in wood burning for heating in rural areas of Crete, which has subsequently led to a worsening of dyspnoea symptoms in patients with COPD and asthma.2 In the countryside, fireplaces have always been used for heating; however, before the financial interventions of the International Monetary Fund, most people invested in central heating, often paying a large amount of money disproportionate to their family annual income. Full-Text PDF
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