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Economic stress and child health—the Greece experience

2019; Wiley; Volume: 108; Issue: 10 Linguagem: Inglês

10.1111/apa.14917

1651-2227

Ariadne Malamitsi‐Puchner, Despina D. Briana,

Global Health Care Issues

In 2008, a harsh economic crisis was triggered by the collapse of Lehman Brothers, a huge international investment bank in America with global financial services. It rapidly spread across the world, lasted for several years and had significant consequences on the health of populations affected by the crisis. Most of the European Union was affected, and Portugal, Spain, Italy and Greece were particularly badly hit, as the financial collapse coincided with considerable migration from countries affected by war or political violence, such as Syria, Iraq, Afghanistan and Libya. Greece was the most severely affected. Unemployment more than tripled, particularly among young people of reproductive age, and the country's gross domestic product, which measures a nation's overall economic activity, fell by 25%. The country was also affected by austerity measures imposed by big lenders, such as the European Commission, European Central Bank and International Monetary Fund, as part of the financial bailout. Government spending on the National Health System, through which residents in Greece receive health care, was adversely impacted, and the per capita government expenditure on health fell significantly. This led to an increase in mortality, which peaked in 2014.1 It is well known that poor socioeconomic living conditions may negatively affect children—a most vulnerable population group—and that prolonged exposure to poverty in early life can irreversibly impair their somatic, cognitive and social health. A number of cumulative stressful factors could be responsible, including reduced parental employment opportunities leading to household tensions, particularly in deprived, single parent and families with low education levels. Other factors include criminal activity, prostitution and/or substance abuse. Increased food costs prohibit healthy food, such as fish, meat, fresh fruit and vegetables, and lead to more 'filling' alternatives causing obesity, such as rice, pasta, potato chips and junk food. Children can also go to school hungry. State cutbacks for public health programmes on maternal and childhood well-being and care can also have an impact. Reports from the United States have shown that poverty led to poorly controlled asthma and improper haemophilia management. The Developmental Origins of Health and Disease concept also suggests there could be long-term harmful effects, including cardio-vascular disease and Alzheimer's in adult life.2 Studies from Portugal, Spain, the United States and Iceland have repeatedly reported associations between economic stress and austerity measures with decrease in the total number of deliveries, as well as increased percentages of low birth weight (below 2500g) and preterm infants, with the exception of Iceland for the latter. These data particularly refer to population groups in most need.3 Two Greek studies have discussed the impact of economic stress on perinatal parameters. One study4 used national birth data from 1980 to 2014, controlled for potential cofounders of maternal age and country of origin, to test how the early and later years of the crisis (‘established crisis’ years), namely 2008-10 and 2011-14, affected infant mortality, low birthweight and preterm infants, stillbirths, and births to women aged 35 plus. The results showed higher levels of infant mortality, which had constantly declined to a historic low of 2.7‰ in 2008, but escalated to 3.8‰ in 2014. Low birthweight deliveries increased in both periods. Greek women under 25 years and women of non-Greek origin had a higher stillbirth rate. Possible reasons included restricted health care, insufficient prenatal follow-up, lower educational levels among young women of low socioeconomic status and communication difficulties among immigrants. The birth rate increased in woman aged 35 years plus, and the healthy immigrant effect was lost among long-standing immigrants. Another study5 of approximately 15 000 neonates born in a public maternity hospital in Athens from 2005 to 2014 examined the impact of the crisis on four important perinatal parameters: birthweight, gestational age, maternal age and mode of delivery. Univariable analysis was used to test the association between the above variables and time periods 2005-2007 (pre-crisis), 2009-2011 (early crisis) and 2012-2014 (established crisis). The year 2008 was excluded from the analysis, due to a cluster of necrotising enterocolitis. Multivariable logistic regression analysis identified factors independently associated with low birthweight, prematurity and Caesarean sections. Authors found an increasing number of deliveries in 2005-2010 followed by a steady annual decline until December 2014 and a significant rise in preterm births and low birthweight infants. The mean birthweight decreased by 64.4 g during the decade studied, with steeper losses in the established phase of the crisis (2012-2014). These findings coincided with population-based data of the Hellenic Statistical Authority. There were significant rises in Caesarean sections and maternal age during both the early and established crisis periods (2009-2011 and 2012-2014). A maternal age of 30 years plus was an independent risk factor for low birthweight, prematurity and Caesarean sections, and low birthweight was an independent risk factor for Caesarean sections. The authors stated that advanced maternal age, which was mainly due to postponing pregnancy because of socioeconomic factors such as poverty, unemployment, labour market uncertainties and emigration, may change placental development and function and ‘programme’ foetal growth. Additionally, not medically justified, iatrogenic preterm deliveries, consequent to elective Caesarean sections in periods of economic crises and declined fertility rates, reflect the supplier (obstetricians)-induced demand for this expensive mode of birth, triggered by financial and convenience incentives. In contrast, free childhood vaccinations remained satisfactory during the economic crisis, despite drastic cuts to public health. According to a 2013 cross-sectional nationwide vaccination coverage study of children aged two to three full years, who attended nurseries-kindergartens, the National Immunisation Programme (NIP) was followed in an accurate and timely manner and not only Greek nationals but also immigrant children had high vaccine coverage. It is noteworthy that for all children residing in Greece (immigrants included), the cost for vaccines incorporated in the NIP and designated as ‘necessary’ is paid by the state. For the inactivated influenza vaccine which is ‘necessary’ only for high-risk groups and for rotavirus vaccine, designated as ‘recommended’, the state reimburses 75% of the price payed by the parents. This partial reimbursement may be why the vaccination rates for the latter two were lower, in addition to the impression of physicians and parents that the disease burden for rotavirus and influenza was lower.6 On the other hand, a Greek study of 632 females aged 11-16 years showed that vaccination for human papilloma virus (HPV) dropped considerably during the crisis years, despite designation of HPV vaccine in the NIP as ‘necessary’. Authors claim financial issues, as visits to the paediatricians, and stress the need to maintain health insurance coverage to children in a country suffering recession.7 A very important issue during economic stress is children's and adolescents’ mental health. One Greek study documented alarming increases in psychosocial problems by 40%, conduct disorders by 28%, early school leaves by 25%, bullying by 22%, suicide attempts by 20%, illegal and addictive substances by 19% and family conflicts by 51%.8 Domestic violence and the numbers of abused and neglected children also rose considerably. Despite this, publicly funded units and services, and not-for-profit child and adolescent mental health community centres faced budget cuts of up to 50%, particularly during 2011-2014, and had to reduce or suspend services. Some parents could not afford treatment, even for children with serious mental health disorders.9 One study found that of 2150 adolescents recruited from a random, but representative sample, of public and private schools in the greater Athens area, those with higher odds for mental health problems said they did not have enough to eat at home in the previous month.10 Referenced studies support the causative role of the economic crisis on impaired child health from the prenatal period to adolescence with possible physical and mental disorders in adult life. However, presented data are mainly observational and should be considered with caution, taken existing limitations of observational studies. Still, governments should seriously assess these issues during times of austerity, safeguard public health programmes, promote international co-operation and stop financial speculators from endangering the health and well-being of the global population. No conflicts of interest. Ariadne Malamitsi-Puchner Despina D. Briana