M. Harvey Brenner

MORTALITY AND THE NATIONAL ECONOMY: A REVIEW, AND THE EXPERIENCE OF ENGLAND AND WALES, 1936-76

Abstract The long-term upward trend in real percaput incomes is associated with better health, but the smoothed curve disguises cyclic fluctuations, recessions followed by periods of rapid economic growth, which may be stressful to certain groups in the workforce and, by extension, to their families. Especially vulnerable in recessions are those in industries whose goods or services are not essential, the less skilled who are the first to lose their jobs and the last to get their jobs back when the economy improves, and those who find that over one turn in the business cycle their skills are no longer needed. For these groups, most often to be found in the lower socioeconomic classes, this lack of economic security is stressful: social and family structures break down and habits that are harmful to health are adopted. Acutely, if the effect manifests as a psychopathological event (e.g., suicide), or after a time lag of a few years or even one or more turns of the business cycle for chronic diseases, economic recessions and subsequent periods of rapid economic growth are associated with a deceleration in the normally declining curve of mortality against time. This model, tested previously on U.S. data, has now been confirmed on data for England and Wales.

Unemployment and health in the context of economic change

Evidence relating unemployment to health is found at every level of social science analysis from national population rates to individual psychophysiological stress response. At the population level of analysis, increase in the unemployment rate indicates recession and/or structural economic decline. At the individual level, unemployment is interpreted as a stressful life event. In both cases, inverse associations are found between measures of unemployment and indicators of health. We identify social science literatures associating health indicators with each of the following: economic growth, socioeconomic status, sociocultural change, economic instability, the status of being unemployed, social stress and work stress. Outstanding research issues include the requirements to identify and measure the effects of conditional factors and control variables in multivariate analysis and to examine a broader range of both severity of unemployment and severity of health outcomes. A research agenda proposes studies at the macro, meso and micro levels of analysis. We urge such research for its potential contribution both to analytic social science and to economic and social policy.

Health Costs and Benefits of Economic Policy

The purpose of this study is to translate research findings on pathological effects of unemployment and other forms of economic distress into a form that would be useful for national economic policy decisions. Economic indices considered by themselves are questionable because such data permit no inferences as to quantitive social implications. In the present report, we have brought together several of the scientific findings on the impact of economic distress in a policy relevant framework which would ultimately permit quantitive estimates of that impact on social pathology. Some success has been achieved in formulating models to explain how the various sources of national economic distress may be associated with pathology. Overall, it is evident that significant relationships exist between economic policy and measures of national well-being. This study indicates that actions which influence national economic activity-especially the unemployment rate-have a substantial bearing on physical health, mental health, and criminal aggression. To the extent, therefore, that economic policy has acted to influence economic activity, it has always been related to the nations social health. It would appear that on a day-today basis, nearly all political and deliberate economic policy decisions which affect the national, regional, and local economic situations also are associated with many aspects of the nations well-being. Indeed, significant amelioration of many of our basic social problems may depend, in part, on national economic policy considerations.

Economic change, alcohol consumption and heart disease mortality in nine industrialized countries

This paper examines the question of whether economic changes--including economic growth, unemployment and business failures--and alcohol consumption by beverage type are independently related to heart disease mortality. Controls for cigarette and animal fat consumption are also employed in a multivariate time series analysis. Data for nine countries in the post World War II era are investigated: Australia, Canada, England and Wales, Denmark, Federal Republic of Germany, Finland, France, Sweden and the United States. In all nine countries unemployment and business failures are positively related to heart disease mortality, and in eight countries the trend of economic growth shows an inverse relationship. The relation of alcohol consumption to heart disease mortality depends on beverage type. When spirits or wine consumption shows a significant relation, occasionally requiring controls for other beverages, it is positive. On the other hand, beer consumption shows an inverse relation to heart disease mortality in all countries. The statistical significance of that relationship also occasionally must be based on controls for other beverages.

Economic change and sex-specific cardiovascular mortality in Britain 1955–1976

Analyses directed toward recent declines in cardiovascular disease mortality rates have typically focused on alterations in important physiological and behavioral risk factors resulting from lifestyle changes and medical advances. In this study, a multivariate model of the impact of more fundamental changes in the socioeconomic and bio-physical environments has been developed and applied to cardiovascular disease mortality rates, by sex, in England and Wales and Scotland during 1955-1976. The predictive model includes factors associated with (1) long-term growth in the economy, (2) deleterious behavioral risk factors loosely associated with economic growth--especially cigarette consumption per capita, (3) economic instability--especially recession as indicated by factors related to unemployment, income loss, and recessional declines in average weekly hours worked in manufacturing industries, (4) health care, and (5) physical environmental disturbances--especially very cold temperatures. This model proves to be an excellent instrument for the statistical explanation of trends and fluctuations in CVD mortality rates for both sexes and both regions in Britain in the post-War period. In general, the overall exponential rate of economic growth is found to be the most powerful factor in the long-term decline in CVD mortality rates. Similarly, disturbances to the national and regional economic situations--especially recessions--have regularly been associated with elevated death rates for all populations observed. Cigarette and unusually high spirits consumption, as well as particularly cold winter temperatures, have also had important deleterious effects on CVD mortality. The proportion of government expenditures devoted to health care is associated with a reduction in CVD mortality in England and Wales.

Organizational Downsizing and Depressive Symptoms in the European Recession: The Experience of Workers in France, Hungary, Sweden and the United Kingdom

Background Organizational downsizing has become highly common during the global recession of the late 2000s with severe repercussions on employment. We examine whether the severity of the downsizing process is associated with a greater likelihood of depressive symptoms among displaced workers, internally redeployed workers and lay-off survivors. Methods A cross-sectional survey involving telephone interviews was carried out in France, Hungary, Sweden and the United Kingdom. The study analyzes data from 758 workers affected by medium- and large-scale downsizing, using multiple logistic regression. Main Results Both unemployment and surviving layoffs were significantly associated with depressive symptoms, as compared to reemployment, but the perceived procedural justice of a socially responsible downsizing process considerably mitigated the odds of symptoms. Perception of high versus low justice was assessed along several downsizing dimensions. In the overall sample, chances to have depressive symptoms were significantly reduced if respondents perceived the process as transparent and understandable, fair and unbiased, well planned and democratic; if they trusted the employer’s veracity and agreed with the necessity for downsizing. The burden of symptoms was significantly greater if the process was perceived to be chaotic. We further tested whether perceived justice differently affects the likelihood of depressive symptoms among distinct groups of workers. Findings were that the odds of symptoms largely followed the same patterns of effects across all groups of workers. Redeploying and supporting surplus employees through the career change process–rather than forcing them to become unemployed–makes a substantial difference as to whether they will suffer from depressive symptoms. Conclusions While depressive symptoms affect both unemployed and survivors, a just and socially responsible downsizing process is important for the emotional health of workers.

Depressive symptoms as a cause and effect of job loss in men and women: evidence in the context of organisational downsizing from the Swedish Longitudinal Occupational Survey of Health

BackgroundFew studies have examined depression as both a cause and effect of unemployment, but no prior work investigated these relationships in the context of organisational downsizing. We explored whether the exposure to downsizing is associated with subsequent depression (social causation), and whether pre-existing depression increases the risk of being laid off when organisations downsize (health selection).MethodsTwo successive waves of the nationally representative Swedish Longitudinal Occupational Survey of Health represented the baseline (2008) and follow-up (2010) of this study. Analyses included 196 workers who lost their jobs through downsizing, 1462 layoff survivors remaining in downsized organisations and 1845 employees of non-downsized workplaces. The main outcomes were: (1) Depressive symptoms at follow-up, assessed with a brief subscale from the Symptom Checklist 90, categorised by severity levels (“major depression”, “less severe symptoms” and “no depression”) and analysed in relation to earlier downsizing exposure; (2) Job loss in persons with downsizing in relation to earlier depressive symptoms. The associations were assessed by means of multinomial logistic regression.ResultsJob loss consistently predicted subsequent major depression among men and women, with a somewhat greater effect size in men. Surviving a layoff was significantly associated with subsequent major depression in women but not in men. Women with major depression have increased risks of exclusion from employment when organisations downsize, whereas job loss in men was not significantly influenced by their health.ConclusionsThe evidence from this study suggests that the relative importance of social causation and health selection varies by gender in the context of organisational downsizing. Strategies for handling depression among employees should be sensitive to gender-specific risks during layoffs. Policies preventing social exclusion can be important for female workers at higher risk of depression.

A Stopping Rule for Standard Chemotherapy for Metastatic Breast Cancer: Lessons from a Survey of Maryland Medical Oncologists

The sequential administration of standard chemotherapy regimens to treat metastatic breast cancer may keep patients and oncologists from considering other important, but more psychologically difficult, issues such as the patients declining health or approaching death. This practice also utilizes health care resources for ever-decreasing individual patient benefit. If generally agreed-upon rules or guidelines were developed about stopping standard chemotherapy after a limited number of regimens, oncologists could recommend treatment discontinuation with greater confidence. Also, resources could be redirected. To inform the development of guidelines on when to stop chemotherapy for metastatic breast cancer, we surveyed fully trained Maryland medical oncologists about their knowledge and beliefs about chemotherapy for metastatic breast cancer. The survey instrument included open-ended questions and clinical vignettes. There was consensus about the value of first-line chemotherapy. Even though oncologists employed second-line chemotherapy, they were unenthusiastic about it. The frequent utilization of second-line regimens probably reflects an effort to offer marginal regimens to patients who want them. Based on these data, it is suggested that standard chemotherapy be stopped after breast cancer fails to stabilize or respond on a standard regimen. Patients who wish further treatment could be referred for investigational therapy if it is available and if they are eligible.

Homicide and Economic Change: Recent Analyses of the Joint Economic Committee Report of 1984

The relation between recession and homicide is classic in the United States. This has been affirmed in the 1976 and 1984 Reports to the Joint Economic Committee (JEC) of the United States Congress. Recent analysis confirms the findings reported in both 1976 and 1984 and demonstrates that the influence of recession on homicide is greater than previously estimated. Differences in the 1976 and 1984 findings on homicide are related to differences in the hypotheses tested, as discussed in detail and highlighted in the 1984 report. JEC staff correctly interpreted and reported the 1984 findings. Reproduction of the 1984 homicide equation is straightforward, provided the same data and any of several standard estimation techniques are used. Evidence does not support any of Cook and Zarkins claims in their critique of the 1984 homicide equation. The JEC report of 1984 used appropriate techniques in the attempt (a) to ensure that influences attributed to economic changes are not actually due to other social factors and (b) to minimize underspecification of models.

Importance of the Economy to the Nation’s Health

It has frequently been observed that the average life span is longer in countries at higher levels of economic development and in subpopulations at higher socioeconomic levels within countries. The hypothesis of this paper is that development of the economy continues to be central to the health of human populations. Underlying this hypothesis is the argument that the economy provides the basic material resources required for survival, including nutrition and management of the physical environment. The economy provides, as well, the sources of investment in the development and dissemination of empirical knowledge relating to human health and survival. It follows that the greater availability of the material and organizational sources of survival is a result of long-term economic growth.