Bad economy, good health? How a troubled economy leads to improved public health

By Susan Brink
Los Angeles Times

Tuesday, September 9, 2008 6:01 PM CDT

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 percent in July, millions of still-employed people who thought they were safe 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 past 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 measures of economic health dip.

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.

“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 in Los Angeles. “They were working as laborers, they ate rice and beans, and they couldn’t afford cigarettes.”

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 tied clearly to a temporary downturn or economic upswing. Also, the majority of cancer deaths are among people older than 65, most likely out of the work force and less susceptible to the cost-cutting whims of an employer.

But deaths, overall, do decrease when times turn bad, Ruhm has found in studying statistics from the United States and the 23 developed nations of the Organisation for Economic Co-operation and Development.

The more 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 one-percentage-point reduction in unemployment was associated with a 0.75 percent 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 Association, for every 10 micrograms per cubic meter increase in particulate matter in the air, a 3.4 percent increase in heart attack rates can be expected. Although elderly people are most vulnerable, pollution can 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. 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-percentage-point increase in the unemployment rate reduces the prevalence of smoking by 0.6 percent, the obesity rate by 0.3 percent and physical inactivity by 1.8 percent. These may not look like big changes, but they represent a trend toward better behavior that could easily have health consequences, Ruhm says.

Another factor that improves public health during hard economic times is people imbibing less. That is to say, people who typically drink a lot of alcohol start drinking less of it. Using CDC data and alcohol sales statistics, Ruhm found that most 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.

Overall, healthful living improves. This is the nuts-and-bolts of Ruhm’s argument. He hasn’t merely found that smoking declines, weight is lost and physical activity rises during economic downturns. He’s also found that the people who make the biggest changes are the ones who need change 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.

In addition to the health benefits from lifestyle changes, traffic accidents also go down when fewer people are working. 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 percent more people have jobs, motor vehicle accidents will go up by 2.1 percent. “Risky activities, such as driving, increase in good economic times,” he says.

Ruhm’s findings have been duplicated by others. 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. Ralph Catalano, an economist at the School of Public Health at the University of California, Berkeley, doesn’t buy it all. “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 a hurricane or 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.

“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 taking fewer risks. “They find ways to cover themselves,” Catalano says.

In other words, they start behaving better. It can serve them well.

For survivors of a layoff, guilt and more

In industries where pink slips are being passed out with abandon, the still-employed survivors are getting pretty bummed out.

Even Christopher Ruhm, an economist known for arguing that recessions are good for physical health, draws the line at hard times being good for mental health.

“I’m not claiming that people are mentally healthier during bad times,” says Ruhm, professor of economics at the University of North Carolina at Greensboro. “It’s quite possible that mental and physical health go in opposite directions. What I’d say is that in bad times, people are healthier, but not necessarily happier.”

A 2001 report, published in the Journal of the Royal Society of Medicine, reviewed studies looking specifically at mental health and job insecurity — as opposed to outright unemployment. It found that job insecurity is a chronic stressor that leads to depression and anxiety.

“If people are threatened with losing their jobs, they report feeling bad. It ranges from demoralization to depression to more serious things,” says C. David Dooley, chairman of the department of psychology and social behavior at the University of California, Irvine, and author of the 2004 book “The Social Costs of Underemployment.”

That includes those still marching to their cubicles after a company downsizes.

“The employment survivors are worse off as well,” Dooley says. “They may be feeling survivor’s guilt. Or they’re overworked. Often, companies make the survivors do the work of everyone who used to work there.” In fact, he’s found, the rate of depression among layoff survivors matches that of their former co-workers.

According to Dooley’s research, job stress, underemployment and unemployment all can affect mental health. “It’s as regular as clockwork,” he says. “They’re depressed.”

Anxiety over a downturn in the economy often doesn’t have much to do with actual income, says Randi Riffkind, a Los Angeles psychologist. “It’s their attitude that’s the determining factor in how much stress they feel,” she says.

So, if you find yourself spiraling down into gloom and doom — things are bad, they’re going to get worse, I’ll lose my job, then I’ll lose my health insurance, then I’ll lose my house — try to make yourself stop, Riffkind says.

“Notice the thoughts and then consciously turn the message around. Not a Pollyanna kind of thing, but something realistic, like, ‘I’ve been through difficult times before, and I’ll get through this.’ ”

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