The Body Economic
Page 14
At the time of the NHS’s establishment, UK public debt stood at over 400 percent of its GDP, a level far higher than any country in Europe today (apart from Iceland). Britain was rebuilding its economy after World War II had devastated its infrastructure. It had set up an emergency war time national healthcare service, in part because private insurance was unable to meet the health needs of the British troops. The service became highly popular. After the War, the Labour party expanded the emergency service to the entirety of Britain, and so the NHS was born on July 5, 1948. As the pamphlet explaining it to the general public put it, “It will provide with you all medical, dental, and nursing care. Everyone—rich or poor, man, woman or child—can use it or any part of it. There are no charges, except for a few special items. There are no insurance qualifications. But it is not a charity. You are all paying for it, mainly as taxpayers, and it will relieve your money worries in time of illness.”16
From its very foundation, critics of the NHS said it would bankrupt the country. Yet it did not—instead it helped to boost the UK’s economic recovery, just as the New Deal had done in the Great Depression.
For over half a century, the NHS has been the world’s strongest model of a universal health care system. The National Health Service provided care for everyone, free at the point of service. To keep costs down, everyone paid in a little, spreading the costs over entire society, not placing the burden just on those who were ill. The NHS also negotiated directly with pharmaceutical companies on behalf of the UK’s citizens, often purchasing medicines in bulk to negotiate better prices. The UK National Institute of Clinical Excellence ensured that doctors prescribed the most cost-effective medications, rather than overcharging patients for pills that were being promoted by drug companies through fancy trips and gifts to physicians. Doctors earned high but fixed annual salaries, instead of being paid per patient or on commission, so that they didn’t rush appointments or have perverse incentives to conduct batteries of unnecessary tests and procedures.17
There is a lot more to say about why the NHS worked, but the bottom line is the data: the UK system saved more lives with less money during the Great Recession.18
Today the NHS’s founding principles are being forgotten, as the conservative Tory government seeks to make the NHS more like the American profit-driven, market-based system. When the Tory government came to power, they revisited a pamphlet developed under the previous Tory government of John Major that called the NHS a “bureaucratic monster that cannot be tamed” and in need of “radical reform.” In 2004, Oliver Letwin, the pamphlet’s lead author, said the “NHS will not exist” within five years of a Tory election victory. Indeed, after the Tories came to power they proposed the Health and Social Care Act, which embodied the free-market principles of the radical pamphlet.19
It was difficult for us to understand this decision. Overall in 2010, before the Tory government began dismantling the NHS, the UK spent less of its GDP on health (8 percent) than Germany (10.5 percent), France (11.2 percent), or the United States (19 percent). Ultimately, the Tories’ position was not based on evidence but ideology—the idea that markets, competition, and profits would always be better than government intervention.20
A highly divisive public debate over the Health and Social Care Act ensued. Over staunch opposition from the Royal College of Nursing and almost all of the medical Royal Colleges (the UK equivalents of the American Medical Association), Parliament approved the Act in 2012. Thus began what many regard as a major move toward privatization of the NHS. Repeatedly, David Cameron promised the British public that the Act was not “privatizing the NHS” and that he would “cut the deficit not the NHS.” The Liberal-Democratic leader Nick Clegg said, “There will be no privatization.” The Department of Health website even stated that “Health Ministers have said they will never privatise the NHS.” But the data tell a different story: increasingly, the government is transferring large swaths of healthcare provision to private contractors.21
Private profiteers are replacing dedicated doctors. In October 2012, the government awarded 400 lucrative contracts for NHS services, worth a quarter billion pounds, in what was called “the biggest act of privatization ever in the NHS.” Virgin, for example, won lucrative contracts to deliver reproductive care (no pun intended). But the result was not the efficiency of private enterprise, but what had already been seen in the US market model—profits at the expense of patients. One journalist found this to be the case at health clinics in Teesside, northeast En gland. After Virgin won contracts to take over the services, the clinic repeatedly missed targets for screening people for chlamydia. It was a simple task that the NHS had fulfilled easily. The journalist found a memo that revealed “staff were asked to take home testing kits to use on friends and family to help make the numbers up.” In Oxford, patients complained about increasing wait times to see their doctors after Virgin took over a local practice. Virgin responded that the practice had been underperforming when it was taken over, and that “there are still improvements to be made but we’re pleased that progress so far was recognised and applauded by councillors.” And so began what continues to be a highly sophisticated public relations campaign.22
The UK’s next step toward US-style market-based medicine is moving forward at the time of this writing. It encourages patients to spend out of their pockets for healthcare rather than use the government-funded NHS. The Tory government is extending pi lot projects to offer those with chronic illnesses “personal budgets” so that they themselves can make choices about how to manage their care, with few safeguards against profit-seeking swindlers or predatory insurance companies despite a government evaluation that highlighted many problems with this approach.23
Early evidence suggests the Health and Social Care Act may in fact be hazardous to the health of the citizens and residents of the United Kingdom. Just before the Coalition government came into power, the NHS had the highest patient approval ratings in its history, over 70 percent. Within two years, approval fell to 58 percent, the largest decline in three decades.24 There are already warning signs that the healthcare situation in Britain may come to resemble that in the US before Obama. Patients are being turned away from privately managed clinics, some of which simply close their doors after meeting a daily quota to fulfill their contractual obligations. And in the first year of reform, emergency room visits jumped to the highest in a decade—perhaps because more people are neglecting preventive care, like Diane.25 As the editor of The Lancet warned, “people will die.”26
Whether the British people will fully accept this radical privatization of their healthcare system remains unclear. But once market incentives take hold of a public system, it becomes difficult, if not impossible to reverse course. In the UK, the recession-fueled combination of austerity-and-privatization seems to be creeping into every dimension of the social protection system. But evidence of its harms should give us all pause.27
The UK is not the only country to go down the path of healthcare privatization and cuts. Greece was perhaps the most extreme example of intentional and large cuts to healthcare, as the IMF targeted healthcare as a key budget area from which to save short-term costs. Spain had a National Health Service, similar to the British. But as its public health budgets were cut, it began to shift care to the private sector. Fees were added to basic services, so that people had to pay more out of pocket—despite clear-cut evidence that these “user fees” reduced access to necessary care and didn’t save money in the long-run.28 Spain also redefined its eligibility criteria from “residents” to “citizens,” purging immigrants from the system as a means to save money. Medicines that were once included in insurance packages were carved out. And in other cases, they simply became unavailable—as in Valencia, Spain, where pharmacies stood empty after the central government cut their funding.
There is an alternative—one that the UK itself had proven during its period of tremendous hardship and enormous debt after World War II. As Italy, Spain, and Greece, under pressu
re from the troika, are also now pursuing radical privatization and austerity reforms to their National Health Services, they would do well to recall the words of the NHS founder, Aneurin Bevan, who back in 1948 put this moral question in ringingly simple terms: “We ought to take pride in the fact that, despite our financial and economic anxieties, we are still able to do the most civilized thing in the world—put the welfare of the sick in front of every other consideration.”29
7
RETURNING TO WORK
On May 4, 2012, a crowd of women waving white flags marched to the entrance of the Italian government’s Equitalia tax office in Bologna. They were the vedove bianche, the White Widows. Following Italy’s austerity drive in response to the Great Recession, their husbands hadn’t been able to find enough work or pay their tax debts. And so the men had chosen to end it all by taking their lives. Saddled with debt, and left to pick up the pieces, the widows were angry and frustrated that the government wasn’t helping them.1
“Non ci suiciderete!” they chanted: “Don’t suicide us.” Tiziana Marrone, the leader of the protest, said, “The government must do something. It is not right what is happening in Italy.” They were upset that the government had turned a blind eye to tax evasion by Italy’s super-rich, but done virtually nothing to support those who had lost everything in the Great Recession. She continued, “My battle is not just mine, it is of all the Italians who find themselves in my condition, and most of all of the widows of those families, who don’t know where to turn to pay all these debts.”2
It was the second protest at the Equitalia building. Five weeks earlier, on March 28, Giuseppe Campaniello, a self-employed bricklayer, and the husband of Tiziana Marrone, went to the same office. He had just received a final notice from Equitalia doubling a fine he reportedly couldn’t pay. So in front of the tax offices, he doused himself with gasoline and set himself on fire. He had left a note for Tiziana: “Dear love, I am here crying. This morning I left a bit early, I wanted to wake you, say goodbye, but you were sleeping so well I was afraid to wake you. Today is an ugly day. I ask forgiveness from everyone. A kiss to you all. I love you, Giuseppe.” He died nine days later.
In the Great Recession, suicide rates rose as unemployment rates jumped by 39 percent across Italy between 2007 and 2010. While the White Widows’ protest drew public attention to their private suffering from the mental health consequences of unemployment in Italy, not everyone agreed with their interpretation of events. Some commentators said that Italy’s economic suicides were just “normal fluctuations.”3
To find out whether this was true and if so why, we looked into the country’s mortality datasets. Italy has a uniquely detailed system for tracking each of its suicides. The death certificates include contextual details about the causes. One example was a certificate of a sixty-four-year-old bricklayer who had lost his job at Christmas. He left a note that said in part, “I can’t live without a job,” then shot himself. In Italy, as in Russia during the early 1990s, unemployment had left people demoralized, hopeless, and ultimately prone to self-harm.4
We found that there was a large rise in suicide death certificates labeled “due to economic reasons” during the recession, well above pre-existing trends. Notably, rates of suicides attributable to all other causes remained unchanged. Overall, we estimated that Italy suffered at least 500 new cases of suicide and attempted suicides beyond what would have been expected if pre-recession suicide trends had continued. Figure 7.1 shows the jump in excess suicides and suicide attempts due to the combination of the Great Recession and the Italian government’s austerity response.
Across the Atlantic, the US suicide data were also on the rise during the recession. In the lead-up to the recession, suicides had already been increasing. For Figure 7.2, we projected the rate of suicides if those trends had continued, as shown in the dashed line. What we found is that the recession made a bad situation worse, as suicide deaths accelerated (Figure 7.2’s solid line), rising by an additional 4,750 deaths during the recession over and above the pre-existing trend.5
There was little doubt that the recession was a major cause of the increase in suicides. But it was neither a necessary cause, nor a sufficient cause of these tragedies. In countries that weren’t helping to buffer families against unemployment, suicides often correlated with job losses, as in Italy and the United States. But in other countries, politicians chose to invest in social programs that helped people return to work. Sweden and Finland experienced large recessions at various times during the 1980s and 1990s, but had no significant rise in suicides despite experiencing large spikes in unemployment. Sweden and Finland found ways to prevent a crashing economy from taking a toll on people’s mental health. Unemployment may be a common shock during recessions, but increased rates of suicidality are not.
FIGURE 7.1 Recession and Austerity Increase Italy’s Economic Suicides and Suicide Attempts6
Since the nineteenth century, it has been known that recessions and unemployment correlate with significantly greater risks of suicide. With advances in data collection, public health researchers and sociologists were able to establish that unemployment is a major risk factor for depression, anxiety, sleeplessness, and self-harm. Losing a job can tip a person into depression, especially in people who lack social support or are alone. People who are looking for work are about twice as likely to end their lives than those who have jobs.7
FIGURE 7.2 Recession Leads to an Increase in Suicides, United States8
During the early 1980s, some British economists began to question this conventional wisdom, asking whether unemployment was actually causing mental health problems per se or whether instead those who lost jobs were more likely to have been depressed in the first place. It was only possible to address this important question with large studies that tracked people over time, enabling researchers to disentangle which came first—job loss or depression. The answer, it turned out, was both: some people became depressed because they lost their jobs, while some were more likely to lose their jobs because they already suffered from depression, and their depression worsened because of unemployment.9
Hence, soon after the start of the Great Recession in 2007, doctors in Spain and the UK began to see a large rise in the number of patients coming to their clinics with acute depressive symptoms. As Peter Byrne, director of public education at the Royal College of Psychiatrists in the UK, said, “In 2009 all of us—whether we work in general practice, general hospitals or specialist services—are seeing an increase in referrals from the recession. The stresses of the downturn are the last straw for many people.”10
With more patients showing signs of depression, doctors began to prescribe more antidepressants. In the UK, antidepressant use rose 22 percent between 2007 and 2009. A survey in 2010 found that 7 percent of those seeking help for “work-related stress” began pharmacological treatment for depression. Doctors gave out 3.1 million more antidepressant prescriptions in 2010 than they had just two years earlier.11
Spain and the United States also saw rises in antidepressant prescriptions. Between 2007 and 2009, the number of people taking daily antidepressants jumped by 17 percent in Spain. In the United States, use of antidepressants rose during the Great Recession to where 10 percent of the adult population were prescribed antidepressants during the recession. A study by Bloomberg Rankings found that rates of antidepressant prescriptions had a very strong correlation with unemployment rates.12
From a statistical perspective, these data demonstrated only that more people were seeking medication for depression during the Great Recession. They did not, in and of themselves, prove that unemployed people were uniquely affected. In theory, it is quite possible that people were simply more stressed and unhappy during the recession for other reasons: the general atmosphere of malaise, increased workloads, anxiety surrounding the possibility of being laid off, etc. These numbers alone did not prove that unemployment per se was the driver of worse depression in this recession.13
&
nbsp; We set out to study which people were showing up to doctors’ offices with depression symptoms. We looked at data on 7,940 patients from doctors’ offices across Spain before the recession (2006) and during it (2010). Spain continues to grapple with one of the largest global increases in unemployment during the recession, but also had kept good track of mental health through a series of standardized depression surveys. Those surveys revealed that the number of patients showing up at the doctor’s office with clinical symptoms of major depression rose from 29 percent to 48 percent between 2006 and 2010. Minor depression rose from 6 percent to about 9 percent, reports of panic attacks went up from 10 percent to 16 percent, and even alcohol abuse rose from less than 1 percent to 6 percent. Recent unemployment was a key statistical predictor of these mental health problems. This remained the case after we controlled for a number of other possible factors, including preexisting depression and access to mental healthcare.14
Of course, there are other ways to address the problem of unemployment than with antidepressants. As Dr. Geoffrey Rose, the father of preventive medicine, put it: “What good does it do to give a patient medicine but send them back to the environment that made them sick in the first place?” The real question that we, along with many other epidemiologists, are now trying to understand is how we can prevent these problems from happening when large numbers of people lose work.
While millions of new prescriptions were being written in the US, UK, and Spain, not all countries facing big spikes in unemployment witnessed such large rises in the use of antidepressants. In Sweden, prescriptions rose by only 6 percent between 2007 and 2010, much less than the rise in Spain or in the UK. Instead of treating symptoms with pills alone, the Swedish response during the Great Recession, and earlier, was to address a root cause of depression—unemployment itself.