Looking Back: Comment on “Economic Crisis, Restrictive Policies, and the Population’s Health and Health Care: The Greek Case”

How do we calculate, and place at the center of the public conversation, the return on investment of spending to protect human health? What is the role of nonhealth policymaking in preserving and elevating health? How do we avoid repeating cycles of health-adverse policymaking? The 2013 article by Kondilis et al., documenting the impact of the late-aughts economic crisis and attendant economic restructuring on population health in Greece, pushes us to consider the persistent and perhaps heightened importance of these questions, 10 years after the article was first published.

Kondilis et al. documented changes in health in Greece between 2007 and 2011.¹ The late-aughts global economic crisis severely affected the Greek economy, and Greece had to rely on loans from the International Monetary Fund (IMF) to finance the country’s debt. The IMF loans came with conditions, including privatization of public enterprises and limits on public spending in sectors like health and education. Data by Kondilis et al. show how, coincident with these changes, a broad range of health indicators in Greece deteriorated. Suicide and homicide mortality, mental disorders, substance abuse, and infectious disease morbidity all worsened, and use of public inpatient and primary care services rose. A decade ago, this was a sentinel analysis showing the relationship between austerity economic policies and health.

The Greek data documented by Kondilis et al. are consistent with other data that illustrate how macro-level austerity economic policies are associated with poor health. Data from Russia, the Caribbean, and New York City show similar findings.^2–4 Conversely, data from countries in Latin America that went through economic crises without succumbing to austerity economic measures show that these countries did not have a commensurate downturn in health,^4,5 further suggesting a link between economic policies and health.

That macro-level economic policies affect the health of populations is not in any way surprising. Any number of conceptualizations of the role of social determinants of health consider upstream factors like economic and social policies as foundational to population health.^6,7 Canonical reasoning in the field, including the work of Geoffrey Rose, suggests that policies set the foundations for the production of health and can shift the distribution of health in populations.⁸ Whereas investment in prohealth policies can result in improvements in health,⁹ policies that limit social and economic achievement can harm health.¹⁰ Revisiting this article by Kondilis et al. a decade after its writing is a reminder of the importance of documenting the consequences of economic changes on health, and of how little has changed in the past decade, despite knowing the impact of economic conditions on health. Their work highlights three important questions that may merit academic and public discussion, to the end of protecting human health from inevitable future economic crises.

SPENDING TO PROTECT HUMAN HEALTH

Our academic and public conversation about spending to protect human health is limited and halting, especially when we expand the scope to focus not only on the prevention or treatment of disease. Although we recognize that there is substantial spending on health and health care—including, for example, US annual health expenditures in excess of $4 trillion—we are much more constrained in thinking strategically about what we are willing to spend to preserve and protect health for longer-term consequences. The most recent example of this is the COVID-19 pandemic in the United States, which has cost the country an estimated $16 trillion, or roughly the annual GDP of China.¹¹ In no small part, the costs of COVID-19 reflect decades of underinvestment in public health and the resulting vulnerability to a previously unknown virus.¹² Similarly, austerity policies are driven in part by a perception that the cost of maintaining good health is too high, even though the cost of poor health is greater in the long term. A key challenge to our ability to countenance spending on health protection is that of time lags. Spending that is largely on medical care becomes “health” in the immediate present; we are spending on imaging machines that are used in the current year. Conversely, spending on public health, much as spending on social and economic infrastructure, can influence health many years down the road. This separates spending in the short term from the benefits that accrue in the long term. The time lag between spending and its consequences separates decision-makers, who have to make difficult decisions in the present, from the potential positive health benefits of their actions. Therefore, we remain limited in our critical thinking about return on investment from health spending, particularly when that return happens on a different time frame than our investment. This was the case during the Greek economic crisis and in the run-up to the COVID-19 pandemic, and it continues to be the case in the present postpandemic reality.

THE ROLE OF NONHEALTH POLICYMAKING IN PRESERVING HEALTH

The social, economic, and political determinants of the health agenda have become broadly established within public health thinking. It is now well understood that policies, urban environments, power, place, structural racism—all macro-level features of the world around us—influence the health of populations and, as such, should be part of the remit of anyone interested in population health and its application to the health of the public. A Health in All Policies approach is the operational manifestation of social determinants thinking, whereby we recognize that to promote health we need to think of and involve sectors—financial, housing, sanitation, law enforcement—that have not historically been seen as “health” sectors.¹³ This recognition has implications both for those who are in the business of promoting health and for those who are in the nonhealth sectors. For the former, it means engaging with different sectors, including policymakers who are socialized to think rather differently, and encouraging them to see consequences of their actions through the lens of health. For the latter, it means making the effort to take on health as an outcome of interest in their deliberations. As the Greek economic crisis and similar case studies show, this is far easier said than done, particularly when coupled, as noted here, with time lags between actions of the nonhealth actors and results in health.¹⁴ However, as this particular case shows, nonhealth sectors have an ineluctable role to play, and health cannot advance without their engagement. This puts the onus on health actors to engage counterparts in thinking about health, and to clarify, to nonhealth actors, the importance of having health as one of the key factors to be balanced in their thinking.

AVOIDING REPEATING CYCLES OF HEALTH-ADVERSE POLICYMAKING

This brings us to the third and perhaps most important implication of the Kondilis et al. analysis a decade later: how do we avoid future policymaking that puts health at risk? Recognizing both that protecting population health requires the engagement of nonhealth actors and that such engagement is difficult to do, particularly when the health benefits are temporally distant from the policy decisions, what are the levers that those in public health can use to mitigate the risk of repeated adverse-policy cycles?

Three thoughts might be helpful in this regard. First, greater and sharper clarity about the role of social and political factors in determining health is a helpful step toward diffusing these ideas. Not long ago, the notion that social factors mattered for health was relatively novel in medicine. That this is no longer the case is good, but it is also true that it has been widely accepted only in relatively recent years. The establishment of social determinants at the center of the health conversation is a necessary first step toward the broader communication of the role of such factors to nonhealth actors.

Second, those concerned with the health of populations need to become substantially better at telling the story of health. This story is still told principally through the lens of medicine, with narratives that center on individual clinicians healing individual, sick patients. Part of changing the public conversation will require better narratives about how investments in the prevention of disease and promotion of health and welfare are far preferable for societies, and well worth the cost.

Third, we need to highlight the moral and pragmatic need for nonhealth policies that advance health. This means empirical and expository scholarship that makes clear the essentialness of health as a human value, and the tremendous societal advantages of healthier populations. It will require this kind of scholarship to change the policy conversation, and to counter historical ideologies that have advanced austerity ideas without regard for their health consequences.

TEN YEARS AFTER THE ECONOMIC CRISIS

It is both sobering and motivating to revisit an analysis, 10 years later, that highlights the health consequences of economic crises, and to realize that such consequences would be the case today in another such crisis, much as we have seen after the recent pandemic. This should both sharpen our focus on investing in prohealth policies and energize the next generation of population health scholars to do the work that can shift the public conversation away from austerity economics once and for all.