Their investigations raise concerns for the wellbeing of many vulnerable groups – especially in rural Australia – but also show there are many unanswered questions about the relationship between recession and health.

Dr Megan Keaney and Rebecca James from Research Australia, write:

“Amongst the millions of column inches written and hours broadcast about the global financial crisis, very little attention has been given to whether recession is bad for our health. It is not difficult to imagine that becoming unemployed is bad for our mental health but are there wider impacts? If so what will they be, who will bear the burden and is our health and welfare system prepared to meet the challenge?

Mental health professionals are already seeing a steady stream of recession casualties.  “BJ” is one such person. At age 57, he lost his business and savings late in 2008 and by November was severely depressed. He took an overdose of medication that left him with memory problems. When he left hospital, his ex-wife of 10 years took him home to a rural town, thinking that he would recover in a few weeks.  Twelve months later she remains his carer and his brain injury means that he has no prospects of returning to work or living independently.

A report released this week by Research Australia, Australia’s Financial Crisis: Implications for Health and Research reveals that becoming jobless is associated with higher rates of a variety of mental health disorders. Suicide rates in young men track the unemployment rate and even keeping a job in an environment where job insecurity is heightened is associated with higher rates of psychological disturbance.

Although the jury is still out, studies from previous recessions suggest that becoming unemployed is bad for physical health too.  For instance, a  UK study from the 1980s showed that job loss led to a 37% higher chance of dying in the next 10 years.

The good news is that for mental health at least, return to the workforce as the economy recovers, leads to improved mental health. If that was the whole story then health departments might be comfortable that although some extra mental health services might be needed to meet extra need during recession, with economic recovery, the status quo should return. However, as BJ’s case highlights, it may not be that simple. And the difference is that recessions don’t have the same impact for everyone.

It is well accepted that there is a strong correlation between socio economic status and health. In Australia people who live in disadvantaged communities with higher rates of joblessness, lower household incomes, lower levels of education and lower social status have much poorer health outcomes across the board than the well off. In Australia there is a strong link between poverty and unemployment.

The real risk of recession is that it adds to the pool of long term unemployed (those people who are out of a job for 12 months or more). The longer people are out of job, their return to the workforce is less likely. Unemployment impacts on those who can least afford it – people with lower education, fewer skills, and intercurrent health problems. Not surprisingly rising unemployment concentrates disadvantage in already struggling communities on the urban fringe and in rural Australia.

We know that long-term unemployment and poverty is bad for our health. So what will this recession bring and are we well prepared to meet that challenge?

During the early 1990s recession the number of long term unemployed receiving income support increased from 170,000 to a peak of 438,000. Although the percentage of unemployed who are long term unemployed in 2009 is low relative to the early 1990s (about 13%) it is feared that this group will rise by 150% over the next two years.

Treasury’s recently revised forecast that unemployment will peak at 6.7% might appear reassuring given that in the last two recessions unemployment rose to well over 10 percent. However the number of people looking for work is not the whole story.

Over the last 20 years there has been enormous uptake of the Disability Support Pension with the number of recipients increasing from 307,000 in 1989 to 750,000 this year. This recession too is a story of underemployment with the labour under-utilization rate increasing from 9.9% to 13.6 % in the 12 months to August 2009.

In other words, 1.5 million Australians are unemployed and looking for work or would like to work more hours. There is no doubt that for these people and their families, financial stress is real. So how will their health suffer?

Long-term unemployment might mean higher rates of illness and premature death from a wide range of illness including heart disease, cancer, mental illness and even accidental injury. Importantly the impacts are likely to be intergenerational.

Western Australian research shows that children from disadvantaged families start out life behind the eight ball with problems including lower birth weight which are carried through to higher rates of childhood illness such as respiratory and mental illness, and even into adult life with international research suggesting that chronic adult disease has its roots in early childhood and even prenatal factors.

Much of this health disadvantage is mediated through social factors such as lower educational levels, fractured families and communities and in turn higher rates of health risk behaviours including smoking, alcohol use, less physical activity and obesity. A good start counts for a lot when it comes to health.

At the other end of life, research shows that for older workers ill health and unemployment is a two way street. Close to half of Australians aged over 45 who retire early do so because of ill health. Older workers who develop heart disease or mental illness are especially unlikely to re-enter the workforce.

For the health care system, more illness means more demand. Australians enjoy relatively good access to the health care system and long-term data tells us that unemployed people and those who reside in urban disadvantaged communities see their GPs more often and have more hospital visits.

However recent polling by Research Australia and MBF reveal that for many Australians, this recession is already affecting choices we make about our health. For instance, over the last 6 months financial stress has caused close to 20% of people to put off seeing a doctor or dentist and a staggering two million people have gone to work ill, rather than take sick leave, because of concern about job security.

Many questions remain unanswered. Recessions might be bad for our health – particularly if we lose our job and never work again. However, as the economy recovers jobs will be regained and fears about joblessness and financial stress will fade. But are there lingering problems for our health? We really do not now whether cyclical economic downturns impact our health in the long term and well accepted research demonstrating that relative socio- economic status correlates with health outcomes provides only some of the answers.

Most importantly when reflecting on the possible consequences of this downturn for our health, we need to consider whether government policies and programmes designed to limit the economic fall out of this recession are working.

Do we need different strategies that better target social and health impacts? Are we making the right investments now to support vulnerable groups so that we have a healthy and productive workforce as we come out of recession?

What is clear is that we need to better integrate our health, economic and social research effort so that we learn the lessons of this recession. Only then will we be able to deal with the public policy challenges that are the legacy of this recession or accompany the next one.”

• (Declaration: Croakey’s moderator Melissa Sweet had a hand in editing the report)

Croakey’s North American correspondent, Dr Lesley Russell, writes:

“While an excellent discussion is underway on Croakey about the value of calorie labeling in tackling obesity, it has been shocking this week to confront front page news that the number of Americans who don’t have enough food is at an all-time high, largely as a consequence of the nation’s economic crisis.

Every year the Economic Research Service of the US Department of Agriculture compiles a report on Household Food Security.

The 2008 report released this week revealed that last year almost 50 million people in 17 million households (14.6% of all US households) were food insecure and families had difficulty putting enough food on the table at times during the year. This is an increase from 13 million households (11.1%) in 2007. The 2008 figures represent the highest level of food insecurity since national food security surveys were initiated in 1995.

Given that unemployment has risen from 7.2% at the end of 2008 to 10.2% today, this might now be an under-estimate of the number of people struggling to put enough food on the table.

The magnitude of the increase in food shortages, or in some cases outright hunger, has startled even anti-poverty advocates and those who have noticed the increasingly longer lines at food banks and soup kitchens.  It is especially concerning that so many children are going hungry.  In 2008 nearly 17 million children (4 million more than in 2007) lived in households where food was sometimes scarce, and children in more than half a million households faced “very low food security”.

The USDA did not actually use the word “hunger”, but President Obama did and in a statement yesterday, he called the report “unsettling.”  Others were even more forthright.  Mariana Chilton, a Drexel University public-health professor, said: “This is a catastrophe. This is not a blip. This recession will be in the bodies of our children.”

The fundamental cause of food insecurity and hunger in the US is poverty and a lack of resources to provide housing, food and health care.  The Obama Administration has taken action to help needy families through the American Recovery and Reinvestment Act of 2009, which provided a significant increase in nutrition assistance benefits for the 36.5 million people (half of whom are children) who participate in USDA’s Supplemental Nutrition Assistance Program (SNAP), formerly the Food Stamp Program.

The USDA also has a National School Lunch program which serves 31 million children a healthy meal each school day – for some children in need, this is their most important meal that day. Also, nearly half of all infants in the US participate in the Special Supplemental Nutrition Program for Women, Infants and Children, or WIC program, which ensures mothers and their children have access to nutritious food.”

• Dr Lesley Russell is the Menzies Foundation Fellow at the Menzies  Center for Health Policy, University of Sydney/ Australian National  University and a Research Associate at the US Studies Centre, University of Sydney.  She is currently a Visiting Fellow at the Center for American Progress in Washington DC.

All these years later, Canada is still mining, manufacturing and exporting asbestos.

At the American Public Health Association conference last week, a resolution (you can download it here) was passed calling for a global ban on asbestos mining, and manufacturing, and the export of asbestos containing products.

Canada received particular mention for continuing to export the stuff to developing countries while banning its local use, and also for blocking the inclusion of chrysotile asbestos in a list of hazardous substances requiring prior informed consent when exporting them under the Rotterdam convention.

But Dr Yossi Berger, an occupational health and safety expert with the Australian Workers’ Union, believes it’s time to shift the debate beyond bans, and to start looking at removing asbestos from buildings and anywhere else it may be putting lives at risk. He writes:

“It’s a good thing that the American Public health Association is calling for a total ban on asbestos containing materials (ACMs).  But it’s now time to shift the paradigm.  There are millions of acres and hundreds of thousands of tonnes of ACMs currently in use around the world.  These, I believe, are ‘faulty’ products that should never have been manufactured.  The Australian Workers’ Union recently called for a once and for all total removal.

Hundreds of thousands more people will be killed by ACMs.  Currently hundreds of thousands of people are the walking wounded as a direct result of exposure to ACMs.  They painfully understand the preciousness of every single unobstructed breath of air.  Their lives and that of their families’ have become nurseries for terror.

Drago told me that, “Each night I don’t know what the morning will bring for me”, and he adds in a rasping voice between laboured breaths and coughing, “I feel guilty when I look into my wife’s eyes and see the pain”.

I believe that ACMs are unsafe in any condition.  This is so despite painting over them, despite cladding over with safer products, and despite various poorly implemented laws and regulations.

No one can tell me which single asbestos fibre entering someone’s lung right now is the one that will not kill them, but if you don’t breathe any fibres you will not suffer an asbestos-related disease.  Doesn’t it follow that whilst extremely dangerous such products can be made safe by reducing exposure to fibres?  Yes, in theory.

But the time I inspect such presumed ‘safe’ ACMs in industry I see a great deal of damaged material, constantly vibrated and shaken material releasing fibres, I see it in broken bits on the ground, split and stuck back on with tape, I see the empty spaces where warning signs should be, I ask in vain for records of the presence and supervision of such materials, I try to find informed people, informed workers about the risks of such materials; in my dreams!  These ‘safe’ materials are temporarily safe only if these things happen, and they typically don’t.  What do I tell the worker who asks me, ‘Can the little bit extra fibres I’ve breathed kill me?’

It’s for these reasons that the AWU makes the case that such materials are ‘unsafe at any speed’.  They present permanent mortal risks that too frequently eventuate.  The AWU has called for what amounts to a total product recall, a total removal program over a 20 year period.

We have called on the federal government to implement a national removal program.  Such a program must be developed as a Prioritised Removal Program (PRP).  Once ACMs are discovered the program commences.  We argue that all buildings – once assessed and the PRP is triggered – (starting with industry, public spaces and schools) must have an asbestos designation and an ACMs identifier that’s colour coded as  red (immediate removal), amber (3-6 months) or green (6-18 months), an  Asbestos Presence Ticket.   This must be prominently displayed.

We need to move past banning and into total removal.  But a ban is good start.”

• A terrific piece bringing some much-needed perspective to discussions about mental illness, especially in the wake of recent murders. By Dr Tanya Ahmed, a registrar in psychiatry and a principal of the health and communications consultancy RaggAhmed.

• More than a million premature deaths across 30 OECD countries could be prevented each year if income inequality was reduced. That’s the best guess of a meta-analysis of studies involving around 60 million people, reported in the BMJ. The authors note that there are many caveats to their findings, including a lack of evidence from developing countries, but say their results have “potentially important policy implications for population health”. Meanwhile, I’m heartened to read that a fellow Crikey blogger is also putting inequality on the public agenda.

• When the law meets public health – Simon Chapman, professor of public health at the University of Sydney, considers the implications of a recent High Court judgment. It dismissed a duty of care negligence claim against a Tasmanian hotel owner who handed back motorcycle keys lodged for safe-keeping to an insistent, belligerent patron who on leaving the pub was killed in a crash while showing a blood alcohol level of 0.253.

• Investigating the ties between drug companies and doctors – A group of researchers from Australia, Canada and the US have done an indepth analysis of disclosures of pharmaceutical sponsorship of gifts and educational events, as has been required of Medicines Australia members since 2007. They conclude that the disclosure does not go far enough and also give some interesting examples of how companies are wooing doctors. Novartis, for example paid flights, accommodation, food, beverages, and conference registration fees for six ophthalmologists to attend a two-day conference in Spain, at a cost of AUD$10,993 per person. For those who follow this field, it will come as no surprise that the researchers include Ray Moynihan, Lisa Bero and David Henry. The other authors are Jane Robertson and Emily Walkom from the University of Newcastle.

I came across this event while doing some research recently on new media and health, which also led me to some blogs that might be of interest. I found many of these at this link to “50 excellent health blogs”.

• The Effect Measure is a public health blog in the US authored by senior public health scientists and practitioners whose identity is kept anonymous, so they can speak frankly. Here’s what they say about themselves: “In epidemiology an effect is the endpoint of a causal mechanism. An effect measure is an estimate of the influence of a particular factor on a population’s health. The Editors of Effect Measure are senior public health scientists and practitioners. Their names would be immediately recognizable to many in the public health community. They prefer to keep their online and public lives separate to allow maximum freedom of expression. Paul Revere was a member of the first local Board of Health in the United States (Boston, 1799). The Editors sign their posts “Revere” to recognize the public service of a professional forerunner better known for other things.”

• The Pump Handle is another public health blog, mainly written by US epidemiologists.  It’s “a place for people interested in public health and the environment to discuss the issues that interest us, particularly when they’re not getting the treatment we think they deserve in the mainstream media.

The story of the pump handle is familiar to any first-semester public health student: During the London cholera epidemic of 1854, John Snow examined maps of cholera cases and traced the disease to water from a local pump. At the time, the prevailing theory held that cholera spread through the air, rather than water, so Snow faced criticism from others in the science community – not to mention resistance from the water companies. He finally convinced community leaders to remove the pump’s handle to prevent further exposure.

More than a century later, thousands of people still die from cholera each year, and providing clean drinking water to the world’s entire population is a far-off goal. The Pump Handle symbolizes both a public health victory and the challenges facing the public health and environmental fields today.”

• Health Wonk Review is a biweekly compendium of the best of the health policy blogs. More than two dozen health policy, infrastructure, insurance, technology, and managed care bloggers participate by contributing their best recent blog postings to a roving digest, with each issue hosted at a different participant’s blog. “For participants, it’s a way to network and share ideas, and for those readers who don’t live in this space every day, it’s a way to sample some of the latest thinking and the ‘best of the best’.”

• Wall Street Journal’s blog on health and the business of health

• CDC’s Public Health Matters blog

• Covering Health is a blog maintained by the Association of Health Care Journalists. It is intended to help keep journalists who report on health and health care issues informed about the latest news in the field, aware of noteworthy stories and reports, and able to connect with colleagues.

•  World Health News, from the Harvard School of Public Health

• Global Health Ideas from some social entrepreneurs

• Gary Schwitzer, University of Minnesota School of Journalism & Mass Communication, Publisher, HealthNewsReview.org

• Hooked: Ethics, Medicine and Pharma from Professor Howard Brody, Director of Institute for Medical Humanities, at University of Texas

• Dr Keven Pho is a primary care doctor in New Hampsire and a prolific blogger who seems worth reading. I’m giving him a trial anyway. He says he was voted the best medical blog of 2008 (I presume that’s in the US), and has over 20,000 RSS subscribers and 15,000 Twitter followers.

Let me know if there are any others worth a mention.

And thanks to Becky Freeman at USyd for putting me on the trail of the Journal of Medical Internet Research. How quickly the world of media and health has and is changing….

BTW, Croakey is now twittering. You can stay abreast of the latest posts here…

And thanks to Pharmacy News for giving Croakey a mention in its cover story on blogging and pharmacy (October issue). As you may have noticed, Croakey is a relative newcomer to the new media world and still finding a way. So it’s nice to get some feedback that Croakey is “out there”…

She wrote about her experiences in a book, Out of the Blue: Facing the Tsunami.  She will donate the sales of her remaining copies to aid the Samoan disaster victims – you can buy them here.

She writes:

“I’m deeply afraid for the people of Samoa. Not just because the tsunami has taken hundreds of lives and thousands of homes. Not just because the country’s main industry, tourism, has been shattered. And not because the tiny country (population: 220,000, coastline 400kms) has little else to fall back on.

I fear for the people of Samoa because they are very soon to become “yesterday’s story”.

This tsunami has lots in common with the 2004 Boxing Day tsunami, which swept onto a beach in Thailand where I had built a house. It was shockingly powerful, took the lives of those most vulnerable and left whole villages without homes.

But where 2004’s quarter of a million dead prompted floods of aid dollars, in this case it appears as if the relatively small number of deaths (170 at time of writing), and the unfortunate coincidence of the Samoa tsunami occurring at the same time as earthquakes and typhoons in the same region, could perversely see Samoans without much ongoing international sympathy to rebuild.

I want to do something about that, and so I have decided to donate 100% of the sales of my book: Out of the Blue, Facing the Tsunami, which describes my experience in 2004, to the Red Cross appeal.

A foreign correspondent for The Australian at the time of the tsunami, I spent another three months in Thailand covering the aftermath. It was impossible not to notice the millions of dollars of aid pouring into the region.

While much of it was used appropriately, an indication of the depth of passion the money evoked was an argument I witnessed between two agencies over the right to build a particular village, while another European development worker who learned I was familiar with the region begged me to identify a school that needed rebuilding as he’d been unable to find one not already spoken for.

I didn’t lose much in the tsunami in the way of material things. But my psyche was shattered and I later realised I could no longer operate as an effective journalist. My book explores surviving the tsunami as well as the aftermath, which for me included an extended period of post-traumatic stress disorder.

Because of all this, I have some knowledge of what is ahead for the people of Samoa, and for those who are reporting on and helping them. The repercussions will come in waves – first the burials, then the physical healing, then the rebuilding of homes (probably in new areas), then the rebuilding of lives.

It will take years. Long after the news is stale, these people are likely to still need help.

So too will be those hundreds of thousands of Samoans who were not directly caught up in the wave but whose way of life and community has also been irrevocably changed.”

Croakey continues:  I strongly recommend the book to anyone interested in the aftermath of trauma in general, and trauma journalism in particular (Kimina and I have a connection through the Dart Centre for Journalism and Trauma).

Check out this great example of clever communication.

(thanks to Dr Trevor Kerr for sending in the link)

Dr Mary Haines, Editor of the Hospital Alliance for Research Collaboration (HARC) eBulletin, has been investigating the lessons from the UK.

She has filed this report, based on the latest HARC eBulletin, released today:

“For those unconvinced about the merits of attempting health reform in Australia, recent success of reducing hospital waiting times in the UK suggest some cause for optimism.

In the late 1990s and early 2000s when significant healthcare reform was implemented in the UK, health care providers were concerned that the reforms may disproportionately advantage higher socio-economic groups.

A recent study published in the British Medical Journal,  profiled in the HARC eBulletin  released today by the Sax Institute,  suggests that healthcare reform reduced inequality in waiting times for elective surgery.

This study examined the question: did the reduction in waiting times for elective surgery between 1997 and 2007 differentially benefit patients in hospitals in more affluent areas compared with those in lower socio-economic areas?

The study found that in 1997 there was a significant positive association between waiting times and hospitals in lower socio-economic areas (i.e. the lower the socio-economic area of hospital, the longer the waiting time).

But by 2007 variation in waiting times became more uniform across different areas: the reforms actually reduced inequality of access to hospitals.

Much has been written about the UK government’s ambitious 10 year health reform agenda that involved measures such as: increasing the supply of doctors, increasing funding for the health service, setting rigid waiting time targets, and introducing market based reforms.

It is not clear what aspect of these reforms led to the reduction in waiting times.  But what these results do show is that the “reforms have not had a deleterious impact on the equity of waiting times for elective surgery in England”.

Embedding evaluation into the roll out of changes in the health system helps clear the air about who are the beneficiaries of reform actions.”

• The HARC (Hospital Alliance for Research Collaboration) eBulletin, is produced by the Sax Institute partnership with the NSW Clinical Excellence Commission and the Greater Metropolitan Clinical Taskforce.

• a lot of people must be working pretty hard and wondering how on earth they’re going to pull it all off

• we will be hearing and reading plenty of reports emphasising the potential benefits of vaccination and maximising concern about the impact of swine flu.

In one sense, this is what happens whenever there is a roll out of a new health program or intervention; the advocates talk it up. But this time, they will no doubt be even more determined to do this, given the questions that are being asked about the merits of the campaign and its timing.

In light of this second point, you might be interested in this piece calling for a “common sense” response to swine flu, recently published by Healthy Skepticism, a group which is not known for being overly enthusiastic about medical marketing.

It is by Juan Gérvas, a rural GP in Spain, and a Visiting Professor, Primary Care, International Department, National School of Public Health (Madrid), Spain. He is also Honorary Professor, Public Health, School of Medicine, Autonomous University (Madrid).

The tips are fairly straightforward; the only one likely to raise eyebrows suggests avoiding terms such as “epidemic”.

This tips says: “Watch your language. People are already anxious, so don’t make the situation worse by using loaded words such as “epidemic.” Even though any public-health official will tell you that just a few cases constitute an epidemic, the word scares people. Use a less loaded word such as “outbreak” whenever possible.”

Personally, I think the tipsheet could have gone a bit harder on the merits of including some broader context when covering such stories, especially given the huge impact of media coverage at times like these – in exciting public alarm and diverting political and policy making focus from other pressing health issues.

This paper estimating the global toll of tobacco in coming decades gives some useful context to the current concerns about swine flu.

Under the baseline scenario, total tobacco-attributable deaths will rise from 5.4 million in 2005 to 6.4 million in 2015 and 8.3 million in 2030. Projected deaths for 2030 range from 7.4 million in the optimistic scenario to 9.7 million in the pessimistic scenario (mind you, all those projections sound rather depressing to me).

According to the baseline projection, smoking will kill 50% more people in 2015 than HIV/AIDS, and will be responsible for 10% of all deaths globally.

Projections of global tobacco deaths (millions)

Now that provides some context to the current concerns about swine flu. It’s fascinating how an epidemic with predictable outcomes (millions of deaths from tobacco resulting in huge economic and social costs) doesn’t excite the same level of political or public alarm as an outbreak of infectious diseases whose consequences are unpredictable but likely to be much more modest.