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.

• 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.

They write:

“John Graham’s suggestion for saving NSW hospitals, as outlined in his recent Centre for Independent Studies monologue, dreams of hospitals managing their own affairs unfettered by outside interference. His piece is called ‘The past is the future for public hospitals’.

He argues in essence: just let us (primarily doctors) get on with it – as we used to do – and all will be well.

The arrogance and lack of ‘back-sight’ in learning from the past are stunning.

We are not going to speculate on how to address the problems of NSW hospitals beyond arguing that Graham’s suggestion is not the way to go.

What is at stake is the question of who has the power to decide how resources in hospitals and health services more generally are used.

Do we want another Bristol or another King Edward Memorial Hospital?  Are doctors to be left in charge? They are trained in medicine but not hospital management which is a major and important discipline in its own rights. We risk producing a culture of ‘medocrats’ and that as the Bristol Inquiry indicated is to be avoided.

The logic of Area Health Services is to address the health of a population not just the patients of a hospital. So what is the role of the hospital in the community under this view from the past? How are questions of equity to be addressed?

Central to any recommendation on governance of our public hospitals must be a recognition of three things.

First hospitals are responsible for allocating resources – for example, setting priorities within the funds available for example – as well as treating patients. Second there needs to be some clear explicit mechanism for ensuring that the culture of hospitals is genuinely conducive to good patient care. And three, hospitals are about power, both power within the hospital and power in the health service more widely.

Whatever else we can learn from Bristol and King Edward’s – and surely from these there must be a learning process – it is that ‘internal’ auditing of hospitals is simply not good enough.

There needs to be openness in all aspects of both patient safety and resource management. Ideally if hospitals  are to serve communities, there needs to be accountability to the citizens in the community they serve such as through citizens’ juries as one of us (MM) organised in the south west of WA [This book has more details].

Graham bemoans the advent of Medicare: “The ideologically driven decision to allow all comers to be treated free regardless of means fundamentally changed the dynamic that underpinned the successful operation of the public hospital system.”

It certainly did. But unlike Graham we welcomed Medicare and want to defend it particularly given the current attempt to undermine it in the floating of Medicare Select by the NHHRC.

Given the ideologically driven ideas in proposing a return to the past in Graham’s CIS paper, it is superfluous to ask what concerns he might have in his proposal for equity (which interestingly was given a big tick in that WA citizens’ jury).”

Of course, if we really care about health equity, health ministers would probably not be at the top of the list of people we should be chasing.

Prime ministers, premiers, treasurers, education ministers, even transport ministers may be just as important when it comes to policy decisions with health equity implications. Besides, many people seem to think that it’s Rudd (or at least his office) who is running the Government’s health reform agenda (whatever that may be…)

The Rural Doctors Association certainly gave this impression in a enthusiastic statement released after the PM’s visit to Bridge Clinic in Murray Bridge, South Australia, on Wednesday. They were delighted the PM gave them an hour of his time when just 15 minutes had been scheduled.

“Pleasingly, after hearing RDAA’s concerns, Prime Minister Rudd invited us to also work directly with his Office in combating the key issues fuelling the continuing health workforce crisis in rural and remote Australia,” said Dr Peter Rischbieth’s statement.

“We came away from the meeting with a great feeling that the Prime Minister now clearly appreciates the wide scope of work that rural doctors undertake in their communities and the additional workload they carry—from providing general practice-based primary care right through to being the emergency doctor at the local hospital.”

Well that’s wonderful. It does make you wonder though why it has taken so long for the PM to gain this appreciation. How long is it now that the problems of rural health have been in the headlines and at the forefront of health policy challenges? Probably easier to measure it in decades than years.

No doubt the PM’s office, with their keen interest in health reform, read this oped from the Business Council of Australia (in the Oz on Tuesday in case you missed it, as I initially did), arguing that health reform is too important to be left to the warring stakeholders. It’s an argument that John Menadue has made powerfully on many occasions.

I only hope they are also familiarising themselves with the mountains of evidence suggesting that health equity impact statements should be a critical part of health reform planning.

Will this further increase the inequities in access to good health and to health services? Or will it help close these gaps?

It doesn’t seem such an unreasonable ask when we have so much evidence that those who are most likely to have health problems are least likely to have access to useful health care.

A study published in the latest Australian and NZ Journal of Public Health provides yet more ammunition for this line of questioning.

Researchers from the ANU and University of Newcastle used data from a 2004 survey of 10,905 women aged 53 to 58 to examine the relationship between socioeconomic status and health service use.

Given that poorer and more disadvantaged groups are generally more likely to have chronic diseases and other health problems, you might expect them to use health services more often.

Not so. While GP use was roughly the same between the wealthier and the poorer, the better off women were more likely to report having used dental services, specialists, allied health practitioners, and alternative health providers.

The researchers say their findings support experts who have questioned the private health insurance rebate, and suggest that it is adding to inequities by enabling wealthier women to access allied health services, often important in the management of chronic diseases, that poorer women without insurance could not afford.

“The pattern of findings suggests that inequalities in care are to some extent shaped by the health care system itself, where out-of-pocket costs and private care influence access,” the researchers said.

“International findings are in line with these conclusions – inequity in ambulatory medical and dental care in universal systems is found to be greatest in countries where private health insurance and direct private payments play some role in access to services.”

The researchers note that their findings don’t prove that poorer women are being under-treated as their study could not rule out the possibility that advantaged women are being over-serviced. “Nevertheless,” they said, “this in itself could still be considered inequitable in that health expenditure is not being distributed according to need.”

The researchers conclude that their findings “suggest unfairness and inefficiency in the allocation of services as those who are sickest and hence potentially have the greatest capacity to benefit from health care, are not those most likely to receive it.”

Meanwhile, the Australian Healthcare and Hospitals Association has just issued this release, putting pressure on the AMA to join its stance opposing the private health insurance rebate.

It says: “The private health insurance rebate is a grossly inefficient means of supporting private health care and would deliver much greater gains to the community if spent directly on health services and infrastructure. AHHA calls on all health groups to unite in advocating for the re-direction of the private health insurance rebate funds into public hospitals and community-based care.”

Now wouldn’t that be something – imagine if the closing the gaps question was asked, not only by Health Ministers, but by powerbrokers like the AMA…what a difference that might make.

But we haven’t heard much at all about what the reforms might mean for one extremely needy group who are often not well served by existing health services or funding structures.

Professor Ian Webster, a longstanding advocate for the homeless, has some suggestions for those driving health reform about what they need to consider if they want to better address the needs of the homeless.

He writes:

“The fact of homelessness is a test of our social and health policies. Between 2001 and 2006 homelessness increased by 17% with 16,000 in Sydney and 14,500 in Melbourne on the census night.

The health reforms currently proposed by the Commonwealth will aim to get primary health care (PHC) into disadvantaged communities and better management for complex health problems. Homeless people are one such community. In parallel with these reforms, the National Mental Health Plan has put social inclusion at the top of its priorities as it recognises the high risk of mental illness in homeless people.

The White Paper, The Road Home: A National Approach to Reducing Homelessness says ‘no person need be homeless’. It aims to ‘turn off the tap’ and prevent homelessness and proposes there should be ‘no wrong doors’.

In other words a person should be picked up at any point between the initial crisis and long-term homelessness.

This is a long way from the Homeless Persons Assistance Act of 1974 introduced by Bill Hayden to assist non-government organisations to provide shelter. Up to that time homeless policy was no policy; that was the job of the churches and charities. That 1974 Act and its iterations have never addressed health needs.

A street clinic in New York found that a homeless person had an average of 9 concurrent medical conditions.   It is the same in Australia: 75% of homeless people in Sydney in 1998 had one or more mental disorders – schizophrenia in 23% of men and 46% of women and an alcohol disorder in 49% of men and 15% of women. Every second person was physically unwell.

To do anything worthwhile for homeless people, a health service must be where the homeless are, in the environment of the homeless, free at the point of delivery and able to respond to multiple needs. Only in this way will there be a doorway into mental health services. The homeless need safe places especially when they are ill as do homeless families as the children have high rates of serious health and psychological problems.

Homeless women have special needs for contraceptive and pregnancy management and need treatment following physical and sexual violence. And for young homeless people a special style of service is the only way to engage with them.

People with mental disorders fall out of the service systems and are inadequately followed up. This is especially true of homeless people. They need assertive follow-up to overcome their reticence and embarrassment of their marginal status. Thus front-line services should be based on ‘open door’ and ‘no wrong door’ principles.

The main funding mechanisms in general practice – the Medicare item-for-service schedule and the Pharmaceutical Benefits Scheme – do not fit this population’s characteristics of transience, loss of identifying papers, intermittent contact and high prevalence of chronic and relapsing diseases such as diabetes, chronic lung disease and especially mental illness and substance use problems.

It is at times an insurmountable task to arrange psychiatric medications, antibiotics, addiction treatment, chronic pain management and even such straight forward measures as wound dressing, for these people.

A new kind of primary healthcare and general practice will need to be constructed if a dent is to be made in the increasing numbers of mentally ill homeless people. Will the proposed health reforms do this?”

• Ian Webster is Emeritus Professor of Public Health and Community Medicine at the University of New South Wales and Consultant Physician.

Dr Sumitra Ananda, a cancer specialist in Melbourne, is hoping the Federal Government acts on the new findings.

She writes:

“The recent report in the MJA by our group supports the fact that the National Bowel Cancer Screening has the potential to save lives and decrease mortality. The first indicator of this is the dramatic shift in stage distribution between those that were diagnosed through the program and through symptomatic presentation.

Bowel cancer is the second most common cancer in Australia and also second in terms of mortality.

We have known from large randomised controlled trials that there is a potential to reduce mortality by 16-33%.

Breast cancer on the other hand, ranks lower in terms of mortality in Australia but has an established widespread screening program targeting women aged 50-69.

The current program has had a limited roll out to those aged 50, 55 and 65 and has only one screening with no re screening offered.

It is crucial that the government fully roles out the program with rescreening which could potentially save lives and ultimately save cost.

Participation is also a key to the success of a program and comprehensive communications campaign to maximise participation are necessary. The main reasons are likely to be the lack of awareness of the benefits of screening and reluctance or embarrassment to collect and send in a stool sample.

The study also suggests the apparent lack of uptake amongst the socially disadvantaged sections of the population. This may be due to lack of understanding, lack of interest  a study showed that people from more economically deprived areas had less interest in pursuing the test) or access (not the case in our study).

Another consideration would be that these individuals are undergoing initial screening but then not pursuing follow up or have difficulty accessing colonoscopy.

Given the potential impact of the screening program and its potential to save lives, the government must consider the complete roll out of the screening program and support the resources needed to sutain it.”

Professor Mark Harris, from the UNSW Centre for Primary Health Care and Equity,  says there is enough evidence, from this and other studies, to suggest that efforts are needed to ensure lower SES groups participate in screening and are able to access related procedures.

He writes:

“The findings of the study in the MJA are interesting but we need to keep three things in mind:

Firstly there is not necessarily evidence of a social gradient in colorectal cancer incidence (i.e. a sliding scale of incidence getting lower as income increases).  There was, however, a social gradient in male bowel cancer mortality in 2000.  The poorest 60% of the population had 1.2 to 1.3 times the colorectal cancer mortality of the richest 20% in men, but not women, aged 25-64 years (AIHW 1998-2000).  This suggests that we may already have had a problem even before the National Bowel Cancer screening program.

The second consideration is that though the study shows that there may be a social gradient in screening – with a bigger proportion of cancers detected by screening in high SES groups (25/605= 4.1%) compared with lower SES groups (7/443=1.6%) – the numbers involved are small.

Thirdly, the pilot CRC screening study showed that there was also a social gradient in the proportion of patients who tested positive who then subsequently had a colonoscopy.   Thus the pilot predicted that there may be a social gradient both in uptake of screening and subsequent colonoscopy of positive cases.  This was not due to lower rates of presentation at GPs (as rates of presentation at GPs were higher in lower SES groups).

Thus on balance we can infer that there is a social gradient in screening (both FOBT and colonoscopy).  This is all consistent with studies overseas that have shown that more educated and richer people respond to initiations to faecal occult blood testing (FOBT) screening (McCaffery K et al J Med Screen 2002; 9: 104-8).

This suggests:

We need to improve the uptake of screening in low SES groups
This may be done by improving the invitation.  The current letter is formal and complex and is unlikely to motivate poorly educated patients.  The content should be simpler and based on health promotion theory.

We should also involve GPs more actively, for example by sending mailed invitations from practices to encourage patients, especially males in poorer areas.  Invitations should be tailored to encourage different groups of patients (Myers RE Prev Med 1990; 19: 502-14).

We need to address barriers to colonoscopy amongst positive patients
Significant socioeconomic barriers to colonoscopy clearly remain.  Despite poorer patients being more likely to see their GP following screening, they are less likely to have a colonoscopy than richer patients.”

That is one worrying implication from a study just published in the Medical Journal of Australia.

Researchers sought to examine the initial impact of the national bowel cancer screening program which offers faecal occult blood testing to those aged 55 or 65.

They reviewed the data on bowel cancers diagnosed between May 2006, when the program began, and June 2008 from a database involving 19 hospitals. The good news is that cancers detected through screening tended to be at an earlier stage than those diagnosed as a result of patients presenting for testing because of symptoms.

The worrying news for anyone concerned about equity is that almost two-thirds of the patients whose cancers were detected through screening were from wealthier backgrounds. Somehow, I don’t think this means that wealthier people are at increased risk of developing the cancer; it is much more likely to mean that the poorer groups are less likely to access screening.

Professor Ian Olver, ceo of Cancer Council Australia, has filed this analysis of the study:

“The recent report on the impact of bowel screening in Australia by analysing patients who present for surgery for colorectal cancer confirms the ability of the program to save lives.

As with studies from other countries, patients who are screened present with earlier stage disease which is more likely to be cured.

The study showed a disparity between low and high socioeconomic groups. Those from lower socioeconomic groups are less likely to have been screened.

Whilst this has been reported from other studies, potential solutions are not as well researched. It is known that certain subgroups like the culturally and linguistically diverse communities and Aboriginal communities will need culturally appropriate translations of information about screening. The access of remote populations may be an issue.

However what of the majority of people in lower socioeconomic groups? A recent American study has shown that educational level is a key factor, because it influences the provision of information about screening by healthcare providers (Ye J et al Cancer Epidemiol Aug 28 epub before press).

Clearly GP’s and other providers have an important role in encouraging participation in screening.

However, the major issue remains that given the proven ability of a bowel screening program to save lives, Australia still only has a one off bowel testing program rather than a full screening program.

There is no rescreening, which should occur every 2 years, and bowel screening kits are only mailed to 50, 55 and 65 year olds. Too many Australians, of all socioeconomic groups, are missing out on a program that could save 30 lives each week if fully implemented. It is urgent that the Government completes the role-out of bowel screening.”

Croakey continues:

The other worrying note from the study is the authors’ comment about the lack of evaluation of the screening program. They wrote:”…no resources have been allocated to determine the program’s ultimate impact on bowel cancer incidence or mortality”.

If true, this seems a remarkable oversight – to roll out a national program without having in place a proper evaluation process. Is this really the case?