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In a study funded by the UK’s Local Government Association, the policy organization Centre for Cities has tried to identify which cities and large towns are most vulnerable to the current economic downturn and those that appear better placed to ride out the storm.1 For readers outside the UK, the specific locations (very broadly, the north is worse off than the south and the east) may matter less than the comment that it is in cities with knowledge-based businesses, such as Oxford and Cambridge, that the prospects seem brighter. How this information helps policy makers tackle the consequences of unemployment in the short term is not obvious and the picture is not clear-cut because there are variations within cities, as well as between them.
Physicians and related professionals care about unemployment because of its negative impact on health, both within and outside cities. This issue has been much researched (and also hotly debated) since the 1980s.2,3 A consensus has emerged that the association between job losses and poor health is real. Eliminate that part of the association that is due to prior illness leading to unemployment and you are left with a fraction that is probably causal.4,5 Plausible biological mechanisms exist too: being unable to find work leads to stress and, in extreme cases, suicide;6 societal support mechanisms may break down; bad habits (smoking, drinking) can intrude; and even where state financial support for the jobless is available, recipients are not going to be as well off as they were before. However, economic downturns do not last for ever. Time lags between job loss and deterioration in health, which several studies have revealed (e.g., Brenner’s work7), could even mean that worsening mortality and morbidity appear to be associated with rising employment. If politicians are ever deserving of sympathy, physicians might spare them a thought here. Short of the utopian solution of eliminating unemployment altogether, what can policymakers do to alleviate a recession’s impact on health? Here are three ideas.
A crude search of the US National Library of Medicine’s PubMed site suggests that, over the past decade, three or four papers on some aspect of unemployment and health have appeared in medical journals every week. Surely, within this mass of information lie clues about the sort of worker who is most vulnerable to medical problems and for whom prevention could be attempted at the workplace (if closure is not abrupt) or via primary care services or upon registration with government unemployment centers. The UK government has already started to think along these lines. In March, 2009, the Department of Health and the Department of Work and Pensions jointly announced the allocation of about $20 million in initiatives (e.g., employment support workers and specially trained people to work with the telephone helpline NHS Direct) to reduce the impact of stress when jobs are lost. Also, primary care trusts are being urged to spend their windfall income from the recent, though only year-long, reduction in value-added tax.8
Bambra and Eikemo have looked at unemployment and self-reported health in 23 countries in the European Union9 and related their findings to the welfare provision (state benefits) offered by the individual countries. Without knowing the result, would we not expect to find that the differences in health between those in work and the unemployed were less where the state offered a lot of help via its welfare system than they were in countries where those out of work had, relatively speaking, to fend for themselves? The classification of the 23 different welfare systems requires some grasp of European social history, but the five groups range from generous benefit provision (Scandinavia), via the “Bismarckian” and Anglo-Saxon, on to Southern and Eastern. Unfortunately, the results do not wholly live up to prior expectations. The health divide between those in and out of work was actually greater for those living under well-developed systems of benefit, and these data would not support a major policy switch on health grounds alone.
Lastly, in another pan-European study, Jagger and colleagues looked at factors influencing healthy life-years.10 As expected, long-term unemployment was negatively associated with healthy life-years in men over 50, but for lifelong learning, there was a positive association. The latter finding seems to fit in with the Centre for Cities’ observation on knowledge-based workforces. Of course, unemployment benefits and education are worth providing even if a benefit to health could not be proved.
Sharp is a freelance writer in Minchinhampton, U.K.