Economic Recession and

Health: the Case of Greece

Dr. Filippos Filippidis

School of Public Health

Imperial College London 1

Outline • Background

• Economic recession in Greece

• Economic recession and health – overview

• Health indices in Greece – Self-reported health

– Mental health

– Infectious diseases

– Traffic accidents

– Physical activity

– Obesity

– Smoking

– Diet

– Health services

– Infant mortality

– All-cause mortality

• Conclusions

2

Background I

3

Background I

4

Background II

5

Background III

Population (millions) 10.8 63.2

GDP per capita ($ PPP) 25,331 37,299

Gini index 33.5 33.0

Human Development Index 0.860 0.875

Life expectancy (years) 80.3 80.4

Infant mortality (per 1,000 live births) 3.1 4.6

Health expenditure (% of GDP, 2009) 9.6 9.8

Expenditure on pharmaceuticals (% of GDP, 2009) 2.4 1.0

Practising doctors (per 1,000 population) 6.1 2.7

Practising nurses (per 1,000 population) 3.3 9.7

6

Outline • Background

• Economic recession in Greece

• Economic recession and health – overview

• Health indices in Greece – Self-reported health

– Mental health

– Infectious diseases

– Traffic accidents

– Physical activity

– Obesity

– Smoking

– Diet

– Health services

– Infant mortality

– All-cause mortality

• Conclusions

7

GDP per capita, Greece

0

5000

10000

15000

20000

25000

2006 2007 2008 2009 2010 2011 2012

GD

P p

er

ca

pit

a (€)

Year

8 Eurostat 2013

Wages and Consumer Prices in

Greece (2009=100)

0

20

40

60

80

100

120

2006 2007 2008 2009 2010 2011 2012 2013

Ind

ex

(2

00

9=

10

0)

Year

Wage index Consumer Price Index

9 Hellenic Statistical Authority 2013

Unemployment in Greece

0

5

10

15

20

25

30

2006 2007 2008 2009 2010 2011 2012 2013

Un

em

plo

ym

en

t %

Year

10 Hellenic Statistical Authority 2013

Outline • Background

• Economic recession in Greece

• Economic recession and health – overview

• Health indices in Greece – Self-reported health

– Mental health

– Infectious diseases

– Traffic accidents

– Physical activity

– Obesity

– Smoking

– Diet

– Health services

– Infant mortality

– All-cause mortality

• Conclusions

11

Effects of economic crises on

health

• Decline in tobacco use

• Decline in road traffic accidents

• Decline in mean alcohol consumption –

increase among the unemployed

• Increased impact of communicable diseases

• Increase in suicides

• Variable effects on all-cause mortality

• Greater impact in vulnerable groups

12

13

Outline • Background

• Economic recession in Greece

• Economic recession and health – overview

• Health indices in Greece – Self-reported health

– Mental health

– Infectious diseases

– Traffic accidents

– Physical activity

– Obesity

– Smoking

– Diet

– Health services

– Infant mortality

– All-cause mortality

• Conclusions

14

Self-reported health, 2006-2011

15 Zavras et al. EJPH 2012

Outline • Background

• Economic recession in Greece

• Economic recession and health – overview

• Health indices in Greece – Self-reported health

– Mental health

– Infectious diseases

– Traffic accidents

– Physical activity

– Obesity

– Smoking

– Diet

– Health services

– Infant mortality

– All-cause mortality

• Conclusions

16

Self-reported mental health I

61% 58%

67%

43% 46%

57%

0%

10%

20%

30%

40%

50%

60%

70%

80%

Happy Calm and peaceful Full of life

% o

f p

op

ula

tio

n w

ho

re

plie

d “

all

or

mo

st o

f th

e tim

e”

2006 2010

17 Eurobarometer 2006, 2010 * Past 4 weeks

Self-reported mental health II

70% 66%

52% 56%

51%

43%

0%

10%

20%

30%

40%

50%

60%

70%

80%

Down in the dumps Downhearted & depressed Worn out

% o

f p

op

ula

tio

n w

ho

re

plie

d “

ne

ve

r o

r ra

rely

”

2006 2010

18 Eurobarometer 2006, 2010 * Past 4 weeks

Depression

2.4%

4.6%

6.7%

3.8%

8.8%

9.9%

0%

2%

4%

6%

8%

10%

12%

2008 2009 2011

1-m

on

th p

reva

len

ce

of m

ajo

r d

ep

ressio

n

Year

Males Females

19 Madianos et al. Soc Psychiatry Psychiatr Epidemiol 2011

Economou et al. J Affect Disord 2013

Suicide in OECD countries (2008)

20

OECD, Health at a Glance Europe 2010

Suicides and homicide in Greece

21

0

1

2

3

4

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Mo

rta

lity

pe

r 1

00

,00

0

Year

Suicides and self-inflicted injury 0-64 Homicide and intentional injury 0-64

Fountoulakis et al. Eur Arch Psychiatry Clin Neurosci 2012

Hellenic Statistical Authority

Outline • Background

• Economic recession in Greece

• Economic recession and health – overview

• Health indices in Greece – Self-reported health

– Mental health

– Infectious diseases

– Traffic accidents

– Physical activity

– Obesity

– Smoking

– Diet

– Health services

– Infant mortality

– All-cause mortality

• Conclusions

22

Infectious diseases

• West Nile virus outbreak

(2010 – 197 cases/35 deaths)

• Malaria outbreak in southern Greece

(2011 – 60 cases)

• Newly diagnosed HIV-1 infections

(57.2% increase from 2010 to 2011)

23 Bonovas et al, J Prev Med Hyg, 2012

Infectious diseases in Greece

24

0

2

4

6

8

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Sta

nd

ard

ise

d m

ort

ali

ty p

er

10

0,0

00

Year

WHO Health for All Database 2013

Outline • Background

• Economic recession in Greece

• Economic recession and health – overview

• Health indices in Greece – Self-reported health

– Mental health

– Infectious diseases

– Traffic accidents

– Physical activity

– Obesity

– Smoking

– Diet

– Health services

– Infant mortality

– All-cause mortality

• Conclusions

25

Transportation costs

0

20

40

60

80

100

120

140

160

180

200

2006 2007 2008 2009 2010 2011 2012 2013

Price

Co

nsu

me

r In

de

x

Year

Price Consumer Index Fuel Road taxes - tolls Public transportation

26 Hellenic Statistical Authority 2013

Car sales in Greece

27

0

100,000

200,000

300,000

400,000

500,000

600,000

2006 2007 2008 2009 2010 2011 2012

Nu

mb

er

of

Ve

hic

les

Year

Hellenic Statistical Authority 2013

Transport accidents in Greece

28

0

5

10

15

20

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Sta

nd

ard

ise

d m

ort

ali

ty p

er

10

0,0

00

Year

WHO Health for All Database 2013

Outline • Background

• Economic recession in Greece

• Economic recession and health – overview

• Health indices in Greece – Self-reported health

– Mental health

– Infectious diseases

– Traffic accidents

– Physical activity

– Obesity

– Smoking

– Diet

– Health services

– Infant mortality

– All-cause mortality

• Conclusions

29

Levels of Physical Activity in Greece I

34.5% 28.4%

41.8% 29.6%

43.9%

29.5%

43.5%

42.6%

38.3%

38.6%

31.5%

36.8%

22.1% 28.9%

19.8% 31.8%

24.6% 33.7%

0%

20%

40%

60%

80%

100%

2006 2011 2006 2011 2006 2011

Socio-economic status

Low Middle High

Higher SES Middle SES Lower SES

30 Physical activity levels according to IPAQ Filippidis et al (under review)

Levels of Physical Activity in Greece I

31

0

2000

4000

6000

8000

To

tal M

ET

-min

/we

ek

Higher Middle Lower

2006 2011 2006 2011 2006 2011

Socioeconomic status

Outline • Background

• Economic recession in Greece

• Economic recession and health – overview

• Health indices in Greece – Self-reported health

– Mental health

– Infectious diseases

– Traffic accidents

– Physical activity

– Obesity

– Smoking

– Diet

– Health services

– Infant mortality

– All-cause mortality

• Conclusions

32

Obesity in OECD countries (2008)

33 OECD, Health at a Glance Europe 2010

Overweight and obesity in Greece

39.6%

40.7%

41.4%

42.3%

40.3%

40.2%

18.2%

18.9%

18.4%

0% 20% 40% 60% 80% 100%

2011

2008

2006

Ye

ar

Normal weight Overweight Obese

34 Filippidis et al (under review)

Outline • Background

• Economic recession in Greece

• Economic recession and health – overview

• Health indices in Greece – Self-reported health

– Mental health

– Infectious diseases

– Traffic accidents

– Physical activity

– Obesity

– Smoking

– Diet

– Health services

– Infant mortality

– All-cause mortality

• Conclusions

35

Smoking in OECD countries (2008)

36 OECD, Health at a Glance Europe 2010

Tobacco control measures

• Partial smoking ban in public places (July

2009)

• Comprehensive smoking ban (July 2011)

• Tobacco tax increases

• Weak enforcement

37

Secondhand smoke in Greece

38 Vardavas et al. J Aerosol Med Pulm Drug Deliv 2012

Tobacco prices

60

70

80

90

100

110

120

130

140

2006 2007 2008 2009 2010 2011 2012 2013

Price

Co

nsu

me

r In

de

x

Year

Tobacco Price Consumer Index

39 Hellenic Statistical Authority 2013

Prevalence of smoking in Greece I

52.4%

48.5% 45.7%

34.5% 37.1%

31.1%

43.1% 42.6%

38.1%

0%

10%

20%

30%

40%

50%

60%

2006 2008 2011

Year

Males Females Total

40 Filippidis et al (under review)

Prevalence of smoking in Greece II

48.8% 48.9%

39.7%

44.4% 44.0% 43.9%

38.9% 35.9%

29.5%

0%

10%

20%

30%

40%

50%

60%

2006 2008 2011

Year

Higher SES Middle SES Lower SES

41 Filippidis et al (under review)

Intention to quit smoking in Greece

42 Schoretsaniti et al. Addict Beh 2013

Outline • Background

• Economic recession in Greece

• Economic recession and health – overview

• Health indices in Greece – Self-reported health

– Mental health

– Infectious diseases

– Traffic accidents

– Physical activity

– Obesity

– Smoking

– Diet

– Health services

– Infant mortality

– All-cause mortality

• Conclusions

43

Prices of fruits & vegetables

60

70

80

90

100

110

120

2006 2007 2008 2009 2010 2011 2012 2013

Price

Co

nsu

me

r In

de

x

Year

Food Vegetables Fruit

44 Hellenic Statistical Authority 2013

Consumption of at least 5 portions of fruit

& vegetables per day

8.0%

9.8% 9.0% 8.4% 8.9%

4.1%

0%

2%

4%

6%

8%

10%

12%

Higher SES Middle SES Lower SES

Socio-economic status

2008 2011

45 Filippidis et al (under review)

Outline • Background

• Economic recession in Greece

• Economic recession and health – overview

• Health indices in Greece – Self-reported health

– Mental health

– Infectious diseases

– Traffic accidents

– Physical activity

– Obesity

– Smoking

– Diet

– Health services

– Infant mortality

– All-cause mortality

• Conclusions

46

Health expenditure (PPP$ per capita)

0

500

1000

1500

2000

2500

3000

3500

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Ex

pe

nd

itu

re P

PP

$ p

er

ca

pit

a

Year

Pharmaceuticals Other

47 WHO Health for All database 2013

Households’ health expenditures

48 Kondilis et al. Am J Public Health 2013

Health services

• 59% of the population had to reduce the

use of health services between 2011 and

2012 because of high costs and/or

accessibility issues

• Increased numbers of outpatients and

inpatients in public hospitals

• Unavailability of pharmaceuticals

• Disruptions in healthcare market

49 National School of Public Health 2012

Outline • Background

• Economic recession in Greece

• Economic recession and health – overview

• Health indices in Greece – Self-reported health

– Mental health

– Infectious diseases

– Traffic accidents

– Physical activity

– Obesity

– Smoking

– Diet

– Health services

– Infant mortality

– All-cause mortality

• Conclusions

50

Infant mortality in Greece

51

0

2

4

6

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Sta

nd

ard

ise

d m

ort

ali

ty p

er

10

0,0

00

Year

WHO Health for All Database 2013

Outline • Background

• Economic recession in Greece

• Economic recession and health – overview

• Health indices in Greece – Self-reported health

– Mental health

– Infectious diseases

– Traffic accidents

– Physical activity

– Obesity

– Smoking

– Diet

– Health services

– Infant mortality

– All-cause mortality

• Conclusions

52

Causes of death in Greece, 2010

53 Institute for Health Metrics and Evaluation 2013

Causes of DALYs in Greece, 2010

54 Institute for Health Metrics and Evaluation 2013

All-cause mortality

55

0

100

200

300

400

500

600

700

800

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Mo

rta

lity

pe

r 1

00

,00

0

Year

Greece United Kingdom European Union

WHO Health for All Database 2013

Outline • Background

• Economic recession in Greece

• Economic recession and health – overview

• Health indices in Greece – Self-reported health

– Mental health

– Infectious diseases

– Traffic accidents

– Physical activity

– Obesity

– Smoking

– Diet

– Health services

– Infant mortality

– All-cause mortality

• Conclusions

56

Conclusions

• Decline in road traffic accidents

• Increase in physical activity levels

• Decrease in tobacco use

• Deterioration of mental health

• No evident short-term effects on all-cause

mortality

• Indications of widening inequalities

57

Long-term effects

58