Bacigalupe IJHS 2015

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the Population Health DOI: 10.1177/0020731415611634
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Impact of the Great
Recession? Reflections
on Three Case Studies
Amaia Bacigalupe1,2, Faraz Vahid Shahidi3,

Carles Muntaner3,4,5, Unai Martı́n1,2, and
Carme Borrell6,7,8,9
Abstract
In the aftermath of the Great Recession, public health scholars have grown increasingly
interested in studying the health consequences of macroeconomic change. Reflecting
existing debates on the nature of this relationship, research on the effects of the recent
economic crisis has sparked considerable controversy. On the one hand there is evi-
dence to support the notion that macroeconomic downturns are associated with
positive health outcomes. On the other hand, a growing number of studies warn
that the current economic crisis can be expected to pose serious problems for the
public’s health. This article contributes to this debate through a review of recent
evidence from three case studies: Iceland, Spain, and Greece. It shows that the eco-
nomic crisis has negatively impacted some population health indicators (e.g., mental
1
Department of Sociology 2, University of the Basque Country (UPV/EHU), Leioa, Spain
2
OPIK-Research Group on Social Determinants of Health and Demographic Change
3
Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
4
Bloomberg School of Nursing, University of Toronto, Toronto, Ontario, Canada
5
Department of Public Health Sciences, Korea University
6
Agència de Salut Pública de Barcelona, Barcelona 08023, Spain
7
Ciber de Epidemiologı́a y Salud Pública, 28029, Spain
8
Universitat Pompeu Fabra, Barcelona 08003, Spain
9
Institut de Recerca Biomèdica Sant Pau (IIB Sant Pau), Barcelona 08025, Spain
Corresponding Author:
Amaia Bacigalupe, Department of Sociology 2, University of the Basque Country (UPV/EHU), Barrio
Sarriena s/n. 48940, Leioa, Spain.
Email: amaia.bacigalupe@ehu.eus
2 International Journal of Health Services 0(0)
health) in all three countries, but especially in Greece. Available evidence defies
deterministic conclusions, including increasingly “conventional” claims about eco-
nomic downturns improving life expectancy and reducing mortality. While our results
echo previous research in finding that the relationship between economic crises and
population health is complex, they also indicate that this complexity is not arbitrary.
On the contrary, changing social and political contexts provide meaningful, if partial,
explanations for the perplexing nature of recent empirical findings.
Keywords
economic recession, Iceland, Spain, Greece, economic crisis, population health
Numerous studies have evaluated the possible consequences of the recent eco-
nomic crisis for population health outcomes. Evidence accumulated on the crises
of past decades provides no clear conclusions, in part because previous analyses
have generated mixed results and focused more or less singularly on mortality
as an indicator of overall health. The purpose of this article is to provide fur-
ther evidence on the population health impact of the Great Recession through
the published literature about three case studies: Iceland, Spain, and Greece.
These three cases are selected due to the diversity they display with respect to
both the intensity of the crisis and the political responses they have mounted to
confront it.
The article begins with a reflection on the characteristics of the current crisis
and its associated aftershocks. It continues with an overview of the extant lit-
erature on the population health consequences of economic crises. The sections
that follow review recent empirical evidence on the effects of the Great Recession
on different dimensions of health within each of our three cases. The article
concludes by way of a discussion of our findings.
What Crisis Are We Talking About When We Talk

About Crisis?
It was late in the summer of 2007 that the term financial crisis first began to
appear as the subject of news reports in the United States. Concerns about an
impending collapse of the global financial system spread around the world with
remarkable speed during the following months. These concerns marked
the beginning of the so-called Great Recession, which is said to have been the
most serious crisis since the Great Depression. Although the trigger for the
collapse was financial, the crisis quickly expressed itself as a more generalized
recession in the nonfinancial sectors of the world economy. Explaining the ori-
gins of this crisis requires pointing to the neoliberal phase of capitalism
that emerged in the early 1980s and promoted the deregulation of markets,
the privatization of public goods and services, a reduction in social spending,
Bacigalupe et al. 3
and a regressive turn in social and fiscal policy.1 While neoliberalization offered
many countries a new basis for economic growth, it also contained the seeds of
its subsequent crises: a deepening of social inequality, an expansion of household
debt, a global financial system increasingly dedicated to speculative activities,
and a series of large asset bubbles.2
The current crisis can be variably understood from at least three perspectives:
neoliberal, neo-Keynesian, and neo-Marxist.3,4 The neoliberal perspective
understands the crisis as a consequence of localized, sectoral, and temporary
market distortions that can be adequately addressed by means of appropriate
state bailouts of financial institutions. From this viewpoint, cyclical declines in
the profitability of capital investments and the need to pave new terrains of
accumulation are perceived to be natural features of capitalist dynamism.5
The neo-Keynesian perspective shares a similar characterization of the crisis
as its neoliberal counterpart. However, drawing on its social democratic under-
pinnings, the neo-Keynesian perspective describes an additional need for stricter
financial regulations and encourages the use of economic stimulus programs to
mitigate the broader impacts of the crisis. Finally, the neo-Marxist perspective
emphasizes that the Great Recession represents more than a mere financial or
economic crisis. This is a crisis whose origins lie in the very nature of the cap-
italist system and, in particular, the fundamental contradiction between labor
and capital that is now being re-articulated in the shape of an “age of austerity.”
From this viewpoint, the current crisis needs to be conceptualized in a distinctly
multidimensional fashion, constituting a set of simultaneous and interacting
crises on a global scale, which together have produced a systemic—affecting
the whole capitalist system—and structural—expressing itself on many
levels—crisis.1–3 On this basis, it is argued that financial bailouts and economic
stimulus programs only serve to delay new and deeper recessions in the future,
since they address only their short-term causes and consequences. Indeed, the
complexity of the current crisis is reflected in the occurrence of parallel political,
cultural, and environmental crises.3
Embodying the Crisis: Do Economic Recessions Harm

the Health of Populations?
A Lasting Controversy
We have long known about the fundamental role that social and economic
conditions play in shaping the distribution of health and disease within and
across populations.6 Given all that we know about the social determinants of
health, it should not come as a surprise that, in recent years, public health
scholars have grown increasingly interested in exploring the population health
impact of macroeconomic change.7 However, very little attention has been
awarded specifically to the impact of economic crises on social inequalities in
health, though there is some mixed evidence suggesting that they tend to increase
during crisis periods.8
Research on the health effects of economic crises has sparked an intense
debate resulting from seemingly conflicting results and conclusions. The
nature of this debate is evident in the titles of the empirical studies involved:
Economic Growth is the Basis of Mortality Rate Decline in the 20th Century,9
Good Times Make You Sick,10 Population Suffering During the Economic Crisis
in Spain,11 or Recessions Lower (Some) Mortality Rates, are just some of the
existing examples.12 In a recent paper, Stuckler and colleagues suggest that this
divergence is in part the result of disciplinary silos that insulate epidemiologists
and economists from one another.13 Notwithstanding this important observa-
tion, research exhibits a degree of inconsistency that itself requires explanation.
On the one hand, there is evidence supporting the idea that macroeconomic
downturns are associated with positive population health outcomes. This evi-
dence has been frequently generated from ecological analyses of the relation-
ship between mortality trends and various macroeconomic indicators, such as
unemployment and economic growth. Such analyses show that all-cause mor-
tality trends behave procyclically, decreasing with economic decline and increas-
ing with economic growth.14–19 Several hypotheses have been forwarded to
explain these counterintuitive findings, and chief among these is the argument
that health behaviors would improve—for example, people are more active and
consume less tobacco and alcohol—during hard times due to individuals’
budgetary constraints and fewer exposures to job-related stressors.20 However,
few studies have empirically analyzed the specific role of these factors to explain
the procyclical pattern of mortality.21 Notably, there are some studies within this
body of scholarship that offer ambiguous evidence of a procyclical relationship,
since analyses of cause-specific mortality indicate that, while some causes such as
cardiovascular disease, infectious disease, and motor vehicle accidents behave
procyclically, others, such as suicide mortality, tend to exhibit countercyclical
patterns.12,17,22,23 Authors reporting procyclical results have also made note of
the possibility that, while a recession may reduce mortality rates in the general
population, they may worsen among specific social groups.10,12,24 In addition,
the need to distinguish between short-term and long-term effects of macroeco-
nomic change has also been emphasized, as they can have opposite effects, in the
sense that while short-lasting expansions may worsen health, sustained economic
growth may improve it.10,19 Indeed, other studies have also demonstrated that
the impact of unemployment and other adverse socioeconomic experiences on
health can become evident many years after the onset of the crises, especially
among deprived populations.25
Given these and other limitations, many other authors have stood in stark
contrast to the findings reported from the procyclical perspective, or at least play
them down. Catalano describes these alternative views on the potential health
impact of crises through the notion of a “net effect” hypothesis, meaning that the
Bacigalupe et al. 5
real impact of crises on health is the result of both pro- and countercyclical
effects and mechanisms happening in different social groups.26 So, while the
contraction of an economy can increase morbidity and mortality among the
unemployed, it can reduce risk taking and, therefore, morbidity and mortality
among the majority who remain employed. In line with this view, different
studies about past crises show that unhealthy habits such as substance abuse,
violent and suicidal behaviors, cardiovascular disease, infant mortality, or poor
mental health behave countercyclically, while the general conclusion that total
mortality increases when the economy declines appears less clear,26–29 especially
in less affluent countries.30 A very well-documented case comes from Russia
after the collapse of the Soviet Union in the 1990s. Mortality rate increased
rapidly in the period immediately after the collapse, and also after the economic
crisis of 1998,31 a shift that has been directly linked to a substantial rise in
alcohol consumption.32 Moreover, inequalities in life expectancy by educational
level also increased dramatically during that period,33 a result consistent with
what happened in past crises, during which health inequalities tended to rise,
although not always in an evident manner for both sexes or for all the health
variables analyzed.8
The Impact of the Great Recession on Health

As of yet, few studies have comprehensively evaluated the impact of the Great
Recession on population health. This is particularly the case for indicators
beyond mortality. Thus far, we have considerable evidence that overall mortality
has not clearly increased,34–36 probably due to the compensatory effect of the rise
of some causes of death, such as suicides,37 and the decrease of others, such as
road traffic fatalities and occupational injuries, that has been observed.35,36,38
Unfortunately, there are hardly any reviews about the influence of the crisis on
health outcomes other than mortality, due in part to the belief of some research-
ers that mortality rates and mortality-based indicators are the most reliable
indicators of population health.39 An exception in the area of child health is a
recent review by Rajmil and colleagues, suggesting that the Great Recession has
harmed the health of children, particularly those who are socioeconomically
vulnerable.40 Moreover, Van Hal has also reviewed the cost of the current eco-
nomic crisis on psychological well-being, concluding that there has been so far a
clear influence on the rise of mental health problems.41
Regardless of the health dimension considered, it appears that welfare state
policies play a role as mediators in the relationship between macroeconomic
change and health, as described by proponents of both the procyclical and
countercyclical perspectives. Gerdtham and Ruhm conclude that stronger pro-
cyclical fluctuations of mortality might occur in countries with relatively weak
social protection systems because individuals will face greater incentives to work
especially hard during good times to offset the potential loss of income and
subsequent experience of financial insecurity during economic downturns.19 On

the other hand, welfare state policies have also been analyzed in terms of insti-
tutional buffers against the potential negative health effects of economic down-
turns.42 In line with this view, many studies have confirmed that the negative
effects of the current recession are more apparent in countries with lower levels
of social protection,34,35 and that active labor market policies and strong social
support networks can mitigate the increase in suicides.7 For example, a recently
published paper has found that the impact of the Great Recession on suicide
mortality has been less significant in countries characterized by greater levels of
unemployment protection.43
In order to generate greater insight into the variable impact of the Great
Recession within particular national contexts, this article reviews available evi-
dence for three case studies: Spain, Iceland, and Greece. We have selected these
three countries because they have experienced and responded to the crisis in
different ways.44 The crisis has been particularly severe in Greece and Spain,
which have experienced greater economic decline, higher rates of unemploy-
ment, and wider fiscal deficits. Iceland, on the other hand, suffered only a
short spell of economic contraction and relatively low levels of unemployment.
Regarding political responses in the aftermath of the crisis, Greece adopted the
most punitive austerity packages among all Organisation for Economic Co-
operation and Development countries. Spain has also adopted strict austerity
measures. Although the magnitude of fiscal consolidation in Spain has been
significantly less than that in Greece, it has intensified in recent years. By con-
trast, the austerity agenda has been relatively muted in Iceland, where political
priorities have favored a macro-expansionary policy agenda.45 Some relevant,
distinctive aspects among the three countries (unemployment rates, and social
protection or health care expenditures) can be seen in Figure 1. We have taken
these three countries as our case studies because we are interested in exploring
both the intensity of the crisis and the political responses to its consequences as
potential variables that may be moderating the established association between
macroeconomic change and population health. In particular, we are interested in
investigating the extent to which such variables offer us a meaningful explan-
ation for the empirical inconsistencies observed across existing studies.
For the analysis, we reviewed studies on the population health impact of the
current crisis conducted in the three countries. We used PubMed to search for
studies and limited our search to peer-reviewed articles published prior to the
end of December 2014. Our search terms included “economic recession,” “cri-
sis,” “recession,” “downturn,” and “collapse.” For the case of Greece, we used
the systematic review published by Simou46 and updated the data for 2013 and
2014. Studies were classified according to the health dimension analyzed (mor-
tality, mental health, self-rated health, intermediary determinants, infant health,
and other health results) and the type of impact (positive, negative, and no
change). Tables 1–3 summarize these results for each country. Studies addressing
Bacigalupe et al. 7
12000 30.0
10000 25.0
8000 20.0
6000 15.0
4000 10.0
2000 5.0
0 0.0
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Greece social protecon Spain social protecon Iceland social protecon
Greece health care Spain health care Iceland health care
Greece unemployment Spain unemployment Iceland unemployment
Figure 1. Total expenditure (euros) on social protection and health care per head, 2001–
2012 (left axis) and total unemployment (%), 2001–2014 (right axis) in Spain, Iceland, and
Greece.
the impact of the crisis on the functioning of health services were excluded from
our analysis.
Spain, Iceland, and Greece in Comparative Perspective

The density of studies varied considerably across the three cases, with the great-
est number conducted on Greece, followed by Spain, and then Iceland.
Spain: Origins and Current Extent of the Great Recession

From the mid-1990s of the 20th century, Spain experienced a long period of
economic expansion, primarily based on the construction sector. In 2006, the
Spanish economy began to show the first signs of exhaustion and, from the
second quarter of 2008, the economy entered a recession. However, the Social
Democratic government in power at that time denied the existence of the crisis
during its first months. Gross domestic product (GDP) dramatically fell in 2008
and 2009 and has only recovered mildly from 2013. According to the Spanish
8
Table 1. Results of Studiesa About the Impact of the Great Recession on Health, According to Different Dimensions and Type of Impact
in Spain.
Mental health and self- Intermediary
Mortality perceived health determinants Infant health Other health results
Ruiz-Ramos et al.49 Total Córdoba-Doña et al.58 Antentas et al.64 Food inse- Rajmil et al.68 Some health Llácer et al.51 Various infec-
mortality and from various Suicidal attempts curity and unhealthy diet behaviours and results tious diseases increased in
causes decreased (except increased increased. Spending on worsened some groups
nervous diseases) food decreased
Regidor et al.50 Premature Miret et al.59 No changes in Ballester et al.67 Some envir- Juárez et al.69 Some perinatal Larrañaga et al.66
mortality from various suicidal ideation, planning onmental risks improved outcomes worsened Reproductive health
causes decreased (except and attempts and others worsened worsened
cancer)
Tapia-Granados.48 Total mor- Urbanos-Garrido et al.56 Utzet et al.65 Exposure to Vila Córcoles et al.70 Sedano de la Fuente et al.38
tality and from various Short-term mental health some work-related psy- Antipneumococcal vaccin- Occupational injuries
causes decreased, and life risks slightly increased but chosocial risks increased ation coverage diminished diminished
expectancy increased not other mental prob-
lems in the last year, or
self-assessed health
Llácer et al.51 Mortality from Robert et al.60 Poor mental
infectious diseases health among immigrant
decreased workers worsened
Benmarhnia et al.53 Decrease Iglesias et al.55 Mental health
of total mortality deceler- disorders (administrative
ated and winter-related data) did not worsen
mortality increased
among > 60
López-Bernal et al.52 Suicide Agudelo et al.61 Poor mental
mortality increased health increased among
immigrant workers with
(continued)
Table 1. (continued)
illegal status or whose
working conditions
worsened
Bartoll et al.57 Poor mental
health increased among
men and other groups
Gili et al.54 Mental disorders
in Primary Care increased
(except eating disorders)
Cáritas62 Mental health and
self-perceived health wor-
sened among population
attending housing services.
Observatorio DESC and
PAH63 Anxiety increased
among evicted population
Regidor et al.50 Self-perceived
health in general popula-
tion improved
a
The impact is positive (green); negative (red); negative in some health variable or social group (pink); no change (grey)
9
10
Table 2. Results of Studiesa About the Impact of the Great Recession on Health, According to Different Dimensions and Type of Impact
in Iceland.
76 81 82 79
Titelman et al. Suicide Snorradóttir et al. Olafsdóttir et al. Smoking Eirı́ksdóttir et al. Infants Asgeirsdottir et al.78
mortality rates did not Psychological distress in prevalence and intensity born small for gestational Hypertension prevalence
change significantly bank employees increased decreased age and low birth weight increased in males
increased. No changes in
preterm births
Hauksdóttir et al.80 High Jónsdóttir and Ásgeirsdóttir84 McClure and Saemundsson85
stress levels increased BMI increase was slowed No changes in dental
between 2007 and 2009 down after job loss health behaviors
only in women experience
McClure et al83 Prevalence of Guôjónsdóttir et al78
smoking decreased Immediate short-term
visits to cardiac emer-
gency services increased,
particularly in women
Asgeirsdottir and
Ragnarsdóttir74 Smoking,
alcohol and consumption
of soft drinks and sweets
decreased. Fruit-vegetable
intake decreased
a
Table 3. Results of Studiesa About the Impact of the Great Recession on Health, According To Different Dimensions and Type of Impact
in Greece.
36 99 106
Stuckler et al. Suicide mor- Economou et al Suicide Filippidis et al Smoking Anagnostopoulos and Bonovas et al111 Increased
tality increased but not attempts increased increased in women Soumaki108 Mental health mortality from influenza,
general mortality between 18 and 34 years. worsened among children emergence of West Nile
Not in men or young and adolescents virus, appearance of clus-
people ters of non-imported mal-
aria and the outbreak of
HIV infection among those
injecting drugs
Kentikelenis et al91 Many Economou et al101 Major Schoretsaniti et al107 Kentikelenis et al109 Low- Paraskevis et al112 HIV infec-
health indicators wor- depression increased Intention to quit smoking birth weight and stillbirths tions in drug users
sened, including suicide increased. Prevalence of increased. Long-term fall increased
mortality smoking decreased among in infant mortality
men reversed, with increases in
neonatal and post -neo-
natal deaths
Karanikolos et al92 Many Economou et al100 Suicidal Michas et al110 Birth rate Sarafis and Tsounis113 HIV
health indicators, including ideation and reported sui- decreased infections in drug users
suicides, worsened cide attempts increased in increased
men
Fountoulakis et al94 Total Mylona et al.102 Self-reported Hedrich et al114 HIV infec-
mortality and suicide depressive symptoms tions in drug users
mortality did not increase increased increased
until 2010
(continued)
11
12
87 103
Kondilis et al Suicide, Nena et al Sleep duration Skoura et al115 Resistance to
homicide and infectious decreased and disturb- HIV treatment increased
diseases mortality rates ances increased in public
increased in men employees facing job
insecurity
Kondilis et al90 Suicide rates Vandoros et al105 Self-rated Danis et al116 Locally
increase in men below 65 health worsened acquired malaria increased
years. Not in women or
those > 65 years
Antoniou and Yannis96. Road Zavras et al.104 Self-rated Karatzanis et al117 Some
fatalities decreased health worsened otorhinolaryngologic dis-
orders visits increased
Michas and Micha97 Road Liatis et al118 Cardiovascular
traffic injuries and fatalities risk of patients with type 2
decreased diabetes of public out-
patient clinics did not
deteriorate and lipid pro-
file improved
Michas et al95 Homicide
mortality increased
(continued)
Kontaxakis et al.93 Suicides
increased, mainly in men
and in some age-groups
Vlachadis et al.98 Mortality in
people older than 55
increased
Antonakakis and Collins89.
Suicide rates increased
among men and the
population aged 45-89
a
13
National Institute for Statistics, the unemployment rate jumped from 9.6% in 2008
to 25.7% in 2013. As of 2014, the overall unemployment rate was 24.0%. Among
youth, it was above 50.0%. The poverty rate in Spain has traditionally been high
and has increased during the crisis, especially among children, reaching a rate of
28.3% in boys and 25.0% in girls in 2012. Households’ difficulty in making ends
meet has also increased clearly, from 28.8% in 2007 to 38.8% in 2013.
Politically speaking, Spain changed government in 2011 from a Social
Democratic party to a conservative one. Austerity measures started in May
2010, when the president Rodrı́guez-Zapatero announced the first cuts to civil
servants’ wages, pensions, and benefits of the Dependence Law and suppression
of the child tax benefit, among others. In 2012, the Spanish conservative govern-
ment requested a bailout of 100,000 million E to Brussels to stabilize the country’s
financial sector. Since then, many other large-scale cuts have been enacted, includ-
ing various labor market reforms that have increased the precariousness of employ-
ment and weakened workers’ rights. A full list of austerity measures and cuts in
Spain since the beginning of the crisis can be consulted elsewhere.47 In response to
these social cuts, continuous protests have characterized the crisis period, especially
after the emergence of the M-15 social movement in May 2011. A part of this broad
social movement became a political party in January 2014 and got five Members of
the European Parliament in the elections of May 2014.
Population Health Impact of the Crisis in Spain

As indicated by Table 1, existing studies show mixed results. Regarding mortality,
some analyzes describe a decline in all-cause mortality rates, premature mortality
rates, and most causes of death from the start of the crisis.48–51 However, using the
latest data of 2012, Borrell and colleagues suggest that, in recent years, the crude
mortality rate has increased, life expectancy has stagnated, and the prevalence of
suicides has increased.11 Similarly, another study reports an 8.0% increase in the
suicide rate above the baseline trend since the start of the crisis until 2010.52
Benmarhnia and colleagues also described that mortality was decreasing at a
slower rate than what would have been expected among the population above
age 60, together with an increase of winter mortality up to 2012.53
With some exceptions, studies describe a deterioration of mental health in the
aftermath of the crisis. For example, Gili and colleagues find that mental health
disorders and alcohol abuse among primary care attendees significantly
increased from 2006 to 2010.54 This is in contrast to another study, which
finds no increase in mental illness during the crisis.55 Using data of the
National Health Survey, an increase of mental health risks in the short term
was reported for the unemployed, although no increase was seen regarding
mental problems in the last 12 months.56 Another study using the same data
source reported a deterioration of poor mental health among men ages 35–54
between 2006 and 2012, which disappeared after adjusting for working status,
Bacigalupe et al. 15
implying that unemployment was playing an important role.57 Finally, regarding

suicide attempts, Córdoba-Doña and colleagues detected a sharp increase from
2008,58 contradicting results reported by Miret and colleagues, who found no
significant changes in suicidal ideation, attempts, and planning between 2001
and 2012, although a slight upward trend in planning could be seen.59 Studies
about specific populations, such as immigrant workers without legal status,60,61
people living in inadequate housing conditions, or evicted populations,62,63
showed a clear increased risk of poor mental health. On the contrary, general
self-perceived health seems not to be worsening, at least until 2012,50,56 although
a clear impact is occurring among populations with housing problems.62 Other
health determinants such as food insecurity64 or harmful exposures to some
psychosocial risks65 also increased, as did some infectious diseases51 and specific
indicators of sexual and reproductive health.66 By contrast, in terms of occupa-
tional injuries and some environmental risks, decreasing tendencies have been
reported.38,67 Regarding infant health, studies again show mixed results. While
some health-related behaviors have improved,68 negative trends have been
reported for perinatal outcomes,69 vaccination coverage,70 and obesity.68
Iceland: Origins and Current Extent of the Great Recession

During the late 1990s and early 2000s, the Icelandic government implemented an
aggressive program of deregulation and privatization of the banking system. As
a result, the Icelandic banking sector experienced rapid growth during the
decade prior to the Great Recession. While standards of living among the
Icelandic population increased during this period,71 so too did external debt,
which was about eight times the size of the country’s GDP. This turned Iceland
into the most heavily indebted economy among developed countries, as mea-
sured by total external debt as a proportion of GDP.
In October 2008, when the three principal international banks collapsed,
Iceland experienced the most rapid and deepest financial crisis recorded in peace-
time history.72 Within a matter of a few months, the unemployment rate doubled
from 2.4% in October to 4.9% in November. Real wages fell by 4.2% in 2008 and
8.0% in 2009.73 The real change rate and purchasing power fell, while the national
and household debt increased.74 Iceland became the first developed country to
require assistance from the International Monetary Fund (IMF) in 30 years.
The collapse created great discontent among the Icelandic population, which
attributed the crisis to financial and political corruption, resulting in a major crisis
of political legitimacy. The social protests toppled the government in early 2009,
leading to the call for early elections. Public pressure also resulted in two referen-
dums in 2010 that rejected the conditions imposed by the IMF and accepted by the
Icelandic government to pay the debt. After the change of government, a different
policy started in the direction of the end of bailouts of financial institutions, more
strict currency control, and the devaluation of the currency. Instead of
implementing hard austerity measures, the social protection system was reinforced
to shelter households, especially the most vulnerable ones, from the consequences
of the crisis.73 This unconventional political response seems to have had positive
effects on recovery, since the IMF rescue loans were repaid ahead of schedule, and
their impact on living conditions was not as deep as originally expected. In 2015,
Icelandic GDP approached pre-crisis levels and the unemployment rate, which has
been decreasing since 2010, is lower than the Organisation for Economic Co-
operation and Development average.
Population Health Impact of the Crisis in Iceland

The speed and sharpness of the Icelandic collapse in 2008 created an ideal scen-
ario for the study of the effects of economic cycles on population health.75
However, there are not many studies about the health effects of the economic
crisis, and most of them consider only a short period of time after the collapse,
based on a longitudinal survey carried out in 2007 and 2009. The described
health effects of the crisis were short-lived, since they were noticeable in the
immediate aftermath of the collapse (Table 2).
No studies about the effect on general health status or general mortality were
found. The only analysis about the change in suicide mortality showed stable rates
during the collapse.76 Using computerized medical records, one study analyzed
the frequency of visits to cardiac emergency services and described an immediate
short-term increase after the collapse, particularly in women.77 Moreover, the
collapse was positively related with hypertension in males, but not significantly
in females.78 Regarding infant health, low birth weight increased after the col-
lapse, and more after the first six to nine months, particularly among infants born
to mothers younger than 25 years and nonworking mothers.79
In terms of mental health, the economic collapse was followed by an increase
in high stress levels in women, especially among the unemployed, students, and
women with middle levels of educations and income brackets. However, the
increase was not described for men.80 Another study that focused on bank
employees described a relationship between downsizing and restructuring pro-
cesses and increased psychological distress among workers involved.81
The economic collapse had an important effect on health behaviors, mainly due
to higher prices of imported goods. In general, this effect was positive, since smok-
ing was reduced,82,83 together with consumption of alcohol, soft drinks, and
sweets.74 On the contrary, no changes were observed in other health-promoting
behaviours such as fish oil intake or recommended sleep time, and fruit and vege-
tables consumption decreased.74 Many of these changes were not explained by
changes in labor market variables, but were due to the increase of prices.
Furthermore, the collapse, and mainly the experience of job loss, could have
reduced body mass index increase.84 Another study described no drastic negative
effects on dental behaviors.85
Greece: Origins and Current Extent of the Great Recession

The Greek economy had an average growth of about 4% per year between 2003
and 2007, but entered into recession in the latter half of 2008, when GDP started
to decrease. This decrease continued until 2014, when the economy stabilized
and began to show signs of renewed growth. Nevertheless, GDP values are still
similar to 2003, according to the Hellenic Statistical Authority. Other indicators
coming from the Quarterly Labor Force Survey give a sense of the depth of the
economic crisis and its social consequences: the unemployment rate increased
from 8.4% in 2008 to 16.1% in 2011 and to 27.8% in the first term of 2014. The
risk of poverty or social exclusion has risen from 28.1% in 2008 to 35.7% in
2013 and income inequalities have also widened, as evidenced by an increase in
the Gini coefficient from 33.4 in 2008 to 34.3 in 2013, according to Eurostat.
Tsarouhas86 considers that the Greek financial crisis has at least three key
players: (1) the Greek governments and the existence of a weak political system
that led to a constant mismanagement of the domestic economy; (2) the financial
markets, in particular the credit rating agencies that had not predicted the 2007
U.S. sub-prime mortgage loan crisis; and (3) the delayed reaction of the
European Central Bank and the Eurozone governments.
Public debt has increased from 109.3% of GDP in 2008 to 174.9% in 2013.
Due to the magnitude of this debt, the Greek government borrowed E110 billion
in 2010 and E130 billion in 2012 from the Eurozone. The loans were conditional
upon a range of austerity measures, including cuts to public services and labor
market deregulation. As described by Kondilis and colleagues,87 the Greek
Ministry of Health implemented three types of reforms in the health sector,
which resulted in clear deterioration of access to and provision of health care
services: first, austerity measures aimed to cut public health expenditures, close
services, reduce equipment, and cut down salaries; second, privatization and
restrictions of access, through the introduction of copayments and contracting
private insurance companies; and finally, deregulation of private health services.
During these years, the government has changed many times: New Democracy
(liberal-conservative) was in government between 2007 and 2009, Pasok (socialist
party) between 2009 and 2012, and New Democracy again between 2012 and
2015. Syriza (left) won in January 2015 on a stated platform that involved revers-
ing earlier austerity measures due to the suffering they caused. In fact, as a
response to all austerity measures, anti-austerity protests have emerged as a
mass movement, involving a significant part of the population.88
Population Health Impact of the Crisis in Greece

Table 3 shows that there are relatively more articles about the changes in health
outcomes during the Greek economic recession. In general terms, the majority of
the studies showed that population health deteriorated during the crisis.
Regarding mortality, although the all-cause mortality rate seemed to continue its
descending trend,36,87 it is worth mentioning the generalized increase in sui-
cides,89–93 although some exceptions exist94 and differences are also reported
depending on the period studied and the specific groups analyzed. For example,
Kondilis and colleagues90 show how suicide mortality increased by 20% between
2007 and 2010 for men aged below 65 years, but not for other age groups or for
women. Antonakakis analyzed how fiscal austerity measures and negative eco-
nomic growth were related with the increase in men’s suicide rates.89 Fewer
publications exist referring to other causes of death, but findings indicate that
homicide (between 2003 and 2012) and infectious disease (between 2007 and
2009 among men < 65 years) mortality also went up,87,95 while road traffic inju-
ries decreased.96,97 One study described an increase in total mortality among
men older than 55. 98 Regarding mental health, in addition to the studies
described above, other findings conclude that the crisis had a negative impact
in terms of suicide attempts99,100 and major depression.101,102 Moreover, among
public employees experiencing job insecurity, sleep duration decreased and sleep
disturbance increased.103 There is also evidence that self-rated health deterio-
rated during the recession.91,104,105
As intermediary determinants, smoking consumption tended to decrease
among men, although it increased among women 18 to 34 years of age.106
Schoretsaniti and colleagues described that smokers who intended to quit smok-
ing increased between 2006 and 2011.107
Three articles commented and reviewed evidence on children’s health, report-
ing a worsening of mental health,108 an increase in low-birth-weight babies, and
a rise in stillbirths and in infant mortality between 2008 and 2010.109 Moreover,
birth rates decreased during the period of the crisis, indicating that the recession
may have impacted fertility rates.110
Many articles described the increase in HIV infections, mainly among drug
users,91,111–114 and more resistance to HIV treatments.115 Other infectious dis-
eases also increased, such as influenza, West Nile virus, and malaria.111,116 Other
pathologies such as otorhinolaryngologic disorders or central serous chorioreti-
nopathy increased during the crisis.117 On the contrary, cardiovascular risk indi-
ces of Greek patients with type 2 diabetes being followed in public outpatient
diabetes clinics did not deteriorate and lipid profiles improved.118
Why is There So Much Controversy Regarding the

Population Health Impact of the Great Recession?
Main Findings
Prior research on the relationship between economic crises and population
health has generated contradictory findings.13 As a result of this inconsistency,
several decades of scholarship have failed to generate unequivocal answers to the
question of whether the public’s health fluctuates with the economy in a procy-
clical or countercyclical manner. In an effort to make sense of this empirical
complexity, researchers have become increasingly sensitive to the central role
that social contexts might play in moderating the population health impact of
economic crises. From this perspective, the absence of consistent evidence
regarding the association between macroeconomic change and population
health does not undermine the potential to generate some hypotheses regarding
its causes.13,119 Rather, it suggests that there is a need for research to better
capture the effect of social contexts this association.
Since the onset of the Great Recession in 2007, advanced capitalist countries
have exhibited considerable levels of cross-national variation both in the degree
to which they have been exposed to the crisis and in the political responses they
have mounted to confront it.120 Using a comparative case study strategy, our
analysis aimed to leverage this quasi-natural variation to generate insight into
the potential influence of social contexts on the relationship between economic
crises and population health.
Despite the limited number of studies on specific causes of mortality and
health-related indicators as well as the reality that some consequences of the
Great Recession have yet to reveal themselves, a discernible pattern emerges
from our comparative analysis of population health trends in Spain, Iceland,
and Greece. While the available evidence is more or less mixed depending on
the country in question, there is clear evidence that the economic crisis has nega-
tively impacted population health in all three countries. Evidence of this impact is
especially strong in the Greek case. According to our results, the recession has
been associated with a significant deterioration of mental health and psycho-
logical well-being, with strong evidence of an increase in suicide-related mortality,
especially in Greece but also in Spain, albeit not in Iceland. Infant health out-
comes have also shown signs of deterioration in all three countries, as did infec-
tious disease outcomes in Greece, specifically. By contrast, no clear increases in
total mortality rates were observed in Spain or Greece, where analyses existed.
Research on health-related behaviors showed positive trends, especially in
Iceland but also in smoking cessation trends in Greece. While no studies of
health-related behaviors were available for Spain, there is some evidence of a
decrease in occupational injuries and some environmental risks in this case.
Finally, self-rated health exhibited diverging trends, with a decrease of perceived
poor health observed in Spain but an increase observed in Greece, while no
studies were found for Iceland.
Limitations
Various limitations should be acknowledged before further discussion of
these findings. First, it should be noted that this was not a systematic review
and that only three countries—Greece, Iceland, and Spain—were considered
for comparison. Moreover, while a dense body of evidence was available in the
Greek case, fewer articles were available in the latter two cases. Third, the quality
of the papers was not considered as a selection criterion for their inclusion, since
the objective of the review was to offer a broad overview of the literature pub-
lished so far about the impact of the most recent crisis on a range of dimensions
related to health and well-being. Finally, we did not include any papers dealing
with the effects of the crisis on health services, nor did we conduct a specific
strategy to identify studies about its impact on social inequalities in health.
Discussion of Results
Some of the results of this review, especially those related to overall mortality
analyses, seem counterintuitive in relation to the conceptual framework of the
social determinants of health, which would expect to find a robust association
between deteriorating living and working conditions and concomitant negative
impacts on population health during crisis times. However, there are some fac-
tors that may help explain some of these apparent contradictions.
It is important to distinguish between the short- and long-term effects
of economic crises. It is plausible, for example, that research has failed to observe
an increase in overall mortality due to a possible lag in the harmful effects of the
crisis, whose ensuing aftershocks are still unfolding. In fact, it has been shown
that, while the temporary effect of an increase in unemployment can be to lower
mortality, the permanent effect can be to increase it.121 It is not yet clear to
researchers in which health variables the effects of the crisis will be more rapidly
noticeable.122 It would nevertheless seem reasonable to suggest that the effects on
chronic health problems, disability, and some major causes of mortality will be
observed much later than other outcomes, such as mental health.123 With respect
to this temporal dimension, it is also important to consider that some cuts in
social benefits and services of the welfare state have occurred only very recently in
both Spain and Greece. Given recent events, the cuts can be expected to continue
with greater intensity, at least in the latter case. These instances of welfare state
retrenchment may give rise to negative health-related consequences that research-
ers will only be able to observe in the future.
While scholars have long debated whether macroeconomic change exhibits a
procyclical or countercyclical relationship with population health, this debate
has largely been restricted to discussions of patterns of mortality. However,
mortality rates alone fail to capture the complex nature of population health
dynamics. In our review, we have therefore attempted to capture a broader set of
health outcomes. Notably, although studies have not observed an increase in
overall mortality, our review demonstrates that the recent economic downturn
has had an adverse impact on a range of alternative health indicators. Future
contributions to this debate should therefore aim to offer a more nuanced reflec-
tion on these broader aspects of health and well-being.
Another important dimension to take into account when interpreting the

association between macroeconomic change and health is the potential for the
direction of this association to vary as a function of the social groups under
consideration. Indeed, as others have already noted, the contraction of an econ-
omy can increase morbidity or mortality among the most vulnerable social
groups, while simultaneously reducing risk taking and, by extension, improving
health outcomes among the better-off.26 Although the present review did not
focus especifically on the issue, the available evidence addressing the impact of
the Great Recession on health inequalities seems to support this hypothesis. For
example, a recent study of Swedish and English data reports that, while an
increase in self-rated health can be observed among the most educated
women, this effect is less pronounced or absent in the case of the less edu-
cated.124 Similarly, in Greece, a significant deterioration in mental health was
observed only among the most disadvantaged.125
Partly in contrast to our original hypothesis, which predicted that political
responses to economic crises moderate the association between macroeconomic
change and population health, our review suggests that the negative effects of the
Great Recession have occurred in all three national contexts, at least in some
important dimensions, although more severely in the Greek case. We argue that
changes in the broader social context provide the most meaningful explanation
for this finding. Our analysis brings attention to three factors. First, policy
responses to the recent economic crisis have diverged significantly from those
formulated in the past.126 By and large, governments responded to earlier crises
by adopting distinctly expansionary policy agendas. They increased social
expenditures in an explicit attempt to protect populations from the socioeco-
nomic consequences of those crises. By contrast, governments have responded to
the recent economic crisis by imposing severe austerity measures that have
reduced established levels of social protection. While such austerity policies
have figured much more prominently in some contexts than others—for exam-
ple, in Spain and Greece more so than in Iceland—political imperatives for
welfare state retrenchment have emerged across the landscape of advanced cap-
italist countries.127,128 This observable shift in the political orientation of crisis
responses from expansion to retrenchment could offer additional insight into
how and why the health consequences of the Great Recession have differed from
those of past crises.
Second, contemporary crisis responses look different in part because novel
political and institutional contexts have severely constrained the menu of policy
options available to governments attempting to cope with crisis consequences.
This is particularly the case with the two Southern European countries we
included in our analysis. By virtue of their integration into the Eurozone,
Spain and Greece suffered from a relative lack of autonomy over fiscal and
economic policymaking.129,130 Consequently, they lacked the political and insti-
tutional flexibility necessary to engage strategies that have proven to be effective
buffers against economic crises, such as the devaluation of domestic curren-

cies.131 The fact that governments faced novel constraints in the process of
responding to the Great Recession in part explains why they have been less
effective at protecting the health and well-being of their populations from its
consequences.
Finally, since their consolidation during the post-war era, the welfare states of
advanced capitalist countries have experienced significant decline.132 During the
Long Recession of the 1970s, relatively comprehensive welfare state policies
existed with which to compensate individuals who experienced socioeconomic
dislocations as a result of economic shocks.133 While similar institutional buffers
continue to operate today, several decades of neoliberal reform have signifi-
cantly reduced their generosity and, by extension, their capacity to protect the
health and well-being of those who most immediately experienced the adverse
consequences of the Great Recession.
Conclusion
While our results echo previous studies in finding that the relationship between
economic crises and population health is characterized by a distinctive level of
complexity, they also indicate that this complexity is not arbitrary. On the con-
trary, our analysis suggests that changing social contexts provide meaningful, if
partial, explanations for the nature of recent empirical findings. This contextual
diversity and specificity defy simple and deterministic conclusions about the
nature of that relationship, including increasingly “conventional” claims about
economic downturns improving life expectancy and reducing mortality. Such
simple macroeconomic predictions are vulnerable to historical and geographical
variations that impact health in contingent and variegated ways. Thus, what
appears to matter more than the direction of macroeconomic change, per se,
are the political and historical conditions in which that change is taking place.134
It therefore makes little theoretical or empirical sense to attribute causal effects
to economic growth or decline without taking broader contexts into consider-
ation. Whether or not we succeed at adequately capturing the influence of those
contexts will depend principally on our willingness to incorporate political and
historical hypotheses more effectively in our analyses.135
Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, author-
ship, and/or publication of this article: This work was partially supported by the
European Community’s Seventh Framework Programme (FP7/2007-2013) under grant

agreement 278173 (SOPHIE project) and by the Ministry of Economy and
Competitiveness (State Programme for Promotion of Scientific and Technical Research
Challenges (CSO2013-44886-R)).
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Author Biographies
Amaia Bacigalupe has a position as a lecturer in the Department of Sociology 2
at the University of the Basque Country (UPV/EHU) and she is member of
OPIK-Research Group on Social Determinants of Health and Demographic
Change of the same university. For years she has combined university teaching
with research work in the the Department of Health of the Basque Government,
with projects about the social factors that influence health, focusing specially on
social inequalities in health and health care, Health Impact Assessment (HIA)
and Health in All Policies (HiAP).
Faraz Vahid Shahidi is a second-year doctoral student in the Dalla Lana School
of Public Health at the University of Toronto. He completed a Master of
Philosophy in Comparative Social Policy at the University of Oxford. He is
currently a fellow in the Canadian Institutes of Health Research Strategic
Training Program in Public Health Policy. His research is located at the inter-
section of population health and political economy. In particular, his research
utilizes a cross-national comparative perspective to investigate the population
health consequences of the current age of austerity and its attendant set of
politics.
Carles Muntaner is a professor at the University of Toronto. He has made

contributions to the advance of research on social class, racism, politics and
population health in North America, Europe, Latin America, Asia, the
Middle East and Western Africa. He has obtained funding from NIH, CIHR
and the EU, among other agencies. He was a knowledge network leader of the
WHO CSOH. His awards include a Fleming Award (Oxford University), a
Fulbright Fellowship (US) and the Wade Hampton Frost Award from the
American Public Health Association.
Unai Martı́n s a position as a lecturer in the Department of Sociology 2 at the

University of the Basque Country (UPV/EHU) and she is member of OPIK-
Research Group on Social Determinants of Health and Demographic Change of
the same university. He has worked as a researcher in the Basque Foundation
for Health Innovation and Research. Currently his main research lines are the
sociology of health, especially the analysis of social inequalities in health, demo-
graphics, especially the analysis of health and mortality, and the methodology of
social research.
Carme Borrell, MD, PhD, a specialist in preventive medicine and public health
and in family medicine. I work at the Public Health Agency of Barcelona (execu-
tive director). Associate Professor at the Universitat Pompeu Fabra. Editor in
chief of the Spanish journal Gaceta Sanitaria (journal of public health). Her area
of research is the study of social determinants of health, having lead many
international projects and having published many scientific articles. Now she
is leading the European Union 7th framework project SOPHIE (http://www.so-
phie-project.eu/).

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Article

International Journal of Health

Why is There so Much Services

Amaia Bacigalupe1,2, Faraz Vahid Shahidi3,

What Crisis Are We Talking About When We Talk

Embodying the Crisis: Do Economic Recessions Harm

The Impact of the Great Recession on Health

subsequent experience of ﬁnancial insecurity during economic downturns.19 On

Spain, Iceland, and Greece in Comparative Perspective

Spain: Origins and Current Extent of the Great Recession

Population Health Impact of the Crisis in Spain

implying that unemployment was playing an important role.57 Finally, regarding

Iceland: Origins and Current Extent of the Great Recession

Population Health Impact of the Crisis in Iceland

Greece: Origins and Current Extent of the Great Recession

Population Health Impact of the Crisis in Greece

Why is There So Much Controversy Regarding the

Another important dimension to take into account when interpreting the

buﬀers against economic crises, such as the devaluation of domestic curren-

Declaration of Conflicting Interests

European Community’s Seventh Framework Programme (FP7/2007-2013) under grant

91. Kentikelenis A, Karanikolos M, Papanicolas I, Basu S, McKee M, Stuckler D.

109. Kentikelenis A, Karanikolos M, Reeves A, McKee M, Stuckler D. Greece’s health

Carles Muntaner is a professor at the University of Toronto. He has made

Unai Martı́n s a position as a lecturer in the Department of Sociology 2 at the

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