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Economic Recession and
Health: the Case of Greece
Dr. Filippos Filippidis
School of Public Health
Imperial College London 1
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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
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Background I
3
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Background I
4
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Background II
5
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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
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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
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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
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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
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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
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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
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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
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13
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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
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Self-reported health, 2006-2011
15 Zavras et al. EJPH 2012
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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
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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
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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
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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
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Suicide in OECD countries (2008)
20
OECD, Health at a Glance Europe 2010
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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)
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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
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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
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Obesity in OECD countries (2008)
33 OECD, Health at a Glance Europe 2010
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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)
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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
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Smoking in OECD countries (2008)
36 OECD, Health at a Glance Europe 2010
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Tobacco control measures
• Partial smoking ban in public places (July
2009)
• Comprehensive smoking ban (July 2011)
• Tobacco tax increases
• Weak enforcement
37
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Secondhand smoke in Greece
38 Vardavas et al. J Aerosol Med Pulm Drug Deliv 2012
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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
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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)
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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)
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Intention to quit smoking in Greece
42 Schoretsaniti et al. Addict Beh 2013
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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
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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
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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)
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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
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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
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Households’ health expenditures
48 Kondilis et al. Am J Public Health 2013
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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
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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
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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
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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
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Causes of death in Greece, 2010
53 Institute for Health Metrics and Evaluation 2013
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Causes of DALYs in Greece, 2010
54 Institute for Health Metrics and Evaluation 2013
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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
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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
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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
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Long-term effects
58