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There
were 3,340,958 unemployed in the UK, according to government statistics
released on 31 January. There is little prospect of a dramatic fall in
the number of unemployed in the near future. What effect does
unemployment- especially long-term unemployment have on those who
experience it? On 1 February CEPR held a one-day workshop to explore the
relationships between unemployment and health. The workshop, organized
as part of the CEPR's programme in Human Resources since 1900, was
chaired by the programme's director, Roderick Floud
(Birkbeck College). The DHSS provided the financial support which
enabled CEPR to bring together sociologists and epidemiologists,
historians and economists, civil servants and journalists to discuss
research in this field. In
his Introduction, Roderick Floud outlined what he hoped might be
achieved in the workshop. One purpose was simply to inform participants
of the variety of approaches to the study of health and unemployment.
What lessons could be learned from past experience? If unemployment did
lead to an increase in morbidity (ill-health), what were the short-term
and medium-term costs of this increase? What were the long-term effects
of unemployment on health? What action should be taken to remedy the
effects of unemployment, and finally, what further research was needed? As
a first step towards answering some of these questions, Dr Derek Cook
(Royal Free Hospital) presented the workshop's first paper 'Unemployment
and Health', written jointly with A G Shaper. It discussed the
findings of a number of recent British studies and also the
methodological implications of their different approaches. Individual
studies of the health of unemployed people showed, Cook suggested, that
ill-health was as much a cause of unemployment as a consequence of it,
and that for both employed and unemployed the greatest health problems
were related to social class. Only by looking at changes in aggregate
measures of health over time would it be possible to say whether
unemployment was itself a cause of ill-health. One approach to this
question would be to compare changes in mortality rates with changes in
the level of unemployment. Such a comparison should not ask whether the
rate of mortality could be correlated with unemployment, but .whether
the rate of mortality decline could be correlated with unemployment.
Finally, Cook warned against attempts to predict the current effects of
unemployment on health from studies of its effects in the past. It was
not reasonable, in his opinion, to assume that the effects of
unemployment on health would be the same from one decade to the next. Cook's
view that the effects of unemployment on health were still not known and
required further intensive research occasioned a lively discussion.
While it was difficult to distinguish the effects of unemployment from
the effects of other kinds of deprivation, nevertheless some
participants believed that it had been clearly demonstrated that
unemployment did cause ill-health. They argued that the need now was to
identify precisely which aspects of unemployment affected health, so
that remedial action could be taken against them. Benefits did not meet basic needs Current
concerns with the effects of unemployment on health are not new. They
were also voiced in Britain during the Depression of the 1930s. In his
paper ‘Health, Welfare and Unemployment During the Depression', Charles
Webster (Wellcome Unit for the History of Medicine and CEPR) asked
whether the substantial extensions of welfare legislation introduced in
that decade had benefited those most in need. At the time, it was
thought that the State's 'safety net' had prevented the overwhelming
majority of those affected by the Depression from experiencing acute
deprivation. Webster argued that this official view was based on
inaccurate statistics and was not credible. For most unemployed people
and their dependants, state benefits were insufficient to meet basic
needs, and In the areas of greatest need, welfare services were least
developed, If there was any lesson to be ,drawn from the 1930s, Webster
argued, it was that in a period of depression, welfare services
organized on a local basis, without effective central planning, were of
little value. Historians
who stress the harmful effects of the Depression are often described as
‘pessimists’, in contrast to the 'optimists' who prefer to emphasise
the more progressive aspects of the period. In the lively discussion
which followed Charles Webster's paper, attention was drawn to his heavy
emphasis on the experience in Wales. The Welsh Board of Health might
have been particularly 'backward' in its arrangements, and health and
welfare in Wales may not have been representative of the country. As
Webster had noted, the 1930s may well have witnessed a slower decline in
the rate of mortality. Nevertheless, the influences on mortality are
very long-term in nature, and some participants found it difficult to
attribute fluctuations in mortality in the 1930s to events such as the
Depression. Webster's
attempt to draw lessons from past experiences in the UK provoked much
discussion; in his own paper Cook questioned the effects of unemployment
on health. Are there lessons to be learned from contemporary
developments in other countries? The two sessions which followed were
devoted to reports of research in progress in West Germany and Sweden. Unemployment
in West Germany declined steadily in the 1950s, and apart from a brief
rise in 1967 it remained low up until the mid-1970s. Following the oil
crisis of 1973, unemployment began to rise again. As it has continued to
rise throughout the present decade, long-term unemployment has become a
more significant problem, This has prompted researchers to look at
ill-health both as a cause and as a consequence of unemployment, and
also as a barrier to re-employment. at both individual and aggregate
levels. Jurgen John (Institute of Medical Information, FRG)
discussed the current state of this research, At the individual level,
it has been shown that the unemployed are indeed more likely to
experience ill-health than those in employment. This is often highly
dependent, however, upon the personal characteristics and circumstances
of the individuals concerned, and it can be misleading to generalise
about 'the unemployed' from these individual studies. John's
own research had been carried out using aggregate data for 1950-1977,
data originally analysed by Brenner. Brenner had found that mortality
was influenced by unemployment, but not by trends and fluctuations in
economic growth. Using a different approach, John showed that on the
contrary, economic growth did influence mortality. John also found that
the relationship between unemployment and mortality was not positive, as
one might expect, but negative. The only exception was infant mortality,
which was positively related to the level of unemployment. Even this
relationship disappeared, however, if the first five years were excluded
from the estimation period. John
concluded that both individual and aggregate data were useful and might
well be combined in the same study, if the very considerable practical
problems involved could be surmounted. More work needed to be done on
the concept of unemployment: the differences between official and
personal definitions of unemployment could in themselves affect the
results of the studies that had been made. John argued that a promising
subject for further research might be the distribution not only of
unemployment but of unhealthy employment among the workforce. Unemployment did result in increased
stress Urban
Janlert (Karolinska
Institutet, Sweden) discussed current Swedish findings in his paper
'Unemployment and Health -Recent Swedish Experience and Research'.
Sweden has historically experienced low levels of unemployment. This,
together with the conviction that the existence of unemployment was an
'accident', meant that until recently the effects of rest of
unemployment did not receive serious study. Even though Swedish
unemployment began to rise in the 1960s, its effects upon health were
largely ignored until the beginning of this decade. A number of
tentative conclusions had since begun to emerge. In one study of the
effects of a factory closure and consequent
redundancies In Olofstrom, unemployment did result in increased stress.
A similar study in Kopmanhoimen had suggested that although differences
in health may have determined who became unemployed, the relative
disadvantage in the health of unemployed people did not increase during
the period of their unemployment. A study of school-leavers in Lulea
also found that health status played an important part in determining
who became unemployed. In contrast to the Kopmanholmen study, however,
those who became unemployed in Lulea then experienced a further
deterioration in their health. The experiences of unemployed shipyard
workers in Finnboda had led researchers to believe that age and marital
status may have a strong influence on the way in which unemployment
affected health. All these conclusions related to the unemployed
individuals themselves. Janlert
suggested that more knowledge was needed on the effects of unemployment
upon the parents and children of those unemployed and on the effects of
white collar unemployment. Future research should also take account of
what he called the 'anticipation effect'. In a period of industrial
depression, expediency or competitive pressures may cause health and
safety conditions in workplaces to deteriorate. Workers in employment
may also experience stress and ill health as a result of the threat of
unemployment. Both these factors related to unemployment are prejudicial
to health. Janlert
was asked whether any studies had been made of the health of young
workers in 'make-work' schemes. In the UK, experience had shown
participants in the Youth Opportunities Programme did not experience the
psychological problems otherwise associated with unemployment, provided
they found employment on completion of the programme. Failure to find
employment resulted in tangible disillusionment. Unfortunately, however,
no similar research had been undertaken in Sweden which might have shed
light on these British findings. Thomas
McKeown has argued that the most important single influence on mortality
levels before the Second World War was the level of nutrition. In the
last 20 years, most mortality rates have behaved in a way broadly
consistent with this hypothesis. The maternal mortality rate, however,
is an important exception. Comprehensive measures of the maternal
mortality rate (MMR) are available from the 1840s. Despite enormous
improvements in nutrition and decline in almost every other mortality
rate, the MMR stayed the same. When it did eventually fall in the 1930s,
it did so spectacularly. Any
explanation of maternal mortality has to account both for the
spectacular decline and for the long period of stability which preceded
it. It has, moreover, to be consistent with the fact that the two
components of the MMR, deaths from puerperal fever and accidents of
childbirth, both fell at roughly the same time. Thus the introduction in
1936 of the sulphonamide drug prontosil to combat puerperal fever can
explain only half the story. In his paper 'The Historical Evidence
Concerning the Effects of Social and Economic Deprivation on Maternal
Mortality', Irvine Loudon (Wellcome Unit for the History of
Medicine) offered a simple explanation consistent with all these facts.
He argued that the availability and quality of obstetric care has been
the single most powerful influence on maternal mortality during the past
two hundred years. In the early 1930s Andrew Topping had introduced
basic reforms in obstetric practice in Rochdale. The MMR in Rochdale
fell from 8.9 to 1.75 deaths per thousand births between 1929/30 and
1935 -before the introduction of sulphonamides, and at the height of the
Depression. One
Important Implication of Loudon’s argument is that social and economic
deprivation had little impact on maternal mortality; Loudon himself
found this difficult to accept. He suggested that the explanation may
lie in the assumption that there is a simple linear relationship between
maternal mortality and malnutrition. Some Third World studies seemed to
indicate that the physiological processes of childbirth were little
affected by quite severe degrees of deprivation. Beyond a certain
threshold, however, deprivation caused maternal mortality to increase
sharply. If deprivation only had effects when it reached this threshold,
Loudon argued, unemployment in Britain today may not induce levels of
hardship severe enough to affect the maternal mortality rate, In the
discussion which followed, it was suggested that the difficulty may lie
as much with the index used for maternal mortality (deaths per thousand
births) as with the phenomenon itself. In
her response to Loudon s paper, Alison Macfarlane (National
Perinatal Unit, Oxford) sought to extend the analysis to other 'outcomes
of pregnancy'. The clear relationship between infant mortality and
social class was generally acknowledged: to what extent was that
relationship due to maternal deprivation before or during pregnancy? How
was infant health affected by previous parental experience of
unemployment? Unemployment and parasuicide rates
related ? Many
of the workshop papers had drawn attention to the clear and unsurprising
relationship between unemployment and stress. How severe can this stress
become? Stephen Platt (Royal Edinburgh Hospital) pursued this
question in his paper ‘Parasuicide and Unemployment Among Men in
Edinburgh 1968 and 1983’. Platt found that over the entire period,
unemployment and attempted suicide rates were positively related. The
estimated relationship was much stronger over the first eight years
only, and in the second half of the sample the relationship was actually
negative, though not statistically significant. A study of the
relationship between parasuicide and unemployment in Oxford had produced
similar results. Unemployment and parasucide were also found to be
related in cross-sectional analyses of Edinburgh in 1971 and in 1981.
The relationship disappeared, however, when a measure of poverty was
included in the estimated equation. Throughout the period Platt studied
the parasuicide rate among unemployed men was much greater than among
employed men, but the difference between the rates had been declining
over most of the period. Either the kind of man now becoming unemployed
was less suicidally inclined, or the increasingly common experience of
unemployment carried a lesser stigma. Although the immediate impact of a
loss of employment was marked, men out of work for long periods were
more likely to attempt suicide than men out of work for shorter periods.
This finding also was in line with the Oxford study. Overall, the
incidence of parasuicide had shown
a tendency to rise in line with unemployment, Platt argued that these
findings were consistent with the view that unemployment was a cause of
parasuicide, but his methodology was heavily criticized in the
discussion which followed. Without further research, these conclusions
will not gain widespread acceptance. Charles
Webster had earlier discussed the effectiveness of State welfare
provision during the 1930s. In the final workshop paper Noel
Whileside (Bristol) returned to the question of the 'Hungry
Thirties', In her paper 'Counting the Cost: Sickness and Disability
among Working People in an Era of Industrial Recession (1920-1939)', she
suggested that we may miss an important effect of the Depression if we
simply regard the increase in claims for health insurance benefits as
reflecting an increase in the level of unemployment. Increased take-up
of health insurance in the 1920s and 19305 may indicate increasing
hardship and disability benefits rose together; in the 1930s, claims for
long-term disability benefits rose disproportionately. Previous
occupation, rather than age, was the most significant factor in
determining the type of claim made. What
could explain these results? The Depression may have made 'hidden' rates
of sickness more visible, and unemployment aggravated its incidence.
Another explanation is that the provision of sickness benefits fostered
a kind of 'voluntary sickness' which allowed the marginally ill to
languish indefinitely at public expense. The latter suggestion seemed
barely credible to Whiteside: in the face of intense competition for
jobs, workers were much less likely to admit to ill-health for fear of
losing the jobs they had. In any event, Whiteside noted, health
insurance payments remained far below the rates available under
unemployment benefit. In a 1938 report the Government Actuary asked
whether it would not have been more economical for the Government to
have promoted health actively rather than sustain avoidable disability.
The question was no less pertinent today. In
the discussion, Whiteside was asked whether it was right to concentrate
on the negative aspects of the Depression: even at its height,
conditions were not as bad as they had been thirty years previously. In
her view, the point was that in any era poverty increases dependence on
public support, and that by neglecting the consequences of poverty we
increase the costs of dependence. What
conclusions emerged from the workshop? The general discussions at the
end of the morning and afternoon sessions focused on two questions: how
are the effects of unemployment on health to be studied, and how are the
results to be translated into policy? Noel Whiteside’s paper served to
remind the workshop how little was known effects of relative
deprivation. Earlier it had been suggested that there was an urgent need
to examine not only the extent to which the health of unemployed people
today might have been affected by unemployment among their parents, but
also to follow through the effects of their unemployment upon their own
children" The danger with all such 'prospective' studies is that
the questions which interest researchers and the techniques they employ
change over time. Nevertheless, the papers presented at the workshop
demonstrated that many of the fundamental concerns remained unchanged
over several decades.
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