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Health and unemployment
Public Health The Journal of The Society of Community Medicine (Formerly the Society of Medical Officers of Health) Volume 98
Number 3
M a y 1984
Health and Unemployment Individuals who have been reared and educated in a society which values work for its own sake, views idleness as laziness and equates it with sin, suffer a serious loss of self-esteem when they are made redundant. While the level of unemployment in society is very high, and the chances of finding a new job are low, the effect on morale m a y be devastating. One might predict for these reasons that communities with a high incidence of unemployment would show an increased incidence of depressive illnesses. So far there has been little evidence of this despite the very marked rise in unemployment in the U.K. in recent years. There has been no rise in suicides nor increase in psychiatric admissions. There has, on the other hand, been at least one published report indicating a relationship between mortality and unemployment. There is also a great deal of anecdotal evidence of death supervening within 2 years of retirement, and this relates not only to those who were manual labourers, but also to Bank Managers. In one community where the prevalence of unemployment doubled in a single year the S.M.R. for deaths from all causes rose sharply a year later. Though no single cause of death accounted for the increase, the biggest contribution was made by ischaemic heart disease. There was no rise in suicides, but the rise in mortality from malignant disease was proportionally similar to that observed in ischaemic heart disease. Clearly this could be a chance association but it does pose the q u e s t i o n - " D o e s unemployment kill, and if so, how?" We have known for years that social classes 4 and 5 have higher mortality than social classes 1 and 2, and though some have attributed this to an effect of poverty, most community physicians take the view that it is in fact due to some aspects of life style associated with poverty rather than an effect of low income. For this reason, and also because the effects of savings during working life and of occupational pension schemes ensure that even after retirement social classes 1 and 2 continue to enjoy a higher standard of living than those who have retired from "blue collar" jobs, "social class" is assessed from an individual's last job, and is not altered when he retires or becomes redundant. M a n y of those who have lost their jobs in the current recession have received substantial redundancy compensation which has temporarily shielded them from poverty. H o w then could unemployment precipitate early death from diseases such as ischaemic heart disease, which represents but one aspect of an atheromatous process which normally takes at least 20 years to develop? One possible explanation might be that just as exercise leading to hypertrophy of the
132
Editorial
myocardium and dilatation of coronary arterioles protects individuals from coronary attacks, the cessation of exercise has the reverse effect. An atheromatous plaque occupying only a third of the lumen of a coronary artery while exercise maintains myocardial hypertrophy might occupy two thirds of the lumen once idleness has led to atrophy. It is also possible that after retirement or redundancy people may smoke more. When carrying out manual work it may be difficult to smoke, and without this constraint tobacco consumption may rise. Equally, with reduction of physical activity and increased opportunity to eat and drink, those made redundant may overeat, and staying in warm comfortable places they will burn up less of this food to maintain body heat and may well put on substantial amounts of weight. Since exercise is negatively and smoking and obesity are positively correlated with mortality from I.H.D. it is conceivable that these mechanisms could increase mortality after retirement or redundancy. On looking for evidence to support this view, however, it was found that in men below the age of 65 deaths from I.H.D. had fallen! The rise had been confined to older age groups. While a health-education programme to persuade those made redundant to modify their life style by regular exercise, suitable diet, and refraining from smoking must clearly be beneficial, it does not follow from this evidence that it would have more effect on this group than on the public as a whole. The nature of any relationship between unemployment and mortality remains a mystery. Doubtless further studies of various populations will show whether there is a real relationship between those variables. Finding whether the relationship is causal, and identifying the mechanism linking them, will be an interesting challenge to community physicians in those parts of the country with high levels of unemployment in the next few years.
Notice to Members As a consequence of the extension of membership to include health visitors, the Society now has an opportunity to review its peripheral activities. Members who would be interested in organizing small local groups and arranging meetings and lectures or discussions in their own District, or who have ideas or suggestions to offer, are invited to write to the Secretary of the Society. Joint meetings of doctors and health visitors from adjacent Districts, whether or not they are in the same N.H.S. Region, might prove a useful means of exchanging ideas. Members are invited to submit suggestions as to the type of local activity they would favour.
Number 3
M a y 1984
Health and Unemployment Individuals who have been reared and educated in a society which values work for its own sake, views idleness as laziness and equates it with sin, suffer a serious loss of self-esteem when they are made redundant. While the level of unemployment in society is very high, and the chances of finding a new job are low, the effect on morale m a y be devastating. One might predict for these reasons that communities with a high incidence of unemployment would show an increased incidence of depressive illnesses. So far there has been little evidence of this despite the very marked rise in unemployment in the U.K. in recent years. There has been no rise in suicides nor increase in psychiatric admissions. There has, on the other hand, been at least one published report indicating a relationship between mortality and unemployment. There is also a great deal of anecdotal evidence of death supervening within 2 years of retirement, and this relates not only to those who were manual labourers, but also to Bank Managers. In one community where the prevalence of unemployment doubled in a single year the S.M.R. for deaths from all causes rose sharply a year later. Though no single cause of death accounted for the increase, the biggest contribution was made by ischaemic heart disease. There was no rise in suicides, but the rise in mortality from malignant disease was proportionally similar to that observed in ischaemic heart disease. Clearly this could be a chance association but it does pose the q u e s t i o n - " D o e s unemployment kill, and if so, how?" We have known for years that social classes 4 and 5 have higher mortality than social classes 1 and 2, and though some have attributed this to an effect of poverty, most community physicians take the view that it is in fact due to some aspects of life style associated with poverty rather than an effect of low income. For this reason, and also because the effects of savings during working life and of occupational pension schemes ensure that even after retirement social classes 1 and 2 continue to enjoy a higher standard of living than those who have retired from "blue collar" jobs, "social class" is assessed from an individual's last job, and is not altered when he retires or becomes redundant. M a n y of those who have lost their jobs in the current recession have received substantial redundancy compensation which has temporarily shielded them from poverty. H o w then could unemployment precipitate early death from diseases such as ischaemic heart disease, which represents but one aspect of an atheromatous process which normally takes at least 20 years to develop? One possible explanation might be that just as exercise leading to hypertrophy of the
132
Editorial
myocardium and dilatation of coronary arterioles protects individuals from coronary attacks, the cessation of exercise has the reverse effect. An atheromatous plaque occupying only a third of the lumen of a coronary artery while exercise maintains myocardial hypertrophy might occupy two thirds of the lumen once idleness has led to atrophy. It is also possible that after retirement or redundancy people may smoke more. When carrying out manual work it may be difficult to smoke, and without this constraint tobacco consumption may rise. Equally, with reduction of physical activity and increased opportunity to eat and drink, those made redundant may overeat, and staying in warm comfortable places they will burn up less of this food to maintain body heat and may well put on substantial amounts of weight. Since exercise is negatively and smoking and obesity are positively correlated with mortality from I.H.D. it is conceivable that these mechanisms could increase mortality after retirement or redundancy. On looking for evidence to support this view, however, it was found that in men below the age of 65 deaths from I.H.D. had fallen! The rise had been confined to older age groups. While a health-education programme to persuade those made redundant to modify their life style by regular exercise, suitable diet, and refraining from smoking must clearly be beneficial, it does not follow from this evidence that it would have more effect on this group than on the public as a whole. The nature of any relationship between unemployment and mortality remains a mystery. Doubtless further studies of various populations will show whether there is a real relationship between those variables. Finding whether the relationship is causal, and identifying the mechanism linking them, will be an interesting challenge to community physicians in those parts of the country with high levels of unemployment in the next few years.
Notice to Members As a consequence of the extension of membership to include health visitors, the Society now has an opportunity to review its peripheral activities. Members who would be interested in organizing small local groups and arranging meetings and lectures or discussions in their own District, or who have ideas or suggestions to offer, are invited to write to the Secretary of the Society. Joint meetings of doctors and health visitors from adjacent Districts, whether or not they are in the same N.H.S. Region, might prove a useful means of exchanging ideas. Members are invited to submit suggestions as to the type of local activity they would favour.