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22 February, 2014

Greece’s health crisis: from austerity to denialism

A report by Alexander Kentikelenis, Marina Karanikolos, Aaron Reeves, Martin McKee, David Stuckler

Key points

Greece’s economic crisis has deepened since it was bailed out by the international community in 2010. The country underwent the sixth consecutive year of economic contraction in 2013, with its economy shrinking by 20% between 2008 and 2012, and anaemic or no growth projected for 2014. Unemployment has more than tripled, from 7.7% in 2008 to 24.3% in 2012, and long-term unemployment reached 14.4%.”

In health, the key objective 748 of the reforms was to reduce, rapidly and drastically, public expenditure by capping it at 6% of GDP. To meet this threshold, stipulated in Greece’s bailout agreement, public spending for health is now less than any of the other pre-2004 European Union members. ”

In 2009–10, the first year of austerity, a third of the street work programmes were cut because of scarcity of funding, despite a documented rise in the prevalence of heroin use.13 At the same time, the number of syringes and condoms distributed to drug users fell by 10% and 24%, respectively. These events had the expected effects on the health of this vulnerable population; the number of new HIV infections among injecting drug users rose from 15 in 2009 to 484 in 2012 and preliminary data for 2013 suggest that the incidence of tuberculosis among this population has more than doubled compared with 2012. ”

In his first act at the end of June, 2013, Adonis Georgiadis, the new Minister of Health (the fourth in a little more than a year), re-introduced a controversial law stipulating forced testing for infectious diseases under police supervision for drug users, prostitutes, and immigrants—a move that is not only unethical but also counterproductive, because it deters marginalised groups from seeking testing during HIV outbreaks. The Joint United Nations Programme on HIV/AIDS has called for the repeal of the law, because it 'could serve to justify actions that violate human rights.'”

... drastic reductions to municipality budgets have led to a scaling back of several activities (eg, mosquito- spraying programmes), which, in combination with other factors, has allowed the re-emergence of locally transmitted malaria for the first time in 40 years. ”

Through a series of austerity measures, the public hospital budget was reduced by 26% between 2009 and 2011 ...”

Despite the rhetoric of 'maintaining universal access and improving the quality of care delivery' in Greece’s bailout agreement, several policies shifted costs to patients, leading to reductions in health-care access. ”

Rapidly increasing unemployment since 2009 is increasing the number of uninsured people. Those without insurance are eligible for some health coverage after means testing, but the criteria for means testing have not been updated to take into account the new social reality. An estimated 800,000 potential beneficiaries are left without unemployment benefits and health coverage. To respond to unmet need, several social clinics (primary care practices staffed by volunteer doctors) have sprung up in urban centres. ”

... cuts have actually had negative economic effects, as acknowledged by the International Monetary Fund. GDP fell sharply and unemployment skyrocketed as a result of the economic austerity measures, which posed additional health risks to the population through deterioration of socioeconomic factors. ”

... in Greece public and non-profit mental health service providers have scaled back operations, shut down, or reduced staff; plans for development of child psychiatric services have been abandoned; and state funding for mental health decreased by 20% between 2010 and 2011, and by a further 55% between 2011 and 2012.”

Findings from population surveys suggest a 2.5 times increased prevalence of major depression, from 3.3% in 2008 to 8.2% in 2011, with economic hardship being a major risk factor. Investigators of another study reported a 36% increase between 2009 and 2011 in the number of people attempting suicide in the month before the survey, with a higher likelihood for those experiencing substantial economic distress. Deaths by suicide have increased by 45% between 2007 and 2011, albeit from a low initial amount. ”

Greece’s austerity measures have also affected child health, because of reduced family incomes and unemployment of parents. The proportion of children at risk of poverty has increased from 28.2% in 2007 to 30.4% in 2011 and a growing number receive inadequate nutrition. A 2012 UN report emphasised that 'the right to health and access to health services is not respected for all children [in Greece]'”.

In summary, although the adverse economic effects of austerity were miscalculated, the social costs were ignored, with harmful effects on the people of Greece .”

The cost of adjustment is being borne mainly by ordinary Greek citizens. They are subject to one of the most radical programmes of welfare-state retrenchment in recent times, which in turn affects population health. ”

Greek Government officials, and several sympathetic commentators, have argued that the introduction of the wide- ranging changes and deep public-spending cuts have not damaged health and, indeed, might lead to long-term improvements. Officials have denied that vulnerable groups (eg, homeless or uninsured people) have been denied access to health care, and claim that those who are unable to afford public insurance contributions still receive free care .”

In view of this detailed body of evidence for the harmful effects of austerity on health, the failure of public recognition of the issue by successive Greek Governments and international agencies is remarkable. Indeed, the predominant response has been denial that any serious difficulties exist, although this response is not unique to Greece; the Spanish Government has been equally reluctant to concede the harm caused by its policies. This dismissal meets the criteria for denialism, which refuses to acknowledge, and indeed attempts to discredit, scientific research. ”

... after Iceland’s acute crisis in 2008, the country rejected advice from the International Monetary Fund to slash its health-care and social services budget and instead opted to maintain welfare policies crucial to support its citizens, with no discernible effects on health.”

At the time of writing, the Troika was in Athens to assess the implementation of the bailout conditions, and €2.66 billion in cuts were announced to the health and social security budget for the following year.”

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