Health without Growth

Do we still need economic growth to stay healthy

or are we at saturation point?

The development of national accounts (including GDP!), in combination with better informed policies and institutions have contributed to a reduction in the business cycles and post-war era of strong economic growth

Health without Growth?

Have you wondered about society's obsession with economic growth?

How does it affect Health?

Who we are

Objectives

NB: we are not economists!

Physical

Sietse Wieringa , GP NIHR London

Greg Irving, GP NIHR Cambridge

Luisa Pettigrew, GP London

Stephanie Kumpunen, LSE London

Correspondence s.wieringa@nhs.net

• To better understand the concepts of:
• economic growth
• health
• GDP

• To think about how to measure these concepts

• To explore how these concepts are linked

• To think about how to measure progress in the future

Health

(IN)Equality

Kuznets' Curve (1955)

Thomas Piketty (2013)

the Kuznets curve was actually just.....

“A concentration of circumstances…created a historically unprecedented situation, which lasted for nearly a century. … All signs are, however, that it is about to end.”

Life Satisfaction

& Happiness

http://www.slideshare.net/equalitytrust/the-spirit-level-slides-from-the-equality-trust#

Happiness

Life Satisfaction

http://www.rollingalpha.com/2014/04/15/the-book-that-all-the-economists-are-reading-das-kapital-in-the-21st-century/

More: Salvatore J. Babones, Income inequality and population health: Correlation and causality, Social Science & Medicine, Volume 66, Issue 7, April 2008, Pages 1614-1626, ISSN 0277-9536, http://dx.doi.org/10.1016/j.socscimed.2007.12.012

Environment

mental

http://www.economist.com/blogs/graphicdetail/2012/02/daily-chart-16

http://www.economist.com/node/21548213

Economic crisis, unemployment and traffic accidents

BMJ 2014;348:f7412

Ambient particulate matter air pollution is estimated to cause 3.1 million deaths worldwide per year, and 22% of DALYs (disability adjusted life years) from ischaemic heart disease. There is an association between outdoor particulate matter and incidence of acute coronary events, even for exposure levels below the current European limits

employment

Long term exposure to ambient air pollution and incidence of acute coronary events: prospective cohort study and meta-analysis in 11 European cohorts from the ESCAPE Project

social

Work & Mental Health

"Work, the activity most people still spend most time engaged in, is increasingly the source of harmful stresses that are outside the control of individuals..."

The impact of the workplace on health

Job insecurity increases the risk of coronary heart disease

BMJ 2013;347:f4944 doi: 10.1136/bmj.f4944 (Published 8 August 2013)

BMJ 2013;347:f4944

Figure 3

shows analysis of the association between job strain and coronary heart disease by demographic characteristics, with exclusion of disease events in the first 3 years of follow-up. The association was significant and broadly similar for men and women, those younger and older than 50 years, and at all levels of socioeconomic status

Source: The Lancet 2012; 380:1491-1497 (DOI:10.1016/S0140-6736(12)60994-5)

BMJ 2014;348:g40 doi: 10.1136/bmj.g40 (Published 21 January 2014)

Job strain as a risk factor for coronary heart disease: a collaborative meta-analysis of individual participant data

Mika Kivimäki, PhD, Solja T Nyberg, MSc, G David Batty, PhD, Eleonor I Fransson, PhD, Katriina Heikkilä, PhD, Lars Alfredsson, PhD, Jakob B Bjorner, MD, Marianne Borritz, MD, Hermann Burr, PhD, Annalisa Casini, PhD, Els Clays, PhD, Dirk De Bacquer, PhD, Nico Dragano, PhD, Jane E Ferrie, PhD, Goedele A Geuskens, PhD, Marcel Goldberg, MD, Mark Hamer, PhD, Wendela E Hooftman, PhD, Irene L Houtman, PhD, Matti Joensuu, MSc, Markus Jokela, PhD, France Kittel, PhD, Anders Knutsson, PhD, Markku Koskenvuo, MD, Aki Koskinen, MSc, Anne Kouvonen, PhD, Meena Kumari, PhD, Ida EH Madsen, Michael G Marmot, MD, Martin L Nielsen, MD, Maria Nordin, PhD, Tuula Oksanen, MD, Jaana Pentti, BSc, Reiner Rugulies, PhD, Paula Salo, PhD, Johannes Siegrist, PhD, Archana Singh-Manoux, PhD, Sakari B Suominen, MD, Ari Väänänen, PhD, Jussi Vahtera, MD, Marianna Virtanen, PhD, Peter JM Westerholm, MD, Hugo Westerlund, Prof, Marie Zins, MD, Andrew Steptoe, DPh, Töres Theorell, MD and for the IPD-Work Consortium

The Lancet

Volume 380, Issue 9852, Pages 1491-1497 (October 2012)

DOI: 10.1016/S0140-6736(12)60994-5

Economic crisis unemployment & suicide

(IN) Fertility

physical activity & Diet

Figure 3. Occupational METs and energy expenditure since 1960.

Church TS, Thomas DM, Tudor-Locke C, Katzmarzyk PT, et al. (2011) Trends over 5 Decades in U.S. Occupation-Related Physical Activity and Their Associations with Obesity. PLoS ONE 6(5): e19657. doi:10.1371/journal.pone.0019657

http://www.plosone.org/article/info:doi/10.1371/journal.pone.0019657

Recession in Cuba caused CVD to drop as a result of less food intake and more exercise, but neuropathy and death of elderly went up.

But

Obesity: a disease for poor people in rich countries?

Trends in the prevalence of sedentary, light and moderate intensity occupations from 1960 to 2008.

WHO Definition of Health (1948)

http://www.usda.gov/factbook/chapter2.pdf

Church TS, Thomas DM, Tudor-Locke C, Katzmarzyk PT, et al. (2011) Trends over 5 Decades in U.S. Occupation-Related Physical Activity and Their Associations with Obesity. PLoS ONE 6(5): e19657. doi:10.1371/journal.pone.0019657

http://www.plosone.org/article/info:doi/10.1371/journal.pone.0019657

Source: compiled by UNEP GRID Geneva from FAOSTAT 1997 and WRI, UNEP, UNDP and WB 1998. http://www.grid.unep.ch/geo2000/english/0063.htm#img73a

mortality 1-4 year olds

"Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity."

there's debate on the 60-year old definition

Total Healthcare expenditure as a % of GDP, 2012

Generally higher income countries spend a greater proportion of GDP on healthcare

More money - more collective spending on healthcare - but signs of 'too much healthcare'

% of GPD

WHO http://gamapserver.who.int/gho/interactive_charts/health_financing/atlas.html

http://dx.doi.org/10.1136/bmj.d4163 (Published 26 July 2011)

warning!

-Correlation does not Equal causation

-could it be cause and / or effect?

Twitter Poll

-Consider the ecological fallacy

what do we want to be 'busy' with?

Is there an economic business model for eating less?

Do we need economic growth to stay healthy?

If yes tweet: #wonca2014 @poll 261465

If no tweet: #wonca2014 @poll 261469

Zeitgeist Movement

Correlations?

• Medicalisation of society
• Counterproductive - with increase of chronic illnesses and new 'diseases' everybody is 'ill'
• Operationalisation of 'Health' is difficult

Health

Increase consumption (increase compliance)

GDP

Increase 'value'

Fast food / processed food

Healthcare

Gardening and Foodies - spent more time on food (be inefficient)

Do we need economic growth to stay healthy?

Can you think of examples where economic growth and the desire to achieve this may not be good for health?

life expectancy

Increase consumption

Is there an economic model that promotes physically activity?

Grow food more efficiently

More gyms / fitness

• Life expectancy
• Child mortality
• Physical activity and Diet
• Fertility
• Life satisfaction and Happiness
• Employment
• Environment
• Equality

More obesity

Less physical activity

Start walking / cycling to work / do things the old way (be inefficient)

SEDLACek

More productivity = more efficiency

What's next

Is there a

“Today we still live in Gilgamesh’s vision that human relations – and therefore humanity itself are a disturbance to work and efficiency. [..] [W]e often consider the domain of humanity (human relations, love, friendship, beauty, art, etc.) to be unproductive” (Sedlacek, 2013)

More individual growth prevents other peoples growth > effect on collective growth?

Growth forever?

correlation?

Future economies?

Solution 1 individual versus collective action:

if not-growing is not beneficial for individual, impose limits to individual growth.

http://www.economist.com/news/united-states/21577378-americas-rampant-health-spending-threatens-its-economic-future-it-also-supports-tens

"I draw the conclusion that [..] the economic problem may be solved, or be at least within sight of solution, within a hundred years. This means that the economic problem is not-if we look into the future-the permanent problem of the human race.

When the accumulation of wealth is no longer of high social importance, there will be great changes in the code of morals. We shall be able to rid ourselves of many of the pseudo-moral principles which have hag-ridden us for two hundred years, by which we have exalted some of the most distasteful of human qualities into the position of the highest virtues. We shall be able to afford to dare to assess the money-motive at its true value."

But simple arithmetic suggests another powerful option for keeping people in work when demand stagnates. What happens if we relinquish our fetish for labour productivity? Sounds crazy at first. We’ve become so conditioned by the language of efficiency. Output is everything. Time is money. The drive for increased labour productivity occupies reams of academic literature and haunts the waking hours of CEOs and Treasury Ministers across the world.

In some places, this still makes sense. Who would rather keep their accounts in longhand? Wash hotel sheets by hand? Or mix concrete with a spade? Between the backbreaking, the demeaning and the downright boring, labour productivity has a lot to commend itself.

But there are places too where chasing labour productivity doesn’t stack up at all. What sense does it make to ask our teachers to teach ever bigger classes? Our doctors to treat more and more patients per hour? Our nurses to rush from bed to bed no longer able to feel empathy and offer comfort. Compassion fatigue is a rising scourge in the caring professions, hounded by meaningless productivity targets. Or to take another example, what – aside from meaningless noise – is to be gained by asking the London Philharmonic to play Beethoven’s 9th Symphony faster and faster each year?

Trivial though this example seems, it has its roots in another famous economic essay by the nonagenarian economist William Baumol. Analysing the dynamics of the cultural sector, he identified a general trend in modern service-based economies to slow down over time. Why? Because services require irreducible inputs of people’s time. The phenomenon has come to be called ‘Baumol’s cost disease’. Low productivity growth sectors are the scourge of modern economies. In formal terms these enterprises barely count. They represent a kind of Cinderella economy that sits neglected at the margins of consumer society.

Yet, people often achieve a greater sense of well being and fulfilment, both as producers and as consumers of these activities, than they ever do from the time-poor, materialistic, supermarket economy in which most of our lives are spent. And here perhaps is the most remarkable thing of all: because these activities are built around the exchange of human services rather than the relentless throughput of material stuff, there’s a half decent chance of making the economy more sustainable.

In short, achieving a green economy may be less to do with ‘sustained growth’ and technological utopianism and more to do with building an economy of care, craft and culture. And in doing so, restoring the value of human labour to its rightful place at the heart of the society.

Tim Jackson is Professor of Sustainable Development at the University of Surrey and Director of the Sustainable Lifestyles Research Group (SLRG) funded by DEFRA and the ESRC. He is author of the controversial bestseller Prosperity without Growth - economics for a finite planet (London: Earthscan/Routledge, 2011).

Keynes, J. (1933). Economic possibilities for our grandchildren (1930). Essays in Persuasion, 358–373. Retrieved from http://www.aspeninstitute.org/sites/default/files/content/upload/Intro_Session1.pdf

Solution 2 culture change: we have not always grown, people and culture can change.

The economist Keynes believed that in 2033 or so economic growth would not longer be necessary.

http://www.nytimes.com/interactive/2014/06/05/upshot/how-the-recession-reshaped-the-economy-in-255-charts.html?_r=0

Cinderella economies

Jackson, T. (2009). Prosperity without growth. The transition to a sustainable economy.

“while economic growth is important for enhancing living conditions, its reach and impact depend greatly on what we do with the increased income”

Amartya Sen, Nobel prize winner economist

Economic growth

"Some economists argue that the past practice of equating growth

in GDP with overall progress is outmoded. These views carry weight and should be taken seriously"

Margaret Chan, director General, WHO - May 2014

If so, what should we measure overall progress with?

What GDP does not capture

Many have criticised the ability of GDP to capture societal well-being

• Quality of education
• Leisure time
• Longevity
• Social equality
• etc ...

"The gross national product does not allow for the health of our children, the quality of their education or the joy of their play. It does not include the beauty of our poetry or the strength of our marriages, the intelligence of our public debate or the integrity of our public officials. It measures neither our wit nor our courage, neither our wisdom nor our learning, neither our compassion nor our devotion to our country, it measures everything in short, except that which makes life worthwhile." - Robert Kennedy

Problem one: Criticism of GDP

GDP ORIGINS

http://tinyurl.com/healthwithoutgrowth

Gross Domestic Product (GDP) was developed in the 1930s in the US to capture all economic production by individuals, companies, and the government in a single measure, which should rise in good times and fall in bad.

GDP

Definition of GDP

If not GDP - what else?

and GDP is not the only measure of how 'well' a gountry is doing...

Growing role of government in the economy

Lack of comprehensive set of national income accounts revealed by the Great Depression

In the 1940s WWII planning needs became the impetus for development of product and expenditure estimates

GDP = the dollar value of final purchases by households, businesses, and government by summing...

• UNITED NATIONS HUMAN DEVELOPMENT INDEX (UNHDI)
• GINI COEFFICIENT
• FORDHAM INDEX OF SOCIAL HEALTH (FISH)
• GENUINE PROGRESS INDICATOR (GPI)
• GROSS SUSTAINABLE DEVELOPMENT PRODUCT (GSDP)
• GROSS ENVIRONMENTAL SUSTAINABLE DEVELOPMENT INDEX (GEDSI)
• OTHERS....

GDP development timeline

consumptions

+

investment

+

government spending

+

net exports

• 1937 GDP is developed by Kuznets
• 1944 GDP becomes established measure for IMF, World Bank
• 1978 GDP per capita first calculated for over 100 countries

GDP AND POPULATION GROWTH

http://www.consultmcgregor.com/documents/resources/GDP_and_GPI.pdf

What’s not in GDP

• Intermediate goods (e.g. car radio)
• Non production transactions (e.g. used goods)
• Non market (e.g. household production)

• To account for population increases in an economy, economists use a measurement of real GDP per capita.

• It is a measure of real GDP divided by the total population.

• Real GDP per capita is considered a useful measure of a nation’s standard of living.

wHAT is economic growth?

Does austerity harm health? Presentation by Aaron Reeves, February 25, 2014, Oxford University

SOME POINTS ABOUT ECONOMIC GROWTH

Annual average growth in real per capita expenditure on health and GDP, 1998-2008

World bank:

• Quantitative change or expansion in country's economy
• Conventionality measured as percentage increase in GDP during one year

Economic growth comes in two forms:

• Extensive growth: Using more resources
• Intensive growth: Using same resources more efficiently

Thomas Malthus

"Much like a satellite in space can survey the weather across an entire continent so can the GDP give an overall picture of the state of the economy"

Samuelson and Nordhaus, 'Economics' 15th edition, 1996

Why is GDP important?

• When economic growth is achieved by using more labour it does not result in per capita income in growth

• When economic growth is achieved by through more productive use of all resources, including labour, it results in higher per capita income and improvement in peoples average standard of living.

• Put simply, intensive economic growth requires economic development

Business cycle

Health expenditure as a share of GDP, 2011 (or nearest year)

Problem two: Limits to Growth?

Global GDP is predicted to peak just after 2052 (club of Rome)?

Then what for health and healthcare?