Death By Zip Code

It stands to reason that people suffer stress when money’s short, but do economically hard times in and of themselves kill people? Sanjay Basu, co-author of “The Body Economic: Why Austerity Kills,” argues that it’s not the economy it’s the austerity that’s deadly.

As he puts it in this interview, “Health doesn’t start on my exam room table or in the intensive care unit. It starts at home with the food that we eat, whether we smoke or drink too much, the safety of our neighborhoods. These are the major determinants of our health.”

Everything else being equal, it turns out that “Zip code is the leading determinant of our health and life expectancy” says Basu. Which is why austerity (cutting services, shrinking care) isn’t just bad for our economy (because it swells layoffs and shrinks spending) it’s also dangerous to human health.

Doesn’t it seem a tad “unseemly” to have to make the case in body-counts before people will care? Well yes it does, says Basu:

“It is somewhat perverse to have to make that point. The economists and my colleagues certainly have already shown the economic point that the austerity rational has already fallen apart. But to really understand what the human costs are you have to look at the most vulnerable and unfortunately they tend to be ignored within the scheme of discussion. “

The American Journal of Public Health now estimates that Americans stand a greater chance of dying from the effects of austerity than being killed in a car crash. According to Basu, homeless Americans have the same life expectancy as people in war-torn Sierra Leone or Congo.

Do policy alternatives exist that are proven to protect public health while also speeding recovery? Yes, reports Basu, citing examples from countries as diverse as Malaysia, Iceland and Sweden.  What’s standing in the way of smarter choices? Ideology, he suggests, and yes, also racism.

Perhaps, he concludes, we should have cared more about the Soviets.  There was a dramatic spike in deaths after the Harvard set (Jeffrey Sachs, Larry Summers et al) imposed austerity there. History is repeating now as the same austerity-triggered “excess deaths” mount in the US and beyond.

“We see the same response and desperate attempts to cover the data,” says Sanjay Basu.   Sanjay Basu is an associate professor of medicine and epidemiology at the University of Stanford.

Laura Flanders: Lets start with making the case. You say austerity kills. How do you know? 

Sanjay Basu: I got interested in this as a physician, seeing a lot more patients come into the emergency room during the recession. I had assumed that recessions wouldn’t necessarily result in increased deaths, people losing their health insurance, getting stressed out, unemployment, drinking and these kinds of things. And I was curious that when I looked in the peer reviewed literature that I found nearly the opposite. A lot of times, death rates go down during recessions. For example, people drive less so they have less car accidents but there was something going on during the recessions in the past and now. And what we found was there sort of a natural experiment going on during the great depression, the eastern European Crisis, the 90s and the East Asian Crisis. Different countries had different policy responses and those seemed to really determine whether or not recessions would result in extra deaths.

Tell about some of the stories you put in your book, of people? 

One of the key patients that I met during the recession was a young girl [of] eight years old. We renamed her Olivia in order to protect her privacy. Her father was in the construction field and was one of the many people laid off during the recession in California. And like about seven hundred thousand other men and women in the United States, he turned to drugs and drinking. And in the course of one of his drinking episodes set the house on fire. And she was a patient as a result of all the burns that she received during the course of his alcoholism. 

You’ve received some criticism from people who say, look, “policy isn’t a pathogen.” No one is forcing somebody to pick up a drink because they’ve been laid off.’ How do you respond to that?

As a doctor, you have to go back to the data and really say what is ultimately the cause of illness. And, if you look at the preventable deaths in the United States of young people, deaths below the age of seventy that could easily be treated and prevented, if everyone had universal healthcare and wonderful access to the best doctors, it turns out body-economic-stuckler-basu-cover-043013-margthat the key calculations that are agreed upon is that only 15 – 20 percent of those deaths might have been prevented through drug or surgery. The other 85 percent plus seemed to be due to social and economic factors. Zip code is the leading determinant of our health and life expectancy. And one of reasons for that is that health doesn’t start on my exam room table or in the intensive care unit. Its starts at home with the food that we eat, whether we smoke or drink too much, the safety of our neighborhoods. These are the major determinants of our health.

You are making a very clear distinction that it’s not just economic hard times interplaying with those factors; it’s policy. What do you mean?

Well, lets look at some of the comparisons. For example in East Asia, which had a terrible economic recession in the 90s, different countries all affected by the same recession took different policy responses. For example, Malaysia decided that it would bolster its anti-hunger programs and its infection disease prevention programs like HIV prevention. Thailand on the other hand and some of its neighbors decided to do the opposite. They followed the advice to go undergo austerity. They dramatically reduced their safety nets and we see the subsequent health and economic outcomes. Thailand actually lost a lot of stimulus and a lot of jobs because of the austerity, the government helping to re-stimulate the economy. And, in the process their HIV rates, which had be receding, (Thailand was used a model case for HIV prevention) just skyrocketed and so did their hunger rates. Malaysia, not only did they preserve their safety net but, with all these doubts — maybe they will have a higher deficit, they’ll have a higher debts, they’ll be cut out of the global scheme — all these threats, they actually ended up recovering first and one of the main reasons is that they kept people employed in addition to keeping them in out of hunger or HIV or any other infectious diseases, they were able to stabilize the economy more quickly.

Now, where does the US rate in this sort of spectrum of experiments?

Right now we’re at a very critical juncture. We, so far, had quite a stimulus that in comparison to say Britain, which underwent austerity, we’ve done fairly well in terms of keeping people out of hunger, having some pretty good housing programs and so forth, in spite of our very dysfunctional healthcare system. But, right now we’re at a precipice. As a result of the sequester, we’re at this point were austerity is starting to creep up. It’s too early for me to know what the data will show but if we follow the same path as Europe then I’m quite worried.

I’m really glad to have the statistics all between the covers of this book. But part of me, I was thinking that, do we really have to prove that people are dying to make the point that austerity is a bad idea? 

Yeah, it is somewhat perverse to have to make that point. The economists and my colleagues certainly have already shown the economic point that the austerity rational has already fallen apart. But to really understand what the human costs are you have to look at the most vulnerable and unfortunately they tend to be ignored within the scheme of discussion. For example during the sequester, many local public health departments suffered greatly and had to close many of their surveillance and treatment dorms. For example, there was a TB (Tuberculosis) outbreak in Jacksonville, Florida in the context of severe cuts to the Tuberculosis budget. Similar to the TB outbreak which happened in New York City which cost $1.2 billion to control in the 90s, in spite of the fact that to prevent it would have cost, the best estimates show, about a tenth of that.

How many lives do you think we are talking about?

It’s impossible for me to estimate. I can estimate from a lower bound from suicides since the clearest correlations are there and they’re on the order of tens of thousands in the U.S. and Europe.

There have been different decisions by different governments. You’ve talked about one case history that’s of course Iceland. Just for our audience, remind people just what Iceland did differently and how.

Iceland is a very interesting outlier. They’re a small country but they had the worst banking crisis in human history relative to the size of their economy. All of the three major banks failed. They had invested in U.S. mortgage bad securities. But Iceland while being recommended to go under austerity did something unique, they put it to a democratic vote, ‘Should we bail out the banks and cut our safety nets or should we gradually repay the debts and help the banks over time, a sort of loan scheduling type of program.’ The population voted for the latter and indeed Iceland has maintained its status as one of the healthiest and happiest countries in the world.

You talk about the ability to do that having to do with the Icelandic people sense of community and social capital. Describe what you mean by that.

There are several unique social, political and economic reasons why Iceland is an outlier and an important lesson. In addition to the fact that its not part of the Eurozone, so it didn’t face the same pressures or same politics as Greece. They are mostly monoculture and they have a lot of social capital. People literally know each other on a very strong basis. There is a lot of social support. People go to these baths together with a lot of indecent exposure in the process but they build social capital. It’s interesting sociologically to see how that seems to be associated with that spirit of, ‘we’re all in it together during the course of the recession.

So is more nudity what we need in this country?

(Laughter) I don’t know. Being from San Francisco I have quite a lot of nudity already but I don’t see it building social capital in all cases.

You do mention San Francisco in the context of the different response homelessness crisis, the “Housing First” policy, that I’d love you to talk about, and let’s shift to what you researched works in the circumstances that we could perhaps be doing and then, why aren’t we?

It’s striking to me as an academic that we have these lovely randomized controlled peer-review trials that we talk about in these journals that all fifteen of us in the field read. And we don’t translate it every well to the population. But there are very good programs that seem to both stimulate the economy and protect public health at the same time. One example that you mentioned are these Housing First policies. We still have 1.4 million houses in foreclosure in the United States… [Housing First] policies in Seattle found net costs saving when people were rapidly rehoused and supported through that process. In part because it helped prevent, for example, new alcoholism and substance abuse as happened to out patient. There were also savings in the emergency departments and from hospitalization because people forgo spending on their medications or preventive healthcare in order to pay for higher expensive rent or food and heating. We have this dichotomy in health called the “heat or eat” dichotomy, when you have to choose one or the other.

You have the startling statistic in the book that homeless Americans have the same life expectancy as people in war-torn Sierra Leone or Congo.  

Sometimes 40-45 years less life expectancy than those of us who are housed.

So prioritizing housing, keeping people in housing, what on the unemployment front works?

There are two other major programs that seem to work. One is called Active Labor Market Programs. They’re part carrot and part stick. Instead of being a standard unemployment check, this is a program in which people who are newly unemployed enroll with a case manager who helps them either get a job or skills training and also works with their firm in order to rapidly get them back into employment. Through that rapid employment we see the notable public health side effects…

Who’s doing this? Where is this happening?

It’s a government-based program. Its being tested in Michigan actually, through some randomized trials, which have been showing some impressive results. But those are some of the early programs in this country. They really were first adopted in Finland and Sweden. Sweden has been able to, through these programs, basically decouple the relationship between unemployment and suicide. They’ve had massive unemployment increases but their suicide rate continues to decrease.

All right then, we have established that austerity policies kill. We’ve established that there are things we can do differently. Why then, to answer the question in your book, are we still seeing austerity policies that kill when we know that there are options and other ways we can go?

There are a variety or theories. At least in my experience there are two major factors about why we’re still doing this in spite of evidence to the contrary. One is frankly ideological. There is a lot of blame upon the victim. Paul Krugman once said, “We sometimes blame soup kitchens for causing the depression.” But in fact, today we are debating in congress whether food stamps should be cut quite severely. But in fact the higher number of people on food stamps is an effect of the recession not the cause. We all know what the cause is in terms of the bank industry. So ideologically it’s very difficult for people to want to support safety nets when there are these almost mythical levels of ideology about the kinds of people that are on welfare.

So that gets to the question of the body politic. The body economic is a reference of course to body politic but we don’t just have one body. We have lots of bodies. They’re all of different colors, different from Iceland. What difference does race make?

It seems to me that it makes quite an impressive difference. Sociology literature for example, the case I’m studying of course is Iceland, Finland, and Sweden. These are mono-cultural places in general with a lot of social capital and not much ethnic ‘factionization.’ And in fact that in our society and other societies where you see people have more ethnic enclaves, there is not as much sense of community on a whole it’s very difficult to preserve safety nets. Many people don’t want to contribute.

So is it ideology or is it racism?

SB: I think a bit of both. (Chuckles.)

We’re chuckling but it makes me wonder how do we move forward? I mean, if the New Deal was easier to pass because it was a different era covering different groups of people, most of them white men and the War on Poverty much harder (even though you quote Kennedy talking eloquently on its behalf) because those programs were going to help people of color and immigrants and women and single moms. How do we get past that?

I will stay humble and say that I don’t have answer for that I don’t have a solution to our grand political crisis. In learning from history I do have great faith in education and democracy. And to read U.S. history and see the tremendous strides that have been made in the civil rights movements and women’s rights movements and so forth continuing to this day. I have great faith that we will continue to move forward in challenging some of these ideologies.

I need statistical proof. Meanwhile, there has been historically, a thesis held in some sectors of our philosophical and economic world, that says well, a kind of “culling of the most vulnerable” is not bad for the globe. It’s not bad for global progress. Obviously, this is not something we endorse. Nobody wants to say they are a Malthusian today. Or do you actually come across people saying it’s good to…

Clean up? Certainly.

So how do you respond to that? 

Suppose that we didn’t care about ethics or morality in this, look at what so many of these folks seem to ascribe to. The idea that those of us who remain and that aren’t vulnerable after the ‘cleanup’ process will be able to lead to a grand society or something like that. And yet, throughout history, some of our most creative and inventive people have been those who somehow survived a childhood that would have been wiped away by a Malthusian approach. We may not have light bulbs if Edison had not made it through hard times.

You write that you and your co-author David Stuckler yourselves would not have made it through these kinds of hard times.  

Certainly. Yes. Both of us had hard times. Both financial problems and a history of illness in our families as do many Americans. I think it’s surprising when we meet a family who hasn’t sufferer through illness or periods of instability. That’s why we as humans aren’t rats and cockroaches who survive purely by the laws of supply and demand we have the capacity to do something better.

Finally, [in your book] you go into the history of transition from the Soviet Union to Russia after communism. I actually read the title of that chapter which is actually “The Post Communist Mortality Crisis” as “Morality Crisis,” and realized that both titles could probably work. Is there something we should have or could have learnt from their experience? 

I learnt a lot. There was a dramatic spike in deaths after the U.S.S.R transitioned to a set of countries including Russia and the Eastern Block. The dramatic increase in mortality was only in certain countries and not in others. And what we found was [that] those who underwent rapid austerity really did very poorly, supporting the overall thesis. But what was also intriguing from that episode was how desperately the promoters of austerity attempted to claim otherwise. And that history itself is repeating now. The Economist, for example, selectively omitted data or made a number of statistical errors, and we find that to be the case now again with austerity. They tried to claim that it was all the alcohol problem [leading to excess deaths in post-soviet states] but in fact the death rates don’t explain the trend. Historically, we see the same response again in terms of criticism of safety nets, through desperate attempts to cover the data.

And some of the same people involved: Larry Summers, Jeffrey Sachs…

LAURA FLANDERS is the host and founder of Follow her on Twitter: @GRITlaura. 

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Laura Flanders interviews forward-thinking people about the key questions of our time on The Laura Flanders Show, a nationally syndicated radio and television program also available as a podcast. A contributing writer to The Nation, Flanders is also the author of six books, including The New York Times best-seller, BUSHWOMEN: Tales of a Cynical Species.  She is the recipient of a 2019 Izzy Award for excellence in independent journalism, the Pat Mitchell Lifetime Achievement Award for advancing women’s and girls’ visibility in media and a 2020 Lannan Cultural Freedom Fellowship for her reporting and advocacy for public media.