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Background and methods

Until at least early August 2020, New Zealand had successfully eliminated community transmission of COVID-19 from the country,1 but then an outbreak was detected on 11 August (at the time of writing). Nevertheless, the associated response to the initial epidemic, including lockdowns and declines in global trade, has resulted in a range of negative social and economic impacts including job losses. The social and economic impacts of the COVID-19 response will have health consequences—some positive (eg, reduced road injury) and others negative (eg, increased elective surgery waiting times). Understanding the wider impacts of the COVID-19 response will be critical as we move further into the ‘recovery’ phase of the response. In this article, we contribute to this understanding by examining the relationship between unemployment (a known economic consequence of the pandemic response) and cardiovascular disease, CVD—a leading cause of health loss and health inequalities in Aotearoa New Zealand.

In April 2020, we conducted a literature search to identify studies, systematic reviews or meta-analyses that analysed the association between unemployment or economic crises and CVD. We only searched for studies that were published in the English language and from 1 January 2000 onwards. We included studies on high-income countries which had unemployment, job losses, or relevant proxies (eg, job insecurity) as the exposure, and CVD or stroke or heart disease as the outcome. Keywords were: (systematic or review or meta) AND (cardiovascular or stroke or coronary or heart) AND (unemployment or GDP or recession or “economic crisis”). A wide range of research databases were utilised, including Scopus, PubMed, Econlit, ESBCOhost, Web of Science and Google Scholar. A total of 951 articles (with duplicates) were identified in these databases and one author scanned all the titles to identify 35 articles for further investigation. Reviewing the abstracts of these articles identified eight relevant articles that investigated the association between unemployment and CVD. Additional searches using “cited by articles” in Google Scholar helped identify further 22 articles, but only one of which was relevant after reviewing abstracts. Furthermore, one author also independently searched the literature for the association between economic crises and CVD.

Findings from the literature on unemployment and CVD

Of 15 relevant articles identified (Table 1), five were review articles and the remainder were original research articles. We identified nine articles through using unemployment as a proxy,2–10 one further article using job insecurity as a proxy,11 and five further articles through additional searches.12–16

Table 1: Summary of the relevant studies that examined the association between unemployment and CVD events in high-income countries for study publication dates from January 2000 onwards.

*Carried out during the Global Financial Crisis (2008–09).

Seven out of nine studies identified through using unemployment as a proxy reported a positive association between unemployment and CVD,2–8 of which three employed individual-level data,3–5 one used population-level data6 and three were review studies (Table 1).2,7,8 These studies tended to employ data for middle-age or working adults. Among these seven studies, four reported hazard ratios (HRs) ranging from 1.19 to 1.84.2–5 The remaining two studies identified through using unemployment as a proxy reported a negative or no association between unemployment and CVD, but they both employed population-level data, implemented simple regression/correlation analyses, used outdated data and did not control for confounding factors.9,10

When considering job insecurity as a risk factor, we found one meta-analysis11 which reported that increased job insecurity was associated with increased coronary heart disease (CHD) incidence (Table 1). This meta-analysis included 174,438 participants with a mean follow-up of 9.7 years and 1,892 incident cases of coronary heart disease from 13 cohort studies.

Our additional search also found five studies that examined the association between economic crises and population level CVD (Table 1).12–16 Most of the studies found used macroeconomic and population-level data12,14,15 as opposed to individual-level data.13,16 Stuckler et al 2009 reported that as unemployment increases there was no change in overall CVD mortality but an increase in intentional violence (suicides and homicides), and a decrease in road traffic crash fatalities.12 However, this study found a strong association between unemployment and CVD mortality for middle-aged men, up to a 0.85% relative increase for a 1% relative increase in unemployment rate. In contrast, other studies have suggested a decline in CVD mortality with an increase in unemployment with many plausible mechanisms around reduced air pollution, reduced occupation stress, impact on smoking affordability and also a decline in circulating infections (eg, from reduced commuting in mass transit).13,14 However, these studies by Tapia Granados et al (2017, 2018) were limited, in particular with arguably inappropriate regression equations, considering data for a young population who had a low background level of CVD risk, and problematic definitions of unemployment (ie, including voluntary unemployment). Another example was the study by Ballester et al 201915 that reported that the largest declines in all-cause mortality were observed in the countries and regions with the largest economic slowdown during the Global Financial Crisis of 2008–09. However, this study only calculated year-to-year average differences in real GDP growth and changes in mortality rate, and used correlation analysis to analyse the association between real GDP and all-cause mortality. The study also did not take into account other factors that may contribute to the reduction in mortality rates. Finally, a study in Iceland showed an increased CVD association with a recession.16 This study employed individual-level data, working-aged adults and included various confounding factors.

In conclusion, the majority of the studies (10 out of 15) suggested a positive association between unemployment and CVD incidence and mortality, especially for middle-aged men. Those studies that suggested a negative association appeared to include data for younger populations who had lower underlying risk of CVD. Also of note is the systematic review level evidence for an association between chronic psychosocial stress and hypertension.17 In addition, it is clear that involuntary unemployment causes stress and forces most people to lower their standard of living; and there is abundant evidence that being in a less financially secure position and/or living in a deprived area, are risk factors for CVD.18–20

New Zealand literature

No New Zealand studies were identified that had explicitly examined the association between unemployment and CVD. One New Zealand study that considered a form of extreme stress (an earthquake damaged house), did report increased rates of CVD and myocardial infarction in the first year after the Christchurch earthquake.21 This cohort-linkage study was able to adjust for small area deprivation.

Existing New Zealand studies do show inequalities in CVD risk and in risk of unemployment. For example, living in a more deprived area (of which unemployment is one measurement variable22) is associated with increased CVD risk (eg, HR=1.11 and 1.08, respectively, for females and males by deprivation quintile)23 and other studies have reported such associations with deprivation.18,19,24–26 However, none of these studies explicitly analysed the association between unemployment and CVD.

Possible impacts on CVD from pandemic-induced unemployment in New Zealand

The unemployment rate in New Zealand due to the COVID-19 pandemic is likely to increase and be persistent over several years. Even though the unemployment figure in June 2020 (4.0%) suggested little change from the pre-pandemic response rate (4.2% in the first quarter of 2020), this is unlikely to reflect the true situation.27 For example, this figure did not account for under-employment arising from reduced hours of work. In addition, people who did not satisfy the definition of unemployment which involves actively looking for job (including during the COVID-19 pandemic related lockdown period), were classified as not in the potential labour force. Furthermore, as the Government wage subsidy was still in effect at the time of this survey (at this time it was scheduled to end on 1 September 2020), the more accurate situation with unemployment arising from the pandemic might not be revealed until the end of 2020. Finally, global economic shocks due to the pandemic might take time to have their full impact on the New Zealand economy.28

New Zealand has a diverse population with CVD-driven health inequalities.29 In particular, ethnic inequalities in CVD are well documented with this burden disproportionally impacting Māori, Pacific and South Asian peoples.30 For example, CVD-related complications are about twice as common in Māori than in non-Māori. These existing inequalities could be further exacerbated by the COVID-19 pandemic (if the elimination of community transmission of the pandemic failed in New Zealand) due to people with long-term conditions being at higher risk of COVID morbidity and mortality, with a 10.5% higher COVID-19 case fatality ratio with the presence of CVD.31 Māori and Pacific peoples are also over-represented in the groups who are on low incomes and occupations vulnerable to economic shocks that trigger unemployment.32 It is important that these existing inequities in CVD risk are considered in the COVID-19 response.

Possible next steps for studying the unemployment to CVD association in New Zealand

While the evidence for unemployment being associated with CVD appears mixed, it seems likely that increased unemployment is generally associated with increased CVD incidence, particularly in middle-aged men. The nature and extent of the likely impact of COVID-19 induced unemployment on CVD is unclear and will require monitoring as part of research to understand the wider health impacts of the COVID-19 response in New Zealand. Given socio-demographic differences in COVID-19 related unemployment compared to previous economic recessions, and differences in policy responses thus far, it is difficult to predict the impact of the COVID-19 response on CVD.

The New Zealand Government response to the COVID-19 pandemic has already included a wide range of economic actions including a NZ$50 billion budget in May 2020.33 This is likely to reduce unemployment associated with the pandemic—by keeping some businesses more viable. The Government has also dedicated some of the budget for job retraining and there have been other measures to assist the most disadvantaged New Zealanders (including restrictions on rent increases and evictions). This differs to the more moderate responses to curb unemployment in previous recessions. Evaluation of the impact of these initiatives on CVD and other health outcomes could shape general policy responses to unemployment in the future, and avoid the negative impacts observed in many of the studies included in this brief review.

To better inform New Zealand policymakers on the problem of increased unemployment associated with the COVID-19 pandemic and impact on CVD, it seems desirable for this to be modelled and quantified. This could be in terms of quality-adjusted life years (QALYs) lost from CVD attributable to the rise in unemployment and the additional health system costs associated with additional treatment of CVD. The impact on any worsening of the already large health inequalities associated with CVD (eg, for Māori and low-income New Zealanders) could also be estimated. Such work may be achievable in coming months as Treasury has estimates for unemployment arising from the pandemic34 and epidemiological/health economic models for CVD in New Zealand exist.35 Indeed, we plan to do such work in coming months and will probably use the effect size from Stuckler et al 200912 for middle-aged men, as this appears to be the most appropriate international study findings to generalise to New Zealand (Table 1). The reason is that this study covers a large number of European countries which typically have reasonable social safety nets, as in New Zealand. In contrast, results from Dupre et al 2012 from places like the US are less generalisable to New Zealand as the social safety net provisions in the US are relatively weak.

Potential policy responses to monitor and mitigate possible negative health impacts from the response to the COVID-19 pandemic

In terms of intervening in the “unemployment to increased CVD risk” pathway, the New Zealand Government could wait until more specific quantified benefits and costs are available (eg, as we have proposed above). Nevertheless, there are multiple CVD-related interventions for New Zealand that are cost-saving or highly cost-effective, and which could be intensified now:

• Intensifying tobacco control given that tobacco is a major contributor to CVD and to health inequalities arising from CVD, and the country has a Smokefree 2025 Goal. Many New Zealand studies show that tobacco control is cost-saving to the health sector36–39 and also is likely to reduce health inequalities between Māori and non-Māori. There is potential for these tobacco control interventions to be more intensively targeted at low-income New Zealanders who are most at risk of unemployment, eg, via the thematic content of mass media campaigns to call the Quitline (another cost-saving intervention36).

• Reducing CVD risk by reducing the permitted level of sodium in processed foods in New Zealand—with nearly all these sodium reduction interventions also being cost-saving and likely to reduce health inequalities between Māori and non-Māori.40–42

• Enhancing use of statins and anti-hypertensives for those at increased CVD risk. Again, there is New Zealand evidence on how this is particularly cost-effective in some age/sex/ethnic groups.35,43

Conclusions

The totality of the evidence we reviewed suggested that increased unemployment arising from economic shocks is associated with increased CVD incidence, particularly for men aged 35–64 years. Continued monitoring and active policy responses are required to prevent increases in CVD (and other health outcomes) as a result of the COVID-19 pandemic response in New Zealand. For example, quantifying the CVD-related health loss from pandemic-associated unemployment, along with the health costs and impact on health inequalities, could help with government decision-making to reduce CVD burdens. This could be via intensifying tobacco control, regulating the food supply (eg, to reduce salt/sodium levels), and improving uptake of CVD preventive medications such as statins and anti-hypertensives.

Summary

Abstract

Despite success with eliminating the COVID-19 pandemic in Aotearoa New Zealand (at least to early August 2020), the response to the pandemic threat has resulted in a range of negative social and economic impacts, including job losses. Understanding the health consequences of these impacts will be increasingly important in the ‘recovery’ phase. This article contributes to this understanding by exploring the relationship between unemployment and cardiovascular disease (CVD)—a major contributor to health loss in Aotearoa New Zealand. We reviewed the literature about the impact of unemployment on CVD. The totality of the evidence suggested that increased unemployment arising from economic shocks is associated with increased CVD incidence, particularly for middle-aged men. Continued monitoring and active policy responses are required to prevent increases in CVD (and other health outcomes) as a result of the COVID-19 pandemic response. For example, quantifying the CVD-related health loss from pandemic-associated unemployment, along with the health costs and impact on health inequalities, could help with government decision-making to reduce CVD burdens. This could be via intensifying tobacco control, regulating the food supply (eg, to reduce salt/sodium levels), and improving uptake of CVD preventive medications such as statins and anti-hypertensives.

Aim

Method

Results

Conclusion

Author Information

Nhung Nghiem, Senior Research Fellow, Department of Public Health, University of Otago, Wellington; Anja Mizdrak, Research Fellow, Department of Public Health, University of Otago, Wellington; Nick Wilson, BODE3 Programme Director, Department of Public Health, University of Otago, Wellington.

Acknowledgements

Correspondence

Dr Nhung Nghiem, Senior Research Fellow, Department of Public Health, University of Otago, Wellington 6021

Correspondence Email

nhung.nghiem@otago.ac.nz

Competing Interests

1. Baker MG, Wilson N, Anglemyer A. Successful Elimination of Covid-19 Transmission in New Zealand. N Engl J Med. 2020; 383(8):e56.

2. Karanikolos M, Heino P, McKee M, et al. Effects of the Global Financial Crisis on Health in High-Income Oecd Countries: A Narrative Review. Int J Health Serv. 2016; 46(2):208–40.

3. Koziel S, Lopuszanska M, Szklarska A, et al. The negative health consequences of unemployment: the case of Poland. Econ Hum Biol. 2010; 8(2):255–60.

4. Meneton P, Kesse-Guyot E, Méjean C, et al. Unemployment is associated with high cardiovascular event rate and increased all-cause mortality in middle-aged socially privileged individuals. Int Arch Occup Environ Health. 2015; 88(6):707–16.

5. Dupre ME, George LK, Liu G, et al. The cumulative effect of unemployment on risks for acute myocardial infarction. Arch Intern Med. 2012; 172(22):1731–7.

6. Brenner H. The impact of unemployment on heart disease and stroke mortality in European Union Countries. Luxembourg: European Commissions; 2016. Available from: http://hdl.handle.net/20.500.12503/28920

7. Falagas ME, Vouloumanou EK, Mavros MN, et al. Economic crises and mortality: a review of the literature. Int J Clin Pract. 2009; 63(8):1128–35.

8. Roelfs DJ, Shor E, Davidson KW, et al. Losing life and livelihood: A systematic review and meta-analysis of unemployment and all-cause mortality. Soc Sci Med. 2011; 72(6):840–54.

9. Sposato LA, Saposnik G. Gross domestic product and health expenditure associated with incidence, 30-day fatality, and age at stroke onset: a systematic review. Stroke. 2012; 43(1):170–7.

10. Svensson M, Krüger NA. Mortality and economic fluctuations. J Popul Econ. 2010; 25(4):1215–35.

11. Virtanen M, Nyberg ST, Batty GD, et al. Perceived job insecurity as a risk factor for incident coronary heart disease: systematic review and meta-analysis. BMJ. 2013; 347:f4746.

12. Stuckler D, Basu S, Suhrcke M, et al. The public health effect of economic crises and alternative policy responses in Europe: an empirical analysis. Lancet. 2009; 374(9686):315–23.

13. Tapia Granados JA, Christine PJ, Ionides EL, et al. Cardiovascular risk factors, depression, and alcohol consumption during joblessness and during recessions among young adults in CARDIA. Am J Epidemiol. 2018; 187(11):2339–45.

14. Tapia Granados JA, Ionides EL. Population health and the economy: Mortality and the Great Recession in Europe. Health Econ. 2017; 26(12):e219–e35.

15. Ballester J, Robine J-M, Herrmann FR, et al. Effect of the Great Recession on regional mortality trends in Europe. Nat Commun. 2019; 10(1):679.

16. Birgisdóttir KH, Hauksdóttir A, Ruhm C, et al. The effect of the economic collapse in Iceland on the probability of cardiovascular events. Econ Hum Biol. 2020; 37:100861.

17. Liu M-Y, Li N, Li WA, et al. Association between psychosocial stress and hypertension: a systematic review and meta-analysis. Neurol Res. 2017; 39(6):573–80.

18. Chan WC, Wright C, Riddell T, et al. Ethnic and socioeconomic disparities in the prevalence of cardiovascular disease in New Zealand. N Z Med J. 2008; 121(1285):11–20.

19. Mehta S, Jackson R, Pylypchuk R, et al. Development and validation of alternative cardiovascular risk prediction equations for population health planning: a routine health data linkage study of 1.7 million New Zealanders. Int J Epidemiol. 2018; 47(5):1571–84.

20. Mackenbach JP, Stirbu I, Roskam A-JR, et al. Socioeconomic inequalities in health in 22 European countries. N Engl J Med. 2008; 358(23):2468–81.

21. Teng AM, Blakely T, Ivory V, et al. Living in areas with different levels of earthquake damage and association with risk of cardiovascular disease: a cohort-linkage study. Lancet Planet Health. 2017; 1(6):e242–e53.

22. Salmond C, Crampton P, King P, et al. NZiDep: A New Zealand index of socioeconomic deprivation for individuals. Soc Sci Med. 2006; 62(6):1474–85.

23. Pylypchuk R, Wells S, Kerr A, et al. Cardiovascular disease risk prediction equations in 400 000 primary care patients in New Zealand: a derivation and validation study. Lancet. 2018; 391(10133):1897–907.

24. Fawcett J, Blakely T, Kunst A. Are Mortality Differences and Trends by Education Any Better or Worse in New Zealand? A Comparison Study with Norway, Denmark and Finland, 1980–1990s. Eur J Epidemiol. 2005; 20(8):683–91.

25. Shackleton N, Darlington-Pollock F, Norman P, et al. Longitudinal deprivation trajectories and risk of cardiovascular disease in New Zealand. Health Place. 2018; 53:34–42.

26. Blakely T, McLeod M. Will the financial crisis get under the skin and affect our health? Learning from the past to predict the future. N Z Med J. 2009; 122(1307):76–83.

27. Statistics New Zealand. Covid-19 and labour market statistics in the June 2020 quarter. Wellington: Statistics New Zealand; 2020. Available from: http://www.stats.govt.nz/methods/covid-19-and-labour-market-statistics-in-the-june-2020-quarter#additional 2020

28. Cazes S, Verick S, Al Hussami F. Why did unemployment respond so differently to the global financial crisis across countries? Insights from Okun’s Law. IZA Journal of Labor Policy. 2013; 2(1):1–18.

29. Health and Disability System Review. Health and Disability System Review – Final Report – Pūrongo Whakamutunga. Wellington: HDSR; 2020.

30. Miner-Williams W. Racial inequities in cardiovascular disease in New Zealand. Diversity and Equality in Health and Care. 2017; 14(1):23–33.

31. Ruan S. Likelihood of survival of coronavirus disease 2019. Lancet Infect Dis. 2020; 20(6):630–631.

32. Ministry of Business, Innovation, and Employment. Māori in the Labour Market. Wellington: Ministry of Business, Innovation, and Employment; 2020. Available from: http://www.mbie.govt.nz/dmsdocument/11267-maori-in-the-labour-market-december-2019-year 2019

33. NZ Herald. Budget 2020: Government's $50b Covid-19 recovery Budget biggest spending package in history. Available from: http://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=12332035 2020

34. The Treasury. Treasury Report T2020/973: Economic scenarios - 13 April 2020, http://treasury.govt.nz/publications/tr/treasury-report-t2020-973-economic-scenarios-13-april-2020. Wellington: The Treasury; 2020.

35. Nghiem N, Knight J, Mizdrak A, et al. Preventive Pharmacotherapy for Cardiovascular Disease: A Modelling Study Considering Health Gain, Costs, and Cost-Effectiveness when Stratifying by Absolute Risk. Sci Rep. 2019; 9(1):19562.

36. Nghiem N, Cleghorn CL, Leung W, et al. A national quitline service and its promotion in the mass media: modelling the health gain, health equity and cost-utility. Tob Control. 2018; 27:434–41.

37. Nghiem N, Leung W, Cleghorn C, et al. Mass media promotion of a smartphone smoking cessation app: modelled health and cost-saving impacts. BMC Public Health. 2019; 19(1):283.

38. Petrovic-van der Deen FS, Wilson N, Crothers A, et al. Potential country-level health and cost impacts of legalizing domestic sale of vaporized nicotine products. Epidemiol. 2019; 30(3):396–404.

39. van der Deen FS, Wilson N, Cleghorn CL, et al. Impact of five tobacco endgame strategies on future smoking prevalence, population health and health system costs: two modelling studies to inform the tobacco endgame. Tob Control. 2017; 27(3):278–286.

40. Nghiem N, Blakely T, Cobiac LJ, et al. The health gains and cost savings of dietary salt reduction interventions, with equity and age distributional aspects. BMC Public Health. 2016; 16(1):423.

41. Nghiem N, Blakely T, Cobiac LJ, et al. Health and economic impacts of eight different dietary salt reduction interventions. PLoS ONE. 2015; 10(4).

42. Wilson N, Nghiem N, Eyles H, et al. Modeling health gains and cost savings for ten dietary salt reduction targets. Nutr J. 2016; 15(1).

43. Wilson N, Jones AC, Nghiem N, et al. Preventing cardiovascular disease in New Zealand: Making better use of statins but also tobacco control, changing the food supply and other strategies. N Z Med J. 2018; 131(1484):61–7.

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Background and methods

Until at least early August 2020, New Zealand had successfully eliminated community transmission of COVID-19 from the country,1 but then an outbreak was detected on 11 August (at the time of writing). Nevertheless, the associated response to the initial epidemic, including lockdowns and declines in global trade, has resulted in a range of negative social and economic impacts including job losses. The social and economic impacts of the COVID-19 response will have health consequences—some positive (eg, reduced road injury) and others negative (eg, increased elective surgery waiting times). Understanding the wider impacts of the COVID-19 response will be critical as we move further into the ‘recovery’ phase of the response. In this article, we contribute to this understanding by examining the relationship between unemployment (a known economic consequence of the pandemic response) and cardiovascular disease, CVD—a leading cause of health loss and health inequalities in Aotearoa New Zealand.

In April 2020, we conducted a literature search to identify studies, systematic reviews or meta-analyses that analysed the association between unemployment or economic crises and CVD. We only searched for studies that were published in the English language and from 1 January 2000 onwards. We included studies on high-income countries which had unemployment, job losses, or relevant proxies (eg, job insecurity) as the exposure, and CVD or stroke or heart disease as the outcome. Keywords were: (systematic or review or meta) AND (cardiovascular or stroke or coronary or heart) AND (unemployment or GDP or recession or “economic crisis”). A wide range of research databases were utilised, including Scopus, PubMed, Econlit, ESBCOhost, Web of Science and Google Scholar. A total of 951 articles (with duplicates) were identified in these databases and one author scanned all the titles to identify 35 articles for further investigation. Reviewing the abstracts of these articles identified eight relevant articles that investigated the association between unemployment and CVD. Additional searches using “cited by articles” in Google Scholar helped identify further 22 articles, but only one of which was relevant after reviewing abstracts. Furthermore, one author also independently searched the literature for the association between economic crises and CVD.

Findings from the literature on unemployment and CVD

Of 15 relevant articles identified (Table 1), five were review articles and the remainder were original research articles. We identified nine articles through using unemployment as a proxy,2–10 one further article using job insecurity as a proxy,11 and five further articles through additional searches.12–16

Table 1: Summary of the relevant studies that examined the association between unemployment and CVD events in high-income countries for study publication dates from January 2000 onwards.

*Carried out during the Global Financial Crisis (2008–09).

Seven out of nine studies identified through using unemployment as a proxy reported a positive association between unemployment and CVD,2–8 of which three employed individual-level data,3–5 one used population-level data6 and three were review studies (Table 1).2,7,8 These studies tended to employ data for middle-age or working adults. Among these seven studies, four reported hazard ratios (HRs) ranging from 1.19 to 1.84.2–5 The remaining two studies identified through using unemployment as a proxy reported a negative or no association between unemployment and CVD, but they both employed population-level data, implemented simple regression/correlation analyses, used outdated data and did not control for confounding factors.9,10

When considering job insecurity as a risk factor, we found one meta-analysis11 which reported that increased job insecurity was associated with increased coronary heart disease (CHD) incidence (Table 1). This meta-analysis included 174,438 participants with a mean follow-up of 9.7 years and 1,892 incident cases of coronary heart disease from 13 cohort studies.

Our additional search also found five studies that examined the association between economic crises and population level CVD (Table 1).12–16 Most of the studies found used macroeconomic and population-level data12,14,15 as opposed to individual-level data.13,16 Stuckler et al 2009 reported that as unemployment increases there was no change in overall CVD mortality but an increase in intentional violence (suicides and homicides), and a decrease in road traffic crash fatalities.12 However, this study found a strong association between unemployment and CVD mortality for middle-aged men, up to a 0.85% relative increase for a 1% relative increase in unemployment rate. In contrast, other studies have suggested a decline in CVD mortality with an increase in unemployment with many plausible mechanisms around reduced air pollution, reduced occupation stress, impact on smoking affordability and also a decline in circulating infections (eg, from reduced commuting in mass transit).13,14 However, these studies by Tapia Granados et al (2017, 2018) were limited, in particular with arguably inappropriate regression equations, considering data for a young population who had a low background level of CVD risk, and problematic definitions of unemployment (ie, including voluntary unemployment). Another example was the study by Ballester et al 201915 that reported that the largest declines in all-cause mortality were observed in the countries and regions with the largest economic slowdown during the Global Financial Crisis of 2008–09. However, this study only calculated year-to-year average differences in real GDP growth and changes in mortality rate, and used correlation analysis to analyse the association between real GDP and all-cause mortality. The study also did not take into account other factors that may contribute to the reduction in mortality rates. Finally, a study in Iceland showed an increased CVD association with a recession.16 This study employed individual-level data, working-aged adults and included various confounding factors.

In conclusion, the majority of the studies (10 out of 15) suggested a positive association between unemployment and CVD incidence and mortality, especially for middle-aged men. Those studies that suggested a negative association appeared to include data for younger populations who had lower underlying risk of CVD. Also of note is the systematic review level evidence for an association between chronic psychosocial stress and hypertension.17 In addition, it is clear that involuntary unemployment causes stress and forces most people to lower their standard of living; and there is abundant evidence that being in a less financially secure position and/or living in a deprived area, are risk factors for CVD.18–20

New Zealand literature

No New Zealand studies were identified that had explicitly examined the association between unemployment and CVD. One New Zealand study that considered a form of extreme stress (an earthquake damaged house), did report increased rates of CVD and myocardial infarction in the first year after the Christchurch earthquake.21 This cohort-linkage study was able to adjust for small area deprivation.

Existing New Zealand studies do show inequalities in CVD risk and in risk of unemployment. For example, living in a more deprived area (of which unemployment is one measurement variable22) is associated with increased CVD risk (eg, HR=1.11 and 1.08, respectively, for females and males by deprivation quintile)23 and other studies have reported such associations with deprivation.18,19,24–26 However, none of these studies explicitly analysed the association between unemployment and CVD.

Possible impacts on CVD from pandemic-induced unemployment in New Zealand

The unemployment rate in New Zealand due to the COVID-19 pandemic is likely to increase and be persistent over several years. Even though the unemployment figure in June 2020 (4.0%) suggested little change from the pre-pandemic response rate (4.2% in the first quarter of 2020), this is unlikely to reflect the true situation.27 For example, this figure did not account for under-employment arising from reduced hours of work. In addition, people who did not satisfy the definition of unemployment which involves actively looking for job (including during the COVID-19 pandemic related lockdown period), were classified as not in the potential labour force. Furthermore, as the Government wage subsidy was still in effect at the time of this survey (at this time it was scheduled to end on 1 September 2020), the more accurate situation with unemployment arising from the pandemic might not be revealed until the end of 2020. Finally, global economic shocks due to the pandemic might take time to have their full impact on the New Zealand economy.28

New Zealand has a diverse population with CVD-driven health inequalities.29 In particular, ethnic inequalities in CVD are well documented with this burden disproportionally impacting Māori, Pacific and South Asian peoples.30 For example, CVD-related complications are about twice as common in Māori than in non-Māori. These existing inequalities could be further exacerbated by the COVID-19 pandemic (if the elimination of community transmission of the pandemic failed in New Zealand) due to people with long-term conditions being at higher risk of COVID morbidity and mortality, with a 10.5% higher COVID-19 case fatality ratio with the presence of CVD.31 Māori and Pacific peoples are also over-represented in the groups who are on low incomes and occupations vulnerable to economic shocks that trigger unemployment.32 It is important that these existing inequities in CVD risk are considered in the COVID-19 response.

Possible next steps for studying the unemployment to CVD association in New Zealand

While the evidence for unemployment being associated with CVD appears mixed, it seems likely that increased unemployment is generally associated with increased CVD incidence, particularly in middle-aged men. The nature and extent of the likely impact of COVID-19 induced unemployment on CVD is unclear and will require monitoring as part of research to understand the wider health impacts of the COVID-19 response in New Zealand. Given socio-demographic differences in COVID-19 related unemployment compared to previous economic recessions, and differences in policy responses thus far, it is difficult to predict the impact of the COVID-19 response on CVD.

The New Zealand Government response to the COVID-19 pandemic has already included a wide range of economic actions including a NZ$50 billion budget in May 2020.33 This is likely to reduce unemployment associated with the pandemic—by keeping some businesses more viable. The Government has also dedicated some of the budget for job retraining and there have been other measures to assist the most disadvantaged New Zealanders (including restrictions on rent increases and evictions). This differs to the more moderate responses to curb unemployment in previous recessions. Evaluation of the impact of these initiatives on CVD and other health outcomes could shape general policy responses to unemployment in the future, and avoid the negative impacts observed in many of the studies included in this brief review.

To better inform New Zealand policymakers on the problem of increased unemployment associated with the COVID-19 pandemic and impact on CVD, it seems desirable for this to be modelled and quantified. This could be in terms of quality-adjusted life years (QALYs) lost from CVD attributable to the rise in unemployment and the additional health system costs associated with additional treatment of CVD. The impact on any worsening of the already large health inequalities associated with CVD (eg, for Māori and low-income New Zealanders) could also be estimated. Such work may be achievable in coming months as Treasury has estimates for unemployment arising from the pandemic34 and epidemiological/health economic models for CVD in New Zealand exist.35 Indeed, we plan to do such work in coming months and will probably use the effect size from Stuckler et al 200912 for middle-aged men, as this appears to be the most appropriate international study findings to generalise to New Zealand (Table 1). The reason is that this study covers a large number of European countries which typically have reasonable social safety nets, as in New Zealand. In contrast, results from Dupre et al 2012 from places like the US are less generalisable to New Zealand as the social safety net provisions in the US are relatively weak.

Potential policy responses to monitor and mitigate possible negative health impacts from the response to the COVID-19 pandemic

In terms of intervening in the “unemployment to increased CVD risk” pathway, the New Zealand Government could wait until more specific quantified benefits and costs are available (eg, as we have proposed above). Nevertheless, there are multiple CVD-related interventions for New Zealand that are cost-saving or highly cost-effective, and which could be intensified now:

• Intensifying tobacco control given that tobacco is a major contributor to CVD and to health inequalities arising from CVD, and the country has a Smokefree 2025 Goal. Many New Zealand studies show that tobacco control is cost-saving to the health sector36–39 and also is likely to reduce health inequalities between Māori and non-Māori. There is potential for these tobacco control interventions to be more intensively targeted at low-income New Zealanders who are most at risk of unemployment, eg, via the thematic content of mass media campaigns to call the Quitline (another cost-saving intervention36).

• Reducing CVD risk by reducing the permitted level of sodium in processed foods in New Zealand—with nearly all these sodium reduction interventions also being cost-saving and likely to reduce health inequalities between Māori and non-Māori.40–42

• Enhancing use of statins and anti-hypertensives for those at increased CVD risk. Again, there is New Zealand evidence on how this is particularly cost-effective in some age/sex/ethnic groups.35,43

Conclusions

The totality of the evidence we reviewed suggested that increased unemployment arising from economic shocks is associated with increased CVD incidence, particularly for men aged 35–64 years. Continued monitoring and active policy responses are required to prevent increases in CVD (and other health outcomes) as a result of the COVID-19 pandemic response in New Zealand. For example, quantifying the CVD-related health loss from pandemic-associated unemployment, along with the health costs and impact on health inequalities, could help with government decision-making to reduce CVD burdens. This could be via intensifying tobacco control, regulating the food supply (eg, to reduce salt/sodium levels), and improving uptake of CVD preventive medications such as statins and anti-hypertensives.

Summary

Abstract

Despite success with eliminating the COVID-19 pandemic in Aotearoa New Zealand (at least to early August 2020), the response to the pandemic threat has resulted in a range of negative social and economic impacts, including job losses. Understanding the health consequences of these impacts will be increasingly important in the ‘recovery’ phase. This article contributes to this understanding by exploring the relationship between unemployment and cardiovascular disease (CVD)—a major contributor to health loss in Aotearoa New Zealand. We reviewed the literature about the impact of unemployment on CVD. The totality of the evidence suggested that increased unemployment arising from economic shocks is associated with increased CVD incidence, particularly for middle-aged men. Continued monitoring and active policy responses are required to prevent increases in CVD (and other health outcomes) as a result of the COVID-19 pandemic response. For example, quantifying the CVD-related health loss from pandemic-associated unemployment, along with the health costs and impact on health inequalities, could help with government decision-making to reduce CVD burdens. This could be via intensifying tobacco control, regulating the food supply (eg, to reduce salt/sodium levels), and improving uptake of CVD preventive medications such as statins and anti-hypertensives.

Aim

Method

Results

Conclusion

Author Information

Nhung Nghiem, Senior Research Fellow, Department of Public Health, University of Otago, Wellington; Anja Mizdrak, Research Fellow, Department of Public Health, University of Otago, Wellington; Nick Wilson, BODE3 Programme Director, Department of Public Health, University of Otago, Wellington.

Acknowledgements

Correspondence

Dr Nhung Nghiem, Senior Research Fellow, Department of Public Health, University of Otago, Wellington 6021

Correspondence Email

nhung.nghiem@otago.ac.nz

Competing Interests

1. Baker MG, Wilson N, Anglemyer A. Successful Elimination of Covid-19 Transmission in New Zealand. N Engl J Med. 2020; 383(8):e56.

2. Karanikolos M, Heino P, McKee M, et al. Effects of the Global Financial Crisis on Health in High-Income Oecd Countries: A Narrative Review. Int J Health Serv. 2016; 46(2):208–40.

3. Koziel S, Lopuszanska M, Szklarska A, et al. The negative health consequences of unemployment: the case of Poland. Econ Hum Biol. 2010; 8(2):255–60.

4. Meneton P, Kesse-Guyot E, Méjean C, et al. Unemployment is associated with high cardiovascular event rate and increased all-cause mortality in middle-aged socially privileged individuals. Int Arch Occup Environ Health. 2015; 88(6):707–16.

5. Dupre ME, George LK, Liu G, et al. The cumulative effect of unemployment on risks for acute myocardial infarction. Arch Intern Med. 2012; 172(22):1731–7.

6. Brenner H. The impact of unemployment on heart disease and stroke mortality in European Union Countries. Luxembourg: European Commissions; 2016. Available from: http://hdl.handle.net/20.500.12503/28920

7. Falagas ME, Vouloumanou EK, Mavros MN, et al. Economic crises and mortality: a review of the literature. Int J Clin Pract. 2009; 63(8):1128–35.

8. Roelfs DJ, Shor E, Davidson KW, et al. Losing life and livelihood: A systematic review and meta-analysis of unemployment and all-cause mortality. Soc Sci Med. 2011; 72(6):840–54.

9. Sposato LA, Saposnik G. Gross domestic product and health expenditure associated with incidence, 30-day fatality, and age at stroke onset: a systematic review. Stroke. 2012; 43(1):170–7.

10. Svensson M, Krüger NA. Mortality and economic fluctuations. J Popul Econ. 2010; 25(4):1215–35.

11. Virtanen M, Nyberg ST, Batty GD, et al. Perceived job insecurity as a risk factor for incident coronary heart disease: systematic review and meta-analysis. BMJ. 2013; 347:f4746.

12. Stuckler D, Basu S, Suhrcke M, et al. The public health effect of economic crises and alternative policy responses in Europe: an empirical analysis. Lancet. 2009; 374(9686):315–23.

13. Tapia Granados JA, Christine PJ, Ionides EL, et al. Cardiovascular risk factors, depression, and alcohol consumption during joblessness and during recessions among young adults in CARDIA. Am J Epidemiol. 2018; 187(11):2339–45.

14. Tapia Granados JA, Ionides EL. Population health and the economy: Mortality and the Great Recession in Europe. Health Econ. 2017; 26(12):e219–e35.

15. Ballester J, Robine J-M, Herrmann FR, et al. Effect of the Great Recession on regional mortality trends in Europe. Nat Commun. 2019; 10(1):679.

16. Birgisdóttir KH, Hauksdóttir A, Ruhm C, et al. The effect of the economic collapse in Iceland on the probability of cardiovascular events. Econ Hum Biol. 2020; 37:100861.

17. Liu M-Y, Li N, Li WA, et al. Association between psychosocial stress and hypertension: a systematic review and meta-analysis. Neurol Res. 2017; 39(6):573–80.

18. Chan WC, Wright C, Riddell T, et al. Ethnic and socioeconomic disparities in the prevalence of cardiovascular disease in New Zealand. N Z Med J. 2008; 121(1285):11–20.

19. Mehta S, Jackson R, Pylypchuk R, et al. Development and validation of alternative cardiovascular risk prediction equations for population health planning: a routine health data linkage study of 1.7 million New Zealanders. Int J Epidemiol. 2018; 47(5):1571–84.

20. Mackenbach JP, Stirbu I, Roskam A-JR, et al. Socioeconomic inequalities in health in 22 European countries. N Engl J Med. 2008; 358(23):2468–81.

21. Teng AM, Blakely T, Ivory V, et al. Living in areas with different levels of earthquake damage and association with risk of cardiovascular disease: a cohort-linkage study. Lancet Planet Health. 2017; 1(6):e242–e53.

22. Salmond C, Crampton P, King P, et al. NZiDep: A New Zealand index of socioeconomic deprivation for individuals. Soc Sci Med. 2006; 62(6):1474–85.

23. Pylypchuk R, Wells S, Kerr A, et al. Cardiovascular disease risk prediction equations in 400 000 primary care patients in New Zealand: a derivation and validation study. Lancet. 2018; 391(10133):1897–907.

24. Fawcett J, Blakely T, Kunst A. Are Mortality Differences and Trends by Education Any Better or Worse in New Zealand? A Comparison Study with Norway, Denmark and Finland, 1980–1990s. Eur J Epidemiol. 2005; 20(8):683–91.

25. Shackleton N, Darlington-Pollock F, Norman P, et al. Longitudinal deprivation trajectories and risk of cardiovascular disease in New Zealand. Health Place. 2018; 53:34–42.

26. Blakely T, McLeod M. Will the financial crisis get under the skin and affect our health? Learning from the past to predict the future. N Z Med J. 2009; 122(1307):76–83.

27. Statistics New Zealand. Covid-19 and labour market statistics in the June 2020 quarter. Wellington: Statistics New Zealand; 2020. Available from: http://www.stats.govt.nz/methods/covid-19-and-labour-market-statistics-in-the-june-2020-quarter#additional 2020

28. Cazes S, Verick S, Al Hussami F. Why did unemployment respond so differently to the global financial crisis across countries? Insights from Okun’s Law. IZA Journal of Labor Policy. 2013; 2(1):1–18.

29. Health and Disability System Review. Health and Disability System Review – Final Report – Pūrongo Whakamutunga. Wellington: HDSR; 2020.

30. Miner-Williams W. Racial inequities in cardiovascular disease in New Zealand. Diversity and Equality in Health and Care. 2017; 14(1):23–33.

31. Ruan S. Likelihood of survival of coronavirus disease 2019. Lancet Infect Dis. 2020; 20(6):630–631.

32. Ministry of Business, Innovation, and Employment. Māori in the Labour Market. Wellington: Ministry of Business, Innovation, and Employment; 2020. Available from: http://www.mbie.govt.nz/dmsdocument/11267-maori-in-the-labour-market-december-2019-year 2019

33. NZ Herald. Budget 2020: Government's $50b Covid-19 recovery Budget biggest spending package in history. Available from: http://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=12332035 2020

34. The Treasury. Treasury Report T2020/973: Economic scenarios - 13 April 2020, http://treasury.govt.nz/publications/tr/treasury-report-t2020-973-economic-scenarios-13-april-2020. Wellington: The Treasury; 2020.

35. Nghiem N, Knight J, Mizdrak A, et al. Preventive Pharmacotherapy for Cardiovascular Disease: A Modelling Study Considering Health Gain, Costs, and Cost-Effectiveness when Stratifying by Absolute Risk. Sci Rep. 2019; 9(1):19562.

36. Nghiem N, Cleghorn CL, Leung W, et al. A national quitline service and its promotion in the mass media: modelling the health gain, health equity and cost-utility. Tob Control. 2018; 27:434–41.

37. Nghiem N, Leung W, Cleghorn C, et al. Mass media promotion of a smartphone smoking cessation app: modelled health and cost-saving impacts. BMC Public Health. 2019; 19(1):283.

38. Petrovic-van der Deen FS, Wilson N, Crothers A, et al. Potential country-level health and cost impacts of legalizing domestic sale of vaporized nicotine products. Epidemiol. 2019; 30(3):396–404.

39. van der Deen FS, Wilson N, Cleghorn CL, et al. Impact of five tobacco endgame strategies on future smoking prevalence, population health and health system costs: two modelling studies to inform the tobacco endgame. Tob Control. 2017; 27(3):278–286.

40. Nghiem N, Blakely T, Cobiac LJ, et al. The health gains and cost savings of dietary salt reduction interventions, with equity and age distributional aspects. BMC Public Health. 2016; 16(1):423.

41. Nghiem N, Blakely T, Cobiac LJ, et al. Health and economic impacts of eight different dietary salt reduction interventions. PLoS ONE. 2015; 10(4).

42. Wilson N, Nghiem N, Eyles H, et al. Modeling health gains and cost savings for ten dietary salt reduction targets. Nutr J. 2016; 15(1).

43. Wilson N, Jones AC, Nghiem N, et al. Preventing cardiovascular disease in New Zealand: Making better use of statins but also tobacco control, changing the food supply and other strategies. N Z Med J. 2018; 131(1484):61–7.

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Background and methods

Until at least early August 2020, New Zealand had successfully eliminated community transmission of COVID-19 from the country,1 but then an outbreak was detected on 11 August (at the time of writing). Nevertheless, the associated response to the initial epidemic, including lockdowns and declines in global trade, has resulted in a range of negative social and economic impacts including job losses. The social and economic impacts of the COVID-19 response will have health consequences—some positive (eg, reduced road injury) and others negative (eg, increased elective surgery waiting times). Understanding the wider impacts of the COVID-19 response will be critical as we move further into the ‘recovery’ phase of the response. In this article, we contribute to this understanding by examining the relationship between unemployment (a known economic consequence of the pandemic response) and cardiovascular disease, CVD—a leading cause of health loss and health inequalities in Aotearoa New Zealand.

In April 2020, we conducted a literature search to identify studies, systematic reviews or meta-analyses that analysed the association between unemployment or economic crises and CVD. We only searched for studies that were published in the English language and from 1 January 2000 onwards. We included studies on high-income countries which had unemployment, job losses, or relevant proxies (eg, job insecurity) as the exposure, and CVD or stroke or heart disease as the outcome. Keywords were: (systematic or review or meta) AND (cardiovascular or stroke or coronary or heart) AND (unemployment or GDP or recession or “economic crisis”). A wide range of research databases were utilised, including Scopus, PubMed, Econlit, ESBCOhost, Web of Science and Google Scholar. A total of 951 articles (with duplicates) were identified in these databases and one author scanned all the titles to identify 35 articles for further investigation. Reviewing the abstracts of these articles identified eight relevant articles that investigated the association between unemployment and CVD. Additional searches using “cited by articles” in Google Scholar helped identify further 22 articles, but only one of which was relevant after reviewing abstracts. Furthermore, one author also independently searched the literature for the association between economic crises and CVD.

Findings from the literature on unemployment and CVD

Of 15 relevant articles identified (Table 1), five were review articles and the remainder were original research articles. We identified nine articles through using unemployment as a proxy,2–10 one further article using job insecurity as a proxy,11 and five further articles through additional searches.12–16

Table 1: Summary of the relevant studies that examined the association between unemployment and CVD events in high-income countries for study publication dates from January 2000 onwards.

*Carried out during the Global Financial Crisis (2008–09).

Seven out of nine studies identified through using unemployment as a proxy reported a positive association between unemployment and CVD,2–8 of which three employed individual-level data,3–5 one used population-level data6 and three were review studies (Table 1).2,7,8 These studies tended to employ data for middle-age or working adults. Among these seven studies, four reported hazard ratios (HRs) ranging from 1.19 to 1.84.2–5 The remaining two studies identified through using unemployment as a proxy reported a negative or no association between unemployment and CVD, but they both employed population-level data, implemented simple regression/correlation analyses, used outdated data and did not control for confounding factors.9,10

When considering job insecurity as a risk factor, we found one meta-analysis11 which reported that increased job insecurity was associated with increased coronary heart disease (CHD) incidence (Table 1). This meta-analysis included 174,438 participants with a mean follow-up of 9.7 years and 1,892 incident cases of coronary heart disease from 13 cohort studies.

Our additional search also found five studies that examined the association between economic crises and population level CVD (Table 1).12–16 Most of the studies found used macroeconomic and population-level data12,14,15 as opposed to individual-level data.13,16 Stuckler et al 2009 reported that as unemployment increases there was no change in overall CVD mortality but an increase in intentional violence (suicides and homicides), and a decrease in road traffic crash fatalities.12 However, this study found a strong association between unemployment and CVD mortality for middle-aged men, up to a 0.85% relative increase for a 1% relative increase in unemployment rate. In contrast, other studies have suggested a decline in CVD mortality with an increase in unemployment with many plausible mechanisms around reduced air pollution, reduced occupation stress, impact on smoking affordability and also a decline in circulating infections (eg, from reduced commuting in mass transit).13,14 However, these studies by Tapia Granados et al (2017, 2018) were limited, in particular with arguably inappropriate regression equations, considering data for a young population who had a low background level of CVD risk, and problematic definitions of unemployment (ie, including voluntary unemployment). Another example was the study by Ballester et al 201915 that reported that the largest declines in all-cause mortality were observed in the countries and regions with the largest economic slowdown during the Global Financial Crisis of 2008–09. However, this study only calculated year-to-year average differences in real GDP growth and changes in mortality rate, and used correlation analysis to analyse the association between real GDP and all-cause mortality. The study also did not take into account other factors that may contribute to the reduction in mortality rates. Finally, a study in Iceland showed an increased CVD association with a recession.16 This study employed individual-level data, working-aged adults and included various confounding factors.

In conclusion, the majority of the studies (10 out of 15) suggested a positive association between unemployment and CVD incidence and mortality, especially for middle-aged men. Those studies that suggested a negative association appeared to include data for younger populations who had lower underlying risk of CVD. Also of note is the systematic review level evidence for an association between chronic psychosocial stress and hypertension.17 In addition, it is clear that involuntary unemployment causes stress and forces most people to lower their standard of living; and there is abundant evidence that being in a less financially secure position and/or living in a deprived area, are risk factors for CVD.18–20

New Zealand literature

No New Zealand studies were identified that had explicitly examined the association between unemployment and CVD. One New Zealand study that considered a form of extreme stress (an earthquake damaged house), did report increased rates of CVD and myocardial infarction in the first year after the Christchurch earthquake.21 This cohort-linkage study was able to adjust for small area deprivation.

Existing New Zealand studies do show inequalities in CVD risk and in risk of unemployment. For example, living in a more deprived area (of which unemployment is one measurement variable22) is associated with increased CVD risk (eg, HR=1.11 and 1.08, respectively, for females and males by deprivation quintile)23 and other studies have reported such associations with deprivation.18,19,24–26 However, none of these studies explicitly analysed the association between unemployment and CVD.

Possible impacts on CVD from pandemic-induced unemployment in New Zealand

The unemployment rate in New Zealand due to the COVID-19 pandemic is likely to increase and be persistent over several years. Even though the unemployment figure in June 2020 (4.0%) suggested little change from the pre-pandemic response rate (4.2% in the first quarter of 2020), this is unlikely to reflect the true situation.27 For example, this figure did not account for under-employment arising from reduced hours of work. In addition, people who did not satisfy the definition of unemployment which involves actively looking for job (including during the COVID-19 pandemic related lockdown period), were classified as not in the potential labour force. Furthermore, as the Government wage subsidy was still in effect at the time of this survey (at this time it was scheduled to end on 1 September 2020), the more accurate situation with unemployment arising from the pandemic might not be revealed until the end of 2020. Finally, global economic shocks due to the pandemic might take time to have their full impact on the New Zealand economy.28

New Zealand has a diverse population with CVD-driven health inequalities.29 In particular, ethnic inequalities in CVD are well documented with this burden disproportionally impacting Māori, Pacific and South Asian peoples.30 For example, CVD-related complications are about twice as common in Māori than in non-Māori. These existing inequalities could be further exacerbated by the COVID-19 pandemic (if the elimination of community transmission of the pandemic failed in New Zealand) due to people with long-term conditions being at higher risk of COVID morbidity and mortality, with a 10.5% higher COVID-19 case fatality ratio with the presence of CVD.31 Māori and Pacific peoples are also over-represented in the groups who are on low incomes and occupations vulnerable to economic shocks that trigger unemployment.32 It is important that these existing inequities in CVD risk are considered in the COVID-19 response.

Possible next steps for studying the unemployment to CVD association in New Zealand

While the evidence for unemployment being associated with CVD appears mixed, it seems likely that increased unemployment is generally associated with increased CVD incidence, particularly in middle-aged men. The nature and extent of the likely impact of COVID-19 induced unemployment on CVD is unclear and will require monitoring as part of research to understand the wider health impacts of the COVID-19 response in New Zealand. Given socio-demographic differences in COVID-19 related unemployment compared to previous economic recessions, and differences in policy responses thus far, it is difficult to predict the impact of the COVID-19 response on CVD.

The New Zealand Government response to the COVID-19 pandemic has already included a wide range of economic actions including a NZ$50 billion budget in May 2020.33 This is likely to reduce unemployment associated with the pandemic—by keeping some businesses more viable. The Government has also dedicated some of the budget for job retraining and there have been other measures to assist the most disadvantaged New Zealanders (including restrictions on rent increases and evictions). This differs to the more moderate responses to curb unemployment in previous recessions. Evaluation of the impact of these initiatives on CVD and other health outcomes could shape general policy responses to unemployment in the future, and avoid the negative impacts observed in many of the studies included in this brief review.

To better inform New Zealand policymakers on the problem of increased unemployment associated with the COVID-19 pandemic and impact on CVD, it seems desirable for this to be modelled and quantified. This could be in terms of quality-adjusted life years (QALYs) lost from CVD attributable to the rise in unemployment and the additional health system costs associated with additional treatment of CVD. The impact on any worsening of the already large health inequalities associated with CVD (eg, for Māori and low-income New Zealanders) could also be estimated. Such work may be achievable in coming months as Treasury has estimates for unemployment arising from the pandemic34 and epidemiological/health economic models for CVD in New Zealand exist.35 Indeed, we plan to do such work in coming months and will probably use the effect size from Stuckler et al 200912 for middle-aged men, as this appears to be the most appropriate international study findings to generalise to New Zealand (Table 1). The reason is that this study covers a large number of European countries which typically have reasonable social safety nets, as in New Zealand. In contrast, results from Dupre et al 2012 from places like the US are less generalisable to New Zealand as the social safety net provisions in the US are relatively weak.

Potential policy responses to monitor and mitigate possible negative health impacts from the response to the COVID-19 pandemic

In terms of intervening in the “unemployment to increased CVD risk” pathway, the New Zealand Government could wait until more specific quantified benefits and costs are available (eg, as we have proposed above). Nevertheless, there are multiple CVD-related interventions for New Zealand that are cost-saving or highly cost-effective, and which could be intensified now:

• Intensifying tobacco control given that tobacco is a major contributor to CVD and to health inequalities arising from CVD, and the country has a Smokefree 2025 Goal. Many New Zealand studies show that tobacco control is cost-saving to the health sector36–39 and also is likely to reduce health inequalities between Māori and non-Māori. There is potential for these tobacco control interventions to be more intensively targeted at low-income New Zealanders who are most at risk of unemployment, eg, via the thematic content of mass media campaigns to call the Quitline (another cost-saving intervention36).

• Reducing CVD risk by reducing the permitted level of sodium in processed foods in New Zealand—with nearly all these sodium reduction interventions also being cost-saving and likely to reduce health inequalities between Māori and non-Māori.40–42

• Enhancing use of statins and anti-hypertensives for those at increased CVD risk. Again, there is New Zealand evidence on how this is particularly cost-effective in some age/sex/ethnic groups.35,43

Conclusions

The totality of the evidence we reviewed suggested that increased unemployment arising from economic shocks is associated with increased CVD incidence, particularly for men aged 35–64 years. Continued monitoring and active policy responses are required to prevent increases in CVD (and other health outcomes) as a result of the COVID-19 pandemic response in New Zealand. For example, quantifying the CVD-related health loss from pandemic-associated unemployment, along with the health costs and impact on health inequalities, could help with government decision-making to reduce CVD burdens. This could be via intensifying tobacco control, regulating the food supply (eg, to reduce salt/sodium levels), and improving uptake of CVD preventive medications such as statins and anti-hypertensives.

Summary

Abstract

Despite success with eliminating the COVID-19 pandemic in Aotearoa New Zealand (at least to early August 2020), the response to the pandemic threat has resulted in a range of negative social and economic impacts, including job losses. Understanding the health consequences of these impacts will be increasingly important in the ‘recovery’ phase. This article contributes to this understanding by exploring the relationship between unemployment and cardiovascular disease (CVD)—a major contributor to health loss in Aotearoa New Zealand. We reviewed the literature about the impact of unemployment on CVD. The totality of the evidence suggested that increased unemployment arising from economic shocks is associated with increased CVD incidence, particularly for middle-aged men. Continued monitoring and active policy responses are required to prevent increases in CVD (and other health outcomes) as a result of the COVID-19 pandemic response. For example, quantifying the CVD-related health loss from pandemic-associated unemployment, along with the health costs and impact on health inequalities, could help with government decision-making to reduce CVD burdens. This could be via intensifying tobacco control, regulating the food supply (eg, to reduce salt/sodium levels), and improving uptake of CVD preventive medications such as statins and anti-hypertensives.

Aim

Method

Results

Conclusion

Author Information

Nhung Nghiem, Senior Research Fellow, Department of Public Health, University of Otago, Wellington; Anja Mizdrak, Research Fellow, Department of Public Health, University of Otago, Wellington; Nick Wilson, BODE3 Programme Director, Department of Public Health, University of Otago, Wellington.

Acknowledgements

Correspondence

Dr Nhung Nghiem, Senior Research Fellow, Department of Public Health, University of Otago, Wellington 6021

Correspondence Email

nhung.nghiem@otago.ac.nz

Competing Interests

1. Baker MG, Wilson N, Anglemyer A. Successful Elimination of Covid-19 Transmission in New Zealand. N Engl J Med. 2020; 383(8):e56.

2. Karanikolos M, Heino P, McKee M, et al. Effects of the Global Financial Crisis on Health in High-Income Oecd Countries: A Narrative Review. Int J Health Serv. 2016; 46(2):208–40.

3. Koziel S, Lopuszanska M, Szklarska A, et al. The negative health consequences of unemployment: the case of Poland. Econ Hum Biol. 2010; 8(2):255–60.

4. Meneton P, Kesse-Guyot E, Méjean C, et al. Unemployment is associated with high cardiovascular event rate and increased all-cause mortality in middle-aged socially privileged individuals. Int Arch Occup Environ Health. 2015; 88(6):707–16.

5. Dupre ME, George LK, Liu G, et al. The cumulative effect of unemployment on risks for acute myocardial infarction. Arch Intern Med. 2012; 172(22):1731–7.

6. Brenner H. The impact of unemployment on heart disease and stroke mortality in European Union Countries. Luxembourg: European Commissions; 2016. Available from: http://hdl.handle.net/20.500.12503/28920

7. Falagas ME, Vouloumanou EK, Mavros MN, et al. Economic crises and mortality: a review of the literature. Int J Clin Pract. 2009; 63(8):1128–35.

8. Roelfs DJ, Shor E, Davidson KW, et al. Losing life and livelihood: A systematic review and meta-analysis of unemployment and all-cause mortality. Soc Sci Med. 2011; 72(6):840–54.

9. Sposato LA, Saposnik G. Gross domestic product and health expenditure associated with incidence, 30-day fatality, and age at stroke onset: a systematic review. Stroke. 2012; 43(1):170–7.

10. Svensson M, Krüger NA. Mortality and economic fluctuations. J Popul Econ. 2010; 25(4):1215–35.

11. Virtanen M, Nyberg ST, Batty GD, et al. Perceived job insecurity as a risk factor for incident coronary heart disease: systematic review and meta-analysis. BMJ. 2013; 347:f4746.

12. Stuckler D, Basu S, Suhrcke M, et al. The public health effect of economic crises and alternative policy responses in Europe: an empirical analysis. Lancet. 2009; 374(9686):315–23.

13. Tapia Granados JA, Christine PJ, Ionides EL, et al. Cardiovascular risk factors, depression, and alcohol consumption during joblessness and during recessions among young adults in CARDIA. Am J Epidemiol. 2018; 187(11):2339–45.

14. Tapia Granados JA, Ionides EL. Population health and the economy: Mortality and the Great Recession in Europe. Health Econ. 2017; 26(12):e219–e35.

15. Ballester J, Robine J-M, Herrmann FR, et al. Effect of the Great Recession on regional mortality trends in Europe. Nat Commun. 2019; 10(1):679.

16. Birgisdóttir KH, Hauksdóttir A, Ruhm C, et al. The effect of the economic collapse in Iceland on the probability of cardiovascular events. Econ Hum Biol. 2020; 37:100861.

17. Liu M-Y, Li N, Li WA, et al. Association between psychosocial stress and hypertension: a systematic review and meta-analysis. Neurol Res. 2017; 39(6):573–80.

18. Chan WC, Wright C, Riddell T, et al. Ethnic and socioeconomic disparities in the prevalence of cardiovascular disease in New Zealand. N Z Med J. 2008; 121(1285):11–20.

19. Mehta S, Jackson R, Pylypchuk R, et al. Development and validation of alternative cardiovascular risk prediction equations for population health planning: a routine health data linkage study of 1.7 million New Zealanders. Int J Epidemiol. 2018; 47(5):1571–84.

20. Mackenbach JP, Stirbu I, Roskam A-JR, et al. Socioeconomic inequalities in health in 22 European countries. N Engl J Med. 2008; 358(23):2468–81.

21. Teng AM, Blakely T, Ivory V, et al. Living in areas with different levels of earthquake damage and association with risk of cardiovascular disease: a cohort-linkage study. Lancet Planet Health. 2017; 1(6):e242–e53.

22. Salmond C, Crampton P, King P, et al. NZiDep: A New Zealand index of socioeconomic deprivation for individuals. Soc Sci Med. 2006; 62(6):1474–85.

23. Pylypchuk R, Wells S, Kerr A, et al. Cardiovascular disease risk prediction equations in 400 000 primary care patients in New Zealand: a derivation and validation study. Lancet. 2018; 391(10133):1897–907.

24. Fawcett J, Blakely T, Kunst A. Are Mortality Differences and Trends by Education Any Better or Worse in New Zealand? A Comparison Study with Norway, Denmark and Finland, 1980–1990s. Eur J Epidemiol. 2005; 20(8):683–91.

25. Shackleton N, Darlington-Pollock F, Norman P, et al. Longitudinal deprivation trajectories and risk of cardiovascular disease in New Zealand. Health Place. 2018; 53:34–42.

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