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From Cradle of European Civilization to Grave Austerity: Does Greece Face a Creeping Health Disaster?

Published online by Cambridge University Press:  29 November 2013

Jeffrey Levett*
National School of Public Health, Athens, Greece
Correspondence: Jeffrey Levett, PhD National School of Public Health, Greece Ilia Rogakou 2 Athens, Greece 10672 E-mail
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LevettJ. From Cradle of European Civilization to Grave Austerity: Does Greece Face a Creeping Health Disaster?Prehosp Disaster Med. 2013;28(6):1-2.

While the global financial crisis started on the American continent, Greece has felt the biggest shock. As a result of government-imposed austerity measures following the implementation of the Memorandum of Understanding,* population health and the health sector have been impacted. This adds a burden to the national health system (NHS), already facing compromised efficiency and effectiveness. Cuts in health and social protection budgets are an additional exacerbation. These events have precipitated serious discussion, variable opinions, and related activity, but there is limited research on the public health impact of austerity.1 In 2011, I suggested that the Memorandum could be damaging to health and that there is a creeping health disaster2 while Kentikelenis referred to the omens of disaster.3 If austerity was tested like a medication in a clinical trial, it would have been stopped long ago, given its deadly side effects, according to Stuckler and Basu.4 According to Blyth, austerity is a dangerous idea.5 In terms of the Utstein template,68 austerity is designated a health hazard, which can be exacerbated when national governance is weak.9 The outcome is a creeping disaster of uncertain dynamics.

Copyright © World Association for Disaster and Emergency Medicine 2013 

Damage to health is increasing and the “evidence of harm” is real.Reference Vandoros, Hessel, Leone and Avendano 10 , Reference Zavras, Tsiantou, Pavi, Mylona and Kyriopoulos 11 Compelling evidence comes from a recent reputable study related to suicide,Reference Marina, Madianos, Peppou, Theleritis, Patelakas and Stefanis 12 which furthers information on depression data. Work relating to forest fires in GreeceReference Papanikolaou 13 provides insight into disaster-related stress and resilience of the population, as well as people's distrust of Greek institutions.Reference Papanikolaou, Gadallah and Leon 14 Recent polls indicate an overwhelming distrust of politicians.

Evidence of a creeping disaster includes psychological distress, non-specific physiological illness, self-rated health changes, suicidal ideation, and suicide attempts, as well as concerns for increased child abuse, adverse birth outcomes, and heart disease. Unemployment, a widely recognized driver of suicide and poverty, may reach 30% in 2014, reaching 65% for youth. Infant mortality has increased by 30%-40% from 2004-2012; from approximately 3-4/1,000 live births to 4-5/1,000 live births. Life expectancy may diminish by an estimated 4-5 years between 2008-2018. In the health sector, daily patient workflow is disrupted, scheduled patients may be sent home, and care seeking could be delayed. With respect to chronic disease, patients are finding difficulties with acquisition and payment for needed medications. With respect to transmissible disease, infection dynamics are changing, as evidenced by increased mortality of influenza, emergence and spread of the West Nile virus, appearance of clusters of non-imported malaria, and an outbreak of Human Immunodeficiency Virus (HIV) infection among youth who inject drugs at lower ages.Reference Bonovas and Nikopopoulos 15 , Reference Giannuli 16

On a personal note, around the clock visits to hospitals provide anecdotal insights into many of the organizational limits of the Greek NHS, as well as to the heroic efforts of its medical, nursing and auxiliary staff. Discharge patients may come too early with subsequent readmission, which suggests problems in the continuity of care and questions of unnecessary cost. As of yet, there is no denial of service at the point of need. Certainly overall cuts in spending on medicines and medical services are occurring, which may have serious implications for the rest of Europe. Certainly with an insightful human resources strategy, some of the effects of downsizing could be ameliorated by using available skills. For example, personnel in education could be organized into design teams for the health sector and for the development of health-related tourism.

Around 1930, public health measures were applied in Greece, dramatically improving sanitation, infant mortality, and life expectancy. Infectious disease was better controlled, malaria was eradicated, and the country entered the league of modern nations. The social policy success of Eleftherios Venizelos, the then-Prime Minister, although short-lived,Reference Theodorou and Karakatsani 17 was supported by the Rockefeller Foundation, the League of Nations, and by the inauguration of the Athens School of Public Health (1929), one of the earliest such institutions in Europe.Reference Levett 18 One important training program was of Greek public health experts in American institutions.Reference Livadas and Sphangos 19 The Athens School later became a founding member of the Association of Schools of Public Health in the European Region (ASPHER, 1966). Over the past decade it has worked closely with the World Association of Disaster Emergency Medicine (WADEM).

While considerable skills are available to analyze what went wrong preceding the novel situation or current crisis, additional skills, programs, and relationships are still necessary to provide greater scientific scrutiny in the health sector, sketch out future scenarios, and better prepare Greece for potential disasters.

Now is the time to reinforce post-graduate education in public health and health disaster management and to extend the current competencies of health professionals as suggested by ASPHER,Reference Birt and Foldspang 20 now endorsed by World Health Organization Europe.Reference Birt and Foldspang 20 There is no better time to undertake related research to examine the extent of ongoing “creep.” Evidence-based science and decision making are essential to the functioning of early warning systems. It seems a good time to refine our thinking in the sense that disaster management runs confluent with public health, as well as to pay heed to the message of Gro Harlem Brundtland that “Disaster preparedness and mitigation make a difference, health systems and communities are better prepared to cope and that with respect to emergencies, we must strengthen the evidence base for disaster reduction from a public health perspective.”

We have only a fuzzy snap shot of current complexities, but it is sufficient to provide the beginnings for further study and in-depth research. What we do know is that once good health indicators are now undergoing some erosion. How much and how fast are research questions. Twenty years after Article 129 of the Treaty of Maastricht first introduced public health as a European competence, it is now time to better protect people against disasters of all kinds. For Greece, the efforts must be more sustained than in the days of dengue, an infectious disease that slipped into Europe through Lebanon from Syria, which prompted a significant yet short-lived revolution in public health.

Today, Greece has national needs for comprehensive, applied policy to support the most vulnerable (children, women, people with special needs, immigrants) and to build community resilience. Social, economic, and environmental drivers of risk enhancement need to be addressed and nationally agreed-upon standards for hazard risk assessment need to be developed. Collaboration with the international community and a strengthening of health diplomacy in the Balkan region are mandatory.

The response to threats that can undermine health status and diminish the quality of life requires a new culture, a new ethic, and a new mindset. A comprehensive framework for public health and disaster management can act to stimulate socioeconomic strategies and promote human security issues. For the health sector, patient care must be shifted to the primary care level and “health in all other policies” ensured. Greece's prospects will improve if given the opportunity to conduct research on public health and disaster management through “natural experiments.” This can add weight to the recent Greek health reform plan supported by the European Commission, which will act as a cushion for those most deeply affected by austerity. 21


* International Monetary Fund pressures on European governments and international markets set in motion budget reforms, to shrink fiscal deficits and public debt. For Greece it included significant reductions in government spending and several packages of tough austerity measures. In February 2012, Greece signed a Memorandum of Understanding with Germany for a 'Health in action' agenda, with the establishment of a Health Reform Steering Committee (September 2012) to supervise, coordinate, and monitor management of the national organization for health care, pharmaceutical policy, hospital management, primary health care, and health tourism.

A creeping disaster is one of insidious onset and slow progress (famine, drought, desertification, health deterioration) which manifests itself over longer time spans.


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