Why Greece's financial crisis is a health crisis too

Greece's crisis isn't only an economic one; it's a health crisis too.

Athina Tatsioni sees it every day at the University Hospital of Ioannina, where she is an emergency room doctor. When she started in 2009, there was a maximum of 280 patients per day. Now she and her colleagues are overwhelmed by more than 600 patients a day. Many have lost their health insurance with their jobs and can't afford to pay for care. They show up with late-stage disease, leaving serious conditions like diabetes untreated until they can't live another day without seeing a doctor.

"There are days when we see several patients in a row, and they all come for similar complaints — chest tightness, headaches. We run all the tests, and we find nothing," Tatsioni told Vox. "And then they start talking about their personal life: how they lost their job, their financial difficulties."

To meet their needs, Dr. Tatsioni now works double shifts — 16 hours, as opposed to eight — a few times a month, in addition to her regular shifts every other day. And she wonders how she'll keep it up. Not only is the pace exhausting, but there are drug and medical supply shortages that have made it increasingly difficult to deliver the kind of care her patients need. She says she now has to worry about whether she'll have the basics to help her patients: saline, antibiotics, painkillers.

No other country in Europe has felt a greater shock from the global economic crisis than Greece. That shock has also impacted Greek health. Over the past five years, cuts in public spending have had a devastating impact on the medical system — with lasting effects on public health.

1) Suicides are on the rise

Historically, Greece had one of the lowest suicide rates in the world. But it's not unusual for suicides to spike when an economy dips, and Greece has experienced the most extreme fallout from the global financial crisis compared with any European country.

Sadly, Greece is now recording the concomitant suicide trend. "The passage of new austerity measures in June 2011 marked the beginning of significant, abrupt and sustained increases in total suicides and male suicides," a 2015 BMJ Open study on the question reads.

In 2012, Greece recorded its highest months of suicide in 30 years. Overall, since 2011 suicides increased by 36 percent. Other population surveys have tracked increases in the prevalence of major depression.

"As future austerity measures are considered," the BMJ authors warned, "greater weight should be given to the unintended mental health consequences of these measures."

2) Health care budgets have been slashed

Laid-off Ministry of Finance cleaning staff protest outside the ministry in Athens on June 18, 2014. (Louisa Gouliamaki/AFP/Getty Images)

Since 2008, federal spending on hospitals dropped from 6.3 percent to 3.9 percent of GDP. Hospitals have had to slash their budgets by as much as 50 percent, firing staff, cutting back on testing and supplies, and abstaining from hiring new doctors to replace those who have retired. According to the Financial Post, "This has far outpaced the rate of economic contraction, where output has shrunk by a Depression-era 25 per cent."

One UK doctor who was recently working in Greece said the conditions in Greek hospitals rivaled those of developing countries:

The moment the hospital doors open on "emergency" days, people flood in. The collapse in official primary and community health care services means everyone who needs healthcare comes to A+E — whether for a major accident, medication for a long term condition or to get their child immunized. Staff told me that serious trauma cases often have to wait hours for X-rays and treatment due to understaffing and that, if too many cases come in at the same time, people die before they can be treated.

Recent studies have found that doctors are routinely experiencing shortages of medical supplies they need to do their job, and doctors are also experiencing burnout.

Cost cutting has also eroded health coverage. Because health care in Greece is linked to social security plans or employment status, government cuts and rising unemployment levels have increased the number of people without health insurance.

Those who would have opted for private coverage are now turning to state hospitals, explaining the overrun hospitals that physicians like Tatsioni have witnessed.

And even those who still have insurance are paying more as a result of cost cutting. This Lancet study did a good job of outlining how costs have been shifted to patients:

In 2011, user fees were increased from €3 to €5 for outpatient visits (with some exemptions for vulnerable groups), and co-payments for certain medicines have increased by 10% or more dependent on the disease. New fees for prescriptions (€1 per prescription) came into effect in 2014. An additional fee of €25 for inpatient admission was introduced in January 2014, but was rolled back within a week after mounting public and parliamentary pressure. Additional hidden costs — eg, increases in the price of telephone calls to schedule appointments with doctors — have also created barriers to access.

3) There's a mass exodus of doctors and scientists to other countries

Greece is among the countries with the highest rate of doctors per population in the world. Even as of 2010, there were 6.2 doctors per 1,000 people. Only a couple of other countries have a higher ratio.

But dismal working conditions and dearth of opportunity has primed the pump for an exodus from Greece.
Many Greek doctors are heading to Germany and Sweden — countries that are cash-rich and physician-poor

Many Greek doctors are heading to Germany and Sweden — European countries that are cash-rich and physician-poor. Saudi Arabia has  been trying to lure doctors away with higher salaries. (Wages abroad are at least double the 1,200 euros a month they currently earn in Greece.)

Last year, the country faced an estimated shortage of 6,000 doctors. In Athens alone, the medical association has recorded the exodus of some 4,000 doctors since public spending cuts were imposed in the past few years.

"The exodus for top-scientists is even more impressive," Dr. John Ioannidis, a Greek physician-researcher who is currently based at Stanford, said in an email. He continued:

Recently, I gave the Trichopoulos Memorial lecture in Athens and I showed with data that although Greeks are only 0.2% of the global population, they represent 1% of all scientists in the world, and 3% of the most-cited scientists. However, 87% of the most-cited Greek scientists are not in Greece, and during the last few years the exodus has been accelerating. Everyone in my previous team in Ioannina has a joint appointment in Europe or the USA currently and I suspect that some/many of them may leave Greece entirely in the near future.

4) There are drug and medical supply shortages. And they're worsening.

One of the unpaid bills on Greece's tab is to pharmaceutical companies that have been providing the country's drug and medical device supply. As early as July, these companies may stop sending their wares to Greek hospitals and health care facilities, which will result in major supply shortages — and preventable deaths.

"In the worst-case scenario of ‘Grexit’, we believe the integrity of the medicines supply chain may be in jeopardy, which would create a risk to public health," said Richard Bergström, director general of the European Federation of Pharmaceutical Industries and Associations, in the Financial Times.

Tatsioni explained, "We have already had to send patients to find a drug in the pharmacy outside the hospital, and then come back to the hospital and get the medication because the clinical ward did not have that drug." She added: "There is an uncertainty on how things will end, how we will overcome this situation."

The drug shortage is also part of an existing structural problem in Europe with how pharmaceuticals are distributed and sold, and it's only been exacerbated by Greece's financial woes. According to Ioannidis, drugs that are being bought up in Greece at low prices are resold elsewhere in Europe at higher prices where drug companies know they can fetch more money, thus further depleting supplies.

5) The country is bracing for more disease

HIV is on the rise in Greece in some populations, particularly intravenous drug users (IDUs). (Lancet)

In August 2014, the Greek health department cut its cancer screening prevention program, imposing an upper limit on the number of exams for uterus, breast, and prostate cancers that doctors can prescribe and placing caps on spending on these exams per physician. Since then, doctors have been raising concerns that this is going to lead to more cancer cases in the country.

"The argument for these new budget cuts is the necessity to control health-care costs," wrote concerned researchers in a 2014 Lancet article. "However, the population in Greece receiving screening services compared with that recommended by the European Council is already low."

For example, while Pap test coverage — to catch early cervical cancer and prevent it from spreading — hovers around 80 percent in Sweden, Finland, and the UK, it’s less than 60 percent in Greece. So cutting the screening program, without boosting other prevention services, "will increase cancer cases in the near future," the doctors fear.

Cuts in health spending have also coincided with increases in infectious disease cases. Between 2009 and 2012, the number of new HIV infections among drug users rose dramatically, from 15 to 484. Cases of tuberculosis in this population more than doubled between 2012 and 2013, according to The Lancet.

What's more, if people aren't getting the health care they need, this may also impact routine and childhood immunizations, meaning the country could see the return of vaccine-preventable diseases very soon.

Clarification: A previous version of this article misstated the number of 16-hour shifts Dr. Tatsioni now works.

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