The Body Economic (16 page)

Overall, the IMF's aim was to make cuts totaling 23 billion euros in three years, about 10 percent of its entire economy, and sell off state enterprises for 60 billion euros to reduce Greece's deficit from 14 percent to less than 3 percent of GDP by 2014. The troika's lending documents revealed that public-sector workers would bear the brunt of the cuts, facing mass layoffs, wage cuts, and pension reductions. The bailout also included conditions to raise taxes on fuel and related commodities by 10 percent, further emptying people's pockets and reducing their buying power.

Protests against the troika plan began in May 2010 with a series of strikes and demonstrations. Led by the Direct Democracy Now! Movement, thousands of protesters from every political party filled Syntagma Square. The protests started peacefully, but soon turned violent, leaving three protesters dead. Fires from Molotov cocktails lit up the Athens skyline at night. Amid the turmoil, one budget sector managed to avoid cuts: the police. Two thousand new police officers were hired and given extra training in riot control. Tear gas, riot gear, and tanks were brought in for use by the police and military.
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As in Iceland, the Greek protesters called for a nationwide referendum on the agreement. Prime Minister Papandreou promised that the government would protect the most vulnerable: “It is not going to be easy on Greek citizens, despite the efforts that have been made and will continue to be made to protect the weakest in society.” Nevertheless, the first IMF austerity package went into effect in May 2010, without a vote.

We had been studying how economic change impacted public health since 2007, before the financial situation deteriorated in Greece. We had pulled together all the data we could lay our hands on from the Greek health system—from hospitals, non-governmental organizations, the health ministry, and house hold surveys. We could see early warning signs of trouble brewing: rising unemployment, mass foreclosures, increasing personal debt—all which were risk factors for declining health. Greece's badly weakened social protection programs were ill-prepared to cope with a sudden rise in the number of people needing support, especially after being crippled by radical austerity measures.

Exact figures on the health impacts of austerity were hard to come by. Government reports on the subject seemed to be perpetually delayed or otherwise unavailable. When they did come, they suggested that the health system was improving. One official government report praised the healthcare system's progress as a result of improvements in efficiency. But anecdotal reports from doctors in both Greek and international newspapers made us concerned that serious problems were looming.

When healthcare systems collapse, good Samaritans sometimes come forward to pick up the slack. One
New York Times
investigation reported on a Greek underground Robin Hood network of doctors who used donated medications and supplies to treat patients no longer covered by the Greek public healthcare system. Dr. Kostas Syrigos, chief of oncology at Sotiria General Hospital in central Athens, described one patient as having the worst breast cancer he had ever seen. She had been unable to get medical care for a year because of the troika's healthcare reforms. When she arrived at the underground clinic, her tumor had burrowed through her skin and started weeping fluid onto her clothing. She was in excruciating pain, and mopping up the ulcerating wound with paper napkins. “When we saw her we were speechless,” Dr. Syrigos said to the reporter. “Everyone was crying. Things like that are
described in textbooks, but you never see them because until now, anybody who got sick in this country could always get help.”
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The stated goal of the troika's austerity plan—“to modernize the healthcare system”—sounded like it would avoid these catastrophes. Who wouldn't want to modernize their healthcare system? Greece's system was indeed in need of reform, a point that was well-known among European public health researchers. The problem is that the troika plan wasn't drawn up by healthcare experts or even based on their recommendations. Rather, it was constructed mainly by economists with little or no input or guidance from healthcare experts. It was as if a government had set out to modernize the automobile industry without talking to anyone who understood how a car was produced.
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The IMF's “recovery” plan was based on the fuzziest math. Its goal was “to keep public health expenditure at or below 6 percent of GDP, while maintaining universal access and improving the quality of care delivery. In the short-term, the main focus should be on macro-level discipline and cost-control.” Where that 6 percent target came from was never mentioned, but it was puzzling, since all other Western countries spend far more than that to maintain basic healthcare. For example, the German government, a premier advocate of the austerity plan in Greece, spends more than 10 percent on healthcare.

The IMF rolled out a series of risky ideas that sounded like good deficit-reduction measures. But in practice they led to people losing access to healthcare. One such idea was to cut spending on medications. The IMF's agreement with the Greek government specifically called for “a target to reduce public spending on outpatient pharmaceuticals from 1.9 to 1 and 1/3 percent of GDP.” As with many IMF programs, these cuts looked even riskier once one delved into the reasons for Greece's rising healthcare costs.

After Greece joined the EU in 2001, the country's spending on pharmaceuticals soared. Quite why was at first unclear, although corruption was a main suspect. There were numerous reports of patients and pharmaceutical companies giving doctors a
fakelaki
(small envelope) or directly depositing large sums into doctors' bank accounts, in exchange for prescribing more pills. Pharmaceutical companies also used creative ways of building relationships with doctors, taking them on lavish Hawaiian vacation-conferences and funding their membership in company advisory committees.
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But while the IMF had correctly spotted a trend of rising costs, its solution made matters worse. Rather than regulating pharmaceutical marketing and sales, it cut hospital budgets, preventing hospitals from obtaining medicines and medical supplies. Hospitals started to run out of antibiotics. Waiting lines doubled and then tripled. Many patients were unable to find a doctor in even the largest city hospitals. In May 2010, just after the first IMF bailout package took effect, the pharmaceutical company Novo-Nordisk pulled out of Greece because it was no longer being adequately paid after the troika's price cuts; the Greek state owed the company $36 million. That pullout not only cost jobs but also deprived 50,000 Greek diabetics of insulin.
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Meanwhile, Greeks were reporting that their health was worsening. In 2009, compared to 2007, they were 15 percent more likely to report that their health was “bad” or “very bad.” These self-reports tend to correlate with overall death rates, making them a widely used indicator for a society's health when other data are unavailable. (Here was another contrast to Iceland, where people reported that they were feeling just as good during as before the economic crisis.
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We looked for more detail as to why these reports showed people's health worsening during the crisis. We found that in 2009, people were 15 percent less likely to go to a doctor or dentist for treatment of medical problems, compared with 2007 (before the crisis). People were losing access because of long waiting times and excessive treatment costs. Fewer people could afford private care, so they turned to public hospitals and clinics. As private hospital admissions dropped, public hospitals filled the gap, with admissions rising approximately 25 percent. Then, instead of boosting support to meet the new demand, the government's austerity budget cut the jobs of 35,000 clinicians, doctors and public health workers. As a result, waiting times became intolerably long. On top of all this, doctors, whose salaries were cut, reportedly turned to a longstanding practice of taking bribes from desperate patients trying to jump the queues, leading to more inefficiency and making it more difficult for impoverished Greeks to access healthcare.
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The combination of recession and austerity was creating a perform storm of misery: budget cuts, clinic closures, and more “hidden” costs. The elderly were among the least resilient to these changes in the systems they had relied on for care. Overall, we estimated that at least 60,000 people over the age of sixty-five have so far forgone necessary medical care during the period of recession and austerity.

Apart from physical health, mental health was also worsening. Suicide rates were rising, most greatly among men—by 20 percent between 2007 and 2009. Consistent with this picture, mental health charities found that calls for help doubled. And this was likely the tip of the iceberg. Many Greeks didn't seek help because of the stigma that still surrounds mental illness there; the Greek Orthodox Church denies funerals to those whose deaths are classified as suicides. Perhaps predictably, therefore, Greece also experienced a rising number of “undetermined injuries” and other mysteriously unidentified causes of death that many doctors suspected were suicides disguised to save the honor of ashamed families.
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With public health programs collapsing because of austerity, the incidence of infectious disease suddenly skyrocketed. The Hellenic Centre for Disease Control and Prevention detected a series of outbreaks immediately after large cuts had been made to infectious disease prevention programs. For forty years, insecticide spraying programs had effectively prevented mosquito-borne diseases from spreading in Greece. After funding had been cut for the southern part of the country, an outbreak of West Nile Virus occurred in August 2010, killing sixty-two people in southern Greece and central Macedonia. Then, for the first time since 1970, there was a malaria outbreak in the southern Greek regions of Lakonia and East Attica. The European Centre for Disease Prevention and Control recommended that travelers to southern Greece stock up on anti-malarials and take other precautions like mosquito spray and nets. It was a special warning that had previously been reserved for travelers to sub-Saharan Africa and tropical parts of Asia.
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But perhaps most strikingly, an HIV outbreak—the only one to occur in Europe in decades—emerged in the center of Athens. At first, the sex trade was suspected to be the sole source. But a closer look at the data revealed that twenty-eight of the twenty-nine sex workers whose pictures Loverdos published online were also intravenous drug users, so drug use was likely also a major factor.
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Epidemiologists at the Hellenic Centre for Disease Control and Prevention were tracking the source of HIV spread. In Greece, as in many other parts of Europe, a significant fraction of all HIV transmission came from sharing infected needles. So the epidemiologists routinely monitored data from street clinics and studies of drug users' blood, to trace outbreaks and respond rapidly when they occurred. In 2011, the epidemiologists identified 384 new
HIV cases from street clinics and studies of drug users. They found little or no change in HIV infection rates from either homosexual or heterosexual activity. Instead, they verified that the bulk of the new HIV cases came from people using infected needles, who suffered a tenfold increase in new infections between January and October 2011.

“I've never seen so many drug users on the streets of Athens,” noted a colleague of ours, who lived most of her life just a few blocks from Parliament Square. Figures from the Athens police department confirmed her perception. Heroin use had risen by 20 percent between 2010 and 2011, as desperate people—particularly youth facing a 40 percent unemployment rate—now lived on the streets and turned to drugs.
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The World Health Organization had a solution to the needle-driven spread of HIV. It recommended that in every country, each drug user should have about 200 clean needles per year available in order to avoid spreading HIV infections. This estimate was based on data from extensive studies in the 1990s showing that needle exchange programs effectively reduced HIV transmission without increasing drug use. But just as the Greek epidemiologists warned of a drug-related HIV outbreak, the budget for Greece's needle-exchange program was slashed. As a result, the Hellenic Centre for Disease Control and Prevention estimated there were only about three needles for every drug user. Moreover, a survey of 275 drug users in Athens in October 2010 found that 85 percent were not enrolled in a drug-rehabilitation program, despite high demand to participate. In Athens and other major Greek cities, waiting times for rehab programs had risen to more than three years under austerity.
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In this situation, there were few options left for Greece's Health Ministry. Its health budget had been cut by 40 percent. But there was a political alternative—the democratic option. One way to protect citizens even when foreign investors clamor for their money is to follow the path set by Iceland. There the public voted to delay the IceSave debt repayments and pay them back slowly over time, protecting essential budgets like public health, sanitation (the garbage hadn't been collected in many parts of Athens for weeks), and other essential services.
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And so, in November 2011, at the time the HIV outbreak became clear, Prime Minister Papandreou tried the Icelandic solution. He announced a referendum on a second round of austerity measures from the IMF and the European Central Bank. It was plainly apparent to the Greek public that the
austerity program was not working. In spite of all the budget cuts, government debt continued to rise—to 165 percent of GDP in 2011. But under pressure from the troika and other European political leaders to pay back German and other investors quickly, Papandreou was forced to call the referendum off. While the referendum initially had support from the Greek cabinet, EU leaders voiced their opposition, and the prime minister faced a no-confidence vote in the Greek Parliament. Papandreou was forced to resign. Ironically, just as Europe praised democracy on the southern shore of the Mediterranean, having helped oust Libya's dictatorial Colonel Muammar Gaddafi, it was blocking democratic voting on the northern shore in Greece, the birthplace of democracy.
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