In the paper by Spijker and Gumà,¹1. Spijker J, Gumà J. The effect of the economic crisis on health in Spain according to educational level and employment status: Does the duration of the crisis also matter? Salud Colectiva. 2018;14(4):655-670. doi: 10.18294/sc.2018.1297.
https://doi.org/10.18294/sc.2018.1297... the authors analyze the effect of the recent economic crisis on the health of Spaniards looking at educational level and employment. This carefully thought-out paper makes reasonable assumptions and outlines historical findings related to times of economic stress and related unemployment as it may affect health. Going back to the work of the British looking at the socioeconomic classes in Great Britain, status - which reflects wealth, education, and other factors - clearly relates to overall health and well-being.²2. Fein O. The influence of social class on health status: American and British research on health inequalities. Journal of General Internal Medicine. 1995;10(10):577-586. Work in the United States has shown the importance of zip code and health.³3. Graham GN. Why your ZIP code matters more than your genetic code: promoting healthy outcomes from mother to child. Breastfeeding Medicine. 2016;11(8):396-397. Although the authors look at what occurred from the relatively recent 2007/2008 economic crisis in the world, and mentioned how it affected Spain, Greece, and Portugal, they could also have pointed to the economic distress in the Soviet Union that preceded this, and the subsequent decrease in life expectancy that was noted, along with an increase in negative factors such as the use of alcohol.⁴4. Rechel B, Roberts B, Richardson E, Shishkin S, Shkolnikov VM, Leon DA, Bobak M, Karanikolos M, McKee M. Health and health systems in the Commonwealth of Independent States. The Lancet. 2013;381(9872):1145-1155.

The data and methods utilized in this paper appear to be quite appropriate. In the section on the characteristics of the sample, the authors comment that the increase in number of women in the workplace can be related to “women’s liberation.” While in part this may be true, it has also been an economic necessity not only in advanced countries like the United States, but elsewhere, where second incomes have been needed to maintain a middle class lifestyle; those in many countries have been suffering this situation since the economic disaster of the last decade. In countries like the United Sates we now see that 47% of people in the work force are, in fact, women.⁵5. United States Department of Labor, Division of Labor Force Statistics. Labor force statistics from the current population survey [Internet]. Washington DC: USDL [citado 10 nov 2018]. Disponible en: Disponible en: https://tinyurl.com/ycesaq4t .
https://tinyurl.com/ycesaq4t... Given that in general women get paid less than men, we have the continuing and heightening problem of family incomes stagnating or declining in light of both inflationary pressures and changes in the whole face of work, with lower paying jobs replacing better paying jobs, multiple part-time jobs replacing full-time employment, and many jobs now coming with few if any benefits.

Some of the findings that health status may have improved over time after the period of greatest economic difficulty neglects to consider that during difficult times the more unhealthy workers may have been let go, or found that increased job requirements meant that they could no longer keep up with employment due to underlying health issues. With layoffs and fewer people working, the physical stress on those still employed can increase, creating more injuries as workloads increase. Also, better educated workers, who may have better health, might be selectively kept over less educated workers. Another potential factor, and one seen in the United States, has been that during times of economic turndowns the number of individuals applying for Social Security disability benefits goes up and such payments are used as an alternative income source in light of not having adequate or any employment.⁶6. Mueller AI, Rothstein J, Von Wachter TM. Unemployment Insurance and Disability Insurance in the Great Recession. Journal of Labor Economics. 2016;34(Suppl 1):S445-S475. Another area not amenable to investigation with the data used is the widening gap between the average wage of workers and the average wage of corporate executives. Although there has been economic difficulty, and during the early years of the economic crisis the clarity that those bankers and others in control made serious errors, they were in large part never punished and in many cases rewarded, while ordinary workers suffered greatly.

There is also one additional area not mentioned in this paper, that should prove to be of interest in undertaking similar kinds of research. When jobs are scarce, and economic pressures great, workplace safety is often seen to suffer. Maintenance of equipment may be deferred, unsafe practices that increase profits tolerated, and an interesting corollary would be to look at rates of injuries during difficult economic times among those working in certain industries.

Overall, there is little to criticize in this paper, but the work does raise additional issues and corollary topics that would be useful for consideration of the health and well-being that becomes modified due to economic difficulties.

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