Review article

HEALTH RISK OF UNEMPLOYMENT

György Ungváry¹, Veronika Morvai² and Imre Nagy¹1

Corresponding author: Prof. György Ungváry
József Fodor National Center of Public Health,
H-1450 Budapest, P. O. Box 36, Hungary
Tel: (+36) 1 215 5491,
Fax: (+36) 1 215 6891
E-mail: ncph@elender.hu

CEJOEM 1999 5(2):91-112

    Regional data show that the number of jobless persons is especially high in the counties of Borsod-Abaúj-Zemplén and Szabolcs-Szatmár-Bereg. No data is available on the unemployment rate in ethnic groups. It should be noted, however, that the number of Gypsies was the highest in the counties mentioned (31,882 and 24,970 persons, respectively, according to the data of KSH (Hungary’s Central Office of Statistics) on the 1st of January, 1990; in the rest of the counties the number of the Gypsy population is less than 10,000).
    Based on the aforementioned facts, it can be concluded that the social situation and the closely correlated hygienic situation, dwelling and nutrition of the nearly half a million unemployed may pose public health problems even if we do not take into account the negative economic and social effects. The analysis of the severe economic, societal and human effects of unemployment is not the objective of the present study, though these are of utmost importance regarding the quality of life.
 

    Among the effects of unemployment determining the quality of life, only the adverse health effects will be discussed here. We wish to answer three questions in the present study:
    1. Whether unemployment itself has adverse health effects.
    2. What kind of adverse health effects of unemployment can be detected in the industrialized countries.
    3. If there is any similarity between the health status of the unemployed in Hungary, Western Europe and the United States of America.
 

DOES UNEMPLOYMENT HAVE ADVERSE HEALTH EFFECTS OF ITS OWN?

Safe work and its productivity for the society is one of the basic needs of human beings. The general validity of this principle can be supported both by philosophic and occupational health knowledge. First we would like to quote two, rather distant philosophies or ideologies on the topic;
– “work is a purposeful activity of human beings, involving the conquering of natural and society forces to satisfy the historically determined needs of mankind” (Szigeti et al., 1972);
– „First of all we must remind ourselves of the basic fact, generally believed by the Church, that work is prior to funds. This principle directly refers to the production processes; in the production processes work is the primary, determinant factor, while funds are the collection of the tools of production. This principle is obviously true and is proven by the experience of the whole human history” (Pope John Paul II, cit. by Sperounis et al., 1988).
    So the human being has need for work, the loss or unavailability of which must have direct effect on the individual. To make this conclusion credible it is advisable to recollect some data and facts, as we often hear and sometimes even say: “I hate my work, I do not like to work!”
    As it is well known, the ancient European languages use different words for the activity which people themselves feel necessary, which is the basis of their mental and physical health and which can be regarded as creative activity and different word for the activity performed on the demand of others, forcibly; this latter can also be work done for money, for living. The English language uses the word ‘work’ in the first instance and the work ‘labor’ in the second instance, in Hungarian the words ‘munka’ and ‘robot’+ express the same difference. Today the original meanings and uses of these words have changed in some languages, or their uses have become mixed, while in other languages one of the words took the place of the other. Both words survived in English but neither of them is used in the original meaning anymore, while in Hungarian both meanings and ideas are expressed nearly exclusively by using the word ‘munka’. The mixing of the meanings of the words is understandable. Originally there was a practical difference between the meanings of ‘munka’ and ‘robot’, as well as of ‘work’ and ‘labor’, respectively.
    In the everyday language the word ‘labor’ is not used anymore when we refer to work as basic human activity, and we “go to work” to do our job. The word ‘work’ has a double meaning nowadays and psychological conclusions, evaluations come from these two meanings. Both the profit motivation and the individual performance or motivation appear in this double meaning and this may be a source of conflict. It is known from US data that 92% of the 110 million workers in the USA are employees. One quarter of the latter are professional managers or supervisors who enjoy partial autonomy of variable extent and have “upper” control, while three quarters (the majority) of them perform only labor to sustain themselves and their families. They have no choice of what to do under the given conditions or under what conditions to work, what will happen to them later, as the employer decides instead of them on all these issues; or, to be more exact, these are determined by the economy, the labor market and prices.
    Reviewing the life style and employment problems of the American workers the Government of the USA states in the publication entitled “Work in America” the following: the fact that work is necessary to stay alive restricts the desire to work to man’s own liking and for good feeling. At the same time, a lot of people continue to work even if they are not in need of money, because they need the social interaction offered by the workplace, they “feel like working”, and they want to share some activities curving the interest of the public.” (Sperounis et al., 1988).
    All these explain well the human ambivalence with respect to work. It explains why most people “hate work” sometimes and “cannot live without work” other times. Here we can try to prove our theory from the point of view of occupational health.
    First of all, work yields stress, as well as the interaction between stress and the genetically encoded human being (individual) characterized by anthropometric parameters, called strain(Fig. 1). To remain healthy, human beings require optimization of strain.

Fig. 1. Stress and strain (Figure is not available on-line)
The interaction between the 24-hour or summa stress (S stress) and the worker (S) is the so called strain. Basic requirement of health is the optimal or near-optimal strain. Unemployment significantly decreases the daily physical and physiological stress. Consequently the strain will be suboptimal, which may result in disease. Agents: workplace pathogenic factors; A: risk of accident.

    Significant long-term deviation of the strain from optimal (both upwards and downwards) leads to illness of the individual. The adverse health effect of exaggerated strain hardly needs explanation. If any factor of the total stress on Fig. 1 – physiological, psychic, mental or physical – exceeds the optimal level significantly, an unfavorable increase of the strain will be caused. The result will be the same when the level or concentration of the work place pathogenic factors – physical (e.g. noise, vibration, ionizing radiation), chemical (e.g. gases, vapors, aerosols), biological (e.g. viruses, bacteria, fungi), psycho-social, ergonomic – increasing above the threshold value. The undesirable life-style habits (smoking, excessive drinking, etc.) are also the source of increased strain (Ungváry, 1993).
    It is also well-known that an unstimulating environment and sub-optimal stress leads to health damage as well (e.g. monotony appears, which may be the source of further health damage).
    Our hypothesis that “work is a basic human need” is so much true that work – with the above mentioned restrictions – is the source of health. Obviously, the loss of a job has direct adverse health effect (Ungváry, 1993). Because of this, it is understandable that people refuse unemployment, regardless of its form, afflicting the individual, whether it is of economic or of other origin, it is “absolute”, “structural” or “frictional”, “long-term” or “temporary”, involves special groups of the society (e.g. women, youth) or a greater segment of the society (Ungváry, 1993).
 

ADVERSE HEALTH EFFECTS OF UNEMPLOYMENT DETECTED IN INDUSTRIALIZED COUNTRIES

Unemployment is continuously present even in the most developed industrialized countries. In addition to the usual case-studies (Broomhall and Winefield, 1990), longitudinal studies have also dealt with the problem (Mattiasson et al., 1990, Winefield and Tiggemann, 1990). The health status of jobless people is worse, they are afflicted with more diseases than those employed. In England, in 1991–1992 unemployed were found to suffer from chronic diseases with twice higher probability than those employed (Arber, 1996). In Australia the 25–64-year old unemployed men and women are in a bad state of health twice more often, have 30–40% more severe chronic diseases, and have 20–30% more new health problems than the matched control group, consequently, smoking, drinking, physical inactivity and weight gain are not responsible for these health differences (Mathers, 1994). In countries with enduring unemployment, the increased frequency of the following health effects should be anticipated:

i) psychosomatic diseases,
ii) neuroses, psychic distress, behavioral disturbances,
iii) suicide attempts, fatalities,
iv) other health effects.

i) Taking into account that frustration, anger, disappointment, fear, desolation and the stress situations, stress effects caused by them increase the frequency of ischaemic heart diseases (angina pectoris, myocardial infarction, sudden cardiac death), hypertensive diseases (Morvai, 1990), cardiovascular diseases are “expectable” consequences of unemployment. In their classic study Kasl and Cobb (1980) reported the increase of blood pressure, serum uric acid and cholesterol in employees of a shipping company in the USA, following its closedown at the end of the 1960’s. The changes of the parameters were attributed to unemployment. An increase in cardiovascular diseases was also reported by Beale and Nethercott (1985) who followed the health status of 129 former employees of an English shipping company and their families after the company closed down in 1982. Iversen et al. (1989) compared the diseases of hospitalized workers of two shipping companies, one of which was shut in 1983, while the other was continuing to operate and it was found that the risk of cardiovascular diseases increased from 0.8 to 1.6 among the workers of the company that had been closed. In their longitudinal study involving 715 shipyard workers Mattiasson et al. (1990) analyzed the effects of employment and unemployment on the risk of cardiovascular diseases. It was found that the serum cholesterol concentration increased, the serum calcium concentration decreased in the group of unemployed workers (compared to a matched control) directly before and following the factory closedown; regression analysis proved a close correlation between serum cholesterol and blood hemoglobin concentrations, body mass, serum triglyceride and serum calcium concentrations, respectively, in the groups unemployed or threatened by the loss of job; there was a positive correlation between serum cholesterol concentration and blood pressure. The authors concluded that in middle-aged men, unemployment increases the serum cholesterol concentration and the frequency and level of other cardiac risk factors and these explain the increased morbidity of the unemployed men. Other authors had similar results (Starrin et al., 1990; Catalano, 1991; Turner et al., 1991).
    Over the past few years new studies have been published on the relationship between risk factors of cardiovascular diseases and the employment situation.
    Morris et al. (1992) studied the effect of unemployment and early retirement on smoking, drinking and body weight in middle aged (40–59 years) Englishmen. According to their findings, smoking and drinking was greater among the unemployed persons just before losing their jobs than among those with continuing employment. Loss of job did not increase smoking and drinking but increased body weight. When comparing the morbidity and mortality of employed and unemployed, the long-term effects of heavy smoking and drinking before losing the job must be taken into account.
    According to a number of further studies smoking and drinking are heavier, nutrition is worse among the unemployed (Power and Estaugh, 1990; Lee et al., 1991; Bertley, 1994; Hammarstrom, 1994).
    According to the 1989–1990 National Health Study in Australia, there is a 40–50% greater chance of unemployed Australians being smokers, but they are also less inactive than the employed (Mathers, 1994).
    Lee et al. (1991) studied the smoking habits and the related health effects in 40–59 year old unemployed and full-time employed persons. There were significantly more smokers and former smokers among both male and female unemployed persons and characteristically, they began smoking at a younger age, most of them as school children. The daily number of cigarettes smoked was less in men than in women. There was no difference between the employed and unemployed groups in that respect, that both were aware of the adverse health effect of smoking.
    Grayson (1993) reported in his study that in Canada the health state of unemployed persons is much worse than that of employees, despite their significant physical activity. The beneficiary effect of physical activity may slightly ease, but is unable to compensate the adverse effects of unemployment.
    On the basis of the study conducted on 8,757 persons (345 jobless and 8,402 employees) in Austria Rusky et al. (1996) concluded that the risk situation is worse in the case of jobless persons, especially men. The jobless persons were less motivated to lose their weight, change their diet and significantly more tension, sleep disturbance occurred among them. Gastrointestinal, chronic liver and respiratory diseases were also more frequent among them and they consulted the doctor more often than those employed.
    On the basis of the abovementioned facts we consider it proven that both the imminent loss of a job (the period when the time of losing the job is known) and unemployment increase the risk of cardiovascular diseases and mortality (Fig. 2, not available on-line).
    In fact, the other two known stress-related diseases (Ink et al. 1991, Turner et al. 1991) gastric ulcer and yperthyroidism are regarded as “expectable consequences” of joblessness.
ii) The most frequent consequences and outcomes of imminent or definite unemployment are behavioral disturbances, mental damages, addiction to alcohol and drugs.
Harm to well-being, psychic distress. Usually already the imminent loss of a job, but definite unemployment will always induce these. The “unemployment psychic stress” is an obligatory disease (Bowman, 1990; Ensminger and Celentano, 1990; Hamilton et al., 1990; Westin, 1990; Berg, 1991; Laurell, 1991). The probability of this is even higher in our country, because neither society, nor the individual was (are) prepared for rational behavior in unemployment situations. In Hungary, unemployment was, is (may be) accompanied by more negative psychic effects, because it is not a consequence of structural changes due to technical development (where planned schemes for job change are available), but the “result” of the dismantling of obsolete, uneconomic technologies and nothing “at hand” to switch to. The new situation was unexpected for the people losing their jobs and for their families – especially in the first years of the decade – they did not have, and do not have even today, appropriate resources, and have sizeable debts, because they felt their job was more secure than working in the “black” or “gray” economy, which many others had been doing. This (may) result in a paradox situation: the escape from unemployment (learning a new vocation, starting an enterprise) is mentally less tempting for many people, for quite a large portion of the population (because of its novelty and the unpreparedness of the individuals), than continuing with the “old” way of moonlighting, or joining the “black” economy.

Fig. 2. Hypothetical mechanism of ischaemic heart disease in unemployment (not available on-line)
The increased frequency of hypertension and hypercholestolaemia (major risk factors) among unemployed persons explains the fact that unemployment increases the risk of ischaemic heart disease. The schematic figure demonstrates a postulated, possible way of causing ischaemic heart disease by unemployment.

    In Germany, psychological distress was more frequent in 45-year old men and this decreased with re-employment (Frese and Mohr, 1987). In Australia, a number of studies demonstrated that the psychological health status of young jobless people was worse than that of the employed. When these people found a job, their mental health improved (Graetz, 1993; Morrell et al., 1994).
    The nature of damages depends on the age of the unemployed. It was observed by Broomhall and Winefield (1990) that the most important issue for young unemployed persons is the quality of social support, whereas for middle-aged men it is leisure activity that follows work. These authors also found that the mental health of middle-aged unemployed persons is far worse than that of the young ones, they are less contented with life than the young persons, but their longing for work is stronger. It is known from the study of Winefield and Tiggeman (1990) that the damage to well-being and the intensity of psychic distress depend also on the duration of unemployment. The distress peaks in the sixth month of unemployment.
    Unemployment often leads to a special type of damage of the personality: in addition to worry, irritability, decreased attention and concentration ability, it leads to uncertain life conduct, crisis of the values that guided behavior earlier, and the development and embedding of neurotic reactions (Berg, 1991; Laurell, 1991; Turner, 1991; Vinokur et al., 1991). In developed countries, the unemployed person is guided by the advisory network from the loss of his or her job to the new work place. In Hungary, the mental-hygienic assistance and therapeutic activities of consultants (and trained psychologists) are badly needed among the unemployed (the training of such consultants began in 1992).
    A new friend or a new school for learning a new profession may cause depression in the unemployed (Adams and Adams, 1991). Questionnaire-interview surveys proved that in the families of unemployed persons quarrels are two-three times more frequent than in the families of persons in employment (Iversen et al., 1989).
    Surprisingly few studies are available on the effects of unemployment on the health of the family members. In England a 20% higher mortality was found among the wives of the unemployed. Other unfavorable effects of unemployment on the family are the following: divorce, aggression at home, unwanted pregnancy, increased perinatal and new-born mortality, unsatisfactory growth of children, seeking medical care frequently (Smith, 1987; Dooley et al., 1996; Shortt, 1996). In Australia, the children of unemployed parents have 26% more chronic illnesses and see the doctor 20–30% more often than children with at least one employed parent (Mathers and Schofield, 1998).
    Several studies have demonstrated a connection between unemployment and neurosis (Rodgers, 1991), depression, as well as abuse (Dooley et al., 1996). The psychological health status of the unemployed was found to be worse than that of employed in cross-sectional and longitudinal studies. A prospective study in the USA demonstrated, that depression and anxiety are more frequent in 35–60-year old men who lost their job, than in those employed (Linn et al., 1985).
    The risk of developing depressive symptoms and clinical depression increase twofold in those persons who lost their job, compared to those who remained employed (Dooley et al., 1994). The most recent studies in Canada proved a relationship between unemployment and mental health (Hamilton et al., 1997). According to the results, good mental health status had a favorable effect on employability. Having a job improved the mental health status of the individuals, while unemployment had a detrimental effect on it.
    Unemployment is more frequent among the following demographic groups: young, old, low income, immigrant, native and unskilled. The health status is even worse in the groups with unfavorable social/economic status within the unemployed people (Arber, 1996). This can be attributed to the smaller chance of re-employment and worse financial situation of the unskilled, which make it impossible to combat the effects of unemployment.
    The risk of mental health damage is greater among unemployed middle-aged men. The health status of unemployed women is not so bad as that of men and they have less risk factors (Mathers, 1994; Arber, 1996). Hammarstrom (1994) – who analyzed the health effects of unemployment among young people – found a stable relationship between unemployment and psychic disorders and illnesses especially among young girls.
    According to Turner (1995), the two main components of stress caused by unemployment are:
a) financial tension, which is stronger among the individuals with low social/economic status;
b) impairment of self-respect, which is characteristic of the victims of unemployment with higher status.
    Based on the above, it can be concluded that imminent or definite unemployment increases the risk of psychic damage, has a detrimental effect on well-being, and thus has adverse health effects.
    Alcohol abuse, drug-addiction. The frequency of addiction among the unemployed is high. The aim of excess drinking among the unemployed is usually problem-solving, the majority of them are “problem drinkers” with the exception of those who lost their jobs due to alcohol-dependence itself (alcohol-dependent drinkers) (Morvai, 1978).
    The clinically significant consumption of alcohol is more frequent among those who lost their job (Catalano et al., 1993; Claussen and Aasland, 1993).
    Regardless of the causes of drinking, the organic damages caused by alcohol are the same in drinkers, whether unemployed or not (Power and Estaugh, 1990; Ink et al., 1991; Catalano, 1991). Unfortunately, alcoholism is more frequent among long-term unemployed young people (Temple et al., 1991). It is also a known characteristic that – although they usually drink more frequently and more than those employed – a higher percent of unemployed declare themselves non-drinkers than those employed (Lee et al., 1990).
    It is proven that unemployment is a risk indicator of excess alcohol consumption, especially in young people, furthermore, it shows a positive correlation with excess smoking and drug-abuse. Mortality rate of young unemployed men and women is significantly higher than that of those employed, mortality due to suicide and accidents is especially high (Hammarstrom, 1994).
    Drug addiction is a much greater threat to the unemployed than to employed people. Unemployed groups of heroine (Hermalin et al., 1990), opiate (Segest et al., 1990), marihuana (Hamid, 1991), and other drug abusers (Solstad et al., 1990) have been described. More precisely: a large proportion of those addicted to the aforementioned drugs is always unemployed. There is an increased danger of HIV infection, too, among the drug addicted unemployed people (Hammond et al., 1991; Vergare de Campos et al., 1991).
    iii) One of the most serious and certainly the most dramatic outcomes of unemployment is the increased frequency of suicide attempts and suicide (Bánfalvy, 1989; Segest et al., 1990). Bánfalvy (1989) cited a shocking series of data from the former West Germany (Federal Republic of Germany). In the FRG, in 1968 the number of suicide attempts was 98 for 100 thousand employed workers, while the same number for the unemployed was 2,848. That is, the number of suicide attempts was more than 29 times higher among the unemployed than the employed. Though this number decreased to 1,149 by 1983, due to the social protective network developed in the FRG and the significant adapting abilities of the otherwise both physically and mentally fragile person, but the frequency of suicide attempts was still ten times higher than among the employed (110 annually).
    Owing to the detailed analysis of recent years, the opinion on the increased frequency of suicide attempts among the unemployed became more complex. Crombie (1990) compared the rate of unemployment among suicide victims in 16 countries between 1973 and 1983. He found that the number of unemployed increased in all 16 countries. In those countries where suicide frequency increased, the increment did not exhibit a steady relationship with the rate of unemployment. He demonstrated also that unemployment influenced suicide attempts among males more significantly than among females. Kreitman et al. (1991) found increased frequency of suicide attempts only among middle-aged unemployed persons. The results of Crombie (1990) and Kreitman et al. (1991) explain the results of Reinfurt et al. (1991) who did not find any proof of increased frequency of suicide attempts in a group of dock-workers who had lost their jobs. The observation of Velamoor and Cernovsky (1990) – according to which groups of employed and unemployed persons surviving suicide attempts behave similarly – may be important from the point of view of predictability of repeated suicide attempts.
    Morrell et al. (1993) reviewed the suicide cases between 1907 and 1990 in Australia. It was found that suicide rate among women was equal during this period, while that of men showed fluctuation with peaks in synchrony with the periods of higher unemployment rate. Recently, in 1966 and 1990, the relationship between suicide and unemployment proved to be strongly significant among 15–24-year old men.
    Yang and Lester (1992) studied the monthly number of suicides and murders between 1957 and 1987, using multiple regression analysis. According to their results, these are in positive correlation with unemployment.
    Cases and Harford (1998) studied the relationship between alcohol consumption and suicide deaths in the USA between 1934 and 1987. They found that while in the population as a whole there was no significant relationship between drinking and suicide, the amount of alcohol consumed per person was significantly related to the increase of suicide rate among the unemployed. This relationship could be observed both in men and women, both in young (below 40 years) and in middle-aged persons (40–59 years), but could not be observed above the age of 60 years.
    No matter how complex a picture is given on the suicide rate among the unemployed in most of the papers published between 1990 and 1993, it seems unanimously proven – at least in the case of some of the endangered categories – that unemployment increases the risk and frequency of suicide attempts and deaths (Table 5).
 

    In the 1970’s Brenner (1977, 1979, 1987) demonstrated a relationship between unemployment and mortality rates for a 40-year-period, in several countries. As other causes might have played a part in the increase of mortality, these studies were sharply criticized (Smith, 1987; Shortt, 1996). More convincing data were supplied as proof of the relationship by the longitudinal studies done in the 1980s. Moser et al. (1987, 1990) used the 1% sample of the census in 1971 and 1981 to analyze the mortality of unemployed men in England and Wales. In both samples the mortality of those employed was lower than the average (“healthy worker effect”). Mortality of previously ill or disabled unemployed was three times higher than the average. Those who were unemployed but were not ill during the first census had a 37% higher mortality during the next 10 years.
    Morris et al. (1994) studied the effect of unemployment and early retirement on mortality in middle-aged Englishmen. They found that the men who became jobless within five years following the first screening, died during the next five and a half years with twice the probability of those who remained employed (relative risk: 2.13). After correcting the results for social and economic factors (dwelling place, social class) and for health related life style factors (smoking, drinking and body weight) the relative risk slightly decreased, to 1.95. The mortality of men retired early but not because of illness increased also compared to those who continued to work (relative risk: 1.87). They concluded that the mortality risk of middle-aged, jobless men increased, even after correction for background variables, so the causative relationship was proved. Tumors and cardiovascular diseases were responsible for the increased mortality. Other studies also found significantly increased mortality among middle-aged unemployed men (Mathers, 1994; Arber, 1996).
    The prospective epidemiological study of Martikainen and Valkonen (1996) analyzed the data of 2.5 million 25–59-year old Finnish men, between 1987 and 1992, a period when unemployment significantly increased in Finland. During the examined period they found an increased mortality among the unemployed compared to the employed after correcting for age, education, profession and marital status.
    Stefansson (1991) studied the mortality data of 28,846 unemployed men and women in Sweden, between 1980 and 1986. The total mortality rate was 1.37–1.6 for men and 1.4 for women. The relative mortality of young/middle-aged men was four times that of all men.

iv) Other health effects. Some other – mainly not satisfactorily proven – health effects were also related to unemployment.
Respiratory system. Kogevinas et al. (1998) studied the respiratory symptoms, lung function and frequency of medical treatment of unemployed and employed men in Spain, where the rate of unemployment was high. In 1993 179 unemployed and 1,868 employed 20–44-year old persons were compared. Bronchitis was more frequent among the unemployed. This was in relationship partly with the more frequent smoking, the worse social status and the earlier occupational exposure. There was no difference among the two groups regarding asthmatic symptoms, atopy and lung function tests, or the frequency of medical treatments.
Offspring damaging effect. Among these we mention that the body length of newborns of unemployed fathers was found to be shorter, and these children were found to be more vulnerable before reaching school age than the control children born in the families of employed parents (Rona, 1991).
Recently Japanese authors reported the newborns of jobless fathers have smaller body weight (Hiroshige et al., 1995).
Immune system. Arnetz et al. (1987) observed damage to the immune system among long-term unemployed women.
Organic nervous system damage. Gronning et al. (1990) reported a relationship between unemployment and the risk of sclerosis multiplex.
Locomotor system. The unemployed often complain about “low-back pain” and this disease – always accompanied by nervous, psychic complaints – is often responsible for the more frequent and longer sick leave of unemployed persons (Clemmer and Mohr, 1991; Greenough and Fraser, 1991).
Adaptation problems. Hamilton et al. (1997), as well as Bowman (1990) called attention to the fact that unskilled young black groups are more sensitive to the psychic and other damaging effects that accompany unemployment and their adaptation to it is deficient. Bowman (1990) attributes this to the unavailability of earlier experiences of success for possible use when it is most needed. These young people soon became discouraged during job hunting and often blame themselves. This problem likely arises in all those countries where unemployment affects a minority or ethnic group similarly to the way it affects the black minority in the USA. Presumably we also have to face this problem among the Gypsy population in Hungary and we must strive to find a solution.
    Taking into account that in Hungary the mortality due to cardiovascular diseases is higher than in any of the industrialized countries, furthermore, that alcoholism is widespread and the suicide rate has been one of the highest in Europe for more than 100 years, we think that adverse health effects of mass unemployment may be more serious than in other countries and may pose public health problems. Special attention must be paid to this presumed consequence even if it is not advisable to apply directly to Hungary the conclusions drawn from the adverse health effects of unemployment observed in the developed industrialized countries.
 

ABOUT THE HEALTH STATUS OF UNEMPLOYED IN HUNGARY

    No publications were available on the relationship between unemployment and detrimental health effects in Hungary until 1993 (Ungváry, 1993). Reports on the health status of a greater number of unemployed persons were published based on the experiences gained in the József Fodor National Center of Public Health during the pre-employment medical examinations of those recruited to work in Tengiz (Ungváry et al., 1997). Between 6 July 1993 and 30 November 1994, 4,085 mostly unemployed “workers” were subjected to pre-employment medical examinations at our Institute; these persons wanted to get jobs in Tengiz (Kazakhstan), as employees of Hungarian and Western European or Canadian firms at the construction of different projects (oil refineries, trade units, hospitals, airports). During the examinations occupational and demographic data (occupational history, occupational disease, cases of increased exposure, lifestyle factors – drinking, drug use, smoking, eating, physical exercise habits, dwelling place, education, vocational training) were registered. In addition to these, family and personal anamnesis, physical and instrumental examinations necessary to decide upon the fitness for the job, were performed.
    The fitness of a worker for the job was decided upon the basis of the findings of a specialist physician at level I. If the worker was decided “unfit” at level I and appealed, the case was decided by the level II Committee, consisting of a specialist for internal diseases, an occupational health specialistphysician and an expert on tropical issues. This committee was entitled to evaluate the abnormal findings.
Demographic data. Of the 4,085 persons 94.5% were males with an average age of 34.9 (18–60) years, the average age of women was 31.8 (18–55) years.
According to dwelling place, 11.8% (483) of the examined population were living in Budapest, while 88.2% of them were living in rural areas.
Life-style habits. Among the examined job hunters there were 2,246 smokers smoking more than 10 cigarettes daily.
Alcohol was consumed occasionally or regularly by 70.9% of the examinees – 64.6%, 26.8% and 8.6% drank beer, wine and spirits, respectively.
Jobs. Males applied most often for the following jobs: tinsmith, engine fitter, locksmith, carpenter, driver, pipe fitter, welder, insulator, operator of heavy machinery, painter, construction worker. Women sought jobs as kitchen aids, cleaning women.
Fitness for work. At the level I and II examinations 3,101 (75.9%) persons of the 4,085 examined proved to be fit for the job and 619 (15.2%) were found unfit; 365 (8.9%) waited for control examination or did not finish the tests at the time of writing the report.
Chronic diseases or alterations diagnosed during the pre-employment medical examinations. Among the 3,860 men examined 1,573 (40.8%), among the 225 women 68 (30.2%) suffered from one or more chronic diseases and/or had at least one abnormal laboratory test value. Their average age was 37.33 for men and 34.85 for women.
    Chronic diseases according to ICD classification. The “unfit” classifications were caused mainly by chronic alterations, symptoms and diseases. Table 6 demonstrates the diseases diagnosed and/or abnormal test results found during the pre-employment medical examinations according to ICD classification.
 
 

    The disease pattern of the population which worked earlier in the construction sector and had been unemployed for a few months to a maximum of 2 years correlates only partly with the disease pattern characteristic to unemployed populations according to the summary of the international literature. The number and rate of those suffering from cardiovasculardiseases is significant in accordance with the international data. These diseases were observed in 20% of all cases. It should be noted, however, that this rate is only slightly higher than the same rate observed among people with similar occupations, dwelling places and ages who had a job.
    This high disease rate is probably related to the Hungarian lifestyle; during the short period of unemployment the frequency of cardiovascular diseases did not increase significantly, unemployment and lifestyle having parallel effects. It deserves emphasis that in 185 cases the blood pressure was higher than 160/95 mmHg.
    The number and rate of behavioral disorders (mental disease, depression) increased in accordance with the international data. Still much more cases of alcoholism occurred among the examined. The fact that following level I examinations, out of the 1,691 candidates who were deemed unfit, 898 (70% of those appealing) became fit-for-work, indicates that alcohol consumption was related with unemployment and hopelessness. The hope of getting a job was enough for the candidates to endure the alcohol-free diet and at the second examination, 8–12 weeks after the first one, they became “fit-for-work” – with normal liver function tests.
    From this study no conclusion could be drawn regarding the most serious health damaging behavior related to unemployment – suicide attempts and the mortality among unemployed – owing to the unsuitability of the study protocol designed for other purposes.
    The No 27/1996 Decree of Hungary’s Minister of Welfare requires that special consultations must be operated in the area of occupational health with the tasks of performing medical examinations prior to vocational training before accepting the applicants to the school and pre-employment medical examinations of unemployed persons before assignment to perform public work. The six special consultations in Budapest are located in the Hungarian Institute of Occupational Health of the József Fodor National Center of Public Health and three of them are operated in the central building of the Institute providing for the Northern part of Budapest. These special consultations began their work with full intensity in 1998; 1,160 unemployed persons were examined between 2 January and 30 June 1998. One-tenth of the examined persons were less than 25 years of age, half of them were more than 40 years of age; women made up 30% of those younger than 25 years, 70% of those between 25 and 40 years of age, and 50% of those older than 40 years. There were a high number of people who were illiterate or had less than 8 years of schooling (6.8%); 50% had 8 years of education, 30.2% had received vocational training, 17.4% had a secondary school education and 3.4% had college or university degrees (most of the latter were alcoholics).
    With the exception of those younger than 25 years, the examined persons had been unemployed for more than two years.
    Compared to the institute’s control, the following diseases were found to be in correlation with unemployment in the examined population:
Skin diseases. 12.5% of all examinees suffered from skin mycoses or pyodermas (Erdélyi, 1998). The latter is probably in connection with bad hygienic conditions. (Note: the rate of skin diseases was less than 1% among those who were unemployed for a shorter period, cf. Ungváry et al., 1997).
Cardiovascular system. The rate of hypertension among the 18–39 year-old men doubled, among the unemployed women and 40–55 year-old men, it was similar to the national average (Erdélyi, 1998).
Behavioral disturbances, suicides. In 5.5% of the cases it was revealed that the parents, one of the parents or the subjects themselves had already attempted suicide. Less than 1% of the Hungarian population attempts suicide once or more times during their lifetimes (Erdélyi, 1998).
Alcohol consumption. Frequent and high-volume alcohol consumption was indicated by the increased frequency of positive liver function test results and increased red cell volume. The examinations carried out so far need completion regarding alcohol consumption (Erdélyi, 1998).
    Similar information was received on the health status of unemployed persons in Hajdú-Bihar county at the Congress of the Society of Hungarian Occupational Health Physicians in 1998 (Tóth, 1998).
    In Hungary, the examination of the health status of unemployed persons started with appropriate intensity in January 1998. Comprehensive analysis of these data is the task of the coming years. Owing to the mandatory pre-employment and fitness-for-job examinations, the Hungarian studies involve a greater proportion (and number) of unemployed than any other study available in the international literature. In drawing conclusions from the analysis of these data, one must take into account that no matter how great a number of unemployed are involved in these studies, they refer only to the “healthier” portion of all unemployed. Obviously, those unemployed who do not feel themselves fit for work due to their illness, will not undergo fitness-for-work examinations. The health alterations identified at these examinations in increased numbers in the whole examined population represent only the “top of the iceberg” (upper half, third). Therefore the importance of the conclusions drawn from these data is probably greater than what follows from the data reported. This means that the quality of life of the unemployed, characterized by their health status, is worse than what the presently available Hungarian data would suggest.
    The suitability for vocational training or fitness-for-job are considered more exact characteristic parameters of the quality of life. Taking into account that the proportion of those unfit for a job among the unemployed is 30–40% – while they think themselves fit for work (healthy) – in contrast with the 0.5–3% found during the examinations of employed persons, we may conclude that unemployment significantly deteriorates the health status of workers, and is health-damaging. A similar conclusion was drawn by Mathers and Schofield in their latest review (1998).
    In summary, we may conclude that the pattern of health damage caused by unemployment in Hungary is similar to that observed in the developed, industrialized countries, but also shows differences; one such difference is the increased frequency of some diseases related to poor hygienic conditions (mycotic skin diseases and pyodermas). On the other hand, it can be stated that unemployment further deteriorates the Hungarian public health situation (increases the rate of chronic, non-communicable diseases) and reduces the chance of people being fit-for-work. Therefore, unemployment is considered to be one of the most significant factors of deterioration of the quality of life.

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