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- Economic crisis
- health disparities
- socioeconomic positions
- health policy
- sociocultural deter
Although still controversial, it has been suggested that overall mortality in industrialised countries tends to rise during economic expansions and fall in recessions, attributed to the boost in traffic and industrial activity and environmental pollution during economic upturns.1 However, as Tapir Granados has demonstrated using Japanese mortality statistics, suicide increases during economic crises perhaps because suicide is usually a consequence of psychological illnesses like depression directly caused by financial hardships due to unemployment or precarious employment.1 Chang et al examined the Asian Financial Crisis in 1997 and found that although economic impacts were the most severe in Thailand, Indonesia, South Korea and Malaysia, Japan showed the sharpest rise in suicide rate following the crisis and the rate has hovered at a record high to the present, despite a macroeconomic recovery afterwards.2 Here, the potential reasons for this Japanese-specific suicide trend over the past dozen years are analysed.
First, the dramatically changed employment systems in Japan through the recession period may explain this. The 1997 crises increased not only unemployment but also the working poor who lost regular employment positions, creating a novel dualism in the labour market.3 4 The share of precarious employment has changed from 20% in 1995 to 34% in 2007, and their average income is nearly half of regular workers.5 The emerging precarious employment issue was in line with the disruption of ‘traditional’ employment systems, namely, the guaranteed lifetime employment and promotion-by-age systems.
Second, even fully employed workers who have ‘survived’ the era of massive layoffs are not safe. Their workloads became strikingly high. In 2000, 28% of regular Japanese employees worked 50 h or more per week, compared to 16% to 21% in New Zealand, USA, Australia and the UK and less than 6% in 13 other industrialised nations.6 The consequence was a rise in karoshi cases - deaths from overwork - that recently reached a record high (figure 1). Karoshi statistics reflect the high levels of stress among regular workers: 31% of the victims were from professional and administrative positions; 27% from clerical, service and sales positions; and 38% from labour positions.7 Given the smaller share of higher occupational positions, actual karoshi risk among higher-status workers might be higher than the values above. A previous study also suggests that there was poorer self-rated health among higher-status workers after the crisis (while the health status of unemployed people is always worse than others, irrespective of economic conditions).8 In addition, a series of lawsuits against franchise chain companies has occurred over the last few years, filed by the families of karoshi victims who were the store managers engaged in extremely long unpaid overtime (typically more than 100 h per month). They were not paid for their overtime because they were contractually in administrative positions. Plaintiffs won in most cases, but these company scandals evoke not only distorted company-employee relationships but also a Japanese cultural background, that is, a feeling of strong responsibility among white-collar workers to their colleagues and company.
Age-specific and gender-specific statistics also provide indirect but important information on the association between deteriorated working environment and suicide. Tapir Granados showed that the economic downturns were most strongly associated with suicide of middle-aged Japanese men.1 Moreover, Chang et al indicated that although the suicide rates in all other countries in Asia have always been higher among older adults, Japan exceptionally showed a reverse in suicide rates between working-age and older people after the 1997 crisis.2 In Japan, working-age men suffered unacceptable changes in their work environment, whereas older adults might be protected by generous welfare policies including universal coverage in healthcare and pensions. Among major Asian nations, the out-of-pocket share of total healthcare spending has been the lowest in Japan.9
So far public response to the suicide issue in Japan is weak. The Basic Act of Suicide Control, established in 2006, primarily focuses on secondary prevention (ie, detection of and support for high-risk cases). As the hovering high suicide rate shows, the Act has not worked well. Meanwhile, in September 2009 Japan experienced the first ever regime change, and the current government, the Democratic Party, has announced a series of policies to strengthen social protection, including the expansion of the unemployment insurance scheme to workers in precarious employment, tighter regulations regarding temporal employment, and the upgrading of safety nets for poor families. There are criticisms to the feasibility of these challenges, but they are potentially effective as primary suicide preventions to the economically disadvantaged precarious workers and the unemployed. Nevertheless, regular workers - whose suicide and karoshi risks may not be mainly from financial problems but from deteriorated work environments and heavy workloads - may not directly benefit from these interventions. For example, although further studies are needed, innovative policies to amend the erosion of workplace social capital (eg, trust, reciprocity and interpersonal ties among colleagues)10 and stronger regulations for paid and unpaid overtime would be important.
We thank Professor Katsunori Kondo, Dr Hirohito Tsuboi, and Dr Yukari Shibata for their useful comments.
Competing interests None.
Provenance and peer review Commissioned; externally peer reviewed.
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