Brian Easton, Larry Burd, Jürgen Rehm, and Svetlana Popova
Abstract
Aim To estimate the
productivity losses due to morbidity and premature mortality of individuals
with Fetal Alcohol Spectrum Disorder (FASD) in New Zealand (NZ).
Methods A demographic
approach with a counterfactual scenario in which nobody in NZ is born with FASD
was used. Estimates were calculated using data for 2013 on the population of NZ,
the labour force, unemployment rate, and the average weekly wage, all of which
were obtained from Statistics NZ.
In order to
estimate the number of FASD cases in 2013 and the related morbidity, the
prevalence of FASD, obtained from the available epidemiological literature, was
applied to the general population of NZ. Assumptions made on the level of
impairment that would affect the ability of individuals with FASD to
participate in the workforce or reduce their productivity were based on data
obtained from the current epidemiological literature.
Results Around 0.03% of
the NZ workforce experiences a loss of productivity due to FASD-attributable
morbidity and premature mortality, which translates to aggregate losses ranging
from $NZ69 million to $NZ200 million in 2013. This amounts to between 0.03% and
0.9% of annual GDP.
These costs
represent estimates for lost productivity attributable to FASD and do not
include additional costs incurred by governmental and private entities
including social costs, such as both higher costs and or less effective
spending by the education, health and justice systems.
Conclusion The estimates of productivity losses further reinforce the value of FASD
prevention as a primary public health strategy.
Text
Across the
world, alcohol is the fifth leading contributor to disability and mortality.
Alcohol accounted for over 5% of worldwide mortality and for nearly 4% of
disability adjusted life years.1 Furthermore, alcohol consumption
often results in harm, not only to the drinker, but also to individuals
associated with the drinker. One example of such harm is the harm caused by
drinking during pregnancy. Prenatal alcohol consumption is an established cause
of Fetal Alcohol Spectrum Disorder (FASD). While no safe level of alcohol
exposure during pregnancy has been identified, it is widely accepted that heavy
drinking seems to confer the greatest risk of FASD.2,3 Among
individuals diagnosed with FASD, prenatal alcohol exposure results in a highly
variable expression of adverse outcomes, the term encompasses a group of
disorders where alcohol exposure can affect any organ system.3
FASD is
comprised of four categorical disorders: Fetal Alcohol Syndrome (FAS), Partial
FAS (pFAS), Alcohol-Related Neurodevelopmental Disorder (ARND) and
Alcohol-Related Birth Defects (ARBD).3,4 The FASD phenotype is
variably expressed and comorbidities are common.3,5,6,7,8,9,10 These
are highly variable disorders with age and development dependent changes in
phenotype.11,12 However, FASD is considered as a ‘hidden’ disability
and a complex diagnosis.13 Damage to the central nervous system is a
unifying concept for nearly all of the FASD diagnoses.4,12,14,15
Although no
research has confirmed the prevalence of FASD in New Zealand, it is generally
taken that the prevalence is approximately 1% of live births, which is reported
in multiple prevalence studies.16,17,18 More recent prevalence
studies have reported prevalence rates well above 1% of live births in some
locations across the world using a screening protocol for school-age children.19
Also, high risk populations with higher drinking rates have increased
likelihoods of alcohol-exposed pregnancies.20,21 These rates are
well above prevalence rates for autism spectrum disorder or Down syndrome .22
In a recent
review of mortality in individuals with FASD, the two leading causes of death
were malformations of the central nervous system and congenital cardiac
abnormalities. The three other leading causes of death were sepsis, kidney
malformations and cancer.23 This study also revealed that over half
of the reported deaths (54%) occurred in the first year of life. Other studies
have demonstrated that FASD is associated with a vast number and wide range of
health and behavioural problems including increased premature mortality rates
compared to the general population.3,5,6,7,8,9,24
The phenotype
for FASD is highly variable and as affected people age, the rates of
comorbidity tend to increase which increases phenotype complexity and severity.6
Because of
difficulties ‘fitting into’ mainstream life, the attempted suicide rate is
reported to be higher among persons with FASD (22%) as compared to the rate of
the general US adult population (3%), and among persons with intellectual
disabilities (8%).25
Thus, since
FASD begins in the prenatal period, the disorders cause a large burden of
lifelong duration on society. The costs change across age groups and only
recently have costs incurred by adolescents and adults been considered. The costs in this age group are incurred
primarily through the health care system, mental health and substance abuse
treatment services, criminal justice system, and the long-term care of
individuals with intellectual and physical disabilities.2,3,26,27,28,29,30,31,32,33,34,35,36,37,38
A significant
portion of the societal economic burden from FASD results from lost productivity
and decreased participation in the workforce including that resulting from
early mortality. Surprisingly, given its significance, the existing cost
estimates of FASD have neglected to examine the productivity losses caused by
reduced participation in the workforce .27,30,39,40,41
FASD has not
yet emerged as a public health priority in New Zealand although the Ministry of
Health is paying more attention to it. Canada already has placed importance on
this issue.17,26,31,32,33,34,35,36,37,38,42,43 The Canadian approach
is due in part to the recognition of the costs associated with the care and
services required by individuals with FASD, but also due to the increased
awareness of the potential to reduce these costs by implementing effective
prevention programs.40 Prevention efforts need to focus on reducing
the number of affected individuals, the severity of the resulting impairments,
and the premature mortality due to prenatal alcohol exposure.6,8,26
These efforts could be accomplished by eliminating prenatal alcohol exposure
or, at the very least, by reducing the number of women who drink heavily during
pregnancy.
The purpose of
this study was to estimate the productivity losses of individuals with FASD due
to morbidity and premature mortality as one aspect of the total costs of FASD
in New Zealand.
Method
The Counterfactual Scenario All cost estimates involve a counterfactual scenario,
which compares the actual state of affairs with an alternative one, the costs
reflecting the economic differences between them valued at appropriate prices.
This report
adopts a counterfactual scenario in which no individual in the population was
born with FASD. It uses the ‘demographic’ method,44 and focuses only
on the impact of market production (the productivity loss) from the morbidity
and premature mortality of individuals with FASD.
This
counterfactual scenario was chosen because it is readily understandable and
because it and its consequential estimation method involves fewer – often
contentious – assumptions. It avoids some of the issues, which bedevil the
estimation of social costs such as how to deal with inflation, economic change
and time discounting. It produces a spot estimate for a particular year (2013)
as the result of effects back through time, instead of the outcome through time
(possibly discounted to a single aggregate) of the effects in a particular
year. A consequence of this particular counterfactual is that the total will
vary through time as a result of economic and population change, and it takes
into consideration the business cycle (unemployment) and price changes
(inflation). However in the medium term these will not change the order of
magnitude.
An alternative
approach to the ‘demographic’ approach is the ‘human’ capital one, which would
be more applicable if the alternative scenario involved a phasing out of FASD
(say as an effective prevention program was introduced over time). In effect
the counterfactual scenario used here assumes an effective program was
introduced many decades ago; the estimate represents the long-term equilibrium.
It may be taken as an indication of the eventual long term productivity gains
from effective prevention.
Population estimates of individuals with FASD New Zealand data on population of the labor force, unemployment rate,
and the average weekly wage were obtained from Statistics New Zealand for the
most recent available year (i.e., 2013).45
For the purpose
of this analysis, three groups of individuals with: 1) Fetal Alcohol Syndrome
(FAS; the most recognisable form of FASD); 2) other-FASD (pFAS, ARND and ARBD);
and 3) FASD overall (FAS, pFAS, ARND, and ARBD) were analysed separately.
In order to
estimate the number of individuals with FAS and other-FASD, the most commonly
cited prevalence of FAS (0.1%)17 and FASD
(0.9%)18 in North America was applied to the general population of
New Zealand in 2013.
All cost
figures are presented in New Zealand dollars for the 2013 year.
Severity levels of intellectual impairment
attributable to FASD As described in Easton et al.,45 population estimates of
individuals with FASD can be stratified by the severity levels of intellectual
impairment attributable to FASD, in order to account the impact of the severity
on the level of participation in the workforce and productivity of individuals
with FASD. Please note that the disabilities attributed to birth defects,
vision or hearing problems or any other physical disabilities were not
accounted.
The individuals
with FAS and with other-FASD will have multiple areas of brain impairment when
measured on standardised tests. For the
purposes of this study, the relevant impairment will be represented by the
domain of intellectual impairment. The
individuals with FASD can be classified into four groups according to severity
level of impairment.47
1) Broad cognitive impairment (does
not meet criteria for intellectual disability). The term minimal brain
dysfunction (MBD) has also been used previously to describe this population.
This category might include individuals with learning disabilities, speech and
language disorders, attention deficit hyperactivity disorder, and other similar
disorders.
2) Mild intellectual disability.
Previously known as mild mental retardation and includes individuals with an
Intelligence Quotient (IQ) and adaptive behaviour scores between 50-75.
Individuals under this category can often acquire academic skills up to the 6th
grade level. They can become fairly self-sufficient and in some cases live
independently, with episodic or ongoing community and social supports.
3) Moderate intellectual
disability. Individuals who have an IQ and adaptive behaviour score of
35-49. They can typically carry out work and self-care tasks with ongoing
supervision at moderate levels. They typically acquire communication skills in
childhood and are able to live and function successfully within the community
in a staffed and supervised environment such as a group home.
4) Severe intellectual disability.
Individuals with an IQ and adaptive behaviour score below 35. Such individuals
may master very basic self-care skills and some communication skills. Their
intellectual disability is often accompanied by neurological disorders, and
they most commonly require continuous supervision, assistance and high levels
of structure.
The
distribution of the levels of mental impairment severity among individuals with
other-FASD was assumed to be the same as that for individuals with FAS [50%
with broad cognitive impairment; 33% with mild intellectual disability; 12%
with moderate intellectual disability; and 5% with severe intellectual
disability.
Further, it was
assumed that 100% of individuals with FAS are impaired and only about 25% of
individuals with other-FASD are impaired. As a result, it was assumed that
these individuals would have different levels of reduction in productivity due
to their intellectual impairment.
The percent
reduction in productivity of individuals with FAS and other-FASD was adapted
from Harwood et al.47 and modified based on experts’ opinion.
Mortality As described above, individuals with FASD have higher mortality. The
effects can be measured by using cause-of-death data combined with a pooled
prevalence estimates of the major disease conditions associated with FASD
obtained from a recent meta-analysis conducted by Popova and colleagues.10
For a detailed methodology on estimation productivity losses due to premature
mortality of individuals with FASD please see Easton et al.48
However it is
unnecessary to add a separate assessment for the purposes of this paper.
Assuming that the rates at birth are the ones assumed (i.e. 1 percent of the
cohort), then the rates in the labour force will be smaller (because of the
higher mortality rate). The counterfactual requires the addition of those who
die to the labour force. Subject to a very small effect, this is equivalent to
assuming that the rate for the labour force is the same as the rate for the
birth effect. Ignoring this small difference means the estimates provided here
are slightly on the conservative side.
Results
Population estimates of individuals with FASD
Using data on
the general population in New Zealand – 4.43 million in 2013 and assuming a
prevalence of 0.1% for FAS and 0.9% for other-FASD, the number of individuals
with FASD was estimated as follows: 4,400 individuals with FAS, 39,900 with
other-FASD, for a combined total of 44,300 individuals with FASD in New Zealand
in 2013 (Table 1).
– Please insert Table 1 about here –
Approximately
54.4% (2.41 million) of New Zealand’s general population participated in the
paid labour force in 2013. By applying this percentage to the number of
individuals with FASD, it was estimated that about 24,100 individuals with FASD
were in the New Zealand labour force in 2013. Based on the assumption that all
individuals with FAS and 25% of individuals with other-FASD have some level of
intellectual impairment, it was estimated that 7.800 individuals with FASD who
are in the work force have decreased productivity (Table 2).
– Please insert Table 2 about here –
Productivity losses of individuals with FASD
due to morbidity It was assumed that the level of intellectual impairment was directly
related to the magnitude of productivity losses of individuals with FASD. Table
2 presents the proportions of individuals with FASD by the levels of
intellectual impairment, as well as the lower and upper boundary for their
percent reduction in productivity by categorical level of impairment. In order
to estimate a weighted average of the lower (24%) and the upper (50%)
boundaries, the percent reductions in productivity were combined across
severity levels and weighted by the number of individuals in each respective
group (Table 2).
Since 6.2% of
the labour force was unemployed, the estimated loss of productivity by the
effective workforce was applied to only 93.8% of those with FASD who were
assumed to be in the labour force (the workforce equals the labour force minus? those unemployed).
Estimating the effect of the counterfactual
scenario of no FASD in New Zealand If there were no cases of FASD in New Zealand (the
counterfactual scenario), then the effective workforce would increase by the
equivalent of 1,760 to 3,660 workers (these numbers are derived by applying a
weighted average of reduction in productivity (24% and 50%; Table 2) to the
number of individuals with FASD with compromised productivity within the
workforce– i.e. the labour force minus? the unemployed: about 7,300 people (Table 1). The
additional (effective) workers represent a boost to the workforce of 2.26
million individuals in 2013, which account for an increase in the New Zealand
workforce between 0.08% and 0.16% (if, as the counterfactual scenario posits,
there were no cases of FASD in New Zealand) (Table 3).
– Please insert Table 3 about here –
Estimated value of the productivity losses of
individuals with FASD due to morbidity The estimates of productivity losses resulting from
decreased labour force participation can then be converted into dollar value by
multiplying the effective reduction in the number of participating workers with
FASD by their marginal dollar product. The standard assumption is that a
worker’s marginal product is comparable to the average wage.44
The average
weekly wage (ordinary plus overtime) in New Zealand was $1,066, which is
equivalent to $55,600 per year. However, it could be argued that the average
worker with FASD comes from a more socially deprived background with a lower
average wage than a typical member of the labour force. In order to provide the
most conservative estimate, it was assumed that, as a ‘low’ estimate, the
actual wages for a person from a background that generates FASD is 29% lower
than average, or $39,500 annually. This discount was calculated by noting that
the New Zealand minimum wage is approximately 42 percent of the average wage,
and by taking the midpoint between the two (71% of the average wage).. This
amounts to an average annual reduction of $3.200 to $9.230 for each worker with
FASD (including those unemployed). This represents 7.8% to 16.2% of the wages
they would earn if they did not have FASD. When this wage is applied to the
difference in the effective workforce, the estimated national income of New
Zealand would increase between $69 million and $200 million, if New Zealand had
no cases of FASD.
Discussion
Conservatively,
around 0.03% of the New Zealand workforce experiences a loss of productivity
due to FASD-attributable morbidity and premature mortality. This markedly
reduces their remuneration and, consequently, the overall productivity of the
New Zealand economy. The immediate effect of FASD-attributable morbidity and
premature mortality is confined to a small proportion of the population; the
estimated aggregate loss ranged from $69 million to $200 million in New Zealand
in 2013.
These estimates
of productivity losses due to morbidity and premature mortality attributable to
FASD are, by design, equally conservative in terms of the total social costs of
FASD. They do not include the additional productivity losses of those caring for
individuals with FASD who are unable to work in the paid labour force due to
their caregiving or from inefficient or otherwise unnecessary expenditure in
the education, health or justice systems. Without these cost pressures from
FASD, these resources could be diverted to other areas of private and public
spending in order to benefit New Zealand as a whole.
Policy makers
could utilize the estimates of productivity losses due to FASD-attributable
morbidity and premature mortality in order to evaluate the potential benefits
of FASD prevention programs. An effective prevention effort to eliminate FASD
in New Zealand which costs less than $20 million a year would produce an
economic benefit from productivity gains alone, over the long term. However,
the benefits would not accrue in total immediately, because the newly born do
not immediately enter the workforce. Prevention efforts need to include
reducing the severity of the resulting impairments of those born with FASD, and
the premature mortality due to prenatal alcohol exposure.
While these
estimates likely underestimate both the total actual costs of FASD and the
potential cost savings from effective prevention efforts, there is some level
of confidence that the estimates of the aggregate productivity losses from FASD
are within the correct range.
In terms of the
productivity losses alone, New Zealand could ultimately spend up to $190,000
per day on an effective prevention program to prevent new cases of FASD.
However the benefit to cost ratio would be considerably higher than 1, because
of the reduced (or more effective) spending in other parts of the economy such
as reduced health related costs, cost reductions in special education, and
reduced burden on corrections systems..43,49,50,51,52
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Table 1.Model
parameters for the calculation of productivity losses due to FASD-attributable
morbidity and premature mortality in New Zealand 2013
<>
|
Parameters
|
Number of individuals
|
Source
|
|
Total population in New Zealand
|
4.43 Million
|
Statistics NZ
|
|
Population participating in paid
labour force in NZ (54.2%)
|
2.41 Million
|
Statistics NZ
|
|
Population with FAS (0.1% of the
total population of NZ)
|
4400
|
PHAC, 2003
|
|
Population with other-FASD (0.9%
of the total population of NZ)
|
39900
|
Roberts and Nanson, 2000
|
|
Population with FASD (1% of the
total population of NZ)
|
44300
|
|
|
Population with FAS participating
in paid labor force (54.4% of the total population with FAS)
|
2400
|
|
|
Population with other-FASD
participating in paid labor force (54.4% of the total population with
other-FASD)
|
21700
|
|
|
Population with FASD participating
in paid labor force (54.2% of the total population with FASD)
|
24100
|
|
|
Compromised productivity of the
workforce with FAS (100% of the population with FAS participating in paid
labor force)
|
2.4
|
Expert opinion
|
|
Compromised productivity of the
workforce with other-FASD (25% of the population with other-FASD
participating in paid labor force)
|
5400
|
Expert opinion
|
|
Compromised productivity of the
workforce with FASD (sum of population with FAS and other-FASD participating
in paid labor force with compromised productivity)
|
7800
|
|
FAS: Fetal Alcohol
Syndrome
FASD: Fetal
AlcoholSpectrum Disorder
Statistics New
Zealand from Infoshare: http://www.stats.govt.nz/infoshare/50
Table 2. Percentage and number of individuals with FAS and other-FASD by level of
intellectual impairment and their percentage of reduction in productivity in
New Zealand in 2013.
<>
|
Impairment Category
|
Percentage of individuals with FAS and other-FASDa,b
|
Estimated number of individuals with FAS and
other-FASD in New Zealand
|
Percentage reduction in productivity of individuals
with FAS and other-FASD
Lower Boundary c
|
Percentage reduction in productivity of individuals
with FAS other-FASD
Upper Boundary d
|
|
Broad cognitive impairment
|
50%
|
3900
|
10%
|
40%
|
|
Mild intellectual impairment
|
33%
|
2575
|
25%
|
50%
|
|
Moderate intellectual impairment
|
12%
|
935
|
50%
|
70%
|
|
Severe intellectual impairment
|
5%
|
390
|
100%
|
100%
|
|
Total
|
|
7.,800
|
|
|
|
Weighted Average
|
|
|
24%
|
50%
|
FAS: Fetal
AlcoholSyndrome
FASD: Fetal AlcoholSpectrum
Disorder
aEstimated based
on expert opinion (Drs. Larry Burd and Albert Chudley)
bAssumption was
used that 100% of individuals with FAS are intellectually impaired and only
about 25% of individuals with other-FASD are intellectually impaired (Dr.
Albert Chudley, expert opinion)
cBased on
Harwood et al. (1984)
dEstimated based
on expert opinion (Drs. Larry Burd and Albert Chudley)
Table 3.Model of potential increases in wages using a counterfactual scenario
(no one is born with FASD) in New Zealand 2013
<>
|
|
Lower Boundary
|
Upper Boundary
|
|
Equivalent number of productivity-compromised
individuals with FASD in labour force
|
1880
|
3840
|
|
Equivalent number of
productivity-compromised individuals with FASD in work force (i.e. allowing
for unemployment)
|
1760
|
3600
|
|
Average annual wage in relevant
population of New Zealand
|
$39,480
|
$55,660
|
|
Loss of annual income per person
with FASD in labour force
|
$3,200
|
$9,230
|
|
Loss of annual income per productivity-compromised
person with FASD in labour force
|
$9,850
|
$2,840
|
|
Productivity
losses due to FASD-attributable morbidity and premature mortality (additional economy-wide income)
|
$69 Million
|
$200 Million
|
FASD: Fetal
Alcohol Spectrum Disorder
Lower bound
based on weighted average reduction in productivity of 24%; upper bound 50%
Numbers are
rounded