Illness imposes a number of costs on the individuals who suffer the illnesses, their families and loved ones, their coworkers, and, more broadly, society as a whole. When estimating the social costs of illness, both in general and with regard to specific diseases or unhealthy behaviors, health economists and others focus on two categories of costs: medical expenditures required to treat the conditions, referred to as direct costs; and productivity losses associated with the conditions, called indirect costs. Indirect costs, often the larger of the two burdens, consist of productivity lost due to the premature deaths of disease victims and to morbidity (sickness) and disability that cause victims to miss work days.
Absenteeism is the term used to describe the fact of an individual's missing his or her regular daily activity. For children and adolescents, absenteeism typically refers to school days missed. For adults, absenteeism generally refers to individuals' absence from their jobs. In analyses of the indirect costs of all illness, all days of absence from work
The costs associated with absenteeism are estimated by multiplying the number of days of absenteeism by the best measure of workers' contribution to productivity: their daily wage rate. In the case of conditions that are distributed among the population reasonably independent of people's age and occupational status, an average wage rate for the population as a whole may be applied. In the case of many illnesses, however, the distribution of the conditions is not independent of age and occupation. In these instances, analysts attempt to associate age-and occupation-specific wage rates with the days of work missed due to morbidity or disability. For example, were one interested in assessing the costs associated with back pain, one of the most common causes of work loss in America, one would emphasize wage rates paid to industrial and other blue-collar workers whose jobs require them to lift and move heavy objects. An analysis of the social costs of breast cancer, a disease that afflicts primarily women, would utilize wages earned by women in calculating the burden of absenteeism attributable to the disease.
Not all disease-related work loss occurs among paid workers. Conditions that afflict people caring for their children or cleaning their homes also impose costs on society. A complete estimate of the burden of disease must account for absenteeism in this sector of the society as well. Formal analyses often include unpaid work loss by multiplying days lost by what economists call a "shadow price," an estimate of the value of the unpaid labor performed. For example, unpaid child care may be valued at the wages of paid day-care providers. Similarly, housework time lost may be valued by the wage rate of paid domestic house cleaners.
Although there is no argument about whether absenteeism imposes a significant cost on members of society, economists and public health analysts frequently differ on whether they consider such absenteeism a social cost. To public health analysts, illness-and injury-related absenteeism represents a burden on society as a whole, a social cost of enormous proportions. In contrast, to economists such productivity losses represent primarily private costs borne directly by the sick and disabled workers and their families, not the broader society. How one classifies such costs is not merely an academic exercise. Certain public health policies, such as the taxation of cigarettes and alcoholic beverages, are based in part on determination of the social cost of the consumption of these products. If the cost to society is deemed large, a high tax may be warranted to signal smokers and drinkers that the implications of their behaviors burden the rest of society, not merely themselves.
However this argument is resolved, no one challenges the notion that illness-and behavior related absenteeism constitutes an important element of the burden of disease.
KENNETH E. WARNER
Cook, P. J. (1991). "The Social Costs of Drinking." In The Negative Social Consequences of Alcohol Use. Oslo, Norway: Norwegian Ministry of Health and Social Affairs.
Deyo, R. A.; Cherkin, D.; Conrad, D.; and Volinn, E. (1991). "Cost, Controversy, Crisis: Low Back Pain and the Health of the Public." Annual Review of Public Health. 12:141–156.
Gold, M. R.; Siegel, J. E.; Russell, L. B.; and Weinstein, M. C. (1996). Cost-Effectiveness in Health and Medicine. New York: Oxford University Press.
Warner, K. E.; Chaloupka, F. J.; Cook, P. J.; Manning, W. G.; Newhouse, J. P.; Novotny, T. E.; Schelling, T. C.; and Townsend, J. (1995). "Criteria for Determining an Optimal Cigarette Tax: The Economist's Perspective." Tobacco Control 4:380–386.