IJE Advance Access originally published online on November 3, 2006
International Journal of Epidemiology 2006 35(6):1398-1399; doi:10.1093/ije/dyl237
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Commentary |
Commentary: The health crisis in the USSR: looking behind the facade
Professor of European Public Health, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
E-mail: martin.mckee{at}lshtm.ac.uk
My first visit to the USSR was in February 1981, by coincidence at exactly the same time that Nick Eberstadt published a commentary on ‘The health crisis in the USSR’ in the New York Review of Books.1 The USSR was one of the two world superpowers, with enough nuclear weapons to take humanity back to the Stone Age but its enormous military capacity did not quite seem to be matched by its basic infrastructure. In all sorts of ways, such as its ability to ensure that jam was available for breakfast in our hotel, it just did not seem to be working. However it had pretensions to greatness, apparent at one of the essential stops on the tourist itinerary, the VDNKh, or Exhibition of Economic Achievements. Created first in 1939 as the All-Union Agricultural Exposition, it celebrated the successes of the USSR. There was much to celebrate. Lenin, and later Stalin, had turned a peasant economy into a major industrial power.2 During the late 1940s and 1950s industrial output rose faster than in most western countries and the achievements of the Soviet health system were lauded by some foreign commentators,3 especially in the USA where universal coverage seemed (and still does seem) an impossible dream. After the customary visits to learn about the electrification of the Soviet Union and similar successes, we managed briefly to slip away from our guide. We had been told that, as our time was limited, we would only be able to visit a few of the many pavilions. Yet when we tried to get into the others they were closed and, in some cases, empty, reminiscent of the villages constructed by Prince Grigori Potemkin to impress Catherine the Great during her visit to the Crimea in 1787. Behind the painted walls of the Potemkin's village houses and the VDNKh pavilions there was nothing. It was all a facade.
Twenty-five years later I am writing this commentary in Moscow's Hotel Cosmos, looking out of my window at VDNKh. The exhibition site has retained many of the elaborate constructions, but it has otherwise changed beyond all recognition, with pavilions converted into shops selling mobile phones, DVDs, and an astonishing array of kitsch. Perhaps this is the true economic achievement, with the free market accomplishing what the USSR could never hope to? Moscow has changed almost beyond recognition. The skyline is increasingly dominated by modern high rise buildings, competing with Stalin's 1930s architectural monstrosities such as the Hotel Ukraine. The emergence of a Russian middle class is signified by the success of IKEA; flat pack furniture is intrinsically middle class. Yet despite the outward signs of progress, all is not well and male life expectancy at birth in 2004 was 2.5 years lower than it had been in 1981.4 Women fared slightly better, but even they could expect to live one year less that in 1981. Statistics on health and on the economy still seem to be painting rather different pictures. Is today's economic success still a façade?
Eberstadt was reviewing an analysis of infant mortality in the USSR, published the previous year by Christopher Davis and Murray Feshbach.5 The Soviet statistical office had stopped disclosing mortality data in 1975, but Davis and Feshbach had carefully assembled a mass of fragmentary evidence to show that the marked improvements during the 1950s and early 1960s were now going into reverse. Davis and Feshbach limited their comments to infant mortality, but as a good reviewer Eberstadt placed their work in a wider context and argued that, when one looked carefully, the health of the USSR was in crisis.
Eberstadt was not the first to suggest that the USSR was in trouble. In 1970 the dissident Andrei Amalrik had asked ‘Will the Soviet Union Survive until 1984?’.6 Amalrik contended that the Soviet Union would eventually disintegrate in the face of irreconcilable social and ethnic tensions. He openly acknowledged that his conclusions were not based on scholarly research but rather on his own observations. Yet he also argued that these still had value to Western observers, in the same way ‘that a fish would have for an ichthyologist if it suddenly began to talk’.6 However Soviet observers in the west largely dismissed his views, swayed by extremely optimistic economic statistics. Indeed, as late as August 1991, some were maintaining their view that the Soviet Union would survive,7 a view that they only reluctantly abandoned when confronted by the news coverage of the attempted coup that sealed the fate of the Soviet Union. Of course, it is now recognized that the economic data were as much a façade as the pavilions in the VDNKh, overstating the true situation by perhaps a factor of 10.8
Eberstadt's commentary was, in retrospect, a remarkably accurate analysis of the Soviet situation, given the enormous difficulties in knowing what was happening behind the facade. He begins his review of health determinants with alcohol. This was before Gorbachev initiated his massive experiment in 1985, in which he used the full power of the Soviet system to clamp down on alcohol use with a thoroughness that few other governments could contemplate.9 Analyses of the pattern of mortality that accompanied this campaign provided the basis for much of the subsequent work on the massive contribution of alcohol to Russian mortality.10
Eberstadt also offered a remarkably insightful critique of the Soviet health care system, challenging the commentators who continued to highlight its achievements. Yet like Amalrik, his analysis was based less on statistical evidence and more on observations. As he notes, the decision to site a cardiology clinic in Moscow on top of a five-story building without a lift speaks volumes about the Soviet attitude to disability. At a time when systematic research would have been impossible, he highlights the crucial role of informal payments in distorting the provision of care. Finally, he explains why it was easier for the Soviet leadership, faced with the demands of the military industrial complex, to insidiously erode social protection while seeking to protect the supply of more visible consumer goods. As with alcohol, Eberstadt anticipated the research that, much later, would show just how far the Soviet Union was falling behind the west, as measured by deaths that could have been prevented with timely and effective care.11
Eberstadt also displays scepticism about some other putative factors. He suggests that the air pollution that accompanied rapid industrialization was unlikely to be an important cause of disease, challenging a view that is still widely held,12 instead suggesting that much greater problems might be attributable to overuse of pesticides and other chemicals, uncontrolled emissions of toxic waste and, especially presciently as he was writing 5 years before the explosion at Chernobyl, radiation releases from inadequately maintained nuclear facilities.
Eberstadt's analysis was crucial because it challenged the widespread view that the Soviet Union was secure and sustainable. However, what was even more important was that it did so from the perspective of population health rather than from an economic or geostrategic viewpoint. Much has been written about how to measure the progress of nations. In private at least, many economists will accept that gross national product (GNP), even if honestly and accurately reported, is a far from perfect measure.13,14 For most people, money has little intrinsic utility; it is only useful insofar as it can be used to purchase something that is desired. Yet, to draw on a well-known phrase, money cannot buy you health, and it is health that people often value most. It is true that greater national wealth is associated with longer life, but this is largely a function of the extent to which the additional wealth is redistributed to the poor and is spent on social protection.15 This has led some commentators, such as Amartya Sen, to advocate the use of alternative measures of progress,16 such as life expectancy or the Human Development Index, which supplements it with measures of poverty, literacy, and education. Yet even if one is determined to cling to purely economic measures of progress it is increasingly difficult to ignore the evidence that good health, like education, is an important driver of growth.17
Drawing on his analysis of the health of the Soviet people, Eberstadt produced an analysis that was much more pessimistic than the then prevailing view. He reminded us that economic and military success can be a façade, in this case obscuring an unfolding health crisis.
Despite a massive transfer of resources from its social sector to the military-industrial complex, the Soviet Union was able to survive and outwardly prosper for a further decade. In the long term, however, the façade fell away. Could this be a lesson for the current leaders of the world's remaining superpower,18 a country that can project its military power globally but still fails to provide health care for all its people?
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References |
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2 Hanson P. The rise and fall of the Soviet economy: an economic history of the USSR 1945–1991. London: Longman, 2003.
3 Sigerist HE. Medicine and Health in The Soviet Union. New York: Citadel Press, 1947.
4 World Health Organisation. Health for All Database. Copenhagen: WHO, 2006.
5 Davis C, Feshbach M. Rising Infant Mortality in The USSR in the 1970s. Washington, DC: United States Bureau of the Census, 1980.
6 Amalrik A. (1970). Will the Soviet Union Survive Until 1984? New York: Harper & Row, 1970.
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13 Cobb CW, Cobb JB. The Green National Product: A Proposed Index of Sustainable Economic Welfare. University Press of America: Lanham, MD, 1994.
14 Gutiérrez-Espeleta EE. The Approximated Sustainability Index. In MacGillivray A. (ed). Accounting for Change, vol. 2: Papers. London: New Economics Foundation, 1995.
15 Anand S, Ravillion M. Human development in poor countries: on the role of private incomes and public services. J Econ Perspect 1993;7:133–50.
16 Sen A. Development as Freedom. Oxford: Oxford University Press, 1999.
17 Suhrcke M, McKee M, Sauto Arce R, Tsolova S, Mortensen J. The contribution of Health to the Economy in The European Union. Brussels: European Commission, 2005.
18 McKee M, Coker R. The dangerous rise of American exceptionalism. Lancet 2003;361:1579–80.[CrossRef][ISI][Medline]
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