IJE Advance Access originally published online on December 4, 2006
International Journal of Epidemiology 2006 35(6):1406-1409; doi:10.1093/ije/dyl242
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Commentary |
Commentary: N Eberstadt's ‘The health crisis in the USSR’ and sustainable mortality reversal in the post-Soviet space during communism and after
1 Max Planck Insitute for Demographic Research, Konrad-Zuse-Str., 1 D-18057 Rostock, Germany.
2 London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK.
* Corresponding author. E-mail: Shkolnikov{at}demogr.mpg.de
In 1965 life expectancy in the USSR began to decrease. Initially this was regarded as a minor and transient fluctuation of little significance. However, by the mid-1970s both scholars and the Soviet authorities alike realized that the unfavourable trend was real and could last longer. In 1974 the Soviet government started to restrict the mortality data that was released, such that by 1976 publication of these data in the public domain ceased entirely. This was justified as being politically desirable given the ongoing ideological struggle with ‘imperialism’. These developments came under intense scrutiny by Nick Eberstadt in his article ‘Health Crisis in the USSR’, published in The New York Review in February 1981.1 The article was based on a few earlier studies evaluating mortality levels and trends in the Soviet Union over the 1950–70s from fragmentary statistical data.2–5 The most important of these—Christopher Davis and Murray Feshbach's book ‘Rising Infant Mortality in the USSR in the 1970s’ was published in September 1980. This provided convincing evidence that the increase in the Soviet infant mortality between 1970 and 1977 was real and that official infant mortality rates were underestimated by about 15%. In addition, it documented a significant increase in mortality of adults and a decline in life expectancy.
Eberstadt's article was written as a review of Davis and Feshbach's book, although it goes far beyond the issues raised by Davis and Feshbach. Using numerous sources on a wide variety of features of Soviet society including its history, economy and finances, ideology, health system, alcohol consumption and other things, he provided an extraordinarily accurate account of the Soviet-Russian health crisis and outlined its driving forces. The main points of the article can be summarized as follows.
Rising infant and general mortality in the USSR are real and represent a major exception from the worldwide mortality decrease. The mortality increase cast a doubt on the Soviet claims to the superiority of the communist system in spite of reported improvements in caloric intake, clothing, housing, educational attainment, and ratio of doctors to people. Unlike some other researchers in the 1970–80s,7,8 Eberstadt confidently attributes the health deterioration to contemporary factors rather than to cohort echoes of the past. Several factors of the crisis are highlighted. Widespread alcohol abuse was described as having the potential to push up not only deaths from accidents but also from cardiovascular disease: the major component of the mortality increase. Air pollution was seen as a cause of respiratory diseases. Overuse of pesticides, careless release of industrial waste, and poorly constructed nuclear facilities present ‘far more deadly pitfalls’. It is notable that this was written five years before the Chernobyl catastrophe.
The shortcomings of Soviet medical care were also deemed to play a role. Although Davis and Feshbach could not prove that the quality of the Soviet health care system was in decline, Eberstadt found indirect evidence for such conclusion. First, the Soviet health strategy was misguided as it mostly spent resources on expanding facilities rather than on upgrading them. Second, the health care labour force in the USSR was underpaid—leading to corruption. The latter worked against the most vulnerable groups such as the poor and those living in remote areas. Third, the slow-down of the Soviet economy in the 1970s and the priority given to financing military and heavy industries led to a decrease of the share of health expenditure in the overall GNP.
Finally, Eberstadt argued about deeper societal and psycho-social causes of the health crisis. In his view, the patriotism of the Russian people has always been combined with continuous suffering and self-sacrificing for purposes, that could be ‘seen and understood.’ This quality was fully exploited by Stalin's system. Eberstadt claims that Stalin ‘managed to raise life expectancy in the Soviet Union from about forty-four when he assumed total power to about 62 when he died in spite of politically inflicted famines and World War II.’ Stalin's successors tried to ‘marry’ a system of total state control over all aspects of country's life with ‘consumerism.’ But in the 1970s this movement turned into a failure. The Russian people had to realize that their hard work did not bring them any closer to communism and also did not provide them with good life standards. This led to adverse psychological changes such as spread of pessimism, demoralization, and alienation from the state.
Today, after four decades of almost continuous increase in mortality in Russia and most of other post-Soviet countries,6 plus much greater access to source data and two decades of extensive empirical research in this area (statistical publications of life tables and mortality rates by age and principal classes of causes of death resumed due to M Gorbachev's glasnost' in 1987–88: at the same time, more detailed current and archive data have become available to scholars), we are in a good position to evaluate the Eberstadt's article. With very little hard evidence, he correctly saw the full significance of the phenomenon which afterwards appeared to be so long-lasting and devastating. He correctly outlined many of the factors fuelling the excess mortality and provided vivid insights into the nature of the Soviet-Russian health crisis. Many of these ideas are still of value and relevance for understanding the more recent dramatic changes in mortality and health in countries of the former Soviet bloc.
Lack of data was a major limitation for studies on the Soviet health of the 1980s and it affected some of Eberstadt's conclusions. In particular, recent historical reconstructions by Andreev, Darsky and Kharkova9, and by Vallin and Meslé10 based on archive data, which were not available in the early 1980s, clearly showed that improvements of health in the Stalin era were actually small. Between 1926–27 and 1938–39 there was almost no increase in male life expectancy at birth, while female life expectancy increased by less than two years. In the late 1930s infant mortality rate in the USSR exceeded 200 per 1000 births, a level observed in western nations in the 19th century. The rapid reduction in infant mortality during the 1950s can be attributed to the introduction of means, such as antibiotics and vaccines for fighting infectious disease, which took place largely after Stalin's death in 1952. One should note that all of these mortality estimates relate only to the ‘civilian’ population (as defined by official Statistics) and do not include enormous wartime losses, victims of politically inflicted famines, and of the Gulag.
One of the main themes of Eberstadt's article in the New York Review was the increasing rate of infant mortality that he assumed was still continuing. However, due to the complete absence of publicly accessible information on mortality in the USSR in the 1970–80s, he was unaware that by the time he wrote the article infant mortality was once again declining. This decline started in 1977 and has continued ever since. However, in contrast it has been adult-age mortality that has seen increases. This means that the USSR as a whole was not on the ‘path toward pre-industrial standards of health’ as was stated in the article but rather faced new health challenges related to the expansion of chronic and man-made diseases, accidents, and violent deaths. It should be noted that, unlike trends seen in Russia, Ukraine, and Belarus, a more traditional mortality pattern has been conserved in Central Asia, where infant mortality was high while adult-age mortality was substantially lower than in other regions of USSR.11
The short-term increase of infant mortality in the USSR in the 1970s that caught Eberstadt's attention has been the subject of detailed investigation subsequently. Studies conducted in the 1980 and 90s suggested that the infant mortality rate increase in 1970–77 could be partly a statistical artifact due to an improvement in the system of reporting infant deaths especially in the Muslim republics and Transcaucasus, where the under-registration was most notable.12–14 However, more recent studies, and especially the conclusive analysis by Velkoff and Miller, have found that the change in the registration practices in the 1970s may have had only a minor role to play, and that, in large part, the increase in infant mortality was real and could be related to a reduction of medical resources in rural areas in the 1960s.15,16,17
The 1990s saw a new and unprecedented access to statistical data on mortality. This has been exploited to great effect by a team of researchers led by Meslé and Vallin. Following a massive data collection exercise going back to original source data, this research has resulted in the construction of a continuous mortality series by cause of death since the late 1950s for Russia, Ukraine, and Baltic countries.10,17,18 These studies provided data that were not available to Eberstadt in 1981. They have enabled detailed analyses of changes in mortality rates from specific medical causes. In turn these have been linked with risk factors and potential causal mechanisms, as well as being used to measure impacts of mortality changes at different ages and from different causes on life expectancy.10,19–21 These mortality trends can be divided into two periods: the period of gradual mortality increase 1965–84, which was discussed in the Ebrstadt's article, and the period of great mortality fluctuations beginning from 1985. During the first period, life expectancy at birth decreased by about 3 years for men and by about half a year for women mostly due to rising mortality at ages 30–60 years (men) and from 50 to 70 years (women). Increases in circulatory diseases and external causes (accidents and violence) were the two broad causes of death that made the greatest contributions to the overall life expectancy decline. Of the more specific causes, important contributions were made by heart and cerebrovascular disorders, male lung cancer, various accidents, suicide, alcohol poisoning, and other conditions directly related to alcohol. These unfavourable changes were partly balanced by decreasing mortality from infectious and respiratory diseases at a young age and from mortality from stomach cancer at older ages.
These patterns seen in the period 1965–84 generally suggest the importance of adverse ‘male’ behaviours such as misuse of alcohol and smoking. However, it is surprising that smoking is not mentioned in Eberstadt's article. Perhaps this can be explained by lack of data on smoking in the USSR and/or the fact that the effects of smoking only become apparent after many years. Estimates by Peto and colleagues show that smoking was responsible for a great number of deaths in the Russia.22 In the 1970–80s tobacco did contribute substantially to the widening of the male-female gap in life expectancy in the Soviet Union, where death rates from lung cancer were almost nine times higher among men than women, reflecting big gender differences in prevalence of smoking. Women in Soviet society being much less likely to smoke than women in many western countries at this time.
Detailed cause-of-death data has also allowed the estimation of mortality from so-called avoidable causes of death presumably reflecting mortality toll caused by inadequacies of the health care system.23 Analysis of avoidable mortality in Russia has shown that it tended to increase between 1970 and 1984.24 This observation together with other signs of ineffectiveness, such as failure to engage with prevention25 and poor equipment of many facilities,26 indicate a failure of Soviet-Russian medicine to protect people's health.
Information on socio-economic mortality differentials27–29 is another important piece of evidence, which was not available before the onset of glasnost. It has been found that in the USSR and Russia in the 1970–80s mortality was especially high among the least educated and the manual workers. Despite the seemingly egalitarian character of the communist system, the Russian socio-economic mortality gradients appeared to be even steeper than those in the West. With a newly discovered archive of data, it has been recently established that the Soviet mortality increase between 1970 and 1979 was almost entirely concentrated among manual workers.30 Non-manual occupations experienced nearly no mortality increase (but also no improvement). Ironically, proletariat, the ‘ruling’ class of the Soviet society, was also the most vulnerable class when it came to death.
The period of great mortality fluctuations in Russia began in 1985. First, in the period 1985–87 a major anti-alcohol campaign launched by M Gorbachev, the new General Secretary of CPSU, produced an unexpected and rapid mortality fall. During three calendar years life expectancy increased by 3 years for men and by one and half years for women. In 1988 mortality began to increase slowly again but remained at a relatively low level till 1991. At the end of 1991 the Soviet Union disintegrated and in January–February 1992 the new Russian leadership headed by B Eltsin launched a package of 'shock' market reforms. These reforms were poorly implemented and led to an abrupt drop in economic productivity, a rapid deterioration of living standards for most of the population, almost entire liquidation of ordinary people's savings, galloping inflation, a steep rise in unemployment, and the emergence of economic uncertainty.31 The alcohol markets were instantly privatized and vodka has since become readily available everywhere, 24 h a day.32 In the short period 1992–94 Russia experienced a fall in life expectancy that is unprecedented for an industrialized nation in peacetime: for men it fell by 6 years, for women by 3 years. After a moderate recovery during the period 1995–98, mortality had again increased following the ruble crisis in August–September 1998. In terms of ages and causes of death, mortality increase in the period 1992–98 was symmetrical to its prior decrease due to the anti-alcoholic campaign of 1985.33 The last reported values of the Russian life expectancy in 2005 are 58.9 years for men and 72.4 years for women. They are lower than in many developing countries and correspond to the longevity gap of about 17 years for men and about 9 years for women when compared with most other industrialized countries.
In the first half of the 1990s other countries of the former Soviet Union experienced mortality fluctuations similar to those in Russia. However, in the mid-1990s a new divide had emerged. A significant difference could be seen between decreasing mortality in Baltic countries on the one hand and lack of progress in Russia, Ukraine, and Byelorussia on the other.34
Although changes in life expectancy in the 1990s were much greater than those in the period 1965–84, they were driven by the same (working) ages and the same causes: cardiovascular diseases and accidents and violence. What is perhaps most remarkable about Eberstadt's article is that his focus on linking alcohol and society's psycho-social conditions to the mortality increase he saw in the USSR in the 1970s prefigures the two main explanatory frameworks that have been put forward to explain the health crisis in Russia in the 1990s. One of them emphasizes the importance of lifestyles and health behaviours and in particular the role of alcohol.32,33,35,36 The other perspective puts more emphasis on the role of psychosocial stress induced by unexpected economic hardships, effort–reward imbalance and absence of transparent and fair conditions for everyone.37–39 In reality probably both have an explanatory role—consistent with Eberstadt's own original formulation.
In 1981 Eberstadt told readers of the New York Review about what has turned out to be only the beginning of a sad story. At the time neither he nor anyone else could have foreseen quite how long the mortality crisis would last and that today, 25 years later, its continuation arguably constitutes one of the most serious challenges to public health outside of sub-saharan Africa.
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