Boris Lvin (bbb) wrote,
Boris Lvin
bbb

Демография - 2

Итак, как обещано, глава из новейшей рэндовской книги, без картинок-сносок и т.д.

http://www.rand.org/publications/MR/MR1273/MR1273.ch4.pdf

RUSSIAN POPULATION LOSSES AND DECLINING LIFE EXPECTANCY


Natural population growth occurs when births exceed deaths. For most of the 20th century, births in Russia have exceeded deaths, and the population has grown. The number of Russian births reached nearly 2.5 million in 1987, a year in which there were 1.5 million deaths, resulting in a natural population increase of about 1 million persons. Since then, the number of births has dropped sharply, due both to declining fertility rates and to declining numbers of women of childbearing age. The number of births in 1999, 1.2 million, was nearly 1 million less than the number of deaths in 1999 and half the 1987 level.

While the declining number of births is most responsible for recent population losses, the increasing number of deaths also has con-tributed to population losses. Between 1987 and 1994, the annual number of deaths in Russia increased from 1.5 million to 2.3 million. In seven of the past eight years there have been at least two million deaths in Russia. By contrast, for most of the 1960s the annual num-ber of deaths in Russia was below one million, and in the 1970s the annual number of deaths never exceeded two million.

Population aging has contributed to increases in mortality; that is, a larger proportion of the Russian population is now of ages where mortality is higher. Yet age-specific mortality rates, or the mortality rates of each age group, have also increased, especially for working-age males. That is, working-age males now suffer higher rates of mortality than they did in past years. Higher age-specific mortality rates have led to declining life expectancy.

Statistics on life expectancy at birth help summarize health and mor-tality conditions for a population. Life expectancy at birth in a given year is a statistical calculation based on the age-specific mortality rates of that year. It reflects the number of years a child born in a particular year could be expected to live if the age-specific mortality rates of that year apply throughout the child's life. By calculating life expectancies for different population groups (e.g., males and fe-males, Russians and others), we can summarize health and mortality conditions for these groups. Life expectancies are better than crude death rates, or the raw number of deaths per 1,000 population in a given year, for comparing mortality conditions across time or place, because crude death rates can be affected by differences in popula-tion age structure, with older populations having higher crude death rates.

Life expectancies for males and females in Russia, and Russian health conditions generally, improved from the 1920s through the early 1960s. During this time, the life expectancy for both Russian males and females increased by nearly 30 years. Whereas be-fore World War II Russian life expectancy had trailed that for the United States by nearly 20 years, by the mid-1960s it was nearly equal to that of the United States for both men and women. Since then, however, Russian life expectancy has been static or has declined, while that in the United States has continued to improve. Russian female life expectancy today is eight years lower than that for U.S. women. Russian male life expectancy is 14 years lower than that for U.S. men, and is also lower than that for males in Guatemala, Indonesia, Iraq, Mexico, Morocco, and the Philippines (U.S. Census Bureau, 2000). We will explore the reasons for recent variations in Russian life expectancy, particularly for working-age males, during the period of improvement from 1984 to 1987, decline from 1987 to 1992, sharp decline from 1992 to 1994, and improvement from 1994 to 1996.

There is considerable variation in life expectancy by region within Russia, with life expectancies for both sexes combined in 1997 rang-ing from 56 to 73 years. Life expectancies are generally lower in Siberia, the Far East, and the North regions, and higher in the southwest, particularly in the Caucasus, Volga, and Black Soil re-gions. As we will see, there are different reasons for this variation in life expectancy, which indicate different problems the Russian health care system faces in each area. Sparsely populated Siberia and the Far East, for example, have higher levels of infant mortality, indicat-ing problems with basic provision of medical services, while several oblasts in the North and Northwest regions have high levels of working-age mortality, indicating greater problems in combating "civilization" ills such as cardiovascular diseases.

INCREASING MORTALITY FOR WORKING-AGE MALES

Recent Russian health problems, particularly those resulting from "civilization" diseases, have not stricken all equally. Life expectancy has declined more for males than females, particularly in recent years. Provisional data indicate that Russian males born in 2000 had a life expectancy of 58.9 years, while that for Russian women was 72.0 years (Gorbacheva, 2001). This difference in life expectancy by sex is among the largest in the world. In only seven other nations do differ-ences in life expectancy by sex exceed ten years; six of these were formerly in the Soviet Union (U.S. Census Bureau, 2000).

At the root of the decline in Russian life expectancy is an increase in mortality for working-age persons, particularly working-age males. Changes in life expectancy from mortality in each age and sex group have been greatest among persons 35 to 64, particularly among males in those age groups. Between 1990 and 1994, mor-tality increases among males aged 35-44, 45-54, and 55-64 were so great as to reduce overall male life expectancy by more than a year each. In 1994, a 20-year-old Russian male had a 1 in 2 chance of sur-viving to age 60, compared with a 9 in 10 chance for a 20-year-old male in the United States or Great Britain (Leon and Shkolnikov, 1998).

Although rising most rapidly in the early 1990s, Russian working-age male mortality has been increasing steadily since the mid-1960s, well before the breakup of the Soviet Union. Despite wide fluctuations in the late 1980s and early 1990s, Russian working-age male mortality in the mid-1990s was not that different from what a long-term trend line (indicated by light dashed line in Figure 4.4) based on data from the mid-1960s through the mid-1980s would have predicted.

A sudden decline in the mid-1980s interrupted the long-term upward trend in working-age male mortality. This decline coincided with an antialcohol campaign by the Gorbachev government, which reduced state alcohol production, launched efforts against distillation and distribution of homemade alcoholic beverages, raised state prices for liquor, and enhanced institutions for compulsory treatment of alco-holism (Shkolnikov and Meslй, 1996). The advent of perestroika and its notions of social democratization also may have cut mortality rates by inspiring hopes for a better future (Notzon et al., 1998). Suicides decreased and mortality rates fell during this period despite casualties from the war in Afghanistan.

Some of the increase in mortality in the late 1980s is apparently due to the abandonment of the antialcohol campaign and may be at-tributed to deaths that the campaign "postponed." That is, many of the persons most susceptible to dying from alcohol-related causes did not do so during the course of the campaign; rather, their deaths were "postponed" until its cessation. Islamic areas of Russia and the former Soviet Union saw less fluctuation in their rates of death at-tributable to alcohol because of their lower levels of alcohol con-sumption (Treml, 1997; Shkolnikov et al., 1998). This gives further credibility to the presumption that the antialcohol campaign played an important role in cutting mortality in the mid-1980s.

Working-age mortality for both men and women increased sharply following the breakup of the Soviet Union in the early 1990s. The re-gions most affected were the urban and most economically devel-oped areas of European Russia, which had high rates of labor turnover, large increases in reported crime, and more unequal distri-butions of household income (Leon and Shkolnikov, 1998; Walberg et al., 1998). This suggests that social stress played a role in increasing mortality, particularly for deaths by such causes as circulatory diseases, injuries from accidents and other trauma, poisoning, and violence.

CHANGING CAUSES OF WORKING-AGE MALE MORTALITY

Analysis of the changes in Russian mortality by age and sex depicted in Figure 4.3 showed that increases in Russian working-age male mortality are most responsible for changes in life expectancy. Further analysis of changes in male life expectancy by cause of death helps identify the reasons for changing health and mortality condi-tions since 1984.

Male life expectancy has fluctuated widely in the past two decades, as have the reasons for changing life expectancy. Changes in deaths by external causes, i.e., those caused by injuries, poisoning, and vio-lence, have effected great changes in life expectancy since 1984, and changes in deaths from circulatory diseases have effected great changes in life expectancy in the 1990s.

Changes in the causes of death since 1984, and subsequent changes in life expectancy, illustrate changing Russian health problems in the past two decades. We consider four subperiods:

From 1984 to 1987, the period of the antialcohol campaign, when male life expectancy increased by more than three years

From 1987 to 1992, the period following the abandonment of the campaign, during which male life expectancy decreased by nearly three years

From 1992 to 1994, the period following the dissolution of the Soviet Union, when male life expectancy decreased by four and a half years, reaching its lowest level in four decades in 1994

From 1994 to 1996, when male life expectancy increased by over two years

Change in male life expectancy (years) Most of the increase in life expectancy from 1984 to 1987 was at-tributable to a decline in deaths from external causes. Nearly all the decrease in life expectancy from 1987 to 1992 is attributable to in-creases in deaths from external causes, often linked to consequences of alcohol and alcoholism. A particularly telling indicator of the effect of alcohol on Russian health is the rate of death from alcohol poison-ing. Russian deaths per 100,000 population from accidental alcohol poisoning have fluctuated from 19.6 in 1984 just before the anti-alcohol campaign to 7.8 in 1988 as the antialcohol campaign was ending to 37.4 in 1994, or about 200 times the comparable U.S. rate (Treml, 1997).

Circulatory disease did not play a large role in variations in life ex-pectancies before the dissolution of the Soviet Union, but it has been of great importance since then. An increase in deaths from circula-tory disease accounted for nearly half the decrease in life expectancy from 1992 to 1994. Such deaths are often attributable to emotional stress, which likely was high in the years immediately following the fall of the Soviet Union (Stone, 2000). Poverty, which increased nearly 20-fold between 1987 and 1993, may have led to stress exacer-bating mortality in the post-Soviet economic transition (Chen, Wittgenstein, and McKeon, 1996). Data on mortality by education in the early 1990s show that persons with lower levels of education, and, hence, perhaps lesser abilities to adapt to changing economic circumstances of the time, suffered greater increases in mortality (Andreev, 1999). As the social and economic transition progressed, it appears that the Russian people reconciled to it and stress levels declined, with decreases in deaths from circulatory disease con-tributing substantially to an increase in life expectancy from 1994 to 1996. Overall, the crude rate of death from circulatory diseases fell 10 percent between 1994 and 1997 (Pashintseva, Voronina, and Kazachenko, 1998).

Respiratory diseases and other causes of death, including cancer, are not important in explaining variations in Russian male life ex-pectancy in the past two decades. Nevertheless, it is important to note that the rates of death from these and virtually every other cause in Russia are unacceptably high. Rates of death by most major causes are higher for Russian working-age men than for their American counterparts.

Overall, Russian working-age males have a death rate about four times that for U.S. males of the same age group.6 Russian males of working age die from external causes such as injuries, accidents, poi-soning, homicide, and suicide at nearly six times the rate U.S. males do. Their rates of death from infectious and parasitic diseases, many preventable or treatable, are five times those for U.S. males. High rates of infectious or parasitic disease, such as tuberculosis, often indicate a less advanced health system. Russian deaths from circula-tory diseases are about three times higher and those from cancers and digestive diseases are about twice those for U.S. males.

Russian working-age males suffer death rates from respiratory dis-eases that are four times higher than those suffered by U.S. males. Smoking likely plays a role in the higher rate of respiratory deaths for Russian males. Smoking prevalence among Russian males is esti-mated to have increased from 53 percent in 1985 to 67 percent in 1992 and remains more than twice the rate for U.S. adult males (Prokhorov, 1997).7 Higher levels of pollution in Russia also may ac-count for the higher number of deaths by respiratory causes there. As we will see, however, while the environment may contribute to high mortality rates in the Russian Federation, it does not appear to be re-sponsible for recent changes in those rates.

HEALTH CARE IN RUSSIA

Overall Russian trends in life expectancy reflect in part the develop-ment, and then the stagnation, of the Soviet and Russian health care systems (Eberstadt, 1990). At its origin the Soviet health system had to address problems for a population whose life expectancy, then only about 40 years, would be among the lowest in the world today, or comparable to that in contemporary Angola, Ethiopia, Malawi, and Mozambique. It sought to bring communicable and infectious diseases under control through a labor-intensive system with low treatment costs. It largely succeeded in doing so, as the life ex-pectancy figures attest. Such a system, emphasizing quantity over quality, did not require highly trained personnel, and the Soviet sys-tem made extensive use of personnel with only brief medical or pub-lic health training.

The overall characteristics of such a system can become weaknesses when health needs change. The progress of the Soviet health system stalled after bringing major infectious diseases under control (Andreev, 1999). By 1965, the Soviet health system appears to have made nearly as much progress as it could against the diseases it was designed to combat. New health problems were confronting the na-tion; specifically, "civilization" diseases, such as cancer, cardiovascu-lar disease, and those resulting from alcohol and tobacco use, were becoming more prominent. Unlike health care systems in the West, the Russian health care system has been unable to enter the next phase of mortality reduction and health care improvement, in which the negative effects of industrialization are overcome through mea-sures to improve living and working conditions as well as health edu-cation. Hence, Russian life expectancy has stagnated in recent decades while that in the West and in other advanced nations con-tinues to improve.

Trends in age-specific death rates since World War II underscore the achievements, and current problems, of the Russian health care sys-tem. While mortality rates for infants and young children are small fractions of what they were in the late 1940s and early 1950s, those for working-age males are nearly identical now to what they were then.8 The improvement in infant and child mortality coupled with increasing overall mortality underscores the role of increasing working-age mortality in increasing Russian death rates.

Previously centralized health planning has led to inefficient health care investments in training and equipment (Bloom and Malaney, 1998). Over time, the Soviet health system has sought to produce more medical professionals with very narrow specializations, giving the system a pronounced vertical character. Soviet physicians chose a narrow specialty at the beginning of their training, with specialties such as those based on age of patient or a particular diagnostic or surgical procedure (Twigg, 2000). This led to such anomalies as heart specialists unable to perform heart surgery and to extensive use of referrals to other professionals for further procedures or diagnoses.

Beyond the problems of overspecialization, the Soviet health system has produced, as the American health system once did, too few health professionals, such as general and nurse practitioners, who could provide general preventive rather than specialized curative care. The most recent comparable statistics on medical professionals show Russia to have nearly 55 percent more physicians per capita than the United States, but 25 percent fewer nurses (World Health Organization, 2000b). The Russian ratio of physicians to population has grown nearly 10 percent since 1992, while the Russian ratio of nurses to population has declined slightly (World Health Organization, 2000c). The concentration of physicians and nurses working in hospitals has increased slightly, while the percentage of general practitioners in primary health care has declined. There are nearly ten times as many physicians in hospitals as there are in pri-mary health care establishments away from hospitals. The growing population of medical professionals is poorly paid. Unlike U.S. physicians, who earn salaries well above the national average, Russian medical professionals earn salaries below the national aver-age; the most qualified physicians thus have incentive to leave Russia (Naumova, 1998).

While the Soviet health system did succeed in controlling infectious and contagious diseases to the point that it brought life expectancy very close to Western levels in the 1960s, it appears that the present health care system has been losing its ability to do so. The political, social, and economic changes of the 1990s have devastated what was an extensive health care system and infrastructure delivering free and accessible health care to all, albeit health care sometimes of questionable quality. One Russian health care official observed that changes in the health care system "have mostly destroyed what ex-isted before, and nothing has replaced it" (Wines and Zuger, 2000).

Resurgence of Russian Tuberculosis

Recent difficulties Russia has had combating tuberculosis illustrate problems the health care system has both in combating disease and in modernizing practices. Worldwide, tuberculosis is a bigger killer than either malaria or AIDS, killing more persons than any other in-fectious disease (Grange and Zumla, 1999). Its recent increase in Russia illustrates the problems Russia faces from the economic tur-moil and social upheaval it has experienced in the 1990s. Tuberculosis rates in Russia are above those in China, Brazil, and Mexico, three times those seen elsewhere in Europe, and about ten times those in the United States and Canada.

Prior to the Soviet revolution in 1917, Russia had one of the highest rates of tuberculosis in Europe and hardly any state policy to combat it (Farmer et al., 1999). During World War I, the number of Russian deaths caused by tuberculosis, 2 million, exceeded the number of Russian soldiers killed by the war, 1.7 million. At that time, there were only 18 sanatoria and fewer than 1,000 beds dedicated to tuber-culosis patients. The control of tuberculosis became one of the top priorities of the Soviet government, and one to which the Soviet au-thorities devoted considerable resources. By the time of World War II, the Soviet Union had more than 100,000 beds available to culosis patients and more than 3,800 specialists trained to serve them, with 18 tuberculosis research centers to seek further advances against the disease. There were periodic reversals in the Soviet battle against tuberculosis, but by 1960 progress had advanced to the point that Soviet authorities were predicting the eventual eradication of the disease in Russia. While rates of death from other causes were rising, tuberculosis death rates declined by two-thirds between the mid-1960s and the late 1980s.

In the 1990s, worsening social and economic conditions, subsequent declines in living standards, and an increase in the number of per-sons without permanent homes or jobs contributed to increases in tuberculosis. In the early 1990s the tuberculosis death rate nearly Tuberculosis deaths per 100,000 persons doubled; by the late 1990s, it reached levels not seen in Russia since the early 1970s.

Recurring, or recrudescent, tuberculosis in Russia presents several challenges for a health system that cannot handle it without help. Russia and the other states of the former Soviet Union are the site of the first widespread tuberculosis recrudescence within Europe in the past century (Farmer et al., 1999). Unfortunately, because most cases of widespread tuberculosis are in developing nations, no one has designed a single effective program to treat increasing prevalence of tuberculosis among patients in nations with "civilization" diseases such as alcoholism and drug addiction or with high imprisonment rates. Russian tuberculosis patients might be better served by the individualized treatment traditionally offered by Soviet and Russian medicine, but this regimen now costs more than the Russian gov-ernment and many individual Russians can afford.

The greatest complication in controlling Russian tuberculosis may be its prevalence, particularly in multidrug-resistant forms, in prisons. With nearly 1 million of its 145 million persons in prison, Russia now has the highest incarceration rate in the world, and its prisons are among the places most infected with tuberculosis. Nearly one in ten Russian prisoners has active tuberculosis; of these, nearly 20 percent have multidrug-resistant strains of the disease (Farmer et al., 1999). The head of medical services for the Russian prison system estimates that approximately $400 million is needed per year, or more than the annual budget for the entire prison system, to combat the disease in Russian prisons (Uzelac, 2000a).

Faced with growing incidence of the disease, increased prevalence of its multidrug-resistant strains, and limited recourses, Russian and international health officials have worked to develop more cost-efficient programs to treat it. The high rates of tuberculosis in Russia present a direct threat to the international community: drug-resistant tuberculosis cases have been reported among travelers from the former Soviet Union to the United States (Farmer et al., 1999).

The Growth of HIV/AIDS in Russia

Increasing rates of tuberculosis may complicate Russian efforts to deal with a growing number of HIV and AIDS cases. Infection by mycobacterium tuberculosis leads to tuberculosis among only one in ten infected, but it is much more likely to lead to the disease among those also infected with HIV (Ravglione et al., 1996). This is especially problematic in Russian prisons which, in addition to high rates of tu-berculosis, also appear to have high rates of HIV infection (Powell, 2000). Furthermore, Russians now contracting tuberculosis are more than three times as likely to die from the disease as they were in 1985 (Feshbach, 2001).

Among the entire Russian population, HIV/AIDS rates appear to be growing rapidly. Russia suffered less than 1,000 AIDS deaths in 1999, but estimates of the current Russian population living with HIV or AIDS range from 130,000 to 500,000 to still more (UNAIDS, 2000; Piper, 1999; Krupenik, 2001; Feshbach, 2001).The current HIV popu-lation is concentrated in or near Moscow, Saint Petersburg, and the Irkutsk region, as well as among men and those 20 to 30 years of age (Bazhenova, 2001b). By comparison, in 1999, there were 20,000 deaths from AIDS and 850,000 persons living with HIV/AIDS in the United States (UNAIDS, 2000). Vadim Pokrovsky, the Chief of the Russian Center for the Prevention of AIDS, estimates that, by the end of 2001, there may be more than one million persons with HIV in Russia (Bazhenova, 2001b). In 2000, the number of HIV carriers and AIDS patients is estimated to have increased fourfold (Interfax, 2001).

Intravenous drug use has caused rapid spread of the disease among Russians. The mid-1990s saw both an increase and change in the number of HIV infections by source in Russia (MacWilliam, 1997). Between 1987 and 1995, about half of the HIV cases registered with health officials were attributable to sexual contact. In 1996, however, more than three in five new HIV cases were attributed to intravenous drug use. A 1999 outbreak of HIV among intravenous drug users in Moscow "resulted in the reporting of more than three times as many new HIV cases that year than in all previous years combined" (UNAIDS, 2000). Intravenous drug use has also led to sharp rises in HIV and AIDS elsewhere in Russia (United Press International, 2000; Wines, 2000a).

Much of the Soviet and later Russian response to AIDS has reflected the ideology of Soviet medicine and the later problems in Russian health care. Original Soviet efforts against the disease featured an emphasis on quantitative indicators, with mass screenings of 140 million persons identifying 774 persons (or about 1 in 200,000) with HIV infection (Powell, 2000). Today most Russian hospitals lack the funds for AIDS drugs or equipment commonly available in the West.

Conclusion

Improvements in the Russian health system may, if implemented, lead to improvements in Russian health care and reduce mortality rates for all Russians. Many such improvements, however, will re-quire many years to implement, and still more years to have an ef-fect. Furthermore, deterioration in the Russian health system cannot adequately explain the most distinct problem of Russian health in the past few years-that of high mortality for working-age males. Therefore, even if it could be done quickly, health care system im-provement would not necessarily help cut mortality among a popu-lation that suffers from behavioral health risks (e.g., smoking and drinking) that cannot be treated effectively by acute care. We there-fore turn to other explanations for recent fluctuations in and high levels of mortality for the population for whom it has changed most: working-age males.

EXPLANATIONS FOR RECENT TRENDS IN RUSSIAN WORKING-AGE MORTALITY

Both the high levels of and fluctuations in Russian mortality in the past decade have drawn considerable attention, which has led to speculation on their possible causes. In addition to the deterioration of the health care system, the other most popular explanations are environmental conditions, varying levels of alcohol consumption, and social and economic change. We discuss each of these below.

Environment

The Russian environment is certainly troubled after years of reckless treatment by the Soviets, and may well be a contributor to high rates of death from respiratory and other ailments in Russia that we have seen. The rate at which Russian industry releases toxic metals such as arsenic and lead into the air is several hundred, and sometimes sev-eral thousand, times that of industry in the European Economic Community (Feshbach, 1995). In the early 1990s, according to gov-ernment monitoring, concentrations of phenols and petroleum products in Russian rivers-the source of drinking water for most of the population-often exceeded ambient water quality standards by a factor of two to ten times (Peterson, 1993). Some Russian re-searchers have estimated that half the population uses drinking wa-ter falling below microbiologic and chemical standards for public health (Tuchinsky and Varavikova, 1996).

While such extreme conditions undoubtedly contribute to the high levels of mortality and adversely affect the health of Russians, they cannot explain recent mortality differentials and trends. Environmental conditions should affect all persons equally, but mortality has increased much more for males than females. Changes in environmental conditions cannot explain why recent changes in mortality have been greatest for persons in their prime ages rather than among the more vulnerable young and old. If environmental conditions were behind recent mortality trends, we would expect changes in deaths caused by cancer or respiratory ailments to be even more pronounced. Finally, the decline and fall of the Soviet sys-tem had an immediate environmental benefit. Industrial emissions fell in the late 1980s and early 1990s as state-run factories floundered, yet this is the period when mortality rates increased the most (Stone, 2000).

Alcohol

Some have suggested that varying levels of alcohol consumption have contributed to variations in Russian working-age mortality, es-pecially for working-age males. There is considerable evidence for this. We have already seen how rates of death, especially for external causes such as accidents and violence often related to alcohol use, decreased for working-age males during the antialcohol campaign and increased after its cessation. We also noted earlier that Islamic areas saw less fluctuation in their rates of death attributable to alco-hol because of their lower levels of alcohol consumption. In this sub-section, we explore further the relationship of trends in mortality rates and life expectancy to trends and patterns of alcohol consumption.

Russian male life expectancy reached its highest levels ever shortly after per capita alcohol consumption dropped sharply in the mid-1980s. When alcohol consumption increased in the late 1980s and early 1990s, life expectancy for all males plunged to nearly 57 years of age. Alcohol consumption increased most among those most affected by the economic crisis of the time, low-income males (Zohoori et al., 1998). Since peaking in 1993, alcohol consumption has declined again. Per capita alcohol consumption for adult Russian males in 1998 was a third less than its level in 1993, and life expectancy for all males was nearly four years higher in 1998 than it had been five years earlier.

Russians still have a very high level of alcohol consumption. Russian per capita alcohol consumption exceeds the level that the World Health Organization says endangers health in a country (Uzelac, 2000b). The Russian style of drinking contributes to its dangers. Traditionally, "holiday-peak" drinking predominated in Russia, with imbibers drinking large quantities during short periods on Sundays or church holidays (Shkolnikov and Nemtsov, 1997). Russia was a highly agrarian society when this pattern developed, and alcohol consumption was low during other times of the week or year. Binge drinking plays a disproportionate role in recent Russian mortality, with sudden deaths from alcohol poisoning, accidents, and violence highest during weekends (Chenet et al., 1998).

Russian preferences in alcoholic beverages also contribute to deaths caused by alcohol consumption. Vodka has long been the alcoholic drink of choice among Russians, and the drinking of large quantities of vodka with little food often results in deaths by accident and vio-lence (Shkolnikov and Nemtsov, 1997). France and Italy in the 1970s had per capita consumption of alcohol similar to that in Russia today but, because most of their alcohol consumption was of wine, it did not lead to high rates of violence or accidental deaths (Medvedev, 1996).

The antialcohol campaign and subsequent state policy appears to have affected Russian tastes, with alcohol restrictions leading Russians to seek more potent drinks, legal or otherwise. One estimate (Treml, 1997) shows vodka consumption increasing from 53 percent of total legal alcohol consumption in 1985 to 81 percent in 1993, while official statistics on alcohol sales show sales of "vodka and liqueurs" increasing 22 percent between 1993 and 1998 (RF Goskomstat, 1999c). Even after the antialcohol campaign ended, per capita consumption of samogon, or illegal homemade alcohol, in-creased, while that of alcohol sold by the state remained at levels from before the campaign (Treml, 1997). The poor quality of much samogon may contribute to alcohol-related deaths. Autopsy reports show a high number of deaths from alcohol poisoning result not from the concentration of alcohol per se but from high concentra-tions of toxins in the alcohol (Shkolnikov and Nemtsov, 1997). Government easing of laws on the production and sale of liquor also appears to have helped increase the availability and consumption of alcohol, leading to a reduction of its price in real terms when alcohol consumption was at its peak (Medvedev, 1996; Shkolnikov and Meslй, 1996).

Social and Economic Change

Much of the variation in alcohol consumption, and the correspond-ing variation in mortality, appears to be attributable to social and economic change. Alcohol consumption was greatest in the early 1990s, shortly after the dissolution of the Soviet Union, when the pace of social and economic change was rapid. Social and economic changes have had both short-term and long-term effects on Russian health and mortality.

As we have seen from trends over the past few decades, increases in Russian mortality, particularly for males, rather than resulting solely from recent economic crises, first started in the mid-1960s. This may have been the point at which not just the Soviet health system but the Soviet economic system more generally began to adversely affect the health of Russians through decisions ostensibly designed to in-crease wealth but having deleterious consequences for the health of Russians.

One example of this is in Soviet agricultural planning. During the 1960s, the Soviet government increased production, marketing, and consumption of meat and dairy products, with the Khruschev gov-ernment specifically calling for the doubling of meat and dairy prod-ucts and some reduction in potato and bread consumption (Popkin et al., 1997). This occurred as Soviet household income, thanks to rising petroleum prices, was increasing. The result was that the Russian diet became one of the richest in the world, with consump-tion of cereals and starches declining and that of sugar and red meat increasing. Such a diet can lead to increased mortality, particularly from coronary heart disease. As we saw earlier, Russian working-age males have rates of death from circulatory disease about three times higher than those prevalent for U.S. working-age males. In a way, we can say that Soviet agricultural policy and, ironically, prosperity of the 1960s probably contributed to the high rates of death from coronary heart disease three decades later.

Recent mortality trends appear to be more directly related to eco-nomic trends. Changes in Russian economic output have been dras-tic in the 1990s, and there appears to have been a strong correlation between life expectancy and performance of the economy. The sharp contraction of the economy saw the gross domestic product per capita decline from more than $6,300 in 1990 (as measured in 1998 U.S. dollars) to less than $3,600 in 1998. It may be that some Russians have been unable to take care of their own health and well-being in the deteriorating economic conditions of the 1990s, particularly as a market-oriented government replaced the paternalism of the Soviet government.
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