Patterns of mortality in the former Soviet Union

Patterns of mortality and their determinants in the countries of the former Soviet Union

This project was funded by United Kingdom Department for International Development and its objectives were to:

• Describe variations in mortality throughout the republics of the former Soviet Union.
• Identify the underlying reasons for this variation, both direct and indirect.
• Identifying those areas that have been affected most and least by the economic transition and understand the factors that have been either protective or disadvantageous.
• Help develop in country capacity to make full use of data already collected.
• Provide policy makers with information that will help them set priorities and develop appropriate policies to tackle the leading causes of premature death in their countries.

The research team

This work was undertaken primarily by researchers from the following institutions:

The project was funded by the United Kingdom Department for International Development (DfID). However DfID can accept no responsibility for the views expressed.

A brief history of the region

The events leading up to the collapse of the Soviet Union are well known. The introduction, by Gorbachev, of the philosophy of glasnost had created an environment in which issues that had been simmering beneath the surface could emerge. Vast nationalist rallies began in the Baltic States in 1988 and 1989. In 1990, nationalist parties won elections in the Baltic Republics. On the 19th August 1991, a coup was mounted against Gorbachev. The following day Estonia and Latvia joined Lithuania in declaring independence. A few days later they were joined by Ukraine, Belarus and Moldova. In December 1991 the presidents of Russia, Ukraine and Belarus declared that the Soviet Union had ceased to exist. The economic circumstances in which the new countries found themselves were far from encouraging. The Soviet Union had suffered greatly from the very high levels of military expenditure during the arms race in the 1980s. Investment in agriculture and in civilian industry was minimal and inefficiencies in the distribution system meant that much of what was produced was wasted. This situation was exacerbated by the collapse of established trading links. The newly emerging countries had been locked into a highly complex system in which raw materials and components from all over the Soviet Union were brought together in a final manufacturing location. The removal of one element by, for example, the closing of borders, brought the entire process to a halt. The economic crisis was also exacerbated by the effects of conflict. The rapid and unplanned process of what can only be described as decolonisation provided very little preparation for self-government and laid down an inheritance of a number of features that, in some countries, mitigated strongly against the development of effective policy responses to major challenges to health. These events coincided with major changes in mortality. In the Soviet Union, life expectancy at birth had been declining steadily from the mid 1960s. A striking improvement in 1985-87, associated with Secretary General Gorbachev·s anti-alcohol campaign, was short lived and there was a steady decline until 1991. In the subsequent three years the decline accelerated markedly, only to reverse in 1995. Between 1991 and 1994, taking all the former Soviet republics together, life expectancy at birth for males fell by 4 years and for females by 2.3 years. Since 1994, life expectancy has improved in Russia and several other former Soviet Republics, although, in Russia, the improvement came to a halt in 1998 and life expectancy is once again falling.

Additional data on trends in mortality are available from the World Health Organisation Health for All Database.

Publications
Papers on trends in mortality and their causes:

Huge variation in Russian mortality rates 1984-1994: artefact, alcohol, or what?
Leon D, Chenet L, Shkolnikov VM, Zakharov S, Shapiro J, Rakhmanova G, Vassin S, McKee M.
Lancet 1997; 350: 383-8.
Death from alcohol and violence in Moscow: socio-economic determinants.
Chenet L, Leon D, McKee M, Vassin S.
Eur J Population 1998; 14: 19-37.
Economic change, crime, and mortality crisis in Russia: a regional analysis.
Walberg P, McKee M, Shkolnikov V, Chenet L, Leon DA.
BMJ 1998; 317: 312-8.

Shkolnikov V, McKee M, Leon DA. Towards an understanding of the improvement in life expectancy in Russia in the mid 1990s. Lancet (in press)

Existing research
To inform this project, a review of the Russian language literature on the health effects of transition was undertaken. This showed that very little of the research published in the rest of the world featured in the Russian language literature. The quality of the Russian language literature was, methodologically, generally poor. This has several implications for policy. First, there is a need to do much more to disseminate information within this region about health and health policy as it relates to the region. Second, there is a need for donor agencies to address the quality of Russian language publications, perhaps by working with medical journal editors.

Publication
Public health in Russia: the view from the inside.
Tkatchenko E, McKee M, Tsouros AD.
Health Policy Planning 2000; 15: 164-169. [PubMed]

Regional variation in mortality in Russia
Between 1995-1999 there was significant regional variation in life expectancy, infant, child mortality and maternal mortality in Russia.
Life Expectancy
In 1995-1999 average life expectancy at birth in Russia was 66.05 years. There were considerable variations across the regions but in general the Eastern region had worse life expectancy than Western regions (figure 3). The two regions with the lowest life expectancy were The Republic of Tuva (56.5 years) and Sakalin region (61.6 years). The highest life expectancy was recorded in the North Caucasian Republics of Ingushetia (72.3 years) and Dagestan (70.5 years). After excluding the four North Caucasian Republics, Belgorod Oblast has the next highest life expectancy at birth for both sexes (68.6 years) and is known to have good death registration data.

Regional variation in life expectancy at birth in Russia (1995-1999)

Infant and Child Mortality (1-4 year olds)
Between 1995-1999 the average Infant Mortality rate for Russia was 17.2 deaths per 1000 births. Infant Mortality rates ranged from 11.7 in St Petersburg City and Leningrad Oblast to over 32 in the Republic of Tuva (32.3) and Chucki autonomous Okrug (32.1). In general, the lowest levels of infant mortality rate were found in the Northern and central parts of European Russia. Rates were generally higher in the East with many of the highest rates in territories located in Southern Siberia. We found that there was no relationship between infant mortality rate and fertility levels in the regions of Russia between 1995-1999.
The average death rate in Russia for 1-4 year olds was 4.1 deaths per 1000. This varied from 2.3 (Murmansk oblast) to 14.6 (Republic of Tuva). The areas with the lowest levels of mortality in the 1-4 year age group are concentrated in the centre and north of European Russia, while the highest mortality rates are concentrated in the east, particularly in Southern Siberia.

Regional variation in infant mortality rates (per 1000) in Russia (1995-1999)

Regional variation in probability of death at ages 1-4 (per 1000) in Russia (1995-1999)

Maternal Mortality
Between 1995 and 1999 the maternal mortality rate in Russia was 48.2 per 100,000 live births. Across the regions maternal mortality varied nearly 10 times, ranging, from 15.9 in Ingushetia to 152 in the Republic of Tuva. The highest rates of maternal mortality are in eastern territories. The lowest rates of maternal mortality are mainly in European Russia and in two North Caucasian Republics. However, the very low maternal mortality in North Caucasian republics might result from under-registration as discussed earlier. We found that there was no significant correlation between rates of abortion (number of therapeutic abortion per 1000 women ages 15-49) and maternal mortality rates across the regions. This is surprising, as abortion is still the largest cause of maternal mortality in Russia.
The 3-10 fold differences in infant, child and maternal mortality, as well as the 7 year difference in life expectancy reflect consistent regional patterns of ill health across Russia. These indicators reveal that the poorest health is consistently found in Eastern regions of Russia (the worst off being the Republic of Tuva), while the best health is found in the West, particularly the northern and central parts of European Russia.

Regional variation in maternal mortality rates per 100,000 in Russia (1995-1999)

The role of alcohol
This project has provided important new insights into the role of alcohol in premature mortality in this region. The suspicion that alcohol was much more important than had previously been recognised arose from the observation that death rates from certain causes fell substantially between 1985 and 1986, coinciding with what is now recognised as, at least initially, a strikingly successful anti-alcohol campaign. The campaign was, however, short-lived, and as its effectiveness declined, coinciding with extensive production of illicit alcohol, deaths from those causes and in those age groups that had seen an earlier improvement began to increase again. Importantly, after 1991, when the Soviet Union broke up, it was again these cases of death that contributed most to the catastrophic decline in life expectancy.
For many of the causes of death involved, a link with alcohol was uncontroversial. Examples include injuries and violence and acute alcohol poisoning. The argument concerning cardiovascular disease, which behaved in the same way, was more problematic. A widely held view, based on many large studies in western countries, is that alcohol, at least when consumed regularly and in moderate amounts reduces the risk of heart disease. Thus it is difficult to see how a reduction in alcohol consumption could lead to a fall in cardiovascular deaths, or a rise in consumption to an increase in deaths.
In a survey of alcohol consumption in Russia we confirmed what was widely known, that drinking typically took place in binges, with large quantities of, typically, vodka, consumed at one go. We then undertook a systematic review of the published literature on alcohol and heart disease. This showed that few studies had looked at the pattern of drinking, simply averaging consumption over a week. Those few studies that did consistently found a strong association between binge drinking, measured either directly or indirectly (such as problem drinking, arrests for drunkenness etc.) and death from heart disease. The association was strongest with sudden cardiac death.

Publications
Patterns of alcohol consumption

Alcohol in Russia.
McKee M.
Alcohol Alcoholism 1999; 34: 824-829. [PubMed]
Alcohol consumption in the Baltic Republics.
McKee M, Pomerleau J, Robertson A, Pudule I, Grinberga D, Kadziauskiene K, Abaravicius A, Vaask S.
J Epidemiol Comm Health 2000; 54: 361-366 [PubMed]

Alcohol consumption in a national sample of the Russian population.
Bobak M, McKee M, Rose R, Marmot M.
Addiction 1999; 94: 857-66. [PubMed]
Daily variations in deaths in Lithuania: the contribution of binge drinking.
Chenet L, Britton A, Kalediene R.
Int. J. Epi (in press).

Papers specifically on the role of alcohol in cardiovascular disease

Alcohol and cardiovascular mortality in Moscow, new evidence of a causal association.
Chenet L, McKee M, Leon D, Shkolnikov V, Vassin S.
J Epidemiol Comm Health 1998; 52: 772-74.
The positive relationship between alcohol and heart disease in eastern Europe:  potential physiological mechanisms.
McKee M, Britton A.
J Roy Soc Med 1998; 91: 402-7.
The relationship between alcohol and cardiovascular disease in Eastern Europe; explaining the paradox.
Britton A, McKee M.
J Epidemiol Comm Health 2000; 54: 328-332 [PubMed]

Alcohol is implicated in the fluctuations in cardiovascular disease in Russia since the 1980s.
McKee M, Shkolnikov V, Leon DA.
Ann Epidemiolo 2001; 11: 1-6.  [PubMed]

Tobacco
Rates of smoking among men were very high in the Soviet Union, contributing to the high rates of cardiovascular disease and cancer. Since independence the situation has been exacerbated by the intensive activities of trans-national tobacco companies, whose advertisements are now visible almost everywhere in the region. As a result, smoking rates among women, which were previously relatively low, are now increasing rapidly, especially among the young and those in large cities where widespread advertsining first took hold.
Perhaps surprsingly, deaths from lung cancer are actually falling at present. This should not, however, give rise to complacency as we have shown that this is a temporary effect. Patterns of smoking are determined in adolesence and the health effects take many years to become apparent. The current decline reflects the low level of availability of tobacco in the post-war years and we can predict with confidence that deaths will soon begin to rise again.

Publications
Papers on cancer mortality

Why is the death rate from lung cancer falling in the Russian Federation?
Shkolnikov V, McKee M, Leon D, Chenet L.
Eur J Epidemiol 1999; 15: 203-6.
Cancer mortality in Russia and Ukraine: validity, competing risks, and cohort effects.
Shkolnikov VM, McKee M, Vallin J, Aksel E, Leon D, Chenet L, Mesle F.
Int J Epidemiol 1999; 28: 19-29.

Papers on the prevalence of smoking

Patterns of smoking in the Baltic Republics.
Pudule I, Grinberga D, Kadziauskiene J, Abaravicius A, Vaask S, Robertson A, McKee M.
J Epidemiol Comm Health 1999; 53: 277-83.
Patterns of smoking in Russia.
McKee M, Bobak R, Rose R, Shkolnikov V, Chenet L, Leon D.
Tobacco Control 1998; 7: 22-26.

Smoking in Ukraine: epidemiology and determinants..
Gilmore A, McKee M, Telishevska M, Rose R.
Preventive Medicine 2001; 33:453-461. [PubMed]

Prevalence and determinants of smoking in Belarus: a national household survey, 2000.
Gilmore A, McKee M, Rose R.
Eur J Epidemiology 2001; 17: 245-53. [PubMed]

Determinants of inequalities in self-perceived health in Ukraine: a neglected former Soviet Republic.
Gilmore A, McKee M, Rose R.
Social Science and Medicine 2002; 55:2177-88 [PubMed]
Determinants of inequalities in self-perceived health in Ukraine.
Gilmore A, McKee M, Rose R.
J Epidemiol Community Health 2001; Suppl: Societies Individuals and Populations, Joint Conference of the Society for Social Medicine and the International Epidemiological Association European Group: A2

Tuberculosis
Rates of tuberculosis have always been high in the countries that made up the Soviet Union but, since the late 1980s, they have experienced a dramatic rise in both cases of and deaths from tuberculosis. The overall level of mortality from tuberculosis in Russia has gone back to the levels of the 1970s.  However, today's mortality from tuberculosis is lower in children and old people and very much higher at working ages, especially among young adult men. The death rate from tuberculosis among men aged 20-24 is now twice what it was in 1965. What is especially worrying is that, while deaths from many causes began to fall in Russia after 1994, those from tuberculosis continued to rise.
Several factors underlie these changes. One is the growth in the prison population. Russian prisons increasingly acting as reservoirs of infection and under-funding and overcrowding have exacerbated pre-existing weaknesses in prison health services to create a situation that is out of control. A related, and extremely worrying factor is the growth in infections that do not respond to the standard anti-tuberculous drugs. Alarmingly, there is growing evidence of how inappropriate treatment regines, which exist in many Russian prison, can increase the rate of resistant infections.
These changes have profound implications for policy on tuberculosis control in Russia. We have examined trends in the incidence of and mortality from tuberculosis in Russia, in collaboration with colleagues in Russia and the United States to seek to understand better the changing situation. We have also contributed to a major study undertaken under the leadership of Paul Farmer at Harvard Medical School that examines the global impact of multi-resistant tuberculosis.

Health services and health
Although the major determinants of premature death relate to lifestyle and its determinants (such as alcohol, tobacco, nutrition and social inequalities), there is growing evidence that health services in the countries of the former Soviet Union lag well behind those in the west. In some countries there is evidence that health care is actually deteriorating. Thus, deaths from certain chronic diseases, where people depend on access to effective care and to medication, are increasing. One example is diabetes. We undertook a study in Lviv, Ukraine, to determine the reasons for this increase. This showed that, while most people with diabetes could obtain insulin, supplies were arratic and they often had to switch products. Material needed for monitoring their diabetes was often very difficult to obtain.As a consequence, it was very difficult to control their condition. However one of the main factors accounting for premature deaths was the almost complete lack of access to dialysis or transplants for those who developed kidney failure.
Even when health services are available, the quality is often poor. This is especially true to vulnerable populations, such as the poor or those whose disease is associated with stigma. An example of the latter is people with sexually transmitted diseases.

Publications
Towards an understanding of the high death rate among young people with diabetes in Ukraine.
Telishevska M, Chenet L, McKee M.
Diab Med 2001; 18: 3-9. [PubMed]
Observations of the management of sexually transmitted diseases in the Russian Federation: a challenge of confidentiality
Platt L, McKee M.
Int J STD AIDS 2000; 11:563-67.[PubMed]

Health and lifestyles in Estonia, Latvia and Lithuania
An understanding of the east-west gap in mortality requires a detailed understanding of how a range of lifestyle related factors, such as diet, smoking, drinking, and physical exercise vary within the relevant populations. In association with WHO and with colleagues in each of the Baltic Republics we have undertaken a series of surveys to understand how these factors varied between and within the three countries.
Prior to this work, information on food availability and dietary patterns in the Baltic Republics was limited. This information is essential for the development of food policies and health promotion strategies designed to ensure sufficient food supply, improve wellbeing and reduce mortality.
The main results of teh surveys were as follows:
Fat intake was high in all three countries while the mean daily consumption of fruits and vegetables was lower than recommended. Complete dependence on home grown foods was twice as high in Lithuania as in Latvia and Estonia.
13% of the respondents were obese and almost half were overweight. Between-country variations in the prevalence of obesity were particularly large in women.
Half the respondents participated only in sedentary physical activities during their leisure time. More than half the male respondents smoked cigarette.
Women from Estonia were more than twice as likely as other women to smoke regularly. The proportion of heavy alcohol drinkers was higher in Estonia than in Latvia or Lithuania in men of all age groups.
The surveys showed important variations in dietary patterns and lifestyle behaviours among the Baltic countries, and have highlighted areas where further development of national nutrition policies and health promotion campaigns are most required. Information from the surveys could also be used as baseline data against which future dietary consumption patterns would be compared.

Publications
Full report: Nutrition and lifestyle in the Baltic Republics [full report available online]
Patterns of body weight in the Baltic Republics.
Pomerleau J, Pudule I, Grinberga D, Kadziauskiene K, Abaravicius A, Bartkeviciute R, Vaask S, Robertson A, McKee M.
Publ Health Nutr 2000; 3: 3-10 [PubMed]
Dietary beliefs in the Baltic Republics.
Pomerleau J, McKee M, Robertson A, Kadziauskiene K, Abaravicius A, Bartkeviciute R, Vaask S, Pudule I, Grinberga D.
Public Health Nutrition 2001; 4: 217-25. [PubMed

Macronutrient and food intake in the Baltic Republics.
Pomerleau J, McKee M, Robertson A, Kadziauskiene K, Abaravicius A, Vaask S, Pudule I, Grinberga D.
Eur J Clin Nutr 2001; 55: 200-207. [PubMed]
Physical inactivity in the Baltic countries
Pomerleau J, McKee M, Robertson A, Vaask S, Kadziauskiene K, Abaravicius A, Bartkeviciute  R, Pudule I, Grinberga D.
Prev Med 2000; 31: 665-672.[PubMed]

Death certification in Estonia

Understanding of the health impact of the transition in Eastern Europe on health has relied extensively upon analysis of routine mortality data.  Few systematic descriptions of the basic processes of death certification, coding and registration are readily available. A systematic evaluation of these issues as they apply to Estonia was published in July 2000.

Publication
Lang K. Evaluation of death certification, coding andregistration in Estonia. [available online].

Central Asia
Policies on health and health care have been examined in detail in a fortcomining study to be published by the European Observatory on Health Care Systems and Open University Press in summer 2001.
The study covers the history of the region, its political and economic position, environment and health issues, poverty, health care financing, hospital systems and health care staffing. It focuses on Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan and Uzbekistan.
One emerging theme is the extent to which the health care systems in the central Asian republics remain deeply embedded in the Soviet health care model.
A common challenge for these countries is the deteriorating health status of their populations. Health care systems must respond to these urgent health needs despite low and unsustainable funding. A second common concern is the poor state of primary health care. Once the pride of these health care systems, primary care has been deteriorating for decades. The countries of the region have all announced policies intended to upgrade primary care, and most have introduced general practice into the medical curriculum, previously geared only to training specialists.
The health care systems remain hospital-centred despite reductions in hospital beds, which until recently were twice the European Union (EU) average. Closing hospitals, however, is proving much more difficult.
The capacity of these countries to develop policy and implement health care system change remains very weak. The extent to which paper policies made centrally are implemented locally is questionable. Most countries receive substantial external technical and financial assistance. Donor organizations are influential, which raises the issue of the sustainability of policies and funding for the health care systems in each country.

Publication
Health sector reform in the former Soviet Republics of Central Asia.
McKee M, Figueras J, Chenet L.
Int J Health Planning Management 1998; 13: 131-47.