In the past 25 years, mortality in Russia has been a subject of thorough studies by the best demographers and public health specialists.1 The ups and downs of the curve of mortality are unprecedented in recent human history, both in amplitude and in the total regress in longevity during the peaceful years. The explanations for the mortality waves offered up to date are heavy Russian drinking, disappointment with reforms,2 and stress of privatization,3 just to mention a few. These explanations are likely to be true at best only for some segments of the wave pattern.4 But if they are not applicable to the next wave, are they true explanations?

There is a fresh idea in the field. There is a possibility that longevity of Russians is effectively influenced by the funding of health care.

In the 1990s, after the Russian Federation became an independent state, the funding of health care decreased year after year and had recuperated to the level of year 1991 only in 2006.5 After 2000, the rise of the oil prices fed the Russian economy, and part of this input was shared with the health care system. First, the special free drug delivery system was introduced in 2005. Being ineffective, it was de facto converted into financial support for eligible people—they take their ‘drug money’ away from the system, at least 80% of them. Next, the ‘Priority National Project Health’ was initiated in 2006, which prepared chairman D. Medvedev to the presidency and poured more money in to the health care system. Since 2010, the health care tax in the form of compulsory health care insurance has increased. It was used by federal bureaucracy mostly to buy equipment and fix the hospital buildings, but, anyway, additional money arrived to the system.

Recently, G. Ulumbekova, who is a strong proponent of the unified national health care system for Russia, prepared the analysis, yet unpublished in full, to show that a 50% increase in the state funding of the health care is needed. Why this increase? Because at a 50% increase of funding, the life expectancy at birth may be 74 years—the announced national goal. Of course, the 50% increase it is too far reaching extrapolation, but look at the line: how nicely the dots are set around (figure 1)!

Figure1

Life expectancy in Russia at birth (ordinate, years) vs. state health care spending (abscissa, Russian roubles in US dollars equivalent purchasing capacity). Prepared using data from RosStat (Russian State Statistics Committee, gks.ru,) by G.E. Ulumbekova and V. V. Vlassov

Figure1

Life expectancy in Russia at birth (ordinate, years) vs. state health care spending (abscissa, Russian roubles in US dollars equivalent purchasing capacity). Prepared using data from RosStat (Russian State Statistics Committee, gks.ru,) by G.E. Ulumbekova and V. V. Vlassov

The idea of increasing life span by investing in health care is well known. Usually, it is thought that only investments in poor countries with low initial level of funding are effective. Russia is an upper middle income country, but with low budget health care spending. The proof for the idea recently arrived from the other end of the spectrum—from the USA, a country with most expensive health care. It was shown that an increase in the access to Medicaid is followed by an increase in longevity in the intervention, but not in control states.6 One may say that it is not about funding but about the support to the vulnerable group. But, anyway, it is about the power of the simple financial tools in the modern world.

Why should we be interested in this perspective? Because I continue to think that connection of the Russian mortality to alcohol consumption is mostly the epiphenomenon of poverty. Probably, when people have more resources than needed for a bottle of vodka, they start to spend them more wisely. If the state wisely spends money for the needs of the people, including health care, again the output may be as good as we see these years in Russia.

Conflicts of interest: None declared.

References

1
Nemtsov
AV
Alcohol-related human losses in Russia in the 1980s and 1990s
Addiction
 , 
2002
, vol. 
97
 (pg. 
1413
-
25
)
2
Notzon
FC
Komarov
YM
Ermakov
SP
, et al.  . 
Causes of declining life expectancy in Russia
JAMA
 , 
1998
, vol. 
279
 (pg. 
793
-
800
)
3
Stuckler
D
King
L
McKee
M
Mass privatisation and the post-communist mortality crisis: a cross-national analysis
Lancet
 , 
2009
, vol. 
373
 (pg. 
399
-
407
)
4
Vlassov
VV
The role of alcohol and social stress in Russia’s mortality rate: recent mortality trend in Russia
JAMA
 , 
1999
, vol. 
281
 (pg. 
321
-
2
)
5
Strategy of the social-economic development of the country
 
preliminary results of the qorkin group 11, Feb. 2011 [Russian]. Available at: http://2020strategy.ru/data/2011/07/14/1214719319/8.pdf (31 August 2012, date last accessed)
6
Sommers
BD
Baicker
K
Epstein
AM
Mortality and access to care among adults after state medicaid expansions
N Engl J Med
 , 
2012
, vol. 
367
 (pg. 
1025
-
34
)

Supplementary data

Comments

1 Comment
Alcohol consumption and life expectancy in Russia
5 August 2014
Sergei V. Jargin

After the anti-alcohol campaign (1985-88), the average expectation of life at birth in Russia has fallen especially sharply for men; by 1993 it had slumped to 59 years - that is, to below the age at which a pension starts to be paid (1). In 2008, the difference between male life expectancy in Russia and some West European countries was estimated to be 20 years (2). One of the causes of the relatively high mortality has been poor quality of alcoholic beverages, in particular, consumption of counterfeit products and surrogates sold also in legally operating shops and kiosks (3,4). During the anti-alcohol campaign, many poisonings were caused by alcohol-containing technical fluids, perfumery and home-made alcohol. For example, large-scale sales of window cleaner, causing many intoxications, were knowingly tolerated by authorities e.g. in some areas of Siberia. The quality of legally sold alcoholic beverages deteriorated during that period; and after the campaign, poor-quality alcohol was produced, imported and sold en masse (3). Numerous cases of death after ingestion of alcohol products in moderate doses (5), with a relatively low blood alcohol level (3) were reported, obviously caused by the substances other than ethanol contained in the consumed products. Considering the above and previously published (4,6-8) arguments, certain policies contributed to the mortality increase among Russian workers and other social groups. Societal consequences of replacement of Russian workers by immigrants will probably come to light in the near future. Admittedly, there has been a gradual improvement in the quality of alcoholic beverages over the last 10-12 years. The relatively high mortality rate from cardiovascular diseases in Russia has been reported and broadly discussed (2,7,9). The reasons are evident for anatomic pathologists with experience of autopsy in the former SU. Since the Soviet time, autopsy has remained obligatory for patients dying in hospitals; however, the attitude towards post-mortem examinations has become less rigorous. Autopsies have often been performed incompletely without much insight (10). If a cause of death is not entirely clear, it is common practice to write on the death certificate 'ischemic heart disease with cardiac insufficiency' or a similar formulation. A tendency to overdiagnose cardiovascular diseases also exists for people dying at home and not undergoing autopsy. It can be indirectly confirmed by the following statement: "Increases and decreases in mortality [have been] related to cardiovascular diseases (CVD), particularly to 'other forms of acute and chronic ischemia' and 'atherosclerotic heart disease', but not to myocardial infarction, the proportion of which in Russian CVD-related mortality is extremely low." (11) The explanation for this discrepancy is evident: the diagnosis of myocardial infarction is usually based on clear clinical and/or pathological criteria, while entities such as 'acute and chronic ischemia' or 'atherosclerotic heart disease' are often used without sufficient evidence. As a result, many cases with undiagnosed and untreated diseases, unnatural causes of death etc., have been regularly misclassified as resulting from cardiovascular diseases (11). The following statement should be commented upon: 'Numerous epidemiological studies led to the consensus that vodka binge drinking is a key reason for these observed changes,' i.e. for premature mortality (2). It is difficult to generalize with no reliable statistics, but heavy binge drinking has been visibly declining in Russia, especially in large cities such as Moscow, since approximately the year 2000 (4). Undoubtedly, the role of alcohol as a cause of premature death in the former SU cannot be denied, but this role was obviously more significant during the 1990s, when alcohol consumption increased as a "recoil effect" after the anti- alcohol campaign (1985-88). It is a well-known fact in Russia that middle-aged and elderly men visit primary health care centers (policlinics) on average less frequently than women of the same age; quantitative observations by the author in a Moscow policlinic produced male/female ratios in this age category from 1/3 to 1/20. In particular, people recognizable as alcohol abusers are sometimes unwelcome in medical institutions, being treated not always in accordance with medical ethics (12); so that many of them stay at home even if they have symptoms. Alcohol ranks third as a risk factor for health in the Comparative Risk Assessment (CRA) in the Global Burden of Disease analyses for 2010, being arguably the most complex risk factor, with links to more than 200 ICD codes (13). However, the causative role of alcohol in Russian mortality rates was obviously exaggerated in some publications, e.g. (14), where "the enormous scale of alcohol-related mortality" is reiterated without mentioning insufficient availability and quality of health care as another cause of premature death. There is a tendency in today's Russian literature to exaggerate the role of alcohol abuse and its causative relationship with mortality (15), especially from cardiovascular diseases (3,14,16,17). In this way, responsibility for higher mortality rates, partly caused by the limitations of the health care system, is in a sense shifted onto the patients themselves: they allegedly suffered from self- inflicted diseases due to their excessive alcohol consumption. At the same time, demonstrative anti-alcohol measures and rhetoric are distracting public attention from other problems: corruption, shortages of public health and social security systems, etc. In fact, statements such as 'Alcohol accounts for most of the large fluctuations in Russian mortality, and alcohol and tobacco account for the large difference in adult mortality between Russia and Western Europe' (18) disguise another important cause of such difference: insufficient availability and quality of health care related to the insufficient funding of health care (19), shortages of medical education, misconduct in medical research and practice (20,21). Another related problem to be mentioned is crime against alcoholics and people with alcohol-related dementia aimed at appropriation of their immobile and other properly (8). Hopefully, with international cooperation, Russia and the former Soviet Union countries can work towards improving life expectancy. References 1. Ryan M. Alcoholism and rising mortality in the Russian Federation. BMJ 1995;310:646-8. 2. Zatonski WA, Bhala N. Changing trends of diseases in Eastern Europe: closing the gap. Public Health, 2012;126(3):248-52. 3. Nuzhnyi VP, Kharchenko VI, Akopian AS. Alcohol abuse in Russia is an essential risk factor of cardiovascular diseases development and high population mortality (review). Terapevticheskii Arkhiv, 1998;70(10):57-64. 4. Jargin SV. Letter from Russia: minimal price for vodka established in Russia from 1 January 2010. Alcohol and Alcoholism, 2010;45(6):586-8. 5. Govorin NV, Sakharov AV. Alkohol-related mortality. Tomsk: Ivan Fedorov, 2012. (Russian) 6. Jargin SV. Alcohol consumption by Russian workers before and during the economical reforms of the 1990s. Int J High Risk Behav Addict. 2013;2(2):48-50. 7. Jargin SV. Health care and life expectancy: a letter from Russia. Public Health, 2013;127(2):189-90. 8. Jargin SV. Alcohol consumption in Russia 1970-2014. LAP Lambert Academic Publishing, 2014; ISBN: 978-3-659-22952-7. 9. Razvodovsky YE. Beverage-specific alcohol sale and cardiovascular mortality in Russia. Journal of Environmental and Public Health, 2010;253853. 10. Jargin SV. The practice of pathology in Russia: On the eve of modernization. Basic and Applied Pathology, 2010;3:70-3. 11. Davydov MI, Zaridze DG, Lazarev AF, Maksimovich DM, Igitov VI, Boroda AM, Khvastiuk MG. Analysis of mortality in Russian population. Vestnik Rossiiskoi Akademii Meditsinskikh Nauk, 2007; (7):17-27. 12. Jargin SV. Renal biopsy research with implications for therapy of glomerulonephritis. Current Drug Therapy, 2012;7(4):263-7. 13. Room R. Alcohol as a public health risk: New evidence demands a stronger global response. International Journal of Alcohol and Drug Research, 2013;2(1):7-9. 14. Nemtsov AV. Alcohol-related human losses in Russia in the 1980s and 1990s. Addiction, 2002;97(11):1413-25. 15. Razvodovsky YE. Estimation of alcohol attributable fraction of mortality in Russia. Adicciones, 2012;24(3):247-52. 16. Paukov VS, Erokhin IuA. Pathologic anatomy of hard drinking and alcoholism. Arkhiv Patologii, 2004;66(4):3-9. 17. Vertkin AL, Zairat'iants OV, Vovk EI. Final diagnosis. Moscow: Geotar- Media. 2009. (Russian) 18. Zaridze D, Brennan P, Boreham J, Boroda A, Karpov R, Lazarev A, et al. Alcohol and cause-specific mortality in Russia: a retrospective caseecontrol study of 48,557 adult deaths. Lancet 2009;373:2201-14. 19. Vlassov V. The enigma of Russian waves and not so bad prospects. Eur J Public Health. 2012;22(6):752. 20. Jargin SV. Some Aspects of Medical Education in Russia. American Journal of Medicine Studies 2913; 1(2):4-7. http://pubs.sciepub.com/ajms/1/2/1/ 21. Jargin SV. Societal and political will for cancer prevention in Russia. Lancet Oncol. 2014;15(8):e298.

Conflict of Interest:

None declared

Submitted on 05/08/2014 8:00 PM GMT