1. Demography of Russia and the Former Soviet Union Lecture 9 Sociology SOCI 20182

2. Demographic Crisis in Russia Fertility and Birth Rates Declined Population Ageing Marriage Rates Declined Divorce Rates Increased Abortion Rates Increased Mortality Rates Increased Natural Growth of Population Declined Which Statement is Wrong? (slide from alarmist lecture of Western researcher)

3. Factors and Trends of Mortality and Health in Russia

4. Gender gap in life expectancy In 1994 gender gap in life expectancy in Russia reached 13.7 years – the largest difference in life expectancy between sexes ever recorded

5. Life table probability of death for Russian men and women, 2005

6. Life table number of dying for Russian men and women, 2005

7. The Role of Education LRC – Lipid Research Clinic study cohort in Moscow and St.Petersburg

8. Protective role of education during 1992-1994 crisis Mortality of adult men with higher education level increased from 1989 to 1994 by 35% vs 57% for men with lower education level Mortality of adult women with higher education level increased by only 8% compared to 30% for women with lower education level Source: Shkolnikov et al., SSM, 1998

9. Education and life expectancy at working ages (20-69). Men, Russia Source: Shkolnikov et al., SSM, 1998

10. Why educated people live longer in Russia? Decomposition by cause of death

11. The role of alcohol consumption in high mortality in Russia The consumption of alcohol has deep cultural roots in Russia where it typically accompanied celebrations, signified hospitality, and enhanced bonding among acquaintances and friends. It also was a tremendous sources of revenue for the Soviet state which exercised a monopoly on its production and distribution.

12. Dynamics of alcohol consumption in Russia Liters of 100% alcohol per person per year 1 – V.Treml; 2 – Goskomstat estimate; 3-A.Nemtsov estimate; 4- sales of alcohol

13. Alcohol is a driving force of mortality crisis in Russia

14. Gorbachev’s anti-alcohol campaign, 1985-1987 Official sales of alcohol fell 51% Real consumption fell 27% Fall of alcohol sales was compensated by alcohol self- production

15. Gorbachev anti-alcohol campaign The favorable effect of the anti-alcohol campaign on Russian mortality was strong and rapid. Mortality began to decrease immediately after the introduction of restrictions on the sale of alcohol in June 1985 and continued month by month in parallel with the reduction in alcohol consumption (Shkolnikov and Vassin, 1994). The largest mortality decrease was observed at adult ages both for males and females during the year 1986. From 1984 to 1987 (mostly in 1986), life expectancy at birth rose from 61.7 to 64.9 years for males and from 73 to 74.3 years for females. (From “Premature Death in the New Independent States,” NAS, 1997)

16. Number of male deaths by month before and after the anti-alcohol campaign Number of deaths in thousand

17. Contribution of different causes of death to changes in LE, men

18. Contribution of different causes of death to changes in LE, women

19. Major effects of anti-alcohol campaign The highest decrease of mortality in regions with initial high levels of mortality at adult ages Regional inequality in mortality decreased Mortality decreased predominantly at middle adult ages due to reduction in external mortality and mortality from cardiovascular diseases

20. Results of anti-alcohol campaign Over 1 million lives were saved Alcohol consumption was decreased but still remained high – 10.5-12.6 liter per person per year in 1986-1991 In 1984 estimated deaths due to direct and indirect effects of alcohol were 525,000 deaths or 31.8% of all registered deaths (4.4% in USA, 3.1% in Canada in 1995) Anti-alcohol campaign decreased alcohol-related number of deaths by 200,000 Estimates by A. Nemtsov.

21. In 1992 and 1998 Russia experienced two serious economic crises accompanied by drop in personal income and rapid impoverishment

22. Alcohol and Inflation In 1992-1993 prices of alcohol increased much less than personal salaries and the general price index, which by June 1994 had increased to 1229 times its December 1992 level. Concurrently, prices of alcohol rose to 421 times their prior levels. It is not surprising that real alcohol consumption in Russia increased sharply during this period of economic crisis and reduction in real wages

23. Total and alcohol-related mortality during the market reforms Total number of deaths in thousand (left) Deaths from acute poisoning by alcohol (right)

24. Decline in alcohol quality during the market reforms In 1992 state monopoly on alcohol sales was abolished Self-production of alcohol became not profitable but over 20% of alcohol sales included technical alcohol Sample control tests showed that proportion of below quality standards alcohol was 5.6% in 1992 and 30.4% in 1994 Imported alcohol had even lower quality: 67.2% below quality standards

25. Copyright restrictions may apply. Notzon, F. C. et al. JAMA 1998;279:793-800. --Change in all-cause mortality rates between 1990 and 1994 by age and sex, Russia

26. Decomposition of changes in LE by cause of death, 1990-1994

27. Alcohol and suicide Suicide (1) and accidental poisoning by alcohol (3) – left Alcohol psychoses (2) - right

28. Alcohol and cardiovascular mortality Alcohol intoxication is an additional risk factor for cardiovascular diseases During anti-alcohol campaign mortality from cardiovascular diseases decreased mainly due to atherosclerotic cardiosclerosis (by 19% in men) and stroke (by 8% in men)

29. Study of autopsies in Barnaul during 1990-2004 (Zaridze et al., 2009) Among 5732 autopsied men aged 35- 69 years who were reported to have died from circulatory diseases 49% had alcohol detected in their blood and in 21% concentration of ethanol was 4g/l and higher (lethal dose) Of 5880 autopsied men aged 35-69 years who were reported to have died from injuries 76% had alcohol in their blood and in 38% concentration of ethanol was 4g/l and higher

30. What about alcohol surrogates? Alcohol surrogates – non-food liquids containing ethanol (polishing liquids, perfume, pharmaceutical tinctures, etc.) Alcohol surrogates are cheap, so they are attractive to poor persons. May be the only source of ethanol for impoverished persons. 47% of men who used surrogates were unemployed. Only 13% of men not used surrogates were unemployed

31. Northern Structure of Alcohol Consumption An example of Sweden

32. Consumption of hard liquors and life expectancy

33. Alcohol-related policy

34. Explanations of Mortality Crisis in 1992-1994 Psychological Stress (and alcohol) Hypothesis (Shapiro, 1995; Cornia, Paniccia, 1995; Shkolnikov et al., 1998) Selection Hypothesis (‘selection of alcoholics’) by Avdeev, Blum, Zakharov, Andreev, 1997.

35. Other Hypotheses (less supported by evidence) Mass impoverishment and malnutrition – if this hypothesis is true then infant mortality should increase Deterioration of the health care system – if this hypothesis is true then again infant mortality should increase Environmental pollution – environmental pollution should increase during 1992- 1994 while in fact it decreased

36. Suggested Factors of Mortality Increase During the Transition Period Rapid Impoverishment Growth of Delinquency Cheap Alcohol Expensive Medicine Tuberculosis, Drug Dependence, Sexually Transmitted Diseases, Homicide Social Stress Cardiovascular Diseases, Suicide, Alcohol-related causes Injuries Diabetes, Asthma Selection

37. Life Expectancy in Russia RussiaYearMalesFemales 199262.073.8 199358.971.9 199457.671.2 199558.371.7 200058.871.7 200660.473.2 China200672.075.0 India200662.064.0

38. Social Context of Trends in Russian Mortality

39. Transition period was accompanied by unprecedented growth of violence, crime rate and homicide mortality

40. Tendencies of Intentional Murders in Russia and the United States

41. Trends in Homicide Victimization Rates for Young and Middle-Aged Adults Data from Russian Vital Statistics MalesFemales

42. Age Profile of Homicide Mortality in Russia: 1981-2002 Males Females

43. Traditionally high rate of alcohol- related mortality increased further during the 1990s

44. Age Profiles of Mortality from Accidental Poisoning by Alcohol Data from Russian Vital Statistics MalesFemales

45. Rapid increase in the number of abandon children and children without parental support during the last decade

46. Degradation of Mortality Statistics in Russia In 1997 Russian parliament made a decision that information about social status, education, marital status and ethnicity should not be indicated in medical death certificates (because of ‘privacy protection’). This decision made studies of mortality inequalities by social status very difficult

47. Social structure of young (16-39) males died in 2004 in Kirov region

48. External deaths in marginal and socially adapted groups of men (%), Kirov region, 2004 Marginalized – unemployed or low-skilled workers

49. Period of reforms, started in the late 1980s, resulted in qualitative changes in the pattern of Russian mortality. These changes may be summarized as marginalization of Russian mortality

50. The main characteristics of marginalization are Degradation of registration of causes of death among socially disadapted Misrepresentation of real mortality pattern Formation of specific social portrait of deceased in the age groups of maximal risk (young and middle working ages)

51. It may be suggested that the growth of mortality in the 1990s was determined by: Widening of marginalized groups of population (more people became involved in these groups) Accelerated growth of mortality in marginalized groups

52. Marginalization of Mortality is Accompanied by Return of Old Infections

53. Tuberculosis and Syphilis 1990-1999

54. MalesFemales Age Profiles of Mortality from Tuberculosis

55. Prevalence of syphilis in Kazakhstan per 100,000 (1991-1999)

60. Causes of death and their classification Established by the World Health Organization as International Classification of Diseases (ICD) Has several revisions. The most recent revision is the 10 th revision. Adopted by most countries in the mid 1990s

61. Classification of causes of death in Russia Classification of causes of death used in the Soviet statistical forms was different from WHO classification. Form #5 (later called form C51) had 185 causes of death. Main differences between WHO and Soviet classification are found in the groups of CVD and injuries

62. New classification of causes of death in Russia After dissolution of the Soviet Union most FSU countries continued to use the old classification of causes of death In 1999 Russia adopted a new classification of causes of death corresponding to the 10 th ICD revision Still incompatible with the WHO classification

63. Major causes of death within the group of injuries. Men

64. Major causes of death within the group of injuries. Women

65. Degradation of mortality statistics in Russia

66. Pace of Growth of Age-Adjusted Mortality in 1989-2000 for Classes of Causes of Death

67. Proportion of deaths from ill- defined conditions is a measure of quality of mortality statistics In developed countries most deaths from ill-defined conditions are diagnosed at older ages

68. Is this increase in mortality from ill-defined conditions related to more cases of deaths from senility?

69. Age Profile of Mortality from Ill-Defined Conditions in Russia MalesFemales

70. Top Five Causes of Death for Young Adult Males (20-24) 19902001 Injuries NeoplasmsSymptoms, Signs and Ill- Defined Conditions Diseases of Circulatory System Infectious Diseases Symptoms, Signs and Ill- Defined Conditions Neoplasms Diseases of Nervous System and Sens.Organs Diseases of Respiratory System

71. Top Five Causes of Death for Young Adult Females (20-24) 19902001 Injuries Neoplasms Diseases of Circulatory System Complications of Pregnancy and Childbearing Symptoms, Signs and Ill- Defined Conditions Diseases of Nervous System and Sens.Organs Infectious Diseases

72. What Causes of Death Are Hidden Behind the Ill-Defined Conditions?

73. We Used Individual Death Certificates With More Detailed Description of Circumstances of Death Collected by Kirov Department of Health Kirov is a Typical Russian Region with Lower than Average Mortality from Ill-Defined Conditions

74. Age-Adjusted Mortality from Injuries in 1996 for Russian Males Aged 0-64 years Data from the WebAtlas Project (http://sci.aha.ru/ATL)

75. Deaths from Ill-Defined Conditions in Kirov Region of Russia in 2003 Sudden infant death (R95) 3.3% Decomposition in water (river, well, pond) (R99) 13.0% Decomposition at home (R99) 53.5% Decomposition in garden, summer house (R99) 1.7% Decomposition in forest or field (R99) 6.0% Decomposition in nonresidential building, on the street (R99) 12.3% Decomposition in water pipe (R99) 0.7% Decomposition on the cemetery (R99) 0.3% Decomposition in bath, lavatory or barn (R99) 1.0% Decomposition in other place (R99) 5.5% unknown (R99) 2.3% senility (R54) 0.3%

76. Mortality in Moscow city

77. Ill-defined conditions and external deaths of undetermined intent are two sides of the same coin It appears that both causes of death may be used for concealing criminal cases of violent death

78. Top Five Causes of External Mortality in Russia and Moscow in 2001 RussiaMoscow SuicideAccidental Falls Undetermined Injury HomicideAll Other Accidental Causes Accidental Poisoning by Alcohol Homicide All Other Accidental CausesSuicide

79. Autopsies in Russia Autopsies are used to verify cause of death Autopsy is mandatory for violent death, death of woman during pregnancy, labor or postpartum period, death of infant below 1 year, death from cancer not supported morphologically, death from any infectious disease

80. Situation with medical examiner services Only 34-48% of jobs are filled by physicians 38-54% of jobs are filled by histologists 35% of workers reached retirement age

81. Current trends in life expectancy

82. Current trends in life expectancy in Moscow and some Eastern European countries

83. Main features of recent improvement Highest gains in working ages (15- 64) Main improvements due to causes directly related to alcohol, accidents and respiratory diseases These improvements may be related to the recent measures of increased control after alcohol production adopted in 2005

84. Additional factor – fluctuations in alcohol-related mortality Age-standardized mortality of men (per 100,000) from accidental poisoning by alcohol

85. Improvement in life expectancy in 2005-2006, Men

86. Improvement in life expectancy in 2005-2006, Women