1. Demography of Russia and the Former Soviet Union Lecture 8 Sociology SOCI 20182

2. The Concept of Life Table Life table is a classic demographic format of describing a population's mortality experience with age. Life Table is built of a number of standard numerical columns representing various indicators of mortality and survival. The concept of life table was first suggested in 1662 by John Graunt. Before the 17th century, death was believed to be a magical or sacred phenomenon that could not and should not be quantified. The invention of life table was a scientific breakthrough in mortality studies.

3. Life Table Cohort life table as a simple example Consider survival in the cohort of fruit flies born in the same time

4. Number of dying, d(x)

5. Number of survivors, l(x)

6. Number of survivors at the beginning of the next age interval: l(x+1) = l(x) – d(x) Probability of death in the age interval: q(x) = d(x)/l(x)

7. Probability of death, q(x)

8. Person-years lived in the interval, L(x) L(x) are needed to calculate life expectancy. Life expectancy, e(x), is defined as an average number of years lived after certain age. L(x) are also used in calculation of net reproduction rate (NRR)

9. Calculation of life expectancy, e(x) Life expectancy at birth is estimated as an area below the survival curve divided by the number of individuals at birth

10. Life expectancy, e(x) T(x) = L(x) + … + Lω where Lω is L(x) for the last age interval. Summation starts from the last age interval and goes back to the age at which life expectancy is calculated. e(x) = T(x)/l(x) where x = 0, 1, …,ω

11. Life Tables for Human Populations In the majority of cases life tables for humans are constructed for hypothetic birth cohort using cross- sectional data Such life tables are called period life tables Construction of period life tables starts from q(x) values rather than l(x) or d(x) as in the case of experimental animals

12. Formula for q(x) using age-specific mortality rates a(x) called the fraction of the last interval of life is usually equal to 0.5 for all ages except for the first age (from 0 to 1) Having q(x) calculated, data for all other life table columns are estimated using standard formulas.

13. Life table probabilities of death, q(x), for men in Russia and USA. 2005

14. Period life table for hypothetical population Number of survivors, l(x), at the beginning is equal to 100,000 This initial number of l(x) is called the radix of life table

15. Life table number of survivors, l(x), for men in Russia and USA. 2005.

16. Life table number of dying, d(x), for men in Russia and USA. 2005

17. Life expectancy, e(x), for men in Russia and USA. 2005

18. Trends in life expectancy for men in Russia, USA and Estonia

19. Trends in life expectancy for women in Russia, USA and Estonia

20. Distribution of life expectancy, Men, 1999

21. Distribution of life expectancy, Women, 1999

22. Mortality reversal Situation when the usual time trend of declining mortality is reversed (mortality is increasing over time). Observed in sub-Saharan Africa (AIDS epidemic), Eastern Europe, and FSU countries including Russia. Mortality Reversal in FSU countries and Russia is particularly strong among male population, with excess mortality at ages about 35-55 years. Particularly high increase in mortality from violence and accidents among manual workers and low education groups.

23. Decline of life expectancy at age 15 between 1998-2005. Men

24. Decline of life expectancy at age 15 between 1998-2005. Women

25. Recent changes in life expectancy in Russia Source: Goskomstat Russia

26. The theory of epidemiological transition Omran, Abdel R. 1971. The epidemiologic transition: A theory of the epidemiology of population change. Milbank Memorial Fund Quaterly, 29: 509-538

27. Definition The epidemiologic transition is that process by which the pattern of mortality and disease is transformed from one of high mortality among infants and children and episodic famine and epidemic affecting all age groups to one of degenerative and man-made diseases (such as those attributed to smoking) affecting principally the elderly. (Encyclopedia Britannica)

28. Stages of the Epidemiologic Transition  Pestilence and Famine  Receding Pandemics  Degenerative and man-made diseases

29. Three stages of epidemiological transition (Omran) “The Age of Pestilence and Famine when mortality is high and fluctuating, thus precluding sustained population growth.” LE – 20-40 years “The Age of Receding Pandemics when mortality declines progressively. LE increases steadily from 30 to 50 years. Sustained population growth “The Age of Degenerative and Man-Made Diseases when mortality continues to decline and eventually approaches stability.” LE exceeds 50 years.

30. The shifts in disease patterns in the 19th century were primarily related to changing in socio- economic development. In the 20th Century more related with disease control activities independent of socio-economic development: e.g. Mexico, China

32. The fourth stage It was believed that by the 1970s life expectancy reached a plateau corresponding to the biological limit to human life However around that time many Western countries started to demonstrate an increase in life expectancy mainly due to successful prevention and treatment of cardiovascular disease. This resulted in a rapid decline of mortality, particularly at older ages.

33. Historical changes in the Gompertz-Makeham mortality components μ(x) = A + R e αx Makeham component declined in history (from 1900 to 1970) to very low values close to zero Gompertz component remained relatively stable during this period Gavrilov et al. 1983. Human life span stopped increasing: Why? Gerontology, 29(3): 176-180 Available: http://longevity-science.org/Mortality-Limits-1983.pdf

34. Historical Changes in Mortality Swedish Females Data source: Human Mortality Database

36. Epidemiologic transition in Russia Soviet Union successfully passed all three stages of epidemiologic transition However Soviet health care system could not respond to the challenges of growing mortality from non- communicable diseases

37. The “Semashko” model of 1918 The health care system was under the centralized control of the state, which financed services as part of national social and economic development plans. All health care personnel became employees of the centralized state, which paid salaries and provided supplies to all medical institutions. The main policy orientation throughout this period was to increase numbers of hospital beds and medical personnel.

38. Initial successes of government- controlled model of health care Russia made massive strides in arresting the spread of infectious diseases. Drastic epidemic control measures were implemented against the spread of tuberculosis, typhoid fever, typhus, malaria and cholera. Community prevention approaches, routine check-ups, improvements in urban sanitation and hygiene, quarantines, etc.

39. Moscow kindergarten, 1930s

40. Vaccination in rural Turkmenistan, 1930s

41. Before World War II Life expectancy (both sexes)

42. Catching up with the West Life expectancy in 1965

43. Stagnation after 1965

44. Mortality reversal Situation when the usual time trend of declining mortality is reversed (mortality is increasing over time). Observed in sub-Saharan Africa (AIDS epidemic), Eastern Europe, and FSU countries including Russia. Mortality Reversal in FSU countries and Russia is particularly strong among male population, with excess mortality at ages about 35-55 years. Particularly high increase in mortality from violence and accidents among manual workers and low education groups.

45. Decline of life expectancy at age 15 between 1998-2005. Men

46. Decline of life expectancy at age 15 between 1998-2005. Women

47. Decomposition of the U.S.-Russia gap in life expectancy by cause USA – 1999; Russia – 2001. Source: Shkolnikov et a. Mortality reversal in Russia.

48. Decomposition of the U.S.-Russia gap in life expectancy by cause USA – 1999; Russia – 2001. Source: Shkolnikov et a. Mortality reversal in Russia.

49. Factors and Trends of Mortality and Health in Russia

50. Sex Differentials of Mortality U.S. population in 1999

51. 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

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

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

54. Life expectancy in Russia

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

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

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

58. 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.

59. 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

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

61. 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

62. 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)

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

64. Trends in the number of deaths Millions of deaths

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

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

67. Age and cause components of LE increase due to anti-alcohol campaign: Men

68. Age and cause components of LE increase due to anti-alcohol campaign: Women

69. 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

70. 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.

71. Mortality reversal Situation when the usual time trend of declining mortality is reversed (mortality is increasing over time). Observed in sub-Saharan Africa (AIDS epidemic), Eastern Europe, and FSU countries including Russia. Mortality Reversal in FSU countries and Russia is particularly strong among male population, with spikes of mortality at ages about 35-55 years. Particularly high increase in mortality from violence and accidents among manual workers and low education groups.

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

73. 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

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

75. 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

76. 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

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

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

79. Drinking and Suicide Number of suicides per 100,000 – left Alcohol (l) per person per year 1 – suicides with alcohol in blood ; 3 – sober suicides (left); 2- alcohol consumption

80. 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)

81. 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

82. Northern Structure of Alcohol Consumption An example of Sweden

83. Consumption of hard liquors and life expectancy

84. Alcohol-related policy

85. 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.

86. 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

87. 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

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

89. Age Profile of Suicide Mortality in Russia: 1981-2001 MalesFemales

90. 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