1. Russia is different… Martin McKee London School of Hygiene and Tropical Medicine & European Observatory on Health Systems and Policies Dubai, January 2006

2. The challenge…  “I cannot forecast to you the action of Russia. It is a riddle, wrapped in a mystery, inside an enigma “ Winston Churchill

3. Death of a nation 50 55 60 65 70 75 1970198019902000 male female years Life expectancy at birth

4. Percentage variation in myocardial infarction explained by nine risk factors Source: INTERHEART … and this is among survivors: In former Soviet Union, twice as many cardiac deaths are sudden

5. Ischaemic heart disease over time 11.5 12 12.5 13 13.5 14 14.5 15 15.5 Wed Thurs Fri Sat Sun Mon Tues % of total weekly deaths 0 100 200 300 400 500 600 700 198019851990199520002005 male female Age standardised death rates per 100,000 Deaths among men aged 35-45 from IHD

6. Could alcohol play a role? Trends in life expectancy at birth Source: WHO anti-alcohol campaign begins rise in illegal production collapse of USSR Life expectancy at birth (years) female male 55 60 65 70 75 1970198019902000

7. Variation in the life expectancy decrease for men across regions of European Russia Walberg, McKee et al., 1998 7

8. 0 10 20 30 40 50 60 70 80 05101520 % fall in male life expectancy sum of hirings and redundancies/1,000 employees Association between labour turnover in 1993/4 and fall in life expectancy 1990-94

9. Contribution of deaths from different causes and at different ages to differences in life expectancy in best and worst regions 0 1 1 2 2 3 3 01-1415-3435-6465+ Other Alcohol related Injuries Respiratory diseases Infectious diseases Other Neoplasms Resp. cancer Cerebro vascular Cardio vascular Years of life lost/ gained Age group

10. And what about health care?  Death rate from avoidable mortality in UK and Russia similar in 1965, when little could be done  Gap began to widen in 1970s, and has continued to do so since

11. The Soviet health system  A great success, at first  But funded according to the “residual” principle – what was left after everything else  It just failed to adapt to modern health care “If communism does not destroy the louse, the louse will destroy communism” Lenin

12. Chronic disease: the critical challenge 0 5 10 15 20 25 30 19801985199019952000 Armenia Azerbaijan Belarus Georgia Kazakhstan Kyrgyzstan Republic of Moldova Russian Federation Tajikistan Turkmenistan Ukraine Uzbekistan Age standardised death rate, Diabetes mellitus, per 100,000

13. Patients speak: interviews with patients living with diabetes in Kyrgyzstan  “It was fine in the old times but now it is worse, …”  “What is the point of going to the health centre if nothing is available, no equipment…. I always go to the city endocrinology dispensary for blood and urine tests even it is more difficult and expensive for me.”  “Our health centre is mainly closed and I never know when it is open.”  “I live far away from the city in a small village where the health centre doesn’t have insulin. I am worried that I won’t get insulin for a few days or even a week because we don’t have a car to go to the rayon (district) health centre and we need to wait until someone in the village goes there.” Hopkinson, Balabanova, McKee & Kutzin, 2004

14. The Izhevsk Family Study Moscow Udmurtia Izhevsk = 0.65 million Udmurtia = 1.6 million Russia = 143 million Investigators: London: Dave Leon Martin McKee Susannah Tomkins Izhevsk Nikolai Kiryanov Lyudmilla Subarova Rostock Vladimir Shkolnikov Evgeniy Andreev

15. The Izhevsk Family Study  Case control study  1700 cases (men dying between ages 25 and 54) and 1700 controls  Information obtained on cases from proxy informants (family members)  Information on controls from the controls themselves and from proxies  Supplemented with detailed information from police, narcology service, social services, and autopsy data

16. Important questions without answers  What proportion of all deaths are caused by alcohol abuse ?  How big is the problem of deaths due to toxic impurities ?  Whether deaths from causes not obviously related to alcohol are in fact due to alcohol abuse?  How big is the problem of problem drinking in the population ?  How strongly is it related to social and economic characteristics ?

17. Drinking in Russia  What is being drunk? Vodka Surrogate spirits Alcohol containing medicines Samogon (moonshine)  8% of healthy controls drink substances not intended for drinking!  How is it drunk Heavy episodic consumption Zapoi – a Russian word meaning getting so drunk that you withdraw from social interaction for several days  12% of controls report zapoi

18. Vodka: a selection

19. Samogon

20. Surrogate spirits

21. Alcohol containing medicines

22. How much ethanol?

23. Correlates of alcohol abuse (in live controls)

24. All case mortality according to frequency of surrogate drinking (relative to never surrogates) Mortality odds ratio 40.0 20.0 10.0 5.0 2.5 1.25 OR1 Adjusted for age OR2 Adjusted f or age and smoking OR3 Adjusted for age and education OR4 Adjusted for age, smoking and education Frequency of surrogate drinking OR1 OR2 OR3 OR4 Every day5-6 times per week 3-4 times per week 1-2 times per week 1-3 times per month A few times a year

25. …and by cause (adjusted for smoking and education)

26. Some more detail

27. Surrogates or ordinary drinking? All cause mortality

28. Of course it is absolute rather than relative risk we are concerned with: The scale of the problem in men of working age (25-54 years)  18% of deaths are due to causes that are certified by a doctor as being directly caused by alcohol (e.g. alcoholic cirrhosis and alcohol poisoning)  A minimum of 20% of deaths from all other causes attributable to alcohol abuse (e.g. surrogates and/or zapoi)  Total burden = 18% + 20% = 38% of all deaths due to alcohol abuse (does not include effect of “normal” drinking)

29. Do these findings help us to understand what happened in Russia in early 1990s?  Life expectancy dropped markedly  But not all causes of death affected to same extent  Almost no change in cancer, but large changes in some other causes Ratio of death rates in 1994 to those in 1987: men aged 40-44

30. Cause-specific mortality odds ratios for surrogate vs non-surrogate drinkers in the Izhevsk Family Study compared with relative changes in age-standardised mortality rates among men aged 25-54 in Russia 1994/1991 Mental disorders 0 1 2 3 4 5 6 0510152025303540 1994/1991 Pearson r = 0.93 0 1 2 3 4 5 6 0510152025303540 Mortality ORs for surrogate drinkingRatio age-stndardised Russian mortality rates Pearson r = 0.93

31. A mechanism? Social and economic factors (pace of transition) Death (un) conventional risk factors stress Health care

32. Back to alcohol: the cirrhosis belt Age standardised death rate chronic liver disease & cirrhosis, age 0-64/100,000 0 10 20 30 40 50 60 70 80 19801985199019952000 Hungary Romania EU average Source: WHO

33. What else is being drunk elsewhere?  Cane spirit (Latin America/ Africa)  Fruit brandies (eastern Europe) Moonshine Hooch Arrack What else? Nascimento, Cardoso, Neto, Franco & Farias, 1998 Szűcs, Sárváry, McKee, Ádány, 2005

34. A night out in Tallinn…

35. What is going on?  In Russian cities, a significant number of people drink surrogate alcohols  Probably different in rural areas, where the equivalent is samogon (home produced)  Surrogates twice as strong and 1/3 the price – i.e. six times cheaper for a given volume of alcohol  Observed effects may be that once someone crosses threshold to regular surrogate consumption, price barrier essentially disappears  However, where home produced spirits drunk, possibility of additional toxic organ damage

36. Implications for PURE?  Russia is different, but maybe not so different  Even in the exceptions, identifiable biological risk factors are likely to be very important  Look beyond beer, wine and spirits  Don’t forget the impact of health care