1. Russia and Eastern Europe Natalia S. Gavrilova Leonid A. Gavrilov Center on Aging NORC and The University of Chicago Chicago, Illinois, USA

2. Russia now The largest country in the world by the area (United States is the 3rd) The 2nd country by the number of immigrants (after the United States) The 10 th rank by population number - 141,377,752 people on July 2007 (United States has the 5 th rank)

3. Russia now The 10 th economy by GDP (CIA World Factbook). But only 75 th by per capita GDP ($14,600) The third largest reserves of foreign exchange and gold - $470 billion (after China and Japan) The largest reserves of natural gas The second in the world by oil production but the 9 th by oil reserves

4. GDP per capita at current prices (dollars) in Russia and other countries Country1990200020102012 Russia384017681061814178 China34793243756070 Kazakhstan18491266938012455 Ukraine174663729623872 Belarus1835104458186726 Finland27852235284409845741 Bulgaria2350161364597004 Mexico3815658289169795 Source: http://data.un.orghttp://data.un.org

5. IndicatorRussiaMexico Infant mortality per 1000 live births7.415 Total fertility rate (mean number of children per woman) 1.72.2 Percent of persons 65+ years of age136 Life expectancy: Men6475 Women7679 Proportion of urban population, %7478 Demographic Indicators of Russia and Mexico Source: Population Reference Bureau. 2013 World Population Data Sheet.

6. Background on Mortality in Russia

7. Before the World War II Life expectancy (both sexes)

8. Catching up with the West Life expectancy in 1965

9. Stagnation after 1965

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

11. GDP Crisis

12. Russia: Trends in life expectancy

13. 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.

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

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

16. Ethnic Differentials in Mortality

17. Trends in Life Expectancy: Men

18. Trends in Life Expectancy: Women

19. Based on the Study of Ethnic Differentials in Adult Mortality in Kyrgyzstan Michel Guillot (PI), University of Wisconsin-Madison Natalia Gavrilova, University of Chicago Tetyana Pudrovska, University of Wisconsin-Madison Demography, 2011, 48(3): 1081-1104

21. Background on Kyrgyzstan Former Soviet republic; became independent in 1991 Population: 5.2 million (2006) Experienced a severe economic depression after break-up of Soviet Union GNI per capita = 440 USD; 28 th poorest country in the world (2005) 48% of population below national poverty line (2001)

22. 2008 Workshop, Bishkek

23. Ethnic Groups in Kyrgyzstan Native Central Asian groups: Kazakh, Kyrgyz, Tajik, Turkmen, Uzbek (Sunni Muslims) Slavs: Russian, Ukrainian, Bielorussian Kyrgyzstan, 1999 census: Central Asians: 79% of pop. (Kyrgyz 65%) Slavs: 14% of pop. (Russian 12%)

24. Recorded trends in adult mortality (20-60 years)

25. Mortality paradox? Soviet period: Russians/Slavs occupied dominant positions in the socio-economic structure of Central Asian societies (Kahn 1993)

26. Mortality paradox? Slavic females more educated than Central Asian females (1989 and 1999 censuses) Slavic males: educational advantage not so clear – varies by age (1989 and 1999 censuses) Slavic households less poor than Central Asians (1993 World Bank poverty survey) Infant mortality lower among Slavs (Soviet and post-Soviet period)

27. Proportion of individuals with post-secondary education, by age and ethnicity, in 1989 census. Females

28. Mortality paradox? Slavic females more educated than Central Asian females (1989 and 1999 censuses) Slavic males: educational advantage not so clear – varies by age (1989 and 1999 censuses) Slavic households less poor than Central Asians (1993 World Bank poverty survey) Infant mortality lower among Slavs (Soviet and post-Soviet period)

29. Proportion of individuals with post-secondary education, by age and ethnicity, in 1989 census. Males.

30. Mortality paradox? Slavic females more educated than Central Asian females (1989 and 1999 censuses) Slavic males: educational advantage not so clear – varies by age (1989 and 1999 censuses) Slavic households less poor than Central Asians (1993 World Bank poverty survey) Infant mortality lower among Slavs (Soviet and post-Soviet period)

32. Mortality paradox? Slavic females more educated than Central Asian females (1989 and 1999 censuses) Slavic males: educational advantage not so clear – varies by age (1989 and 1999 censuses) Slavic households less poor than Central Asians (1993 World Bank poverty survey) Infant mortality lower among Slavs (Soviet and post-Soviet period)

33. IMR by ethnicity, 1958-2003, Kyrgyzstan

34. Data Unpublished population and death tabulations since 1959 collected from local archives Individual census records – 1999 Individual death records – 1998- 1999 obtained from national statistical office

37. Possible explanations for mortality paradox Data artifacts Migration effects (esp. 1989-99) Cultural effects

38. Data artifacts? Could the lower recorded mortality among Central Asian adults be due to lower data quality among them (coverage of deaths, age misreporting)?

39. Migration effects? 1/3 of Russian population has left Kyrgyzstan since 1991 Could the increased disparity between Russian and Kyrgyz adult mortality be due to selective migration (healthy migrant effect)?

40. Cultural effects? Culture may affect mortality in various ways:  individual health and lifestyle behaviors (e.g., diet, smoking, alcohol, use of preventive care)  family structure and social networks (denser social networks may produce lower stress levels and better health) Could different cultural practices among Slavs and Central Asians explain the observed mortality differentials?

41. Data artifacts? Intercensal estimates of death registration coverage above age 60 (Guillot, 2004): 90+ % as early as 1959 in urban areas coverage in rural areas was low initially (~50%) but caught up with urban areas in 1980s Total population: 92% for 1989-99 period Adult deaths (20-59) usually better reported than deaths 60+

43. Health selection?

44. Cohort-specific changes in educational attainment, Males, 1989-99

45. Cohort-specific changes in educational attainment, Females, 1989-99

46. Cultural effects? Analysis of causes of death by ethnicity, 1998-99 Calculations based on micro-data Deaths: vital registration (1998-99) Exposure: census (March 1999) Ages 20-59 Ethnicity: Central Asians vs. Slavs ~20,000 death records; ~2.2 million census records

47. Age-standardized Death Rates at working ages (per 100000), 1998-99, by cause and ethnicity, Males

48. Contribution of causes of death to the difference in life expectancy at working ages ( 40 e 20 ) between Slavs and Central Asians Males (total difference = 2.90 years)

49. Age-standardized Death Rates at working ages (per 100,000). Detailed Injuries, Males

50. Age-standardized Death Rates at working ages (per 100,000), 1998-99, by cause and ethnicity, Females

51. Contribution of causes of death to the difference in life expectancy at working ages ( 40 e 20 ) between Slavs and Central Asians Females (total difference =.28 years)

52. Age-standardized Death Rates at working ages (per 100,000) Detailed Injuries, Females

53. Alcohol-related Causes of Death (Chronic alcoholism, Alcohol psychoses, Alcohol cirrhosis of the liver, Accidental poisoning by alcohol) Age-standardized Death Rates at working ages (per 100,000)

54. Multivariate analysis Do ethnic mortality differentials at adult ages remain once we account for differences in education and urban/rural residence? Negative binomial regression Dependent variable: deaths from all causes; deaths by major cause (7) Explanatory variables: exposure, dummy variables for age, ethnicity, urban/rural residence, education (3 cat.) Males and Females analyzed separately Model 1: age, ethnicity Model 2: age, ethnicity, education, residence

55. Males, all causes of death

56. Risk Ratio Slavs/CA Males

57. Risk Ratio Slavs/CA Females NS

58. Conclusions Excess mortality among adult Slavs (Soviet and post-Soviet period) is not likely due to data artifacts or migration effects Excess mortality due to important ethnic differences in cause-specific mortality – alcohol and suicide in particular Differences remain unexplained by education or residence

59. Conclusions Role of cultural characteristics? Alcohol tied to cultural practices (“culture of alcohol” among Russians; Impact of Islam for Central Asians) Denser social networks and stronger social support among Central Asian ethnic groups?

60. Divergent paths for adult mortality in Russia and Central Asia: Evidence from Kyrgyzstan Guillot, M, Gavrilova, N, Torgasheva, L, Denisenko, M. Divergent Paths for Adult Mortality in Russia and Central Asia: Evidence from Kyrgyzstan. PLOS ONE, 2013, 8(10): e75314, DOI: 10.1371/journal.pone.0075314 Further developments

61. 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

62. Trends in Life Expectancy: Men

63. Trends in Life Expectancy: Women

64. 40 M 20 (Russia) – 40 M 20 (Kyrgyzstan), 1979-2009, all causes and strongly alcohol related causes

65. Framework for Understanding Health Crisis in Russia vs. Central Asia RussiaKyrgyzstan (Central Asia?) Infant mortality DeclinedStalled Adult mortality Large increaseModerate increase Explanatory framework Greater importance of detrimental adult health behaviors Greater importance of health care deterioration

66. Mortality of disabled people in Russia, 2011 Source: Pension Fund of Russia Men Women

67. Acknowledgements National Statistical Committee of the Kyrgyz Republic Zarylbek Kudabaev, Orozmat Abdykalykov, Liudmila Torgashova, Larissa Mimbaeva, Elena Komandirova and Mikhail Denisenko NICHD: R03 HD38752, R01 HD045531

68. CCBAR Supported by the National Institutes of Health (P30 AG012857) NSHAP Supported by the National Institutes of Health (5R01AG021487) including: National Institute on Aging Office of Research on Women's Health Office of AIDS Research Office of Behavioral and Social Sciences Research Natalia Gavrilova, Ph.D. Stacy Tessler Lindau, MD, MAPP Biomarkers in Population-Based Aging and Longevity Research

69. Chicago Core on Biomarkers in Population-Based Aging Research CCBAR website http://biomarkers.uchicago.edu/

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