1. DYING TOO YOUNG: CHALLENGES AND OPTIONS IN THE RUSSIAN FEDERATION THE WORLD BANK Human Development Sector Unit Russia Country Department Europe and Central Asia Region Patricio Marquez February 3, 2006

2. President Vladimir Putin State-of-the-Nation Address, Federal Assembly of the Russian Federation, April 25, 2005 “We cannot reconcile ourselves to the fact that the life expectancy of Russian women is nearly 10 years and of men nearly 16 years shorter than in Western Europe. Many of the current mortality factors can be remedied, and without particular expense…The reasons are well known. And we should implement a whole range of measures to overcome this dreadful situation….

3. Presentation Overview 1. The demographic decline and the health deficit 2. Determinants 3. Consequences 4. Strategies and interventions to prevent non-communicable diseases and injuries in Russia 5. Actions to confront non-communicable diseases and injuries 6. Expected health improvements 7. Potential economic benefits 8. Conclusions and the way forward

4. Estimated Population Growth Rates, Russia, 1980–85 to 2020–25 Source: UN Population Projections, 2004 Revisions

5. Life Expectancy and Adult Mortality in Selected Countries, 2000–2001 CountryLife expectancy at birth (2001) Probability of dying between ages 15 and 60 (2000–2001, % males) Probability of dying between ages 15 and 60 (2000–2001, % females) Russian Federation 6642.415.3 Japan 819.84.4 France 7913.75.7 United States 7814.18.2 Germany 7812.66.0 United Kingdom 7710.96.6 Denmark 7712.98.1 Mexico 7318.010.1 Poland 7022.88.8 Turkey 7021.812.0 Brazil 6825.913.6 Kyrgyz Republic 6633.529.9 Source: World Bank World Development Indicators

6. Mortality among the Working-Age Population in Russia Drives Fluctuations in Life Expectancy Source: WHO European Health for All Database

7. Life Expectancy at Birth: Russia and the EU, 1970–2000 Source: WHO European Health for All Database

8. Healthy Life Expectancy (HALE) at Birth in Russia and Four European Countries, 2002 Source: WHO Health For All Database

9. Male Adult Mortality and Gross National Income per Capita in Selected Countries, 2000 Source: World Bank World Development Indicators. Note: “PPP” is purchasing power parity.

10. Is Economic Growth Sustainable in Russia without Good Health in Russia? Source: World Bank World Development Indicators 2005/WHO/ERO HFA Database 2005. Note: When calculating GNI in U.S. dollars from GNI reported in national currencies, the World Bank follows the Atlas conversion method, using a three-year average of exchange rates to smooth the effects of transitory exchange rate fluctuations.

11. The Russian Population Structure: 2005 and 2020 Source: UN Population Projections, 2004 Revisions

12. Deaths and DALYs Lost Attributable to the 10 Leading Diseases and Injuries in Russia, 2002 Source: WHO/EURO Health Database RankCause Total deathsTotal %RankCause Total DALYs lostTotal % 1 Ischemic heart disease711,57129.6%1 Ischemic heart disease 5,472,30813.9% 2 Cerebrovascular disease533,67522.2%2 Cerebrovascular disease 3,930,36710.0% 3Poisonings66,9302.8%3 Unipolar depressive disorders 1,574,6954.0% 4Self-inflicted injuries59,0152.5%4Violence 1,459,9273.7% 5 Trachea, bronchus, lung cancers58,8992.4%5Self-inflicted injuries 1,297,1523.3% 6Violence47,4612.0%6Road traffic accidents 1,292,7523.3% 7Road traffic accidents44,5801.9%7Poisonings 1,272,3663.2% 8Stomach cancer44,5571.9%8Alcohol use disorders 1,258,9363.2% 9 Colon and rectal cancers38,1411.6%9 Hearing loss, adult onset 765,9881.9% 10Cirrhosis of the liver37,4261.6%10Tuberculosis 700,9971.8% All causes2,405,721100.0%All causes39,409,946100.0%

13. Cause-Specific Adult Mortality Rates, Age 15–64 Deaths per 100,000 population RussiaEU-15 Russia’s death rates as % of EU-15 NCDs605206294% Injuries28158484% Source: WHO Mortality Database

14. Deaths and DALYs Lost Attributable to 10 Leading Risk Factors in Russia, 2002 RankRisk factor Total Deaths %RankRisk factor Total DALYs % 1High blood pressure35.51Alcohol16.5 2High cholesterol23.02High blood pressure16.3 3Tobacco17.13Tobacco13.4 4Low fruit and vegetable intake12.94High cholesterol12.3 5High BMI12.55High BMI8.5 6Alcohol11.96Low fruit and vegetable intake7.0 7Physical inactivity9.07Physical inactivity4.6 8Urban outdoor air pollution1.28Illicit drugs2.2 9Lead1.29Lead1.1 10Illicit drugs0.910Unsafe sex1.0 Source: WHO/EURO Health Database.

15. Non-Communicable Diseases and Injuries Are the Leading Causes of Death and Ill Health in Russia Cardiovascular Disease: CVD death rate in Russia (2002) = 994 per 100,000 population (United States = 317, Portugal = 363, Brazil = 225) Traffic Injuries: Mortality due to traffic injuries in Russia = 20.6 deaths per 100,000 population (G-8 rate = 11) Suicide: Russia’s suicide rate is much higher than that of EU countries (when it peaked in 1994, suicide rate for Russian men aged 50–54 was over six times that in the United States) Alcohol Abuse: Adult per capita alcohol consumption in 1999 was 10.7 liters per adult in Russia versus 8.6 liters in the United States and 9.7 liters in the United Kingdom Violence: In 1999, close to 30,000 persons died from homicide in Russia. Alcoholism is closely related to crime; the proportion of crimes committed by men and women while intoxicated in 2002 was about 30 percent and 12 percent, respectively.

16. The Preventable Risk Factors for NCDs and Injuries Tobacco Consumption: Russia has one of the world’s highest rates of smoking among men. While smoking prevalence among men decreased slightly to 61 percent in 2004, the prevalence of smoking among women increased from 7.3 percent in 1992 to 15 percent in 2004. Drug Use: At the beginning of 2005, drugs users were estimated to number 500,000. High Cholesterol: About 60 percent of Russian adults have higher than recommended cholesterol levels, and about 20 percent are at high risk and in need of medical attention. Psychosocial Stress: Stress resulting from the economic transition and reduction in the social safety net manifests as depression and anxiety and can lead to incapacity, suicide, and other violence- related injuries. Low Socioeconomic Status: People of lower socioeconomic status have higher mortality and are more likely to report bad health than people of higher status.

17. Consequences of the Demographic Decline and The Health Deficit Impact on labor: Fewer workers; high absenteeism due to ill health; and job losses Destabilization of families: The death of a household member affects other household members’ welfare and behavior, including alcohol abuse Growing regional disparities: Disparities in life expectancy in different regions and among social and ethnic groups could exacerbate existing differences and may give rise to social and political challenges, especially in a country as vast as Russia Chronic illness has negatively affected household incomes, particularly during 1998–2002, when it is estimated that chronic illness contributed to an annual loss of 5.6 percent of per capita income High medical treatment costs on the economy

18. Impact Of NCDs and Injuries on Health Care Costs and the Economy Source: Frid 2005.

19. Distribution of Risk Factors in a Population Theoretical presentation of the difference between individual risk and the proportional attributable risk 5 percent People with low factor level 70 percent People with average risk factor level 25 percent People with clinically high risk factor level Individual risk of CHD Distribution of people according to risk factor level Source: Rose 1992, as shown in North Karelia Project Presentation, National Public Health Institute, 2005

20. Strategies and Interventions to Prevent Non-communicable Diseases and Injuries Policies, Strategies, and Capacity-building at the Federal Level:  Develop legal, policy, and strategy support for priority population-based subprograms  Build institutional capacity to implement priority subprograms  Assure federal oversight and accountability Priority Subprograms in the Regions:  Population-based Primary Prevention Interventions: Alcohol, Tobacco, Changes in Diet, and Promotion of Physical Activity  Secondary Prevention: Hypertension, Cholesterol, Diabetes Control  Regional support subprograms for implementing the national mortality reduction program  Improved road safety and emergency medical services

21. What Health Improvements Could Result from an Intensified Program of Action? Estimated Improvements in Life Expectancy if Mortality Rates Are Reduced by 20 and 40 Percent, Russian Males, 2000 CurrentCirculatoryDigestiveExternal causes Life expectancy 204020402040 Birth57.7762.563.958.359.861.362.5 20–2440.0844.046.240.641.945.446.2 25–2935.7441.744.236.337.540.442.0 30–3431.8237.840.632.333.435.736.1 35–3927.7833.834.628.329.630.932.9 40–4424.1930.030.824.625.126.627.9 45–4920.4026.128.320.820.922.225.3 50–5417.3322.524.817.617.718.619.2 55–5913.9218.721.514.2 14.715.4 60–6411.4815.117.011.6 11.914.1 Source: Author’s calculations

22. What Health Improvements Could Result from an Intensified Program of Action? Estimated Improvements in Life Expectancy if Mortality Rates Are Reduced by 20 and 40 Percent, Russian Females, 2000 Source: Author’s calculations CirculatoryDigestiveExternal causes Life expectancy204020402040 Birth72.373.975.273.274.172.873.1 20–2454.055.656.954.955.854.554.8 25–2949.350.952.250.251.149.850.1 30–3446.646.247.545.546.445.145.4 35–3940.043.642.940.941.840.540.8 40–4435.437.038.336.337.235.936.2 45–4930.932.533.831.832.731.431.7 50–5426.728.329.627.628.527.227.5 55–5922.624.225.523.524.423.123.4 60–6418.820.421.719.720.619.319.6

23. Main Findings The static economic benefits of gradually bringing the adult NCD- and injury-mortality rates down to the European Union (EU-15) rates by 2025 are estimated at 3.6 to 7.1 percent of the 2002 Russian GDP When a broader concept than GDP per capita is considered, the “welfare” benefits from achieving EU-15 rates by 2025 are estimated to be as high as 29 percent of the 2002 Russian GDP The impact of improving adult health on economic growth rates is significant and grows over time: while in 2005 the difference in the per capita GDP between the status quo scenario and the most optimistic scenario is US$105–$324, by 2025 this difference grows to US$2,856–$9,243

24. What Are the Potential Economic Benefits of Mortality Reduction in Russia? Russian GDP per Capita Forecasts in the Three Scenarios 1996 constant U.S. dollars Source: Suhrcke at al. 2005

25. Conclusions Russia is experiencing a major and complex demographic and health crisis characterized by premature mortality; ill health and disability among young adults; and a reduction in population size, coupled with the aging of its population. Poor adult health negatively affects economic well-being at the individual and household level; if effective action were taken in Russia, improved health would play an important role in economic growth Most non-communicable diseases and injuries could be prevented and controlled through a comprehensive national program operating at the federal, regional, and municipal levels, adapting best practices that have proven effective internationally The time has come to acknowledge the breadth of social and economic factors that affect health, including the responsibility of individuals for their own health and government responsibility for creating an enabling environment for its population to make healthier choices