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Premature Death in the New Independent States (1997)

Chapter: Epidemiological Transitions in the Former Socialist Economies: Divergent Patterns of Mortality and Causes of Death

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Suggested Citation:"Epidemiological Transitions in the Former Socialist Economies: Divergent Patterns of Mortality and Causes of Death." National Research Council. 1997. Premature Death in the New Independent States. Washington, DC: The National Academies Press. doi: 10.17226/5530.
×

6
Epidemiological Transitions in the Formerly Socialist Economies: Divergent Patterns of Mortality and Causes of Death

Christopher J.L. Murray and José Luis Bobadilla

Introduction

Eastern Europe and the New Independent States (NIS), known collectively as the Formerly Socialist Economies, are a unique demographic and epidemiological region.1 Mortality trends in the region over the last three decades appear to define a new pattern of the epidemiological transition, one that deviates from the collective experience of other developed countries and the middle-income countries of Latin America and Asia (Murray et al., 1992; Kingkade and Arriaga, in this volume). The goal of this chapter is to examine the levels, trends, and patterns of causes of death in the region, with an emphasis on identifying the patterns that may explain its unusual mortality experience.

Health or, more accurately, mortality in the Formerly Socialist Economies has been the focus of substantial and sustained academic interest since the mid-1970s (Anderson and Silver, 1988, 1989, 1990, 1991; Blum and Monnier, 1989; Cooper, 1981, 1983, 1985, 1987; Cooper and Sempos, 1984; Cooper and Schatzkin, 1982a, 1982b; Davis and Feshback, 1980; Deev and Oganov, 1989; Dutton, 1979, 1981; Eberstadt, 1990, 1993; Forster and Jozan, 1990; Jones and Grupp, 1983; Jozan, 1989; Medvedev, 1985; Meslé et al., 1993; Ryan, 1982, 1988; Treml, 1982).

Interpretation of the current pattern of age-specific mortality and causes of death in the region must be undertaken in light of its trends in mortality over the last two to three decades. Because the trends and explanations of trends for these countries have been contentious (as discussed in several other chapters in this volume), we try to clarify the situation by separating the discussion of changes in

Suggested Citation:"Epidemiological Transitions in the Former Socialist Economies: Divergent Patterns of Mortality and Causes of Death." National Research Council. 1997. Premature Death in the New Independent States. Washington, DC: The National Academies Press. doi: 10.17226/5530.
×

child mortality (under age 5) from that of changes in adult mortality (over age 5). There are reasons to suspect that the changes and explanations for these two groups are fundamentally different.

The publication in the Soviet Union of infant mortality rates for 1971-1975—showing an increase from 22.9 to 30.6 per 1,000 births, generated considerable discussion and analysis (Blum and Monnier, 1989). Publication of the infant mortality rate was discontinued by the Soviet government in the face of still worsening mortality after 1975. With glasnost, the rates were again published, with back figures given from 1980, when the rate was 27.3.

For infant (under age 1) and child (ages 1-4) mortality in most of Eastern Europe (noteworthy exceptions being Romania and Bulgaria), we have long series of data for which there is widespread consensus that registration has been adequate for many years. The data show that changes in these rates over the last decades in Eastern Europe have not paralleled those in the former Soviet Union. Throughout the period following World War II, child mortality in Eastern Europe was similar to that in the rest of Europe, except in Romania and Bulgaria. In addition, the pace of improvement has been the same (except for an increase in Romania since 1985), with no evidence of worsening infant or child mortality during the last two decades. If the above increase in the Soviet Union in fact occurred, we must seek explanations for that change that are specific to the Soviet Union and not applicable to all Formerly Socialist Economies. The divergence in pattern also emphasizes the importance of examining time trends in the former Soviet Union by republic.

In contrast with infant and child mortality, the patterns of adult mortality observed in Eastern Europe and the partial data for the Soviet Union tell a more consistent story. With regard to mortality among adult women, the levels over the last four decades have been higher in Eastern Europe than in the former Soviet Union, but the trends until 1980 were identical. Since then, trends in the two regions have diverged. Patchy data on age-specific mortality for the former Soviet Union suggest a pattern of stagnation or slow decline among most female age groups (Blum and Monnier, 1989; Eberstadt, 1993), whereas in Hungary and Poland, mortality among women aged 30-44 and 45-59 has increased slightly.

The major demographic and epidemiological puzzle of the Formerly Socialist Economies is the sustained increase in adult male mortality, which has affected those aged 30-44, 45-59, and 60-69, and remarkably began in almost exactly the same year—1964—in all countries of the region. Partial data for the former Soviet Union indicate that similar developments occurred throughout the region at the same time (Anderson and Silver, 1990; Ryan, 1982; Cooper, 1981; Eberstadt, 1993). The increases in adult male mortality continued over nearly two decades and led to a 60 percent increase among some age groups in some countries.

Cooper and colleagues (Cooper, 1981, 1983, 1985, 1987; Cooper and Sempos, 1984; Cooper and Schatzkin, 1982a, 1982b) have argued that other

Suggested Citation:"Epidemiological Transitions in the Former Socialist Economies: Divergent Patterns of Mortality and Causes of Death." National Research Council. 1997. Premature Death in the New Independent States. Washington, DC: The National Academies Press. doi: 10.17226/5530.
×

countries, such as the United States, Japan, and Chile, have experienced similar phases of increasing adult mortality. Yet while mortality among males aged 4559 increased from 1961 to 1968 in the United States, the length and the magnitude of the increase in the Formerly Socialist Economies are without parallel in demographic history (Stolnitz, 1974). Explanations for this unique mortality reversal in an industrialized region in the face of continued improvements in child health, at least in Eastern Europe, have included smoking, alcohol, occupational exposures, pollution, diet, the health care delivery system, and a cohort effect from hardships endured during World War II. Moreover, explanations for the increase in male mortality must simultaneously explain the improvements or at worst stagnation in female mortality in the former Soviet Union since 1980.

The next section reviews the data sources and methods used for this study. The section that follows presents results of the analysis with respect to mortality patterns and years of life lost. This is followed by discussion of the unique mortality trends and cause-of-death patterns in the region of the Formerly Socialist Economies that includes the northern European former Soviet republics. The final section presents conclusions.

Data Sources and Methods

Before analyzing the patterns of causes of death based on vital registration data for the former Soviet republics and Eastern Europe, careful attention must be paid to the validity of those data. In the following sections, we evaluate the proportion of infant deaths captured in the vital registration system, the proportion of adult deaths recorded, and finally the quality of the attribution of deaths to particular causes. We also describe our method for calculating years of life lost due to premature mortality. Note that unless otherwise indicated, the analysis of mortality in this chapter refers to deaths that occurred in 1990.

Underregistration and Alternative Definitions of Neonatal Deaths

The Soviet definition of infant mortality is not the same as the World Health Organization (WHO) standard (see also the chapters by Shkolnikov et al. and by Kingkade and Arriaga, in this volume). As a consequence, the number of neonatal deaths—deaths before age 1 month—in the former Soviet republics is seriously underreported. The result is an underestimate of infant mortality, which is the sum of neonatal and post-neonatal mortality. In the present analysis, we correct neonatal mortality rates (NMR) for the former Soviet republics by using the relationship between NMR and post-neonatal mortality rates (PNMR) observed in countries with good vital statistics. We expect the PNMR (deaths between ages 1 and 12 months) to be unaffected by the Soviet definition of an infant death, except for possible age heaping at 1 month of age.

We analyzed 1,327 pairs of NMR and PNMR available for 35 countries over

Suggested Citation:"Epidemiological Transitions in the Former Socialist Economies: Divergent Patterns of Mortality and Causes of Death." National Research Council. 1997. Premature Death in the New Independent States. Washington, DC: The National Academies Press. doi: 10.17226/5530.
×

Figure 6-1

Neonatal and post-neonatal mortality rates. (Data over a 40-year period from countries with good vital statistics registration.) These 1,327 data points are drawn from 35 countries over a period from 1945 to 1989. The R2 from the regression of NMR vs. the logit transformation of PNMR is .80 and both the coefficient and the constant from the equation are significant (p 8 0.001). The coefficient is .0166 and its standard error is 0.0002. The constant is 0.0555 and its standard error is 0.0005.

a 40-year period.2 Figure 6-1 shows the relationship between the two rates. When the PNMR is transformed to its logit form,3 the relationship is linear. An ordinary least squares regression equation was fitted:

NMR = .0555 + (-.0166 * logitPNMR)

The R2 for the equation is 0.80, and the p-values for the slope and constant are each less than 0.001. The standard error of the constant is 0.0002, and the standard error for the slope is 0.0006. In addition, the residuals are homoskedastic.

We estimated the corrected neonatal mortality rates (NMRc) by applying the PNMR for each of the former Soviet republics (thought to be accurate) to the above regression equation. Adding this newly generated NMRc to the PNMR yields a new estimate of the infant mortality rate, IMRc. It should be noted that all of the correction made to the infant mortality rates is due to correction of the neonatal mortality rate (from NMR to NMRc). Table 6-1 shows the NMRc and IMRc for all the former Soviet republics and the estimated proportion of underregistered neonatal and infant deaths; for NMR, this percentage varies from 26.6 percent in Turkmenistan to about 53.5 percent in Latvia. The different definition

Suggested Citation:"Epidemiological Transitions in the Former Socialist Economies: Divergent Patterns of Mortality and Causes of Death." National Research Council. 1997. Premature Death in the New Independent States. Washington, DC: The National Academies Press. doi: 10.17226/5530.
×

TABLE 6-1 Infant Mortality Reported and Corrected in the NIS, 1990

 

Reported Infant Mortality Rate (IMR)

Reported Neonatal Mortality Rate (NMR)

Reported Post-Neonatal Mortality Rate (PNMR)

Corrected IMR

Corrected NMR

Percentage underestimation of reported IMR

Percentage underestimation of reported NMR

Republic

Armenia

20.4

9.2

11.2

27.9

16.7

27.1

45.2

Azerbaijan

26.2

6.1

20.1

33.4

13.3

21.6

54.2

Belarus

11.8

7.3

4.6

19.4

14.8

38.8

50.8

Estonia

14.7

10.2

4.6

22.1

17.6

33.5

42.2

Georgia

19.6

9.9

9.7

27.0

17.3

27.6

43.1

Kazakstan

25.9

10.9

15.0

33.1

18.2

21.9

40.0

Kyrgyz

32.2

10.3

21.9

39.6

17.7

18.7

41.8

Latvia

11.1

6.4

4.8

18.4

13.7

39.6

53.5

Lithuania

10.7

6.8

3.9

18.1

14.3

41.0

52.1

Moldova

20.4

9.9

10.5

27.9

17.4

26.8

43.0

Russian Federation

17.8

10.6

7.2

25.1

17.9

29.2

41.0

Tajikistan

43.2

10.3

32.9

50.6

17.7

14.6

41.8

Turkmenistan

54.7

15.5

39.1

60.3

21.1

9.3

26.6

Ukraine

13.0

6.9

6.1

20.4

14.3

36.5

51.9

Uzbekistan

37.7

11.8

25.8

44.7

18.9

15.7

37.3

All Soviet Union

22.7

10.0

12.7

30.1

17.4

24.7

42.8

Suggested Citation:"Epidemiological Transitions in the Former Socialist Economies: Divergent Patterns of Mortality and Causes of Death." National Research Council. 1997. Premature Death in the New Independent States. Washington, DC: The National Academies Press. doi: 10.17226/5530.
×

of neonatal death may not account for all of this wide variation in the neonatal mortality rate; some variation may be due to higher rates of underreporting of neonatal deaths.

Underregistration of Adult Deaths

Most authors presume that registration of mortality in the Russian Federation, the Baltic states, and the other former Northern republics is complete. Anderson and Silver (1990, 1991, and in this volume), however, have analyzed regional mortality patterns in the former Soviet Union and concluded that there is substantial underregistration of adult deaths in the former Central Asian republics. To date, judgments that there has been substantial underreporting of deaths in certain republics have been based solely on the fact that observed mortality rates appear to be too low. Such assessments presuppose that the determinants of relative levels of adult mortality within the former Soviet Union or among industrialized countries are known. For example, Anderson and Silver (1990, 1991) report lower age-specific mortality in Tajikistan than in the United States for males; in the age groups over 70 years, the differences are as high as 20 to 50 percent. The authors conclude that lower adult mortality in Central Asia than in the United States is "implausible," although they provide no epidemiological justification for this judgment.

Studies of adult mortality patterns (ages 15-59) in industrialized and developing countries have demonstrated wide variations in adult male and female mortality as measured by 45q15—the probability of death between ages 15 and 60. For example, in Japan, male 45q15 is 113 per 1,000, compared with 175 per 1,000 for all U.S. males, 300 for U.S. black males, and 187 for Finnish males (Murray et al., 1992). Given the wide range in adult mortality levels that is not easily explained by variables such as income per capita, it is not convincing to argue that there is significant underregistration in Central Asian states solely because their observed rates are lower than those of other states.

To define further the extent of underregistration in different states of the former Soviet Union, we use the growth balance method and the Bennett-Horiuchi technique (United Nations, 1983). We apply the growth balance method using registered deaths in 1989 and the census population for 1989 by age for each republic. Application of this method depends on having a population that approximates a stable population with a long-term constant birth rate and no net migration. The relationship between Nx/Nx+ and Dx+/Nx+, however, is not linear for almost all republics; Nx is the population at age x, Nx is the population over age x, and Dx+ is deaths over age x. The age group "birth rate," Nx/Nx+, is markedly lower for the age groups 70-74 and 75-79 for most republics, which may reflect the World War II experience of this cohort. Excluding these age groups and 80+ years, the estimated coverage for the former Soviet Union com-

Suggested Citation:"Epidemiological Transitions in the Former Socialist Economies: Divergent Patterns of Mortality and Causes of Death." National Research Council. 1997. Premature Death in the New Independent States. Washington, DC: The National Academies Press. doi: 10.17226/5530.
×

TABLE 6-2 Estimated Coverage of Mortality Registration in the New Independent States, 1990

 

Growth Balance Method

Bennett-Horiuchi Technique

Bennett-Horiuchi 50+

 

Estimated coverage (%)

Estimated coverage (%)

Estimated coverage (%)

Republic

Female

Male

Female

Male

Female

Male

Latvia

77.5

83.3

109.2

106.0

106.1

105.8

Lithuania

71.3

82.9

107.5

106.1

105.4

104.7

Belarus

66.1

65.1

101.6

101.3

102.5

104.7

Estonia

83.4

79.4

103.1

103.4

102.4

104.5

Azerbaijan

73.1

62.3

80.8

93.0

85.7

103.8

Ukraine

71.5

80.4

103.5

101.3

102.0

103.5

Russian Federation

72.8

62.9

97.7

102.2

100.4

102.7

Georgia

64.9

59.0

89.6

96.8

91.4

97.5

Moldova

68.5

72.9

100.4

92.3

102.9

95.4

Kazakstan

79.3

73.2

80.4

83.2

84.7

91.9

Turkmenistan

104.6

88.0

82.5

81.3

86.2

90.9

Armenia

62.9

56.7

69.8

77.2

78.7

90.4

Uzbekistan

102.3

86.0

81.4

84.3

84.7

89.3

Kyrgyz

85.4

74.0

79.1

84.2

82.8

88.9

Tajikistan

86.7

124.0

74.7

82.6

79.3

87.6

All Soviet Union

103.0

102.3

97.2

99.5

98.8

101.9

Suggested Citation:"Epidemiological Transitions in the Former Socialist Economies: Divergent Patterns of Mortality and Causes of Death." National Research Council. 1997. Premature Death in the New Independent States. Washington, DC: The National Academies Press. doi: 10.17226/5530.
×

bined is 103 percent for females and 102 percent for males. Estimates of coverage using the growth balance method for each republic range from 65 to 120 percent, as shown in Table 6-2. These estimates follow no clear geographic pattern; Armenia, Georgia, Belarus, and Moldova have the lowest estimated coverage, rates below 70 percent. The assumptions underlying the growth balance method clearly do not hold at the republic level, making these estimates of coverage.4

The Bennett-Horiuchi technique for assessing vital registration completeness is a more powerful method that does not require assumption of a constant birth rate over the past 80 years, but does assume a closed population (Bennett and Horiuchi, 1981). As input, two censuses and all registered deaths by age and sex for the interval between the censuses are required. Censuses were conducted in each republic in 1979 and 1989; unfortunately, registered deaths by age and sex are available for the majority of years between 1979 and 1989, but not all. As a first approximation, we used the average number of registered deaths for each age group for all available years 1979-1989, multiplied by 10. For the former Soviet Union combined, the estimated completeness of registration for females is 99 percent and for males 102 percent. The estimated coverage may be somewhat exaggerated (over 100 percent, for example) because of overstatement of age at older ages (Bennett and Garson, 1983).

Table 6-2 provides the estimated coverage of death registration for each republic by sex. The median estimated completeness is severely affected by internal migration; those republics, such as Lithuania, which had substantial net immigration over the period 1979 to 1989 show overregistration of deaths, while those with net emigration show underregistration. The third column of Table 6-2 shows the estimated completeness of death registration for the population over age 50, which may be less affected by migration between republics. To the extent that the approximations used in the application of the Bennett-Horiuchi technique are plausible, registration is over 90 percent in all locations except for males in Uzbekistan, Kyrgyz, and Tajikistan and females in Azerbaijan, Kazakstan, Turkmenistan, Armenia, Uzbekistan, Kyrgyz, and Tajikistan.

The lower levels of vital registration coverage for many of the Central Asian republics and females in Azerbaijan are probably due to a combination of net emigration and lower completeness of vital registration. Given that vital registration for the Soviet Union as a whole is very close to complete, we suspect that internal migration in the former Soviet republics may play an important role in explaining the low coverage. Nevertheless, it is reasonable to suspect that vital registration coverage in Central Asia and Azerbaijan is lower than in other parts of the former Soviet Union. The estimates of registration coverage for all Central Asian republics, Georgia, and Azerbaijan are considerably lower for women than for men. This sex difference in vital registration coverage could be explained by more age overstatement by males than females or by sex bias in death registra-

Suggested Citation:"Epidemiological Transitions in the Former Socialist Economies: Divergent Patterns of Mortality and Causes of Death." National Research Council. 1997. Premature Death in the New Independent States. Washington, DC: The National Academies Press. doi: 10.17226/5530.
×

tion. Further work using more detailed data on migration between republics by age and sex is needed to improve the estimates of sex-specific underregistration.

We conclude that for most republics, registration of adult deaths is 95 percent or more complete. Registration of adult deaths in the Central Asian republics is probably between 85 and 95 percent. Registration coverage of adult female deaths in Central Asia, Georgia, and Azerbaijan may be lower than that of adult male deaths. For our analysis, we have chosen not to adjust the reported levels of adult mortality based on the Bennett-Horiuchi technique. The 10 to 15 percent underestimation that may be present does not affect any of our major conclusions. Where appropriate, we draw attention to the effect corrections might have on the observed patterns of mortality and years of life lost.

Classifications of Causes of Death

There are two distinct sets of concerns with the attribution of causes of death in the republics of the former Soviet Union: the classification system and the quality of the coding of each individual death.

The countries of Eastern Europe switched from the Soviet system of classifying causes of death after World War II; the NIS countries, however, have continued to use the Soviet system. Meslé et al. (1993) report that the Soviet system has undergone four major revisions since 1950; the last three revisions have been based on the International Classification of Diseases (ICD-7, ICD-8, and ICD-9), but contain many fewer causes (see also Kingkade and Arriaga, in this volume). The latest Soviet revision, in use since 1981, has also been slightly modified to include additional causes, such as AIDS (Goskomstat, 1987). Based on a translation of a bridge-coding manual prepared by the Soviet Central Statistical Administration (Goskomstat), we have mapped the Soviet codes to ICD-9. In turn, we have mapped the ICD-9 codes to the simplified list of diseases proposed by Murray and Lopez (1994). Without a formal bridge-coding exercise, whereby the same set of deaths is coded for both ICD-9 and the Soviet system, a potential error in interpretation is introduced. As discussed below, this is a significant problem only for complex groups of causes, such as cardiovascular diseases.

In addition, poor diagnostic skill in the NIS may introduce systematic error in the cause-of-death data. One of the only objective indicators of the quality of cause-of-death attribution is the proportion of deaths coded by physicians (Lopez, 1989). Even in Central Asia, more than 99 percent of deaths are coded by physicians (Goskomstat, 1987). Follow-up studies (where coding was reviewed by a panel of experts) from 1965 in central Russia, 1979 in Russia, and 1981-1982 in Belarus and Turkmenistan reveal that the percentage over- or underestimation for most large groups of causes, such as cardiovascular disease, is very small, e.g., 3.1 to 2.3 percent. The largest errors are in coding of respiratory disease, with errors of 1 1.3 to 17.2 percent (see Shkolnikov et al., in this volume).

Although nearly all registered deaths are coded by physicians, and the three

Suggested Citation:"Epidemiological Transitions in the Former Socialist Economies: Divergent Patterns of Mortality and Causes of Death." National Research Council. 1997. Premature Death in the New Independent States. Washington, DC: The National Academies Press. doi: 10.17226/5530.
×

follow-up studies demonstrate that the estimated population cause-specific mortality rates are reasonable, there may be substantial differences in diagnostic practice among countries. The results presented below, however, do not suggest that there is more diagnostic error in the data for the former Soviet republics than is observed for other developed countries.

Years of Life Lost Due to Premature Mortality and Excess Years of Life Lost

To capture the importance of death at different ages, we compute years of life lost due to premature mortality, using the methods outlined by Murray et al. (1994) and applied by Murray (1994).5 Estimation of years of life lost due to premature mortality provides a picture of the major causes of mortality, but not of avoidable premature death. To identify avoidable or excess years of life lost, we make comparisons with the rates of years of life lost observed for the Established Market Economies (Murray and Lopez, 1994). Excess years of life lost is then defined as the difference between observed years of life lost for each age and sex by cause and the number expected if the rates of the Established Market Economies are applied in a region. Excess years of life lost thus defined can be negative for a cause if the mortality rates by age and sex for a given disease are lower in a region than in the Established Market Economies.6

Results

This section presents results for geographic patterns of mortality (1990), years of life lost due to premature mortality, and excess years of life lost for the Formerly Socialist Economies.

Geographic Patterns of Mortality, 1990

Summary results for each of the NIS and Eastern European countries comprising the Formerly Socialist Economies are provided in Table 6-3a for males and 6-3b for females. These tables provide 5q0 (the probability of death between birth and age 5); 45q15 (the probability of death between ages 15 and 60); 10q60 (the probability of death between ages 60 and 70); and e(0), or life expectancy at birth. Within the group of Formerly Socialist Economies, 5q0 ranges from 15 to 95 per 1,000 for boys and 11 to 78 for girls. Among adults, male 45q15 ranges from 194 to 305 per 1,000 and female 45q15 from 94 to 155. The high level and extensive range of adult male mortality is most remarkable. Adult male mortality in the Russian Federation, for example, is equal to that of India, whereas adult Russian women enjoy mortality that is 52 percent lower than in India.

The Formerly Socialist Economies are not a homogeneous group as most

Suggested Citation:"Epidemiological Transitions in the Former Socialist Economies: Divergent Patterns of Mortality and Causes of Death." National Research Council. 1997. Premature Death in the New Independent States. Washington, DC: The National Academies Press. doi: 10.17226/5530.
×

TABLE 6-3a Child and Adult Mortality in the Formerly Socialist Economies, Males, 1990

 

5q0 per thousand

45q15 per thousand

10q60 per thousand

e(0)

Country

Armenia

38.8

194.8

267.7

67.7

Azerbaijan

65.5

238.9

289.2

65.1

Belarus

21.1

272.1

291.5

66.0

Estonia

22.9

269.6

315.2

64.9

Georgia

34.3

218.4

272.2

67.5

Kazakstan

47.5

293.0

338.7

63.0

Kyrgyz

63.1

267.7

301.4

63.1

Latvia

22.8

290.8

315.2

64.3

Lithuania

18.1

276.0

287.0

66.2

Moldova

37.2

270.6

296.6

65.2

Russian Federation

29.3

303.5

336.0

63.5

Tajikistan

85.8

193.7

238.0

65.2

Turkmenistan

94.6

269.6

321.9

61.1

Ukraine

26.3

270.3

308.0

65.2

Uzbekistan

70.0

225.8

264.8

64.7

Bulgaria

20.3

216.5

270.9

68.2

Czechoslovakia

14.9

242.6

329.2

67.3

Hungary

18.8

305.2

332.6

65.1

Poland

20.1

263.4

308.2

66.5

Romania

36.5

233.4

267.1

66.4

Yugoslavia

27.2

194.9

265.6

69.0

 

SOURCE: Vital registration data and adjusted mortality rates.

analyses tacitly assume. Figure 6-2 shows child mortality (5q0) on the x-axis and adult male mortality (45q15) on the y-axis. Three clusters of countries can be identified by simple inspection: a group with moderate child and moderate adult mortality, a group with low child and low adult mortality, and a group with low child and high adult mortality. Remarkably, each of these clusters contains a set of geographically contiguous countries. In fact, the countries are arrayed on the diagram in a manner that approximates a map of the Formerly Socialist Economies. Accordingly, we have divided the countries into three groups, which we term Central Asia, South FSE (for Formerly Socialist Economies), and North FSE. Notably, Kazakstan, which is sometimes included with the four Central Asian republics, is on the demographic boundary with North FSE in terms of the child-adult mortality map. We have included it with North FSE because of its high adult mortality. Summary measures for each of the three regions are provided in Table 6-4. As the table shows, even if adult mortality is adjusted for underregistration, the Central Asian republics remain a distinct cluster with high child and moderate adult mortality.

Suggested Citation:"Epidemiological Transitions in the Former Socialist Economies: Divergent Patterns of Mortality and Causes of Death." National Research Council. 1997. Premature Death in the New Independent States. Washington, DC: The National Academies Press. doi: 10.17226/5530.
×

TABLE 6-3b Child and Adult Mortality in the Formerly Socialist Economies, Females, 1990

 

5q0 per thousand

45q 15 per thousand

10q60 per thousand

e(0)

Country

Armenia

31.2

99.3

159.4

73.8

Azerbaijan

55.9

106.0

157.2

72.3

Belarus

15.7

102.5

145.3

75.0

Estonia

16.0

114.1

156.9

74.1

Georgia

27.3

93.9

145.4

74.6

Kazakstan

37.8

130.8

184.0

71.9

Kyrgyz

52.0

130.8

173.6

70.9

Latvia

16.4

117.2

155.1

73.9

Lithuania

14.6

107.8

141.0

75.2

Moldova

29.0

155.1

199.4

71.1

Russian Federation

21.8

109.6

165.7

73.6

Tajikistan

73.5

133.4

162.7

69.9

Turkmenistan

78.0

155.2

217.5

67.5

Ukraine

19.5

107.4

156.0

74.0

Uzbekistan

57.0

135.1

172.4

70.6

Bulgaria

15.2

96.6

153.0

74.8

Czechoslovakia

11.2

97.7

161.7

75.4

Hungary

15.0

132.8

173.0

73.7

Poland

15.7

101.7

153.2

75.4

Romania

30.3

119.1

166.0

72.3

Yugoslavia

24.9

94.0

151.9

74.7

 

SOURCE: Vital registration data and adjusted mortality rates.

Another way of putting in perspective the dissonance between child and adult mortality is to compare their current and expected levels. Expected levels can be determined using two different methods: the level of adult mortality expected from the level of child mortality based on a model life table (or vice versa), or the level of adult and child mortality expected on the basis of income per capita.

For the first method, the North model life table was chosen for comparison (Coale and Demeny, 1966). Table 6-5 shows the difference between observed adult mortality and adult mortality expected on the basis of observed child mortality from the model life table. The residuals confirm our clustering of countries into three groups. Central Asia has moderate child mortality (60 or more per 1,000) and expected or slightly higher levels of adult mortality. South FSE has low child mortality (less than 60 per 1,000) and moderately higher levels of adult mortality than expected (less than 10 percent excess adult mortality). And North FSE has low child mortality rates and very high levels of adult mortality (twice or more the model life table value). The deviation between female adult mortality

Suggested Citation:"Epidemiological Transitions in the Former Socialist Economies: Divergent Patterns of Mortality and Causes of Death." National Research Council. 1997. Premature Death in the New Independent States. Washington, DC: The National Academies Press. doi: 10.17226/5530.
×

Figure 6-2

Adult male mortality vs. child mortality in the Formerly Socialist Economies of Europe and Central Asia.

and that expected based on model life table North is notably different than that for males. In Central Asia, adult female mortality is on average 42 per 1,000 lower than expected (although this may be explained in part by underregistration); in South FSE it is 5 per 1,000 lower than expected; and in North FSE it is 16 per 1,000 higher than expected. While women actually have better or close to expected mortality, the geographic pattern is symmetrical with that of males, confirming the significance of our three-part division of the Formerly Socialist Economies for both males and females.

Alternatively, we can compare observed levels of child and adult mortality with those expected on the basis of income per capita. Using data from the World Development Report 1993 (World Bank, 1993), we found that the relationship between the natural log of 5q0 and 45q15 and the natural log of income per capita in international dollars 7 is linear. The fitted regression equations can then be used to determine whether levels of adult and child mortality in each republic are above or below the levels expected on the basis of income per capita (Table 6-5). The average levels of adult and child mortality for the three regions are also shown. In Central Asia, child mortality is higher than expected, and adult mortality is slightly lower. South FSE has somewhat higher adult mortality than expected. But North FSE has markedly higher adult mortality than expected for its moderate income per capita. This method of defining excess mortality confirms that the three regions have distinct epidemiological profiles even when income per capita is considered.

Suggested Citation:"Epidemiological Transitions in the Former Socialist Economies: Divergent Patterns of Mortality and Causes of Death." National Research Council. 1997. Premature Death in the New Independent States. Washington, DC: The National Academies Press. doi: 10.17226/5530.
×

TABLE 6-4 Basic Indicators and Mortality Figures for Three Regions of the Formerly Socialist Economies, Circa 1990

 

 

 

 

 

 

Health Expenditures

 

5q0 per 1000

45q15 per 1000

10q60 per 1000

e(0)

GNP/Capita (1991 US$)

Per Capita (1991 US$)

As % GDP

Total Fertility Rate

Regions

Males

Central Asia

72.8

228.9

276.1

64.7

1418

112

5.45

3.62

South

30.7

213.8

266.4

67.7

1586

171

4.94

2.12

North

27.1

287.3

323.1

64.8

2773

172

4.26

2.25

Females

Central Asia

60.4

130.1

172.3

71.2

1418

112

5.45

3.62

South

26.0

103.7

156.7

73.8

1586

171

4.94

2.12

North

20.4

109.5

162.3

74.4

2773

172

4.26

2.25

 

SOURCE: World Bank (1993). country vital registration data, and adjusted mortality rates.

Suggested Citation:"Epidemiological Transitions in the Former Socialist Economies: Divergent Patterns of Mortality and Causes of Death." National Research Council. 1997. Premature Death in the New Independent States. Washington, DC: The National Academies Press. doi: 10.17226/5530.
×

TABLE 6-5 Deviations from Predicted Mortality, 1990

 

Deviation from 45q15 Predicted Based on Model Life Table North

Deviation from Male Mortality Predicted Based on GDP per Capita

Country

Male

Female

5q0

45q15

North FSE

149.9

16.2

2.3

87.4

Belarus

151.3

20.0

-1.0

76.5

Czechoslovakia

144.2

31.8

-10.2

45.6

Estonia

139.2

26.7

n.a.

n.a

Hungary

192.4

53.6

-4.9

101.7

Kazakstan

113.3

0.3

20.1

84.8

Latvia

165.9

41.1

n.a.

n.a.

Lithuania

159.7

26.6

-5.2

76.9

Moldova

113.9

44.4

8.4

60.2

Poland

146.0

20.3

-10.9

41.1

Russian Federation

163.9

15.0

6.7

113.9

Ukraine

134.9

16.5

-0.6

61.6

South FSE

62.6

-5.2

3.2

12.2

Armenia

19.2

-19.6

10.0

-16.5

Bulgaria

98.6

16.8

-10.6

18.8

Georgia

64.9

-15.9

0.7

-0.2

Romania

67.9

-4.9

-0.8

32.9

Yugoslavia

55.4

-14.4

11.9

-0.5

Central Asia

2.4

-41.5

33.1

-15.7

Azerbaijan

27.4

-57.5

31.0

-4.4

Kyrgyz

56.8

-28.7

26.3

30.0

Tajikistan

-57.9

-62.8

38.9

-71.9

Turkmenistan

35.4

-54.2

57.4

37.3

Uzbekistan

6.4

-31.6

29.4

-24.2

NOTE: Subregional figures are weighted averages.

n.a. = figures were not available.

SOURCE: Vital registration data and adjusted mortality rates.

Years of Life Lost Due to Premature Mortality by Cause, Age, and Sex

Combining the registered deaths for each of the countries in each region, we have created regional figures for North FSE, South FSE , and Central Asia. The structure of cause of death is different in each of the three regions, as presented in Table 6-6. North FSE is dominated by injuries and noncommunicable causes

Suggested Citation:"Epidemiological Transitions in the Former Socialist Economies: Divergent Patterns of Mortality and Causes of Death." National Research Council. 1997. Premature Death in the New Independent States. Washington, DC: The National Academies Press. doi: 10.17226/5530.
×

TABLE 6-6 Years of Life Lost Disaggregated by Large Groups of Causes for Each Subregion, 1990

 

North FSE

South FSE

Central Asia

Age Group and Cause

YLL

As % of total

YLL

As % of total

YLL

As % of total

0-4 years

Group I

2,335,731

61.8

589,034

65.7

2,537,713

83.7

Group II

1,080,974

28.6

233,815

26.1

312,569

10.3

Group III

365,766

9.7

73,059

8.2

181,666

6.0

Total

3,782,471

 

895,908

 

3,031,948

 

5+ years

Group I

743,853

2.7

205,228

4.6

169,317

8.5

Group II

20,012,036

73.5

3,614,346

80.8

1,430,845

71.9

Group III

6,475,645

23.8

654,059

14.6

390,846

19.6

Total

27,231,533

 

4,473,634

 

1,91,008

 

All Ages

Group I

3,079,587

9.9

794,259

14.8

2,707,032

53.9

Group II

21,093,008

68.0

3,848,163

71.7

1,743,416

34.7

Group III

6,841,412

22.1

727,116

13.5

572,508

11.4

Total

31,14,006

 

5.369,537

 

5.022,956

 

NOTE: Group I is communicable, maternal, and perinatal causes; Group II is noncommunicable causes; and Group III is injuries.

YLL = Years of life lost.

Suggested Citation:"Epidemiological Transitions in the Former Socialist Economies: Divergent Patterns of Mortality and Causes of Death." National Research Council. 1997. Premature Death in the New Independent States. Washington, DC: The National Academies Press. doi: 10.17226/5530.
×

(Group II). The large share of years of life lost due to injuries in this region as compared with other regions in the world, such as the Established Market Economies, is notable. In South FSE, because of a younger population and slightly higher child mortality than in North FSE, Group I (communicable, maternal, and perinatal causes) is still an important cause of years of life lost. Injuries are much less important than in North FSE or Central Asia. In Central Asia, nearly half of all years of life lost is attributable to Group I. The division by large groups of causes divided into age groups reveals that in the population over age 5, injuries (Group III) claim a very large share of years of life lost.

More detailed information on years of life lost by cause is provided in Table 6-7. In North FSE, the results are notable in Group I for a considerable burden of tuberculosis and respiratory infections. Lung cancer causes over 4 percent of all years of life lost, reflecting the prominent role of smoking in defining the health problems of adults. Other cancers causing more than 1 percent of the total burden include lymphoma/leukemia and cancers of the stomach, colon/rectum, and breast. Cardiovascular diseases cause 35 percent of the total years of life lost—ischemic heart disease representing nearly half of this total, followed by cerebrovascular disease. The residual category, ''other cardiovascular," still causes 7.6 percent of the total; this category needs to be further defined to determine the contributing components. Unexpectedly, alcoholic cirrhosis is not a large cause of death in this region. Alcohol-associated deaths fall to a large extent under the categories of neuropsychiatric (alcohol dependence) and poisoning (58 percent of years of life lost due to adult poisoning in North FSE is attributable to alcohol). The consumption of hard liquor in preference to other forms of alcohol may explain the distinctive manifestation of alcohol in the mortality data for this region. Injuries cause an extraordinary 22 percent of total years of life lost in North FSE. Motor vehicle accidents, suicides, poisonings, and homicides, in descending order, are the largest contributors to this total. Treml (1982 and in this volume) has pointed out that a considerable portion of the poisonings is probably due to alcohol intoxication.

The results for South FSE are notable for the much larger share of years of life lost (7.1 percent) attributable to respiratory infections, mostly among children (68 percent). Reflecting a slightly less advanced smoking epidemic, lung cancer causes 3.4 percent of years of life lost, followed by cancers of the stomach and breast, lymphoma/leukemia, and cancer of the colon/rectum. As in North FSE, cardiovascular diseases are the most important cause of death, accounting for 38 percent of years of life lost. The pattern within this category, however, is distinctly different. Ischemic heart disease and cerebrovascular disease have nearly equal shares, 12.6 and 11.0 percent, respectively. Other cardiovascular diseases represent the largest component, 14.0 percent. This residual category is worrisome. Local coding practices may be responsible for assigning to this category some ischemic heart disease deaths, or possibly deaths from some other major cardiovascular causes, such as cardiomyopathy or arrhythmia. Further

Suggested Citation:"Epidemiological Transitions in the Former Socialist Economies: Divergent Patterns of Mortality and Causes of Death." National Research Council. 1997. Premature Death in the New Independent States. Washington, DC: The National Academies Press. doi: 10.17226/5530.
×

TABLE 6-7 Percent Distribution of Years of Life Lost by Major Causes of Death, by Region, 1990

Cause

North

South

Central Asia

Group I: Communicable, maternal, and perinatal diseases

9.9

14.8

53.9

   Infectious and Parasitic

2.7

3.1

15.2

      Tuberculosis

1.0

0.8

0.9

      Diarrheal disease

0.5

0.9

8.6

      Meningitis

0.4

0.4

0.8

      Hepatitis

0.1

0.2

2.6

   Respiratory infection

2.9

7.1

29.7

   Maternal

0.1

0.4

0.2

   Perinatal

4.3

2.8

9.5

Group II: Noncommunicable diseases

68.0

71.7

34.7

   Malignant neoplasm

18.7

16.4

6.0

      Esophagus

0.5

0.2

0.6

      Stomach

2.7

1.7

0.9

      Colon/rectum

1.6

1.3

0.4

      Lung

4.1

3.4

0.8

      Breast

1.3

1.4

0.3

      Cervix

0.5

0.6

0.2

      Lymphoma/leukemia

1.6

2.0

0.8

   Diabetes

0.7

1.1

0.5

   Nutritional endocrine

0.4

0.4

1.0

      anemia

0.0

0.1

0.0

   Neuropsychiatric

1.8

2.4

1.8

   Cardiovascular

35.0

37.5

15.6

      Ischemic heart disease

17.2

12.6

8.6

      Stroke

10.3

11.0

4.1

   Other

7.6

14.0

 

   Respiratory

3.2

3.0

2.2

   Digestive

3.3

5.3

3.2

      Cirrhosis

1.4

3.0

1.5

   Genito-urinary

1.3

1.5

1.3

   Congenital

2.8

2.9

2.9

Group III: Injuries

22.1

13.5

11.4

   Unintentional

15.5

11.8

9.5

      Motor vehicle accident

6.2

2.3

3.3

      Poisoning

2.7

0.2

0.5

      Fall

1.0

0.4

0.5

      Fire

0.4

0.2

0.6

      Drowning

1.8

0.3

1.7

   Intentional

6.6

1.7

1.9

      Suicide

4.4

1.3

1.1

      Homicide

2.1

0.4

0.8

Total

100.0

100.0

100.0

Number in millions

31.0

5.4

5.0

Suggested Citation:"Epidemiological Transitions in the Former Socialist Economies: Divergent Patterns of Mortality and Causes of Death." National Research Council. 1997. Premature Death in the New Independent States. Washington, DC: The National Academies Press. doi: 10.17226/5530.
×

work on defining the specific cardiovascular causes coded in this group is urgently required. Digestive diseases cause over 5.3 percent of years of life lost in South FSE, with cirrhosis being responsible for more than half of this amount. As a group, injuries are much less important in South than in North FSE. Motor vehicle accidents cause 2.3 percent of deaths, followed by suicides (1.3 percent).

In Central Asia, years of life lost is dominated by child deaths; thus the associated causes are more in Group I. Respiratory infections (29.7 percent), diarrheal diseases (8.6 percent), and perinatal causes (9.5 percent) are the most important. Among cancers, lymphoma/leukemia and cancers of the lung and stomach account for more than 1 percent of years of life lost each. Cardiovascular diseases cause 15.6 percent of deaths; of these, over one-half are attributable to ischemic heart disease and about one-fourth to cerebrovascular disease. The injury pattern is similar to that of South FSE, except for the prominent role of drownings (1.7 percent), suicides (1.1 percent), and homicides (0.8 percent).

Annex Table 6-1 provides estimates of years of life lost by cause for each of the NIS countries, to facilitate more detailed comparisons among states within each of the epidemiological regions.

Excess Years of Life Lost

Table 6-8 shows the distribution by age, sex, and region of excess years of life lost, by disease group and all causes of death. Figures 6-3a, b, and c present the excess years of life lost by age in South FSE, North FSE, and Central Asia, respectively. Total years of life lost in Central Asia is 80 percent higher than expected based on rates of the Established Market Economies, and in North FSE and South FSE is 67 and 50 percent higher, respectively. The excess can be apportioned among different age and sex groups. In Central Asia, 80 percent of the excess is due to child mortality (under age 5). The excess is concentrated among children because of high fertility and a young age structure, combined with moderately high levels of child mortality even by developing world standards. Adult men and women account for 9.9 percent of the excess years of life lost in the region. In South FSE, excess years of life lost is distributed across nearly all age groups, with 28.9 percent being among children under age 5 and 25.3 percent being among adult males. In North FSE, almost half of the excess (44.8 percent) is among adult men aged 15-59, confirming the unique mortality pattern of this region. Just over 15 percent is among children under age 5, and a further 10.6 percent is among women age 15-59. Mortality among the population over age 60 contributes 26 percent to the total excess.

In Central Asia, the major problem is excess mortality in the age group 0-4 years. Figure 6-4 provides the distribution of excess years of life lost among this age group by major causes. Nearly 90 percent is from communicable and perinatal causes. More specifically, 56 percent is due to respiratory infections, a pattern characteristic of a developing country. The second-largest share (17 percent) is

Suggested Citation:"Epidemiological Transitions in the Former Socialist Economies: Divergent Patterns of Mortality and Causes of Death." National Research Council. 1997. Premature Death in the New Independent States. Washington, DC: The National Academies Press. doi: 10.17226/5530.
×

TABLE 6-8 Excess Years of Life Lost, by Region, Sex, Age Group, and Cause, 1990 Region

 

Group I

Group II

Group III

All Causes

North FSE

Males

0-14

865,083

373,834

313,983

1,552,862

15-59

18,815

3,231,019

2,967,022

6,216,820

60+

-43,270

1,744,205

121,496

1,822.418

Females

0-14

558,821

270,845

154,463

984,168

15-59

37,884

1,072,697

362,978

1,473,591

60+

-119,316

1,877,736

57,227

1.815.649

Central Asia

Males

0-14

1,317,594

117,276

110,491

1,545,363

15-59

7,745

166,488

183,483

9,248

60+

-1,302

62,467

630

61,795

Females

0-14

1,030,529

88,042

73,690

1,192,262

15-59

33,570

123,003

-19,204

137,373

60+

-2,467

121,257

-619

118,167

South FSE

Males

0-14

245.826

88,635

44.744

379.311

15-59

4,594

435,276

81,154

521,062

60+

-3,197

286,337

10,754

293.901

Females

0-14

196,058

70,154

28.158

294,366

15-59

27,912

200,872

2,021

230.803

60+

-7,144

344,336

2,285

339,460

attributable to diarrheal diseases, followed by perinatal causes (11 percent), hepatitis (4 percent), and drowning (2 percent). The prominent role of hepatitis in this age group is highly unusual; further efforts are needed to confirm the coding and validity of this burden. Measles, diphtheria, pertussis, and tuberculosis are not large contributors to the excess mortality among children in this region, indicating the effectiveness of immunization programs in the region, at least up until 1990.

Suggested Citation:"Epidemiological Transitions in the Former Socialist Economies: Divergent Patterns of Mortality and Causes of Death." National Research Council. 1997. Premature Death in the New Independent States. Washington, DC: The National Academies Press. doi: 10.17226/5530.
×

Figure 6-3a

Excess years of life lost by age, South FSE region.

Figure 6-3b

Excess years of life lost by age, North FSE region.

Suggested Citation:"Epidemiological Transitions in the Former Socialist Economies: Divergent Patterns of Mortality and Causes of Death." National Research Council. 1997. Premature Death in the New Independent States. Washington, DC: The National Academies Press. doi: 10.17226/5530.
×

Figure 6-3c

Excess years of life lost by age, Central Asia region.

Figure 6-4 

Excess years of life lost by cause for ages 0-4, Central Asia region.

Suggested Citation:"Epidemiological Transitions in the Former Socialist Economies: Divergent Patterns of Mortality and Causes of Death." National Research Council. 1997. Premature Death in the New Independent States. Washington, DC: The National Academies Press. doi: 10.17226/5530.
×

North FSE males account for nearly one-third of all excess years of life lost in the entire region of the Formerly Socialist Economies. Approximately half of this excess is due to noncommunicable diseases and half to injuries. The literature on the rising mortality among adult males, particularly in North FSE, has stressed that most of the increase is due to cardiovascular disease. Here, we are examining not only the cause of the increase, but also the difference in the level of mortality. Some of this excess already existed before the increases in adult male mortality began in 1965. Differences in level or trend viewpoints can lead to different health priorities (see also Anderson and Silver, in this volume). Clearly, for the population affected, differences in current mortality levels or years of life lost by cause are the more important.

Figure 6-5 allocates the excess years of life lost in these age groups by more detailed causes. The figure shows that 21 percent is due to ischemic heart disease. In descending order of magnitude, road traffic accidents, suicides, poisoning (which includes acute alcohol ingestion), cerebrovascular disease, lung cancer, drowning, and homicide each contribute more than 5 percent to the total excess years of life lost. Over 16 percent is distributed across a large number of more specific causes, each of which contributes less than 1 percent to the total. Given the real concern about heavy intake of hard alcohol in the region, it is surprising that there is no excess death due to cirrhosis. This may reflect a coding

Figure 6-5

Excess years of life lost by cause for males, ages 15-59, North FSE region.

Suggested Citation:"Epidemiological Transitions in the Former Socialist Economies: Divergent Patterns of Mortality and Causes of Death." National Research Council. 1997. Premature Death in the New Independent States. Washington, DC: The National Academies Press. doi: 10.17226/5530.
×

practice, however. In some countries, alcohol-related deaths are coded to various other causes, such as acute alcohol poisoning; alcohol dependence; and drug-use, subcode alcohol.

We turn now to a more detailed examination of the mortality patterns in North FSE.

Understanding North FSE

The mortality trends and cause-of-death patterns in North FSE are unique. Many hypotheses advanced to explain the rising adult mortality in the former Soviet Union really apply primarily to this region. The same set of factors can also be invoked to explain not only the trend, but also the high level of adult male mortality. Each of these factors is discussed in turn below.

Alcohol. Excessive intake of hard liquor has been the most popular explanation for adult mortality in the Former Socialist Economies (see the chapters by Treml and Shkolnikov and Nemtsov, in this volume). Some of the share of excess years of life lost due to cirrhosis, neuropsychiatric causes, motor vehicle accidents, poisonings, falls, drownings, suicides, and homicides is probably related to alcohol; nevertheless, total alcohol consumption rates are lower than in a number of West European countries (NTC, 1992). Alcohol probably plays a greater role in acute intoxication and the associated risk of injury or poisoning. This profile of alcohol-related mortality is consistent with the short-term reduction in mortality associated with Gorbachev's anti-alcohol campaign (Blum and Monnier, 1989).

Smoking. Smoking rates are high in the Former Socialist Economies. The Monitoring Cardiovascular Disease Study (MONICA) surveillance sites in Warsaw, Budapest, and Moscow show age-standardized rates of regular smoking of 58, 52, and 47 percent, respectively, for males in 1984 (World Health Organization, 1994). Total cigarettes per capita is, however, still lower than in many Western communities (U.S. Department of Agriculture, 1993). The cause-of-death profile shows that lung cancer accounts for nearly 4 percent of total years of life lost. Other smoking-associated causes play a large role as well. Lopez (in this volume) provides estimates of smoking-attributable mortality by republic in the age groups 30-69 and 70+. Because of the high underlying rates of cardiovascular disease in this region, the Peto et al. (1992) method may exaggerate the proportion of these causes attributed to smoking.

Cohort Effect. A popular explanation for the rise in mortality among adult males within the former Soviet Union is the effect of deprivation during World War II on a cohort of adult males. As Eberstadt (1990) notes, there are two main reasons to suggest that this effect may not be very important. First, some areas severely affected by World War II, such as The Netherlands, failed to experience a similar mortality increase. Second, some of the age groups affected by rising adult male mortality in North FSE were born after World War II.

Suggested Citation:"Epidemiological Transitions in the Former Socialist Economies: Divergent Patterns of Mortality and Causes of Death." National Research Council. 1997. Premature Death in the New Independent States. Washington, DC: The National Academies Press. doi: 10.17226/5530.
×

Figure 6-6a

Hypertension and high total cholesterol among men.

Source: World Health Organization (1994).

Diet. Dietary practices, such as a high proportion of fat in the diet or excessive caloric intake, could explain some of the cardiovascular disease in North FSE (see also the chapters by Popkin et al., Puska, and Pearson and Patel in this volume). Comparable data on hypertension and cholesterol, as well as smoking, are available from MONICA sites in the Czech Republic, Hungary, Lithuania, Poland, and Russia (World Health Organization, 1994). Figures 6-6a and b show where these populations lie in terms of hypertension and cholesterol for males and females, respectively, compared with other MONICA sites in Europe and China. The figures show that there are a number of other populations in Europe with higher rates of hypertension and cholesterol. Nor do the observed levels explain the difference in past trends for males as compared with females, who presumably share a similar diet.

Pollution. It is difficult to blame rising adult male mortality on pollution in the face of declining child and adult female mortality, yet pollution could offer a partial explanation for the high levels of mortality among adult males in the region. Causes of death associated with air pollution, such as chronic respiratory disease and some cancers, do contribute to excess years of life lost. Attributing the excess to air pollution, however, would require substantially more evidence than has currently been marshaled.

Occupational Exposures. Medvedev (1985) has suggested that the rise in adult male mortality could be explained by occupational exposures in heavy industry. While this is a possibility, positive evidence has not been presented.

Health System. The health system cannot be blamed for increasing mortality among adult males in North FSE, but could be part of the reason for a higher level

Suggested Citation:"Epidemiological Transitions in the Former Socialist Economies: Divergent Patterns of Mortality and Causes of Death." National Research Council. 1997. Premature Death in the New Independent States. Washington, DC: The National Academies Press. doi: 10.17226/5530.
×

Figure 6-6b

Hypertension and high total cholesterol among women.

Source: World Health Organization (1994).

of adult male mortality in the region than in other parts of Europe. Given that the systems in South FSE and Central Asia are probably similar to if not worse than those in North FSE, the health system is unlikely to be the primary contributor to the problem. However, it is quite possible that adult mortality would be much lower with a better health system. Of note, the marked decline in noncommunicable disease mortality experienced since 1980 in West Europe among males and females has not occurred in North FSE. Perhaps some of this is due to medical technology that has not come into common use in the latter region.

Communism. In reviewing the list of likely explanations, Eberstadt (1990, 1993) has argued that not all of the increase in adult male mortality can be attributed to smoking, alcohol, diet, and pollution. Some, he argues, may be due to the communist system itself. Life under an oppressive communist regime may increase cardiovascular disease mortality. Clearly, similar excesses of adult male mortality are not present so far in South FSE, Central Asia, or for that matter China. On the other hand, the increase in adult male mortality in all these countries began at the same time (1964-1965), which is difficult to ascribe to coincidence.

As the above discussion suggests, the set of causes that explains the unusual adult male mortality levels and trends in North FSE remains poorly defined. Further studies building on increasingly available data may elucidate the mix of factors responsible. Yet health reform and the design of a health policy response to the health problems in North FSE need not await these more sophisticated studies. Many of the problems, such as lung cancer, ischemic heart disease, and motor vehicle accidents, can be attacked now with cost-effective interventions.

Suggested Citation:"Epidemiological Transitions in the Former Socialist Economies: Divergent Patterns of Mortality and Causes of Death." National Research Council. 1997. Premature Death in the New Independent States. Washington, DC: The National Academies Press. doi: 10.17226/5530.
×

Conclusions

Several conclusions emerge from the above analysis.

First, the Formerly Socialist Economies are not a homogeneous group. Mortality indicators suggest that these countries can be divided into three groups: Central Asia, North FSE, and South FSE. There is no clear difference between the former republics of the Soviet Union and East European states in terms of mortality indicators within the South and North FSE regions. The three regions have distinct epidemiological profiles that call for different health sector policies. The current practice of generalizing across all Formerly Socialist Economies in many development agency reports should be discouraged.

Second, in North FSE, adult male mortality is markedly higher than expected based on income per capita or achievements in child mortality. This excess is probably caused by many factors, but the major contributors are cardiovascular disease, unintentional and intentional injuries, and lung cancer. Efforts to address this unusual mortality and cause-of-death profile must focus on the extraordinary conditions of adult males in the region. Addressing the widening health gap between men and women and children in the same society must be the number one health priority for this region.

Third, the fact that adult male mortality is so high in North FSE and has risen in most countries in that region since 1964 defines a new route in the epidemiological transition. In most Western, Latin American, and Asian countries with long series of vital registration data, development has been accompanied by mortality reduction at all ages (Feachem et al., 1992). There are some exceptions: adult male mortality rose modestly over a brief period in the United States from 1961 to 1968 and in the United Kingdom during the 1920s (Blane et al., 1990). These episodes of mortality increase, however, are of a different magnitude than the increases witnessed over 30 years in North FSE. The declines in age-specific mortality rates witnessed in nearly all these countries occurred despite rising levels of smoking, increased sedentary lifestyles, increasing fat intake, and other behavioral changes that are known to be risk factors for ischemic heart disease. Is the unfortunate experience of North FSE an historic anomaly, or is it a route of the epidemiological transition that could be repeated in some developing countries? The answer to that tantalizing question rests in the reasons for the mortality increase in North FSE. Evidence from Latin America suggests that reversals in mortality and morbidity are not uncommon (Frenk et al., 1996). Further work on defining the determinants of the North FSE mortality pattern and adverse trends is required before a reasoned answer can be provided.

Fourth, practically all the Formerly Socialist Economies had systems of financing and health care provision based almost entirely on the state. The irony is that the greatest neglect in control interventions was for those adult diseases and injuries that fell unequivocally under the state's responsibility. Government failure seems to be one of the ultimate causes for the epidemiological profile

Suggested Citation:"Epidemiological Transitions in the Former Socialist Economies: Divergent Patterns of Mortality and Causes of Death." National Research Council. 1997. Premature Death in the New Independent States. Washington, DC: The National Academies Press. doi: 10.17226/5530.
×

described here, but government intervention is what is needed to counter it, at least for the public health component of the response to the mortality increase. The clinical services required to control communicable diseases and to treat injuries are largely in place in all the countries studied, but the quality of care leaves much to be desired. Policies for selection of the most cost-effective interventions and investments to improve the associated quality of care need to be implemented in the Formerly Socialist Economies.

We conclude by reiterating that the main findings from this chapter and the conclusions presented above are unlikely to be affected by errors in the completeness of death registration or in the coding of causes of death.

Acknowledgments

The authors gratefully acknowledge the contributions to this study made by Alan Lopez, Robert Hartford, Francis Notzon, Xinjian Qiao, Magda Orzeszyna, and the World Bank's Eastern Europe division.

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Notes

  • 1.  

    Table 1-1 in Chapter 1 of this volume shows the countries encompassed by various terms used to designate groupings of countries in the region.

  • 2.  

    Data were provided by the U.S. National Center for Health Statistics. The countries analyzed were Australia, Austria, Belgium, Canada, Chile, Costa Rica, Cuba, Czechoslovakia, Denmark, England and Wales, Finland, France, German Democratic Republic, German Federal Republic, Greece. Hong Kong, Hungary, Ireland, Israel, Italy, Japan, The Netherlands, New Zealand, Northern Ireland,

Suggested Citation:"Epidemiological Transitions in the Former Socialist Economies: Divergent Patterns of Mortality and Causes of Death." National Research Council. 1997. Premature Death in the New Independent States. Washington, DC: The National Academies Press. doi: 10.17226/5530.
×
  •    

    Norway, Poland, Portugal, Puerto Rico, Scotland, Singapore, Sweden, Switzerland, the United States (separated into black and white populations), and Yugoslavia.

  • 3.  

    The logit transformation was used to convert the data into a linear form required by ordinary least squares (OLS) regression.

  • 4.  

    We also attempted to apply the generalized growth balance method, where intercensal growth rate data are used on the left-hand side of the growth balance equation. That method, however, did not perform well, and the results are not shown.

  • 5.  

    We have chosen to measure the importance of each cause of death in this way to be consistent with the recent work on global patterns of causes of death and the burden of disease. The number of years of life lost due to a death at each age is based on the expectation of life at each age from model life table West, Level 26 (Coale and Demeny, 1966). Streams of lost life due to death at each age have been adjusted by incorporating age weights so that years of life that would have been lived as an adult aged 15-59 are given more weight than years of life at younger or older ages. Finally, the age-weighted streams of years of life lost due to premature mortality have been discounted at a rate of 3 percent. The method of calculating years of life lost is described more fully elsewhere (Murray, 1994).

  • 6.  

    Established Market Economies include Portugal, Greece, Ireland, New Zealand, Spain, The United Kingdom, Australia, Italy, The Netherlands, Belgium, Austria, France, Canada, United States, Germany, Denmark, Finland, Norway, Sweden, Japan, Switzerland, and 14 other economies with a population of less than 500,000(World Bank, 1993).

  • 7.  

    International dollars are calculated using purchasing power parity ratios, which reflect the relative values of currencies, taking into account local prices of goods and services.

Suggested Citation:"Epidemiological Transitions in the Former Socialist Economies: Divergent Patterns of Mortality and Causes of Death." National Research Council. 1997. Premature Death in the New Independent States. Washington, DC: The National Academies Press. doi: 10.17226/5530.
×

Annex Table 6-1

Suggested Citation:"Epidemiological Transitions in the Former Socialist Economies: Divergent Patterns of Mortality and Causes of Death." National Research Council. 1997. Premature Death in the New Independent States. Washington, DC: The National Academies Press. doi: 10.17226/5530.
×

ANNEX TABLE 6-1 Detailed Years of Life Lost Attributable to Major Causes by Country. 1990

 

North FSE

Cause

Belarus

Estonia

Kazakstan

Latvia

Lithuania

I. Communicable, Maternal & Perinatal

66,149

11,237

476,597

19,533

19,984

   Infectious and Parasitic

18,088

2,448

118,917

7,155

6,313

      Tuberculosis

5,301

1,013

26,313

2,652

3,287

      Diarrheal diseases

1,836

206

48,188

190

577

      Meningitis

4,423

564

12,219

1,339

1,114

      Hepatitis

488

80

6,688

203

258

   Respiratory infections

19,153

2,304

218,373

3,239

2,653

   Maternal

1,114

266

3,963

624

463

   Perinatal

28,965

6,289

138,403

8,820

11,056

II. Noncommunicable

669,917

113,305

895,005

198,408

239,587

   Malignant Neoplasm

179,428

30,589

238,674

52,429

64,623

      Esophagus

2,907

571

20,155

1,013

963

      Stomach

33,318

4,210

36,510

7,350

8,418

      Colon/rectum

14,245

2,352

14,859

4,549

5,351

      Lung

34,897

6,510

48,455

10,800

12,736

      Breast

11,965

2,446

13,278

3,884

5,665

      Cervix

3,486

858

6,479

1,079

2,092

      Lymphoma/leukemia

15,637

2,479

18,625

4,185

5,848

   Diabetes

4,848

1,161

9,321

1,820

1,859

   Nutritional endocrine

3,221

751

7,944

1,326

1,577

      anemia

n.a.

n.a.

n.a.

n.a.

n.a.

   Neuropsychiatric

18,940

2,875

25,270

4,582

9,786

   Cardiovascular

348,719

62,343

408,485

109,363

122,562

      Ischemic heart disease

209,245

38,071

198,752

62,725

83,576

      Cerebrosvascular

95,599

17,997

131.578

34,979

27,163

   Respiratory

43,827

3,046

60,223

5,659

10,809

   Digestive

21,943

3,874

49,528

6,329

8,159

      Cirrhosis

7,216

944

22,160

1,514

3,308

   Genito-urinary

13,439

1,924

22,889

4,579

5,238

   Congenital

29,656

4,849

65,321

10,663

12,850

III. Injuries

208,657

35,127

358,351

68,670

88,348

   Unintentional

148,966

24,383

260,216

50,881

63,543

      Motor vehicle accidents

58,154

9,770

95,762

24,698

28,876

      Poisoning

30,830

3,579

35,285

4,502

7,480

      Fall

8,497

2,160

12,718

4,536

6,480

      Fire

4,261

1,355

10,446

3,143

1,594

      Drowning

20,571

2,666

33,428

7,627

10,492

   Intentional

59,691

10,744

98,135

17,790

24,805

      Suicide

43,639

7,894

61,807

12,403

19,950

      Homicide

16,052

2,851

36,328

5,386

4,856

Total

944,723

159,670

1,729,953

286,611

347,919

n.a. = not available

Suggested Citation:"Epidemiological Transitions in the Former Socialist Economies: Divergent Patterns of Mortality and Causes of Death." National Research Council. 1997. Premature Death in the New Independent States. Washington, DC: The National Academies Press. doi: 10.17226/5530.
×

Cause

Moldova

Russia

Ukraine

Czechoslovakia

Hungary

Poland

I. Communicable, Maternal & Perinatal

70,673

1,598,546

391,568

89,917

67,032

268,350

   Infectious and Parasitic

441,572

16,724

132,595

7,709

12,746

58,598

      Tuberculosis

4,023

189,186

65,475

2,379

6,802

16,875

      Diarrheal diseases

3,675

72,919

11,116

471

204

1,736

      Meningitis

3,570

72,080

24,172

2,058

2,646

11,947

      Hepatitis

1,739

14,021

4,242

452

255

2,917

   Respiratory infections

28,123

430,214

92,995

38,080

14,350

55,440

   Maternal

803

29,724

6,414

419

735

1,946

   Perinatal

25,126

714,294

163,051

44,334

39,658

153,439

II. Noncommunicable

286,195

10,175,652

3,743,760

1,145,294

983,476

2,642,410

   Malignant Neoplasm

66,131

2,803,127

1,007,144

345,048

282,013

716,789

      Esophagus

1,182

77,677

18,676

5,621

6,865

11,934

      Stomach

6,995

498,669

146,700

24,027

21,436

60,610

      Colon/rectum

6,184

239,302

88,678

40,567

31,992

54,252

      Lung

12,625

612,074

214,227

75,345

68,836

170,001

      Breast

5,603

182,424

76,290

24,123

20,861

47,882

      Cervix

1,763

61,894

24,685

7,593

7,330

25,166

      Lymphoma/leukemia

7,082

218,590

83,729

40,007

29,118

80,889

   Diabetes

3,156

80,844

28,024

19,744

14,753

47,162

   Nutritional endocrine

2,508

50,686

23,220

4,671

5,423

15,138

      anemia

n.a.

n.a.

n.a.

926

968

3,201

   Neuropsychiatric

8,879

253,833

98,402

28,484

31,097

78,273

   Cardiovascular

122,115

5,363,031

1,935,622

590,377

485,998

1,312,738

      Ischemic heart disease

68,277

2,734,970

1,040,814

307,213

202,391

401,671

      Cerebrosvascular

38,736

1,788,185

584,283

155,493

130,658

185,295

   Respiratory

14,271

496,772

222,545

29,397

36,917

67,271

   Digestive

42,896

422,347

165,188

85,632

111,416

113,857

      Cirrhosis

31,705

135,631

68,192

51,040

79,561

42,661

   Genito-urinary

5,120

188,442

66,838

26,998

10,764

41,914

   Congenital

18,734

419,457

162,183

26,207

21,241

98,009

III. Injuries

102,341

3,947,935

1,063,296

195,324

194,538

578,825

   Unintentional

78,277

2,705,250

772,342

138,082

118,758

442,427

      Motor vehicle accidents

35,964

1,035,106

318,948

50,208

56,716

197,840

      Poisoning

8,255

513,406

152,005

9,628

4,917

57,200

      Fall

4,570

128,088

41,749

29,205

25,846

44,266

      Fire

2,239

84,070

16,998

2,532

3,281

7,938

      Drowning

9,879

338,464

93,302

10,100

7,936

37,084

   Intentional

24,064

1,242,685

290,954

57,256

75,699

136,406

      Suicide

15,509

779,248

203,171

50,308

68,985

111,526

      Homicide

8,555

463,436

87,783

6,945

6,710

24,925

Total

459,208

15,722,132

5,198,624

1,430,465

1,245,038

3,489,650

Suggested Citation:"Epidemiological Transitions in the Former Socialist Economies: Divergent Patterns of Mortality and Causes of Death." National Research Council. 1997. Premature Death in the New Independent States. Washington, DC: The National Academies Press. doi: 10.17226/5530.
×

 

South FSE

Cause

Armenia

Georgia

Romania

Yugoslavia

I. Communicable, Maternal & Perinatal

72,732

97,963

357,400

200,552

   Infectious and Parasitic

17,145

21,664

74,548

44,510

      Tuberculosis

1,481

5,642

22,029

9,722

      Diarrheal disease

8,544

5,600

9,848

22,735

      Meningitis

487

2,169

13,936

3,917

      Hepatitis

229

195

7,814

934

   Respiratory infection

31,766

48,683

218,668

40,579

   Maternal

496

1,120

17,015

1,090

   Perinatal

24,283

27,085

n.a.

86,986

II. Noncommunicable

147,412

309,071

1,706,681

1,007,686

   Malignant Neoplasm

37,464

60,458

366,894

265,926

      Esophagus

590

831

3,128

4,108

      Stomach

4,519

6,975

36,990

24,646

      Colon/rectum

2,578

3,816

25,527

21,648

      Lung

7,725

10,782

75,302

58,023

      Breast

3,957

7,790

28,465

21,551

      Cervix

981

2,182

22,240

5,602

      Lymphoma/leukemia

4,224

6,584

50,424

31,688

   Diabetes

3,742

5,671

16,974

19,513

   Nutritional endocrine

1,482

1,100

9,413

5,955

      anemia

n.a.

1,587

1,133

579

   Neuropsychiatric

3,490

4,723

74,187

33,871

   Cardiovascular

69,500

194,385

866,168

482,130

      Ischemic heart disease

43,951

117,140

263,727

118,260

      Cerebrosvascular

18,167

67,699

239,944

129,940

   Respiratory

6,964

9,905

98,059

28,992

   Digestive

8,626

19,517

162,303

62,436

      Cirrhosis

2,681

12,359

90,788

38,930

   Genito-urinary

3,907

6,516

37,431

18,391

   Congenital

10,481

4,998

94,913

27,458

III. Injuries

43,476

60,922

345,298

173,445

   Unintentional

39,957

51,614

345,298

120,696

      Motor vehicle accident

13,019

21,428

n.a.

58,307

      Poisoning

1,058

2,981

n.a.

3,078

      Fall

2,286

3,114

n.a.

7,928

      Fire

968

3,427

n.a.

1,930

      Drowning

1,217

4,360

n.a.

6,422

   Intentional

3,519

9,308

n.a.

52,705

      Suicide

1,556

4,202

n.a.

46,116

      Homicide

1,963

5,106

n.a.

6,563

Total

263,620

467,956

2,409,391

1,381,675

n.a. = not available

Suggested Citation:"Epidemiological Transitions in the Former Socialist Economies: Divergent Patterns of Mortality and Causes of Death." National Research Council. 1997. Premature Death in the New Independent States. Washington, DC: The National Academies Press. doi: 10.17226/5530.
×

 

 

Central Asia

Cause

Bulgaria

Azerbaijan

Kyrgyz

Tajikistan

Turkmenistan

Uzbekistan

I. Communicable, Maternal & Perinatal

65,612

319,242

237,419

488,018

329,818

1.332,535

   Infectious and Parasitic

10,224

86,607

51,591

186,627

106,454

332,293

      Tuberculosis

2,457

8,486

4,513

3,407

5,982

20.752

      Diarrheal disease

1,412

50,758

24,586

123,555

72,083

160.521

      Meningitis

1,869

1,648

5,966

9,615

3,584

18,297

      Hepatitis

887

4,793

8,751

15,528

11,149

92,269

   Respiratory infection

40,488

192,115

138,840

244,084

180,478

735.780

   Maternal

633

980

1,076

1,549

1,417

5,464

   Perinatal

14,318

46,270

46,861

74,741

47,350

264,254

II. Noncommunicable

677,313

338,135

200,982

197,974

187,624

818.701

   Malignant Neoplasm

151,471

61,824

37,006

35,796

28,717

136.519

      Esophagus

2,850

3,924

1,354

2,763

5,995

15,238

      Stomach

18,603

10,834

7,039

6,294

3,437

19.421

      Colon/rectum

16,218

3,909

2,546

3,603

1,796

8,070

      Lung

31,869

10,114

6,551

4,669

2,651

16,257

      Breast

12,174

3,661

2,087

1,831

1,154

7,160

      Cervix

3,587

1,236

1,307

1,008

885

3.312

      Lymphoma/leukemia

16,853

7,078

3,489

5,822

3,536

18,745

   Diabetes

13,993

5,459

1,995

3,806

2,578

11,299

   Nutritional endocrine

1,851

14,025

3,017

3,683

5,617

21,709

      anemia

n.a.

 

n.a.

 

n.a.

 

   Neuropsychiatric

12,979

18,982

6,725

10,400

8,316

44,665

   Cardiovascular

400,596

159,192

89,826

79,085

89,123

364,334

      Ischemic heart disease

135,703

96,490

40,934

40,001

46,240

207,385

      Cerebrosvascular

133,364

36,796

33,128

20,502

14,627

101,101

   Respiratory

18,223

16,209

20,623

13,679

11,217

49,085

   Digestive

33,828

21,128

16,547

26,353

21,106

73.640

      Cirrhosis

17,686

11,517

9,208

7,344

8,143

38,588

   Genito-urinary

14,570

10,227

6,691

9,930

5,098

34,930

   Congenital

16,804

29,153

15,949

12,836

14,753

73,393

III. Injuries

103,975

68,343

85,988

63,409

55,146

299,622

   Unintentional

77,604

61,040

68,889

56,390

45,768

247,091

      Motor vehicle accident

31,643

25,424

26,833

15,242

14,501

82,672

      Poisoning

5,115

2,331

6,339

2,839

2,423

11,109

      Fall

7,517

2,864

3,642

3,782

2,467

10,527

      Fire

2,312

5.743

1,163

4,805

3,828

14,929

      Drowning

6,002

5,511

10,960

11,345

10,849

49,221

   Intentional

26,400

7,303

17,099

7,019

9,377

52,531

      Suicide

19,854

4,057

10,397

466

4,852

29,520

      Homicide

6,508

3,245

6,703

2,553

4,525

23,011

Total

847,026

725,720

524,390

749,401

572,588

5,022,957

Suggested Citation:"Epidemiological Transitions in the Former Socialist Economies: Divergent Patterns of Mortality and Causes of Death." National Research Council. 1997. Premature Death in the New Independent States. Washington, DC: The National Academies Press. doi: 10.17226/5530.
×
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Suggested Citation:"Epidemiological Transitions in the Former Socialist Economies: Divergent Patterns of Mortality and Causes of Death." National Research Council. 1997. Premature Death in the New Independent States. Washington, DC: The National Academies Press. doi: 10.17226/5530.
×
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Suggested Citation:"Epidemiological Transitions in the Former Socialist Economies: Divergent Patterns of Mortality and Causes of Death." National Research Council. 1997. Premature Death in the New Independent States. Washington, DC: The National Academies Press. doi: 10.17226/5530.
×
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Suggested Citation:"Epidemiological Transitions in the Former Socialist Economies: Divergent Patterns of Mortality and Causes of Death." National Research Council. 1997. Premature Death in the New Independent States. Washington, DC: The National Academies Press. doi: 10.17226/5530.
×
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Suggested Citation:"Epidemiological Transitions in the Former Socialist Economies: Divergent Patterns of Mortality and Causes of Death." National Research Council. 1997. Premature Death in the New Independent States. Washington, DC: The National Academies Press. doi: 10.17226/5530.
×
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Suggested Citation:"Epidemiological Transitions in the Former Socialist Economies: Divergent Patterns of Mortality and Causes of Death." National Research Council. 1997. Premature Death in the New Independent States. Washington, DC: The National Academies Press. doi: 10.17226/5530.
×
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Suggested Citation:"Epidemiological Transitions in the Former Socialist Economies: Divergent Patterns of Mortality and Causes of Death." National Research Council. 1997. Premature Death in the New Independent States. Washington, DC: The National Academies Press. doi: 10.17226/5530.
×
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Suggested Citation:"Epidemiological Transitions in the Former Socialist Economies: Divergent Patterns of Mortality and Causes of Death." National Research Council. 1997. Premature Death in the New Independent States. Washington, DC: The National Academies Press. doi: 10.17226/5530.
×
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Suggested Citation:"Epidemiological Transitions in the Former Socialist Economies: Divergent Patterns of Mortality and Causes of Death." National Research Council. 1997. Premature Death in the New Independent States. Washington, DC: The National Academies Press. doi: 10.17226/5530.
×
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Suggested Citation:"Epidemiological Transitions in the Former Socialist Economies: Divergent Patterns of Mortality and Causes of Death." National Research Council. 1997. Premature Death in the New Independent States. Washington, DC: The National Academies Press. doi: 10.17226/5530.
×
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Suggested Citation:"Epidemiological Transitions in the Former Socialist Economies: Divergent Patterns of Mortality and Causes of Death." National Research Council. 1997. Premature Death in the New Independent States. Washington, DC: The National Academies Press. doi: 10.17226/5530.
×
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Suggested Citation:"Epidemiological Transitions in the Former Socialist Economies: Divergent Patterns of Mortality and Causes of Death." National Research Council. 1997. Premature Death in the New Independent States. Washington, DC: The National Academies Press. doi: 10.17226/5530.
×
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Suggested Citation:"Epidemiological Transitions in the Former Socialist Economies: Divergent Patterns of Mortality and Causes of Death." National Research Council. 1997. Premature Death in the New Independent States. Washington, DC: The National Academies Press. doi: 10.17226/5530.
×
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Suggested Citation:"Epidemiological Transitions in the Former Socialist Economies: Divergent Patterns of Mortality and Causes of Death." National Research Council. 1997. Premature Death in the New Independent States. Washington, DC: The National Academies Press. doi: 10.17226/5530.
×
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Suggested Citation:"Epidemiological Transitions in the Former Socialist Economies: Divergent Patterns of Mortality and Causes of Death." National Research Council. 1997. Premature Death in the New Independent States. Washington, DC: The National Academies Press. doi: 10.17226/5530.
×
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Suggested Citation:"Epidemiological Transitions in the Former Socialist Economies: Divergent Patterns of Mortality and Causes of Death." National Research Council. 1997. Premature Death in the New Independent States. Washington, DC: The National Academies Press. doi: 10.17226/5530.
×
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Suggested Citation:"Epidemiological Transitions in the Former Socialist Economies: Divergent Patterns of Mortality and Causes of Death." National Research Council. 1997. Premature Death in the New Independent States. Washington, DC: The National Academies Press. doi: 10.17226/5530.
×
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Suggested Citation:"Epidemiological Transitions in the Former Socialist Economies: Divergent Patterns of Mortality and Causes of Death." National Research Council. 1997. Premature Death in the New Independent States. Washington, DC: The National Academies Press. doi: 10.17226/5530.
×
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Suggested Citation:"Epidemiological Transitions in the Former Socialist Economies: Divergent Patterns of Mortality and Causes of Death." National Research Council. 1997. Premature Death in the New Independent States. Washington, DC: The National Academies Press. doi: 10.17226/5530.
×
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Suggested Citation:"Epidemiological Transitions in the Former Socialist Economies: Divergent Patterns of Mortality and Causes of Death." National Research Council. 1997. Premature Death in the New Independent States. Washington, DC: The National Academies Press. doi: 10.17226/5530.
×
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Suggested Citation:"Epidemiological Transitions in the Former Socialist Economies: Divergent Patterns of Mortality and Causes of Death." National Research Council. 1997. Premature Death in the New Independent States. Washington, DC: The National Academies Press. doi: 10.17226/5530.
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×
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×
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Suggested Citation:"Epidemiological Transitions in the Former Socialist Economies: Divergent Patterns of Mortality and Causes of Death." National Research Council. 1997. Premature Death in the New Independent States. Washington, DC: The National Academies Press. doi: 10.17226/5530.
×
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×
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×
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Suggested Citation:"Epidemiological Transitions in the Former Socialist Economies: Divergent Patterns of Mortality and Causes of Death." National Research Council. 1997. Premature Death in the New Independent States. Washington, DC: The National Academies Press. doi: 10.17226/5530.
×
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Suggested Citation:"Epidemiological Transitions in the Former Socialist Economies: Divergent Patterns of Mortality and Causes of Death." National Research Council. 1997. Premature Death in the New Independent States. Washington, DC: The National Academies Press. doi: 10.17226/5530.
×
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Suggested Citation:"Epidemiological Transitions in the Former Socialist Economies: Divergent Patterns of Mortality and Causes of Death." National Research Council. 1997. Premature Death in the New Independent States. Washington, DC: The National Academies Press. doi: 10.17226/5530.
×
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×
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×
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×
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Suggested Citation:"Epidemiological Transitions in the Former Socialist Economies: Divergent Patterns of Mortality and Causes of Death." National Research Council. 1997. Premature Death in the New Independent States. Washington, DC: The National Academies Press. doi: 10.17226/5530.
×
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In recent years there have been alarming reports of rapid decreases in life expectancy in the New Independent States (former members of the Soviet Union). To help assess priorities for health policy, the Committee on Population organized two workshops—the first on adult mortality and disability, the second on adult health priorities and policies. Participants included demographers, epidemiologists, public health specialists, economists, and policymakers from the NIS countries, the United States, and Western Europe. This volume consists of selected papers presented at the workshops. They assess the reliability of data on mortality, morbidity, and disability; analyze regional patterns and trends in mortality rates and causes of death; review evidence about major determinants of adult mortality; and discuss implications for health policy.

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