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



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