8
The Anti-Alcohol Campaign and Variations in Russian Mortality

Vladimir M. Shkolnikov and Alexander Nemtsov

Introduction

Many observers, including several of the authors of earlier chapters in this volume, have noted the recent dramatic rise in mortality in Russia. This problem has political significance. Policymakers and journalists both inside and outside Russia tend to connect the increase with the economic and political crises of Eastern European societies at the turning point of the economic transition. This is partially true. But to see the full truth one must take into account the relationship between the recent changes in mortality and variations in the past. In particular, Russia's sharp mortality increase in the early 1990s depends to some extent on the long-term unfavorable trend that started in the mid-1960s and on the substantial short-term variations of the 1980s. We posit that the latter fluctuations were induced primarily by Gorbachev's anti-alcohol campaign and its termination (see Treml in this volume for another discussion of the anti-alcohol campaign). In fact, as shown in Figure 8-1, the trend in the standardized death rate in Russia1 is associated with variations in alcohol consumption since the mid- 1970s.

The rapid mortality decrease observed for the years 1984 to 1987 can be assumed to reflect largely a pure effect of reduced alcohol abuse on mortality, because there were no other significant changes in public health conditions that could have resulted in such an abrupt change in so short a period of time. The increase in life expectancy during the period was more than 3 years for males and a little less than 1.5 years for females. This means about one-fourth of the gap in life expectancy between Russia and the Western countries in the mid-1980s is attributable to alcohol abuse.



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--> 8 The Anti-Alcohol Campaign and Variations in Russian Mortality Vladimir M. Shkolnikov and Alexander Nemtsov Introduction Many observers, including several of the authors of earlier chapters in this volume, have noted the recent dramatic rise in mortality in Russia. This problem has political significance. Policymakers and journalists both inside and outside Russia tend to connect the increase with the economic and political crises of Eastern European societies at the turning point of the economic transition. This is partially true. But to see the full truth one must take into account the relationship between the recent changes in mortality and variations in the past. In particular, Russia's sharp mortality increase in the early 1990s depends to some extent on the long-term unfavorable trend that started in the mid-1960s and on the substantial short-term variations of the 1980s. We posit that the latter fluctuations were induced primarily by Gorbachev's anti-alcohol campaign and its termination (see Treml in this volume for another discussion of the anti-alcohol campaign). In fact, as shown in Figure 8-1, the trend in the standardized death rate in Russia1 is associated with variations in alcohol consumption since the mid- 1970s. The rapid mortality decrease observed for the years 1984 to 1987 can be assumed to reflect largely a pure effect of reduced alcohol abuse on mortality, because there were no other significant changes in public health conditions that could have resulted in such an abrupt change in so short a period of time. The increase in life expectancy during the period was more than 3 years for males and a little less than 1.5 years for females. This means about one-fourth of the gap in life expectancy between Russia and the Western countries in the mid-1980s is attributable to alcohol abuse.

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--> Figure 8-1 Age-standardized death rate (SDR) and annual alcohol consumption in Russia, 1970-1993. The increase in mortality since 1988 is more complex because it has coincided with both increased alcohol consumption and important socioeconomic changes in Russian society. We have found that the increase in adult mortality in the period 1988-1992 is symmetrical with the previous decline in the period 1985-1987 (Shkolnikov et al., 1994a). The ageand cause-specific pattern of the decline in death rates during 1985-1987 is rather similar to that of the rise in the period 1988-1992. Moreover, trends in age-adjusted and age-specific death rates for many leading causes of death are closely associated with the trend in real alcohol consumption (Shkolnikov et al., 1994a). This is especially true for external causes of death, which strongly affected life expectancy tendencies in the 1980s and the early 1990s (Meslé et al., 1994). Thus the recent mortality increase in Russia can be explained largely by increases in alcohol consumption. During the anti-alcohol campaign, alcohol consumption was very much reduced, and alcohol-related adult mortality was reduced accordingly. Following the campaign, alcohol consumption started rising (in 1992, it approximated the level of 1984), and mortality rose correspondingly. Actually, recent changes in Russian mortality are more complex than this simple picture (Shkolnikov et al., 1994b), particularly as regards the dramatic mortality rise in 1993. In that year, life expectancy at birth dropped by 3 years for men and by 1.8 years for women. It is difficult to distinguish the effects of

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--> increased alcohol consumption on this rise in mortality from the effects of other negative factors. From our previous studies, as discussed below, we know that in the period 1988-1992, the biggest share of the increase in Russian mortality was attributable to alcohol consumption. It seems that in 1993, the influence of negative factors other than alcohol may have become much more pronounced, and that the mortality pattern of that year indicates a serious deterioration in basic health conditions. The impact of the anti-alcohol campaign on trends in Soviet mortality and life expectancy has been discussed elsewhere (Dmitrieva and Andreyev, 1987; Andreyev, 1990; Anderson and Silver, 1990; Meslé et al., 1992). This study first reviews patterns of alcohol consumption in Russia and describes the anti-alcohol campaign. The next section examines variations in mortality levels during and following the campaign and the number of deaths prevented as a result of it. The following section focuses specifically on male mortality trends and patterns. Finally, we explore the question of whether alcohol abuse alone can explain the large increase in mortality in Russia in 1993. Alcohol Consumption in Russia and the Anti-Alcohol Campaign Traditionally, ''holiday-peak" drinking predominated in Russia. At the beginning of the twentieth century, Russia was mainly an agrarian country, with the majority of people living in rural communities. The individual behavior of the inhabitants was under communal control. People were used to drinking in quantity, but only for short periods during holidays of the Russian Orthodox Church and on Sundays. At other times, particularly during the season of intensive field work, they drank much less. Hence, average annual alcohol consumption was rather low. Changes in Russian social life at the end of the nineteenth century resulted in the growth of the urban population and a substantial rise in alcohol consumption in cities. Alcohol abuse became a serious social problem, and in the period 1885-1890, the sober movement arose in Russian society. In 1913, the officially reported alcohol consumption in Russia was 3.4 liters of pure alcohol per capita (4.7 liters according to some other sources). In 1914, strong anti-alcohol rules were introduced in the capitals (St. Petersburg and Moscow) and in many provinces as a result of the beginning of World War I. In 1919, the Soviet government introduced a dry law,2 which was in force until 1926, when it was abolished. In 1927, Stalin explained that the state sale of alcoholic drinks was admissible because it provided money essential for the development of socialist industry. In that year, the annual level of state alcohol sales reached 3.7 liters per capita (quite comparable to the level of 1913). During the 1930s and 1940s, state sales decreased—to 2.3 liters per capita in 1940 and to 1.9 liters per capita in 1950. This decrease can be explained by the rigid civil laws and disciplinary administrative regulations of the Stalin era.

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--> Starting in the 1950s, state production and sales of alcohol increased continuously in spite of two anti-alcohol resolutions of the Central Committee of the Communist Party of the Soviet Union, released in 1958 and in 1972. At the beginning of the 1980s, a consumption level of about 10 liters of pure alcohol per capita was first recorded in the Soviet Union; in Russia this level was reached even earlier, in the mid-1970s. The Russian style of drinking has several important features. First, it is a northern type of drinking dominated by the consumption of vodka. The acute consequences of alcohol consumption in Russia (e.g., accidents and violence) are often the result of drinking large doses of vodka in a short time with poor food intake. (See also Treml, in this volume.) The attitude of the Soviet leadership toward the alcohol problem was always dual. On the one hand, alcohol caused many public health and social problems and led to economic losses; on the other hand, it was a unique source of "fast" money for state needs. The whole history of the struggle against alcoholism in the Soviet Union confirms this duality. It is also important to keep in mind that indicators of alcohol consumption officially reported by Goskomstat (the former Soviet Central Statistical Administration) do not include strong homemade alcoholic beverages (samogon) (see the discussion of this issue by Treml, in this volume), although from 1971 through 1989, Goskomstat did produce estimates of samogon production (see Table 8-1). Therefore, the real figures on alcohol consumption in the Soviet Union are higher than all the values mentioned above. True annual alcohol consumption in the Soviet Union for the early 1980s has been estimated at between 11 and 14 liters of pure alcohol per capita (12.1 + 0.5 liters on average) (Zaigrayev, 1992; Treml, 1982; Ducham and Sheregi, 1986). Among the Russian population, alcohol consumption was even higher than among the total population of the Soviet Union. Russia has always been near the top of the list of former Soviet republics with regard to the level of alcohol consumption (as have the Baltic republics). Moreover, the proportion of unrecorded alcohol consumption in Russia in the early 1980s was about 30 percent of officially recorded alcohol sales (see Table 8-1). Nemtsov (1992; Nemtsov and Nechaev, 1991) has attempted to estimate real alcohol consumption in Russia on the basis of the proportion of violent deaths recorded by the regional Buro Sudebno-Meditsinskoi Expertizi (Bureau of Legal-Medical Findings) involving the presence of alcohol in the blood (see Annex 8-1). For the period 1981-1987, the resulting estimated levels of alcohol consumption in Russia are only a little higher than the sum of the Goskomstat estimates of samogon consumption and the official values of state alcohol sales fro the same period (Table 8-1). This difference becomes much larger in the period 1988-1989, when the deficit of sugar in the state trade biased the Goskomstat estimates of samogon production.3 (For that reason, Goskomstat stopped producing such estimates after 1989.) The officially recorded figures for

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--> TABLE 8-1 Annual Alcohol Consumption in Russia, 1970-1993 (liters of pure ethanol per capita) Year (1) Sales in the State Trade (Goskomstat)a (2) Illegal Production of Samogon (Goskomstat)b (3) Real Alcohol Consumption (Estimate) (4) Unreported Alcohol Consumption (4) – (2) 1971 8.3 — — — 1972 8.6 — — — 1973 8.7 — — — 1974 9.1 — — — 1975 9.9 — — — 1976 10.2 — — — 1977 10.4 — — — 1978 10.6 — — — 1979 10.6 — — — 1980 10.5 — — — 1981 10.2 3.1 13.7 3.5 1982 10.1 3.0 13.4 3.3 1983 10.3 3.0 14.1 3.8 1984 10.5 3.3 14.2 3.7 1985 8.8 3.5 13.3 4.5 1986 5.2 5.0 10.6 5.4 1987 3.9 6.1 10.7 6.8 1988 4.4 3.9 11.2 6.8 1989 5.3 3.4 11.8 6.5 1990 5.9 — 12.1 6.2 1991 5.6 — 12.3 6.7 1992 5.0 — 13.8 8.8 1993 6.0 — 14.5 8.5 a Sales of alcohol from state resources. b In 1971-1980, Goskomstat produced estimates of samogon, but they were not available to the authors. SOURCE: Goskomstat and evaluations of A. Nemtsov. The Goskomstat figures for the 1970s and the early 1980s were collected from unpublished reports by D. Bogoyavlenskiy (Center of Demography and Human Ecology, Moscow). state alcohol sales became completely unrealistic in the late 1980s because of the increase in illegal samogon distillation, and were even more unrealistic in the early 1990s because of the growth of underrecorded private alcohol sales (Table 8-1). In 1984, the last year before the beginning of the anti-alcohol campaign, annual state alcohol sales were 10.5 liters per capita, and real consumption was about 14 liters. At that time, alcohol consumption in Russia was probably at the

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--> highest level in the world (as compared with 13.5 liters per capita in France in 1984). Before the anti-alcohol campaign began on June 1, 1985, there was no real mass anti-alcohol movement in Russia. Anti-alcohol ideas were shared by some people, particularly medical professionals and organizers of medical services, who made a substantial contribution to the scientific basis for the anti-alcohol ideology. However, in practice the campaign was conducted in a very primitive and unrealistic way. The anti-alcohol measures were directed to restricting the public access to alcoholic drinks, but not to addressing the causes of alcohol abuse. Under these conditions, the effects of the campaign could not continue for long. The main directions of the campaign were a reduction in state alcohol production, a reduction in state alcohol sales, efforts against the distillation of samogon, increases in the state prices of alcohol (in August 1985 and August 1986), and further development of the special health care system for compulsory treatment of alcoholism (the so-called LTP, first organized in 1976). Between 1984 and 1987, the number of stores selling wine and vodka in Russia was reduced by 5 times. Eight breweries, just bought in Czechoslovakia, were taken down. The agricultural acreage for wine grapes was reduced by about 30 percent. These measures resulted in recorded state alcohol sales4 2.7 times lower than before the campaign. Real alcohol consumption was in fact reduced from 14.2 to 10.6 liters. This reduction is very substantial, but considerably smaller than the official figures would indicate (25.4 percent instead of 65.3 percent). According to Goskomstat, the structure of sales of alcohol changed substantially in the years between 1980 and 1987. The share of vodka was reduced from 56.4 to 49.8 percent, the share of wine was reduced from 30 to 22.9 percent, and the share of beer grew from 11.4 to 20.3 percent. Variations in the use of other forms of alcohol were of minor importance. Certainly, we place too much trust in these estimates, recalling the large difference between reported and true levels of alcohol consumption shown in Table 8-1. In spite of the massive propaganda, Russians did not demonstrate enthusiasm for the goals of the anti-alcohol campaign. Every day one could see very long lines at the doors of "vino-vodka" stores. In the period 1985-1987, the distillation of samogon nearly doubled. For these reasons, real alcohol consumption in Russia was slightly higher in 1987 than in 1986. Finally, at the end of 1987, the Soviet leadership decided to expand the production of alcohol, effectively ending the anti-alcohol campaign. In the period 1988-1991, the backsliding in alcohol consumption was rather slow. The situation changed radically in the period 1992-1993, when the process of hyperinflation started. Prices of alcohol increased much less than personal salaries and the general price index, which by June 1994 had increased to 1229 times its December 1992 level. Concurrently, prices of alcohol rose to 421 times their

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--> prior levels. It is not surprising that real alcohol consumption in Russia increased sharply during this period of economic crisis and reduction in real wages (see Table 8-1). The anti-alcohol campaign was of rather short duration, but it led to very important consequences for the public health and mortality in Russia. These consequences are discussed next. Variations in Mortality Levels and Deaths Prevented by the Campaign The favorable effect of the anti-alcohol campaign on Russian mortality was strong and rapid. Mortality began to decrease immediately after the introduction of restrictions on the sale of alcohol in June 1985 and continued month by month in parallel with the reduction in alcohol consumption (Shkolnikov and Vassin, 1994). The largest mortality decrease was observed at adult ages both for males and females during the year 1986. From 1984 to 1987 (mostly in 1986), life expectancy at birth rose from 61.7 to 64.9 years for males and from 73 to 74.3 years for females. Decreasing mortality from external causes of death at working ages and from cardiovascular diseases at ages 40 to 65 contributed most to the total increase in expectation of life at birth. In 1988 the pattern reversed, and mortality began to increase. Between 1987 and 1992 (mostly in 1992), life expectancy declined to 62 years for males and 73.8 years for females.5 Finally, in 1992, mortality returned approximately to the level of 1984 (in fact, in 1992 it remained a little lower). As suggested in the introduction, we can assume that the above short-term fluctuations in Russian mortality and life expectancy were induced largely by the anti-alcohol campaign and its termination (see also the discussion in the next section). If we assume for analysis purposes that these fluctuations were caused entirely by variations in alcohol abuse, it is possible to assess the number of deaths avoided as a result of the campaign. In the period 1985-1992, mortality rates deviated from what might have been expected in light of the rates for prior years. What might this "natural" trend have been like? To evaluate the expected age-specific death rates during 1985-1992, we apply three realistic scenarios, corresponding to three different basic levels of mortality. For the first (low-mortality) scenario, we suppose that the death rates in 1985-1992 are equal to the average level of the period 1980-1984 (in the period 1981-1983, the level of mortality was significantly lower than in 1980); for the second (medium-mortality) scenario, we continue the long-term linear trends of the period 1970-1983; and for the third (high-mortality) scenario, we use the fixed death rates of 1984. An estimate of the total number of deaths prevented by the anti-alcohol campaign can be derived from the difference between the observed and expected age-specific death rates for the period 1985-1992. According to the above three

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--> TABLE 8-2 Difference Between Observed and Expected Mortality by Sex and Age: Russia, 1985-1992 (estimation of deaths prevented by the anti-alcohol campaign in Russia, in thousands)   Differences by Age Group Year 0-14 15-29 30-44 45-59 60-74 75+ Total Males 1985 0.0 -6.3 -10.9 -9.0 0.5 3.3 -22.4 1986 -2.4 -15.4 -31.6 -43.4 -18.5 -6.4 -117.7 1987 -2.9 -15.9 -34.9 -42.7 -17.4 -6.0 -119.8 1988 -3.5 -11.9 -33.4 -40.5 -18.6 -5.2 -113.1 1989 -5.5 -6.8 -26.2 -30.6 -20.3 -10.8 -100.2 1990 -6.1 -5.9 -21.6 -21.3 -14.0 -8.3 -77.2 1991 -3.0 -2.9 -18.0 -19.8 -20.9 -9.0 -73.6 1992 -4.1 3.5 6.7 6.0 -0.3 -9.6 2.2 1985-1992 -27.5 -61.6 -169.9  -201.3 -109.5 -52.0  -621.8 Females 1985 -0.6 -0.9 -1.4 -1.1 4.7 14.6 15.3 1986 -2.2 -2.0 -5.7 -13.0 -8.8 -12.9 -44.6 1987 -2.7 -2.3 -6.9 -13.7 -5.5 -8.6 -39.7 1988 -3.1 -1.4 -6.8 -14.3 -7.6 -3.7 -36.9 1989 -4.4 -0.6 -6.1 -11.8 -14.8 -27.6 -65.3 1990 -4.9 -0.7 -5.6 -9.3 -11.6 -17.6 -49.7 1991 -2.9 0.3 -4.8 -8.7 -17.3 -25.3 -58.7 1992 -3.5 1.5 0.1 -1.9 -4.5 -22.1 -30.4 1985-1992 -24.3 -6.1 -37.2 -73.8 -65.4 -103.2 -310.0 scenarios, the estimate varies from 433,000 to 779,000 deaths prevented for males and from 181,000 to 476,000 deaths prevented for females. Such a wide range reflects serious differences among the three underlying assumptions. It is not clear which scenario should be preferred, so the values presented in Table 8-2 are actually averages of those resulting from all three. The number of prevented deaths for males is twice as high as for females. Even if we exclude the contribution of ages under 15 to the total, the number of prevented deaths from excess alcohol consumption in Russia during the 8 years between 1985 and 1992 is only a little less than 900,000. For men, the maximum gains of the anti-alcohol campaign occurred in the age group 45 to 59, and for women in the oldest age group. Over the calendar years, the maximum gain for men was in 1988 and for women in 1989. We know that the maximum gains in expectation of life at birth and in the age-standardized death rate concern younger ages and the years 1986 and 1987. These differences

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--> in results should certainly be ascribed to the different nature of the indicators, as the absolute death numbers depend strongly on mortality among the elderly and even on the proportion of the total population in older age groups. We can also mention here that in reality, not all the deviations of mortality rates from the expected or "natural" trend are related to the anti-alcohol campaign. For example, it is difficult to imagine that the substantial improvement among women aged 75+ is entirely attributable to either a direct or indirect impact of the anti-alcohol measures. Variations in Male Mortality by Age and Cause of Death In this and the next section, we consider the mortality trends and patterns for men. The phenomenon of alcohol-related mortality is certainly less important for Russian women than for men, and less dramatic. Moreover, most of the results obtained for males are similar for females, although at much lower levels for the latter. The trends in age-specific death rates exhibit a wide variety of responses to the sharp variations in alcohol consumption since 1984, as shown in Figure 8-2. The trends in infancy and childhood do not show the same sharp fluctuations as those for adults (though perhaps with the exception of some acceleration in decline between 1985 and 1986). The long-term decline in the infant mortality rate continues with small fluctuations until 1990. Some increase occurs in the period 1991-1992 and a more significant increase in 1993. In contrast, death rates at ages 20 to 55 exhibit very large variations. The maximum decrements of the age-specific death rates in the period 1985-1986 are about 30 to 40 percent of the basic levels of 1984. At older ages, the variation in mortality trends is gradually reduced from about 15 percent at ages between 45 and 54 to less than 7 to 8 percent among the elderly. At working ages, death rates increase significantly starting in 1988, with an accelerated increase in 1992. By 1992, death rates have increased to just above the levels of 1984. This is not the case for ages above 55. Death rates for these ages grow rather slowly until 1992, when they rise substantially, though they remain slightly below the previous extreme point of 1984. The similarities and dissimilarities in the age patterns of the mortality decrease in the period 1985-1987 and the increase in the period 1988-1992 are summarized in Figure 8-3. Certainly, the two age distributions of age-specific death rates have the same general shape. However, the age distribution of the mortality increase is slightly shifted to the left as compared with the age distribution of the mortality decrease. This means that for younger ages, the growth is higher than the previous decline, while, for older ages, the decrease in death rates is larger than the later increase. Hence, some difference can be found between mortality trends for younger

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--> Figure 8-2 Age-specific death rates in Russia, males, 1975-1993. and older adult ages. To clarify this matter, let us consider the trends in age-specific death rates by classes of causes of death (Figure 8-4). (Note that in Figure 8-4 the logarithmic scale is used for better visual comparability of the trends in different causes of death.) The three age groups 20-24, 45-49, and 65-69 represent the range of young, middle, and older ages. Since 1985, all leading causes of death except neoplasm exhibit fluctuations to a greater or lesser extent. Changes in the trend in death

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--> Figure 8-3 Ratios of age-specific death rates (ASDRs) for periods of decrease (19841987) and increase (1987-1992) in annual alcohol consumption in Russia, males. ASDR in 1984 divided by ASDR in 1987; ASDR in 1992 divided by ASDR in 1987. rates for external causes over each age group are relatively larger than those in the trends for other causes of death. The corresponding standardized death rates start increasing immediately after 1987, when alcohol consumption began to grow, whereas the trends in circulatory diseases and in respiratory and digestive diseases are more inert, showing a rather moderate increase in the period 1988-1991. Only in 1992 does this increase become more substantial. Thus the age-specific death rates for external causes are slightly higher in 1992 than in 1984, while for circulatory diseases the situation is reversed. This difference in the tendencies for these two main components of Russian mortality is even more obvious in the scatter chart shown in Figure 8-5. In this figure, the annual ethanol consumption per capita is on the horizontal axis, and the age-standardized death rate per 100,000 is on the vertical axis. Ischemic heart disease (upper lines) and external causes of death (lower lines) are shown. Generally, the slope of two-dimensional movements for external causes is relatively larger than that for ischemic heart disease. In the period 1988-1992, the backward movement in external causes ends at the level of the standardized death rate, which is higher

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--> Figure 8-5 Annual alcohol consumption and the standardized death rate for ischemic heart disease (IHD) and external causes of death in Russia, males, 19841992. Note: The arrows indicate movement in time from 1984 to 1992. than in 1984. The trace corresponding to ischemic heart disease finishes at the value of the standardized death rate, which is lower than in 1984. Hence, the difference in mortality trends between the young adult and older adult ages in the period 1988-1992 could be explained by the difference in the structure of causes of death. At young adult ages, external causes, directly related to alcohol abuse, predominate and control the trend of the total age-specific death rate; at older ages, mortality from circulatory diseases predominates. Alcohol Abuse and the Large Increase in Mortality in 1993 A sharp increase in death rates occurs at almost all ages in 1993, as shown in Figure 8-6. The highest increase is at ages 40-44. Within the range of ages 25 to 64, the increase in age-specific death rates is more than 20 percent. In contrast with 1992, mortality increases very substantially at ages other than working ages, among the elderly population in particular. The serious deterioration occurs for all leading classes of causes of death (Figure 8-3). For ages above 65, the rise in

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--> Figure 8-6 Rise in Russian male mortality in the early 1990s. ASDR in 1992 divided by ASDR in 1991, ASDR in 1993 divided by ASDR in 1992 death rates between 1992 and 1993 looks like a discontinuity in the trend. However, this is not so obvious for ages under 65. After a steady decline, the trend in the infant mortality rate exhibits some increase in the period 1991-1992; this increase is more pronounced in 1993, when the rate went from 18 to 20 per 1,000. However, the latter increase could be partly attributable to the change in the Russian definition of a live birth (see Anderson and Silver in this volume). Death rates among children from exogenous causes are a good indicator of a society's general state of health and sanitary conditions. The standardized death rate for respiratory, infectious, and digestive diseases combined for ages under 15 declines continuously in Russia until 1990, in spite of rising mortality from these causes of death among adults. This decline, indicated in Figure 8-7, probably reflects some better defense against these diseases provided for children by the Russian medical care system. In the period 1991-1992, the standardized death rate for this combination of causes of death is almost constant, but in 1993 it rises significantly. Certainly, this new increase in infant and child mortality rates in Russia is a very alarming sign of a general deterioration in health conditions. But at the present level of infant mortality, it does not strongly affect the value of life

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--> expectancy at birth. The enormous reduction in the latter is due mostly to mortality increases at adult ages, as is the case in the period 1988-1992. We now examine whether the most recent mortality increase can be attributed to a continuation of the alcohol-related increase of the period 1988-1992. Two reasons can be given for such an explanation: first, alcohol consumption increased between 1992 and 1993 (Table 8-1), and second, as noted above, cardiovascular mortality in 1992 was still lower than in 1984, before the anti-alcohol campaign. To examine the question, we approximate the observed death rates by cause of death at ages 30-34 and 60-64 by a linear function of real alcohol consumption and calendar year (see Annex 8-2) and then compare the model estimates of age-specific death rates with the levels observed in 1993. The trends of observed and model age-specific death rates for classes of causes of death are depicted in Figures 8-8 and 8-9. Clearly, the deviation (excess) observed from model death rates increases very substantially in 1993 as compared with the preceding years. The approximate nature of the simple model applied here does not allow us Figure 8-7 Standardized death rates for respiratory, infectious, and digestive diseases combined in Russia, males, 1980-1993.

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--> Figure 8-8 Observed and predicted death rates at age 30-34 by causes of death (approximation by a linear function of alcohol consumption and time): Russia, males, 19801993. to be very confident about the quantitative results obtained. (Annex Table 8-1 gives enough data for evaluation of possible errors.) However, the main qualitative result seems to be evident. The rise in adult mortality between 1992 and 1993 cannot be explained solely by alcohol abuse. Some other factors appear to have caused the health conditions of the Russian adult population to deteriorate substantially. Obviously, these factors could be related to the great socioeconomic shocks that occurred in Russia in the 1990s. Finally, we can examine Russian male mortality in terms of standardized death rates by 25 principal causes of death. The values of standardized death rates for selected causes of death are presented in Table 8-3 for the following years: 1970 (to give an idea of the direction of the long-term trend), 1984, 1987, 1992 (extreme points of mortality variation due to the anti-alcohol campaign), and 1993. Comparison of these standardized death rates with those of other countries could highlight the main unfavorable features of the Russian pattern of mortality by causes of death. For many causes of death, Russian standardized death rates are among the worst of the developed countries. Of particular note are the extremely high levels of cardiovascular mortality, especially from cerebrovascular

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--> Figure 8-9 Observed and predicted death rates at age 60-64 by causes of death (approximation by a linear function of alcohol consumption and time): Russia, males, 1980-1993.

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--> TABLE 8-3 Age-Standardized Death Rate for Selected Causes of Death per 100,000, Russia, Males Cause of Death 1970 1984 1987 1992 1993 All causes 1,705.0 1.874.3 1,627.7 1,821.0 2,145.2 Infectious/Parasitic Diseases 56.0 31.9 23.9 25.0 33.4    Tuberculosis 47.4 22.0 16.6 19.7 26.2 Neoplasms 288.9 299.8 311.6 325.3 330.6    Cancer of stomach 74.2 71.1 65.7 58.9 58.2    Cancer of esophagus 15.1 8.8 10. 12.7 12.8    Cancer of lip, oral cavity, and larynx 4.8 8.8 10.0 12.7 12.7    Cancer of intestine and rectum 14.8 24.1 25.8 28.3 29.8    Cancer of bronchus and lung 72.0 92.2 99.5 104.8 105.7    Cancer of prostate 7.5 9.1 10.2 11.8 11.9 Circulatory Diseases 814.3 975.3 887.1 915.7 1089.3    Ischemic heart disease 439.8 546.5 490.7 486.6 581.8    Cerebrovascular disorders 268.7 315.6 298.4 299.7 343.8    Hypertensive disease 20.1 9.8 7.5 9.7 12.0 Respiratory Diseases 198.5 159.7 120.2 116.9 149.5 Digestive Diseases 44.1 53.8 44.9 51.3 59.5    Cirrhosis of liver 16.0 24.3 18.3 19.1 24.2 Alcoholism 0.7 1.5 1.0 1.6 2.1 External causes 241.7 284.4 172.8 304.4 400.0    Motor vehicle accidents 23.1 31.4 22.4 42.0 42.3    Accidental poisoning by alcohol 29.6 35.2 14.5 31.9 54.3    Other poisonings 10.8 17.2 12.8 16.6 20.3    Suicide 61.6 66.4 42.1 57.4 71.4    Homicide 11.1 19.3 11.5 37.9 50.2    Other external causes 61.5 115.0 69.6 118.7 161.6 disorders, and enormously high mortality from accidental alcohol poisoning, suicide, and homicide. As far as we know, Russia now occupies third place among all countries reporting mortality data according to the level of the male standardized death rate from homicide (after Colombian males and U.S. black males). The very impressive increase in the standardized death rate for accidental poisoning in 1993 can be explained not only by rising alcohol consumption, but also serious deterioration in the quality of alcohol consumed (see also Treml in this volume). For instance, the Moscow sanitary service found that about 40 percent of the content of the alcohol sold in stores was falsified. Autopsy reports indicate that the number of deaths from alcohol poisoning with a nonfatal alcohol

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--> concentration in the blood is increasing as a result of the consumption of alcohol with a high concentration of toxic elements. Annex 8-1 Estimation of Real Alcohol Consumption in Russia The formula for estimation of real alcohol consumption in Russia is based on observations of sugar sales, alcohol sales, and deaths from accidents and violence in Moscow in the period 1984-1987 (Nemtsov, 1992; Nemtsov and Nechaev, 1991). The level of illegal production of samogon in Moscow was always one of the lowest among territories of the Russian Federation. This can be explained by the higher educational level of the population and the relatively good development of the state alcohol trade. Nearly all samogon distilled in the city has been produced from sugar (this is not the case for many other areas: see note 3). Just after June 1, 1985, fear of the anti-alcohol measures resulted in a decrease in the illegal production of samogon. As a result, sales of sugar in Moscow were unusually low in the period August to December. We took the level of annual sugar consumption for the year 1985 as the baseline (24.88 kilogram [kg] of sugar per capita). This estimate is rather close to the Soviet nutritional standard promulgated by the Institute of Nutrition (Academy of Medical Sciences of the Soviet Union), which was 24.0 kg in 1980. It is possible to produce about 1.3 liters of 40 percent samogon from 1 kg of sugar (Goskomstat estimate). The levels of sugar consumption in both 1984 and 1986 were substantially higher than the 1985 baseline. This allows us to calculate illegal samogon production in 1984 and 1986 in Moscow as 0.61 and 1.49 liters per capita, respectively. Finally, we can add these estimates for samogon production to the official figures for alcohol sales per capita and derive estimates of true alcohol consumption in Moscow in 1984 and 1986 of 11.89 and 8.48 liters, respectively. These figures, as well as the results for the period 1981-1983, are close to the corresponding estimates by Goskomstat. Until 1988, it was possible to continue evaluating samogon production on the basis of sugar consumption in Moscow. Unfortunately, in 1988 the trend in sugar consumption shifted as a result of the deficit of sugar in the state trade, which resulted in a ''sugar panic." When sugar once again became available, the level of sugar sales rose as high as 37.8 kg per capita. Thus after 1988, it became impossible to evaluate samogon production from sugar consumption. Under these circumstances, it is reasonable to look for an indicator of alcohol consumption other than sugar sales that is less sensitive to external influence. The ratio of accidental and violent deaths with alcohol present in the blood (VDA) to "sober" accidental and violent deaths (VDS) satisfies this condition. (Accidental poisonings by alcohol are excluded from VDA and VDS figures because in this case, alcohol causes death independently of other factors.)

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--> The data on VDA and VDS are available from the findings of regional legal medical bureaus, which are responsible for autopsy investigations. In Russia, almost all accidental and violent deaths are supposed to be investigated with an autopsy. (In practice, the proportion of violent and accidental deaths investigated through autopsy is more than 90 percent.) It is evident that in Moscow, the X indicator is closely associated with temporal changes in real alcohol consumption, derived from sugar consumption in the period 1981-1987 (r = 0.97, p < 0.0001). Thus, it is possible to develop a linear regression equation between real annual alcohol consumption in liters (RAC) and X: This formula was applied for the calculation of RAC in other regions of Russia. In the period 1981-1990, the data for evaluation of X were received from 25 regions of the Russian Federation (the level of oblast'). In the period 19911993, for various reasons, it was possible to collect data from only 14 regions. The values of RAC in the period 1981-1993 for the whole country were calculated as a weighted average of regional estimates. (The weights were proportional to the sizes of regional populations.) Annex 8-2 Comparison of Actual and Predicted Cause-Specific Death Rates for 1993 We fit linear models to the age-specific death rates for each year 1980 through 1992 (13 data points for each cause), relating the dependent variables (annual age-specific death rates for each cause and for all causes combined) to alcohol consumption and a linear trend variable. The general form of the regression equation, summarized in Annex Table 8-1, is where ASDR is the death rate per 100,000 for each cause and each age group in each year 1980-1992; ALCOHOL is the annual estimates of per capita alcohol consumption; YEAR is the calendar year (1980-1992); is an error term; and β0, β1, and β3 are estimated coefficients. We used each model to estimate age-specific death rates by cause for 1993. We then compared the resulting predicted values for 1993 with the observed age-specific death rates for 1993. The difference between observed and predicted values (column 8 in Annex Table 8-1) shows the degree to which age-specific death rates in 1993 differ from what would have been expected from alcohol

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--> ANNEX TABLE 8-1 Coefficients from Regressions of Age-Specific Death Rates (ASDRs) by Cause of Death on Alcohol Consumption and Yearly Trend, 1980-1992 Cause of Death Alcohol Consumption Calendar Year Intercept r2 Observed ASDR in 1993 Predicted ASDR in 1993 Difference Observed/Predicted Age 30-34 Infectious/ Parasitic 1.43 (0.21) N.S. -1.98 0.81 24.1 18.8 5.3 Neoplasm N.S.   0.34 (0.07) 11.87 0.68 22.9 21.5 1.4 Circulatory 6.26 (0.62) N.S. -21.68 0.90 89.0 68.4 20.6 Respiratory 2.80 (0.51) N.S. -26.02 0.76 16.4 16.6 -0.2 Digestive 3.16 (0.39) N.S. -26.66 0.86 18.7 19.2 -0.5 External causes 44.01 (5.4) N.S. 242.87 0.88 506.4 395.3 111.1 Other causes 2.81 (0.43) N.S. -15.03 0.80 25.7 28.3 -2.6 All causes 61.56 (5.03) N.S. 322.55 0.93 706.1 570.1 136.0 Age 60-64 Infectious/ Parasitic 3.63 (1.21) -1.90 (0.42) 16.98 0.85 60.8 44.9 15.9 Neoplasm N.S.   14.81 (1.12) 891.60 0.94 1080.8 1090.9 10.1 Circulatory 68.94 (6.20) 6.09 (2.11 697.70 0.93 2194.4 1776.5 417.9 Respiratory 11.28 (2.54) -4.95 (0.87) 67.38 0.94 365.6 282.6 83.0 Digestive 7.16 (1.16) N.S. 32.44 0.79 136.3 146.3 10.0 External causes 43.55 (5.11) 4.18(1.64) -303.77 0.88 515.20 383.0 132.2 Other causes 3.15 (0.71) 0.67 (0.20) 31.11 0.68 104.4 85.5 18.9 All causes 144.20 (10.61) 18.40 (3.49) 1,457.80 0.94 4,457.50 3,787.9 669.6 NOTE: N.S. = not statistically significant; standard deviations of estimates in parentheses.

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--> consumption and recent underlying trends alone if the relationships had remained stable. These calculations are presented separately for ages 30-34 and 60-64. The simple regression models fit the data for the period 1980-1992 fairly well; the values of the r-square statistic range from 0.68 to 0.94 for the individual regressions. Alcohol consumption is a statistically significant predictor of age-specific death rates for all causes except neoplasm for both age groups. At ages 30-34, the linear trends are statistically insignificant for all causes except neoplasm. At ages 60-64, by contrast, the linear trend is significantly associated with age-specific death rates for most causes For both age groups, the death rates for all causes combined in 1993 are much larger than would be predicted from these models estimated on the 1980-1992 data: 136 excess deaths per 100,000 for ages 30-34 and 670 excess deaths per 100,000 for ages 60-64. Most of the difference is accounted for by diseases of the circulatory system (20.6 excess deaths for ages 30-34; 418 excess deaths for ages 60-64) and deaths due to external causes ( 111 excess deaths for ages 30-34; 132 excess deaths for ages 60-64). References Anderson B., and B. Silver 1990 Trends in mortality of the Soviet population. Soviet Economy 3(3):191-251. Andreyev, Ye.M. 1990 Prodolzhiitelnost zhizni i prichini smerti v SSSR. [Life expectancy and causes of death in the USSR]. Pp. 90-116 in: Demograficheskiye processi v SSSR /Demographic Processes in the USSR]. Moscow: Nauka. Dmitrieva, R.M., and Ye.M. Andreyev 1987 O sredney prodolgitel'nosti zhizni naseleniya SSSR [On the average length of life of the population of the USSR]. Vestnik statistiki 12:31-39. Ducham, N.Y., and F.E. Sheregi 1986 Prichini i sotsial'niye posledsviya piyanstva [Causes and social consequences of drunkenness . Sotsiologicheskiye issledovaniya [Sociological Studies] 2:144-152. Meslé, F., V. Shkolnikov, and J. Vallin 1992 Mortality by cause in the USSR in 1970-1987: The reconstruction of time series. European Journal of Population 8:281-308. 1994 Brusque montée des morts violentes en Russie. Population 3:780-790. Nemtsov, A. 1992 Uroven realnogo potrebleniya alkogol'ya v Rossiysoy Federatsii [The level of real alcohol consumption in the Russian Federation]. Sotsialnaya i klinicheskaya pychiiatriya [Social and Clinical Psychiatry] 2 (4):46-53. Nemtsov, A., and A. Nechaev 1991 Alkogolnaya situatsiya v Moskve v 1983-1990 godah [Alcohol situation in Moscow in 1983-1990]. Sotsialnaya i klinicheskaya psychiiatriya [Social and Clinical Psychiatry] 1:75-83. Nemtsov, A.V., and V.M. Shkolnikov 1994 Jit' ili pit'? [To live or to drink]. Izvestiya, 135. (19 Iyuliya 1994).

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--> Shkolnikov, V., F. Meslé, and J. Vallin 1994a Life expectancy and causes of death in Russia: The overview of trends in 1970-1992. Paper presented at the Conference on Geodemography of the Former Soviet Union. Radford, Virginia. 1994b Recent trends in life expectancy and causes of death in Russia (1970-1993). Paper presented at the Workshop on Mortality and Adult Health in the Newly Independent States, Washington, D.C. Shkolnikov, V., and S. Vassin 1994 Spatial differences in life expectancy in European Russia in the 1980s. Pp. 379-402 in W. Lutz, A.Volkov and S.Scherbov, eds., Demographic Trends and Patterns in the Soviet Union before 1991. New York-London: Routledge-IIASA. Treml, V. 1982 Alcohol in the USSR; A Statistical Study. Durham: Duke University Press. Zaigrayev, G.G. 1992 Obshestvo I Alkogol' [Society and Alcohol]. NIIMVD [Research Institute of the Ministry of Interior Affairs], Moscow. Notes 1.   Here and below we use the old European population standard of the World Health Organization. The direct method of age adjustment is applied. 2.   Actually it was a "half-dry" law, because only drinks stronger than 20 percent alcohol content were forbidden for distillation and sale. 3.   This was probably the case because Goskomstat evaluated only the samogon produced from sugar. Actually, some proportion of samogon has been made from other products (e.g., potatoes or grits). 4.   Recorded state alcohol sales per capita is equivalent to annual alcohol consumption officially reported by Goskomstat. 5.   The trend in male expectation of life at birth in the period 1980-1992 looks like a mirror image of the alcohol consumption trend (Nemtsov and Shkolnikov, 1994).