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female life expectancy gap has widened in all the countries except Turkmenistan, but again most dramatically in Russia. The infant mortality rate has worsened in Russia, Kazakstan, and Tajikistan, but improved elsewhere.

Age-specific mortality trends reveal distinct patterns. In Central Asia, those with the largest increases in death rates have tended to be younger, aged 10-30. In Russia, the largest increases in mortality during the transition period have been among those aged 35-44, especially males. External causes explain the largest portion of rising death rates for both men and women, and may be linked to the stress and uncertainty associated with the transition (Nell and Stewart, 1994). Moreover, while age-adjusted mortality rates from cardiovascular disease have tended to decline in Western Europe (by 35 to 50 percent between 1960 and 1985), they have risen dramatically in the Soviet Union over the past three decades (Chernichovsky et al., 1996; Klugman and Schieber, 1996:Table 4; Murray and Bobadilla, 1994; Shkolnikov et al., 1994).

Epidemiological Situation

The epidemiological situation of a population is a clear indicator of its health needs and demands. International historical experience suggests that changes in the pattern of disease among a population proceed in two steps: the first is the demographic transition, when mortality from infectious diseases declines, and, partly as a result, fertility decreases as well; the second is the epidemiological transition, when the population becomes older, and noninfectious diseases become the main causes of mortality (World Bank, 1993).

Russia appears largely to have passed through the demographic transition, although reports of infectious disease outbreaks have been fairly frequent in recent years. In Central Asia, however, pre-epidemiological transition conditions, such as a high prevalence of infectious diseases and high infant mortality, coexist alongside health problems such as ischemic heart disease, emphysema, and motor traffic accidents, which are typical in richer industrial countries (Phillips et al., 1992). Moreover, some previously eradicated disorders have seen a resurgence. In some Central Asian countries, such as Turkmenistan and Tajikistan, classic pre-demographic transitional disorders such as acute respiratory infections and diarrheal diseases cause high infant mortality, indicating that they have never been completely controlled in these areas. High mortality (and morbidity) from other disorders surrounding childbirth continue. Russia's infant mortality rate is significantly lower than the rates in Central Asia.

Maternal mortality rates were high in all the countries prior to independence; since then, experiences have diverged (Table 12-1). Maternal mortality rates in Uzbekistan are now reported to be only about half the regional average as a result of declines in fertility and infant mortality rates of 9 and 14 percent, respectively. A comprehensive program aimed at women of child-



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