Causes of Declining Life Expectancy in Russia

RUSSIA (officially known as the Russian Federation) has been undergoing unprecedented political, economic, and social change during the last several years. All aspects of the society have been affected, including the health status of the population. There have been dramatic outbreaks of infectious diseases and decreases in the availability of health services. The most noticeable effect, however, has been an unprecedented decline in life expectancy.¹

It has been widely recognized that key public health indicators have been worsening since the 1960s. For example, cardiovascular mortality rates increased by about 26% between 1960 and 1985.² However, until recently the extent to which conditions had been degrading was not well understood because of the lack of published data. It is in the context of declining trends in health that the phenomenal changes of the late 1980s through the present are overlaid.

This article is a summarization of a collaboration between the Public Health Institute, MedSocEconomInform, and the National Center for Health Statistics, Centers for Disease Control and Prevention. This analysis represents an effort to present Russian health statistics in ways that are comparable to US vital statistics and, in instances where this is not possible, to document the differences.

The purpose of this article is to compare and contrast mortality trends in Russia with the United States with the goal of understanding the impact of major mortality determinants on the decline in life expectancy.

Both published and unpublished information on births and deaths in Russia were obtained from Goskomstat, the Russian central statistical agency. The US National Center for Health Statistics provided comparative data on births and deaths in the United States. Russian life expectancy data used for long-term mortality trends came from life tables prepared by Goskomstat.³ However, because Goskomstat life-table methods have varied over time, life expectancy figures for detailed calculations covering the interval 1990 through 1994 were derived from life tables developed by MedSocEconomInform using Goskomstat mortality data and standard life-table methods.⁴

We used a life-table partitioning technique to measure the contribution of various causes of death to change in life expectancy over time.^{5 - 6} The same technique also was used to determine the contribution of mortality change in each age group to variations in life expectancy over time. This approach provides a more accurate measure of the impact of changes in mortality by age or by cause than can be obtained from the relative change in mortality rates over time. The life-table partitioning technique combines information on relative change in mortality rates with data on the absolute level of mortality, thus providing a clearer image of the major contributors to the mortality rise in Russia.

To compare relative mortality risks across the 2 countries and over time, we calculated age-adjusted death rates for each country, for all causes combined, and for selected cause groups. We used the direct method of age adjustment, in which age-specific death rates are applied to the relative age distribution of the standard population.⁷ The standard population chosen was the World Health Organization "old" European standard population.⁸ This age distribution is roughly midway between the age distributions of the 2 countries.

Goskomstat does not use the International Classification of Diseases, Ninth Revision (ICD-9)⁹ for the coding of causes of death. Instead, they use a coding system developed by the Soviet Union with a total of 175 causes of death. Goskomstat uses an algorithm to convert these codes into ICD-9 equivalents for international reporting of Russian mortality data. The results necessarily provide data in relatively broad ICD-9 categories.

We combined the cause of death codes to provide mortality measures for a limited number of leading causes of death in Russia. Most of the cause groups used are similar to those used in the United States. Two cause groups deserve some comment because they are somewhat different from the usual leading causes of death. The cause group "other alcohol-related causes" contains information on deaths attributable to alcohol intoxication. In Russia, a large proportion of deaths due to alcohol intoxication are coded to alcohol poisoning (Russian code 163), an external cause of death.¹⁰ In western countries including the United States, the vast majority of alcohol-related deaths are assigned to causes such as alcohol dependence syndrome (ICD-9 code 303) and nondependent use of alcohol (ICD-9 code 305.0), and only a small proportion of deaths to accidental poisoning by alcohol (ICD-9 code E860).

The cause group "other alcohol-related causes" combines information on alcohol dependence syndrome and alcohol poisoning (codes 75 and 163) for Russia and, for the United States, it includes ICD-9 codes 303, 305.0, and E860. The cause group "other injuries" includes all the external causes of death with the exception of motor vehicle crashes, alcohol poisoning, suicides, homicides, and legal interventions. It includes occupational injuries, drownings, falls, and the like, as well as injuries with intent undetermined and injuries due to operations of war.

The rapid rise in mortality since 1990 in Russia has been extensively reported in the press and in some scientific articles.^{11 - 15} However, the recent rise in deaths is best understood in the context of long-term health trends in Russia. As shown in Figure 1, health outcomes in Russia have not experienced any long-term improvement for several decades, as measured by life expectancy. In fact, male life expectancy went through 2 decades of gradual decline, from the mid-1960s to the mid-1980s; female life expectancy stagnated over the same interval. The United States life expectancy was only slightly higher than Russia's in the mid-1960s, but the gap has increased steadily since 1970.

The remarkable rise in Russian life expectancy in the 1980s requires careful examination. Between 1985 and 1987, male life expectancy increased by more than 2 years, and female life expectancy rose by more than 1 year. No such sharp increase took place in the United States. There was no major improvement in Russian living standards, access to medical care, or quality of care that might help to explain the sudden rise in life expectancy in both sexes. However, 2 aspects of life changed dramatically at that time: the sudden drop in per capita alcohol consumption, brought about by Gorbachev's antialcohol campaign, and the period of perestroika that introduced the notion of social democratization and inspired hopes for a better future. The antialcohol campaign reduced consumption by raising the price of alcoholic beverages, reducing the production of alcohol, and limiting access by restricting the hours of state liquor stores.¹⁶ As shown in Figure 2, the campaign resulted in a rapid drop in alcohol consumption that correlated very well with the temporal rise in life expectancy. An analysis of the changing composition of causes of death has shown that most of the rise in life expectancy was due to a sharp decline in external causes of death, particularly for men, as well as a decrease in deaths due to cardiovascular diseases.¹⁶ The impact of perestroika on mortality levels is more speculative but has been mentioned as a factor in the sharp drop in suicide deaths in the Soviet Union from 1985 to 1988.¹⁷

Russia experienced a significant rise in mortality between 1990 and 1994. In that 5-year period, the annual number of deaths rose by almost 650000, or about 39% (Table 1). Combined with a sharp drop in the annual number of births, the mortality increase led to a significant excess of deaths over births in Russia beginning in 1992.

The Russian age-adjusted mortality rate, already high in 1990 as compared with the United States and most industrialized countries, rose almost one third by 1994, with increases of 36% for the male death rate and 23% for the female rate (Table 2). Similar data for the United States showed a decline in age-adjusted mortality between 1990 and 1994. The negative trend in Russian life expectancy quickly erased the gains of the 1980s and then continued downward. Overall, male life expectancy fell by more than 6 years, from 63.8 years in 1990 to 57.7 years in 1994, while female life expectancy declined by more than 3 years to 71.2 years in 1994. The male-female differential in life expectancy of 10.6 years in 1990, already the highest in Europe, rose to 13.5 years in 1994.

From 1990 through 1994, mortality rates rose sharply for every sex and age group (Figure 3). For both men and women, the largest increases were in the middle-aged groups; the death rate for men aged 35 to 44 years increased almost 100%. United States mortality rates for most sex and age groups fell from 1990 to 1994, with the largest declines among the very young (Figure 4).

Even in 1990, mortality rates for certain causes of death were much higher in Russia than in other industrialized countries. Russian death rates exceeded US rates in 1990 by 25% or more for heart diseases, stroke, chronic liver diseases and cirrhosis, other alcohol-related causes, motor vehicle crashes, suicide, homicide, and other injuries (Table 3). Particularly notable was the 4- to 5-fold Russian excess in strokes. However, the cancer mortality rate was roughly equal in the 2 countries, and mortality due to pneumonia and influenza was substantially lower in Russia.

Major increases in mortality took place in Russia for most cause categories between 1990 and 1994. Mortality rates increased by 100% or more for other alcohol-related causes, pneumonia and influenza, and homicide. Sharp increases also were noted for major causes of death such as diseases of the heart (40% increase) and stroke (20% increase). Thus, in 1994 almost all the Russian cause-specific death rates were substantially higher than the US rates: 2 times higher for diseases of the heart, 3.4 times higher for homicides, 3.5 times higher for suicides, 6 times for stroke and other injuries, and 16 times higher for other alcohol-related causes. However, the neoplasm death rate remained roughly equal to the US rate. For all causes combined, the Russian mortality rate was almost exactly double the US rate (Table 2).

A more accurate way to summarize the overall impact of these changes in age- and cause-specific rates is by measuring their contribution to changes in life expectancy.^{5 - 6} Table 4 provides the contribution of the mortality change in each age group to the change in life expectancy, for men, women, and the total population. The results confirm the information previously presented on the pattern of change by age and sex; for both men and women, the bulk of the change takes place in the middle ages, in particular for ages 25 to 64 years. The contribution of infant mortality to the decline in life expectancy is small for both sexes, less than 0.1 years for both men and women. Among men, mortality change in the ages 35 to 54 years led to a drop in life expectancy of 2.9 years or almost half of the total decline for men. For women, the age pattern was similar but with a larger contribution from the older age groups than for men.

The same partitioning method was used to assess the contribution of each cause of death to changes in life expectancy. As shown in Table 5, the largest contributors to the decline in life expectancy between 1990 and 1994 were diseases of the heart (26% of the total decline) and other injuries (18%). Other major contributors were stroke, other alcohol-related causes, homicides, and suicides. Infectious disease mortality was not a major factor in the decline in life expectancy; despite a 64% rise in deaths due to infectious diseases, the 1994 mortality rate for infectious diseases remained far smaller than for other causes of death. The contributions of cancer and motor vehicle crashes were negligible. Among women, stroke was a much larger contributor to the decline in life expectancy than for men; the contribution of pneumonia and influenza, homicides, infectious diseases, and particularly suicides was smaller for women than for men.

Information on the contribution of each age group and cause of death to the fall in life expectancy can be combined to provide some additional details on the rapid rise in mortality in the middle age groups. For both men and women, the age group 45 to 64 years accounted for almost 45% of the total decline in life expectancy. For men in this age group, heart disease and stroke combined accounted for a drop of 1.1 years in life expectancy, while deaths due to other injuries contributed a 0.5-year reduction and other alcohol-related causes a 0.3-year decline. Homicide, suicide, and pneumonia and influenza each contributed about 0.1 years to the decline in life expectancy. For women aged 45 to 64 years, the changes were smaller but cardiovascular mortality trends led to a drop of 0.5 years in life expectancy and stroke a 0.2-year decline.

The mortality increase in Russia from 1990 to 1994 is outside the peacetime experience of 20th-century industrialized countries. It is difficult to conceive of health and other problems that could lead to a 5-year decline in life expectancy in only 4 years' time. With increases of this magnitude, it is reasonable to consider whether data quality problems, such as deterioration in completeness of death reporting or underestimation of the population at risk, could explain a major part of this change. A recent study considered these and other data quality issues that might account for the mortality rise and concluded that the mortality increase was real, not artifactual.¹⁸

Data problems affect the quality of Russian mortality information, however, and should be considered here. Infant deaths have been historically underreported in Russia because of a Soviet-era definition that excludes all infants dying within 7 days of birth who were substantially preterm (less than 28 weeks' gestation, under 1000 g birth weight, or less than 35 cm birth length). This difference is estimated to understate Russian infant mortality by about 25%.^{19 - 20} The official Russian definition was modified to conform to the World Health Organization standard in 1993, but the traditional reporting practice remains unchanged.²¹ Indeed, the infant mortality rate for 1994 did not show any major increase over previous years. Because the level of underreporting does not appear to have changed between 1990 and 1994, no attempt was made to adjust infant mortality rates for underreporting.

The Soviets suppressed information on homicide and suicide deaths until the late 1980s.²² However, recent access to Soviet files confirms that rather than removing all deaths due to homicides and suicides from mortality reporting, the Soviets added these deaths to the "cause not specified" category.²² In addition, all restrictions on the release of data disappeared by the late 1980s, so it is unlikely that such practices would affect the measurement of mortality trends from 1990 and the following years.

Concerns have been expressed about the accuracy of Russian cause-of-death coding practices, in particular concerning cardiovascular diseases.²³ Reservations about the accuracy of deaths due to heart disease, a major component of Russian mortality and of the recent rise in death rates, were contained in a recent article on cardiovascular risk factors in 1 region of Russia.²⁴ In addition, as noted earlier, the level of mortality due to cerebrovascular disease mortality is so much higher than the United States and other industrialized nations as to make these data suspect as well. Studies of the quality of cause-of-death coding in Russia do not support the notion of overregistration of cardiovascular mortality, as coding errors noted for specific components of cardiovascular disease in fact tended to compensate for each other.²² Nonetheless, the low levels of mortality in Russia due to causes such as pneumonia and influenza would lead to a reasonable suspicion that some of these deaths are being erroneously assigned to cardiovascular diseases.

If no plausible statistical or reporting factors explain the rapid rise in Russian mortality from 1990 to 1994, evidence clearly exists of a broad-based and substantial deterioration in survival. Russia is not alone in experiencing drops in life expectancy; all the nations created from the breakup of the Soviet Union have reported a decline in life expectancy since 1990, although none has been as large as in Russia.²⁵ Most Eastern European countries reported a decline in life expectancy in the mid-1980s, at least among males.²⁶ Several hypotheses may explain the rapid rise in Russian mortality. We will discuss each one in turn, although many may have occurred simultaneously.

There is no doubt that Russia is undergoing a painful social and economic transition: average per capita real income declined by almost two thirds between 1990 and 1995, and the number of families living in poverty rose from 2% in 1987 to 38% in 1993.¹³ Per capita income is an extremely important factor in determining health outcomes, and long-term improvements in health status depend heavily on income growth and distribution.²⁷ Increasing poverty and the dissolution of social controls may have played a key role in the rising levels of homicide and suicide in Russia. The rapid rise in per capita alcohol consumption since the late 1980s may be partly a result of reduced social controls.

The rise in alcohol consumption since the late 1980s has resulted from the decline in government controls, rising stress, and other forces of instability. Declining living standards have not reduced alcohol consumption for 2 reasons. First, an increasing proportion of alcohol consumed is produced at home (samogon). Second, the price of alcohol has risen much less than most other consumer prices since 1990.¹⁶ A recent nutrition study has documented a rapid increase in alcohol consumption in the general population.²⁸

The increase in alcohol consumption has contributed to the rise in deaths due to alcohol poisoning, which is included in the "other alcohol-related causes" category. The declining quality of alcoholic beverages, ie, the rise in toxic substances contained in alcohol, also is an important factor in alcohol poisoning deaths.¹⁶ Alcohol consumption may also contribute to components of the "other injury" group, including occupational injuries and drownings. The role of alcohol in deaths due to homicides and suicides is no doubt substantial.²⁹ Finally, chronic alcoholism undoubtedly plays a role in increasing chronic disease mortality, eg, stroke mortality.

The prevalence of smoking among adults in Russia has long been high.^{30 - 32} The prevalence for men was above 60% in the 1990s and near 10% for women. There is some evidence of an increase in smoking rates since 1985. The level of tobacco imports has risen sharply since 1990, but it is uncertain whether this is due to increased smoking or to a substitution of foreign tobacco for domestic production. Therefore, the level of smoking is another factor explaining historically high mortality levels in Russia but insufficient to account for more than a part of the post-1990 rise in mortality.

Diet is frequently cited by Russian individuals and health professionals as a key factor in rising mortality rates.^{11 ,14 ,32} Government and private surveys indicate that the declining living standards of recent years required families to spend an increasing proportion of their income on food and also led to a reduction in consumption of certain foodstuffs, such as meat.^{13 ,28} However, the effect of this reduced consumption on nutritional status is not clear. While one study reports widespread weight loss among elderly pensioners in 1992, another finds high levels of obesity and short-term stability in the average weight of the general population and among pensioners between 1992 and 1994.^{28 ,33 - 34} In addition, the Russian diet in the latter stages of the Communist era could not be considered healthy. During the last 3 decades, it became increasingly high in fat and, in particular, rich in animal food products with little consumption of fresh vegetables or fruit.²⁸ Although vegetable and fruit consumption has dropped further since 1990, at the same time there has been a considerable reduction in the percentage of energy derived from fat.²⁸

Recent research in the United States and other countries has shown that stress, anxiety, and depression contribute to chronic diseases, such as hypertension, heart disease, and myocardial infarction.^{35 - 39} Other studies have begun to elucidate the mechanisms by which stress, anxiety, and depression may affect the cardiovascular system to increase the risk of cardiac death.⁴⁰ These psychosocial factors, along with growing hopelessness in the face of increasing unemployment, negative economic growth, and social strife, may in turn underlie the rapid growth in per capita alcohol consumption.

The deteriorating economic situation has seriously impaired the ability of the health care system to respond to rising health problems. There have been numerous reports of the crumbling of the health care system, increasing demands for payments "under the table" for care provided, and the virtual disappearance from the market of certain essential pharmaceutical drugs.^{13 - 14} Although attention typically focuses on the declining quality of urban health care, the situation is even worse in the rural areas and smaller cities and in towns.²⁷ Nevertheless, the deterioration of the health care system did not begin in 1990; it has in fact been going on for some time and probably accounts for only a small part of the recent decline in life expectancy.^{13 ,18}

More than half of the recent decline in life expectancy can be assigned to 2 major cause groups: the cardiovascular diseases (CVDs) (eg, heart disease and stroke) and injuries (motor vehicle crashes, suicides, homicides, and other injuries). While the size of the increase in deaths due to injuries is unusual, there is no doubt that the mortality rate from injuries can rise or fall quickly. The level of CVD mortality, however, is believed to change more slowly, generally in reaction to previous exposure to risk factors.

The recent rise in homicide and suicide deaths has been an important component in the growth of the injury group. Information from recently released Soviet files shows that homicide rates were also high in the past; in 1965, the Russian homicide rate for men was 10 times the rate in France.²⁰ Possible contributors to the rapid rise in homicides and suicides include diminishing social controls, a large increase in alcohol consumption, and growing economic instability. The rise in suicides may be due in part to growing hopelessness in Russian society.

The largest component of the external cause group, other injuries, is an area for which we do not have a great deal of detail. Certain parts of this category, such as occupational injuries and drownings, may owe a substantial part of their increase to rising levels of alcohol consumption. A study of injury deaths in the former Soviet Union found that the death rate due to drownings was 3 times the rate in the United States and Australia.⁴¹ Russian drowning deaths were concentrated in the early adult years, quite different from other countries.

Finally, little is known about the magnitude of deaths due to acts of war. Although war-related deaths may have contributed to the rise in mortality due to other injuries, the largest recent outbreak of fighting—in Chechnya—did not begin until December 1994. In addition, as noted before, the annual number of deaths in Russia rose by about 650000 over the study period—an amount far in excess of the estimated loss of life in Chechnya.

Because heart diseases and stroke develop over an extended period, mortality from these diseases is not believed to be subject to rapid change. However, rapid declines in CVD morbidity and mortality following a reduction of risk factor exposures have been reported from preventive trials and cohort studies.^{42 - 43} The opposite phenomenon of rapidly rising mortality as a result of new or increased exposure to risk factors has not been reported but would appear to be a possibility. A review article on rapid mortality change due to chronic diseases indicates a rapid change in CVD mortality is most likely to occur in the younger middle ages, in part because younger individuals are more likely to modify their behavior.⁴⁴

Another contributor to the long-term rise in CVD in Russia is the absence of public health programs designed to reduce risk factor prevalence.²⁷ The unavailability of pharmaceuticals, such as blood pressure medication, may also account for some of the rising death rate due to CVD. In addition, CVD mortality rates in the former Soviet Union have been rising, along with CVD risk factors, since the early 1960s.^{2 ,45} How much of the recent increase is due to the long-term trend and how much is due to recent developments is not clear.

The rapid growth in Russian mortality may be coming to an end. Data from 1995 indicate an increase in life expectancy for both men and women, to 58.3 and 71.7, respectively.⁴⁶ It is too soon to tell if this is the beginning of a return to the lower mortality levels of the recent past or simply the leveling-off of mortality rates at an extremely high level.

The rapidity and scale of the Russian mortality increase exceed those of any other industrialized country in recent memory. From 1990 to 1994 age-adjusted mortality rose by one third, resulting in a decline in life expectancy of more than 6 years for men and more than 3 years for women. The pattern of diseases and mortality have particularly affected the young and middle-aged adult population, that is, those aged 25 to 64 years. The most important contributors to the decline in life expectancy were cardiovascular diseases and external causes of death, respectively, accounting for 36% and 29% of the decrease. The rise in mortality was related to a number of factors, including rapidly declining social and economic conditions, poor personal health behaviors, and a deteriorating health care system.

Returning Russian life expectancy to the level of 1990 will require substantial and long-term efforts to improve the economy, social order, and health care systems of Russia. The lesson for the Russian health care system is the same as for the health care system of the United States or other industrialized countries: current levels of life expectancy should not be considered permanent. Life expectancy can decline and under unusual circumstances those declines can be rapid and substantial.