1
Premature Death in the New Independent States: Overview

José Luis Bobadilla and Christine A. Costello

Introduction

Following the breakup of the Soviet Union, reports of an unprecedented drop in life expectancy in the New Independent States (NIS) began to receive wide attention. Yet declines in life expectancy are not a new phenomenon in this region of the world; indeed, they have been a feature of the last several decades.

In the decades following World War II, the Soviet Union invested in social services to improve the welfare of its citizens and experienced positive effects in many areas of human development, including school enrollments, nutritional status, prevention of childhood communicable diseases, and availability of housing. But the adult death rates among large population groups did not decline. Rather, they increased or stalled for many years, producing declining or stagnating life expectancy.

A notable decline in life expectancy in the Soviet Union occurred during the 1960s. It continued for more than two decades, followed by an increase in the 1980s. These life expectancy reversals, shared with Central Europe, contrast sharply with trends of steadily increasing life expectancy found in other countries of Europe, Japan, and the United States during the same period. In the 1990s, further declines in life expectancy were reported for the NIS, driven largely by an extremely high incidence of premature death among the middle-aged adult population, particularly males. In 1993, adult males in the northern states of the NIS (Russia, Ukraine, and the Baltics) experienced mortality rates comparable to those of India in 1990 or Guatemala in 1960. In contrast with India or Guatemala, however, where the majority of excess adult mortality is attributable to



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--> 1 Premature Death in the New Independent States: Overview José Luis Bobadilla and Christine A. Costello Introduction Following the breakup of the Soviet Union, reports of an unprecedented drop in life expectancy in the New Independent States (NIS) began to receive wide attention. Yet declines in life expectancy are not a new phenomenon in this region of the world; indeed, they have been a feature of the last several decades. In the decades following World War II, the Soviet Union invested in social services to improve the welfare of its citizens and experienced positive effects in many areas of human development, including school enrollments, nutritional status, prevention of childhood communicable diseases, and availability of housing. But the adult death rates among large population groups did not decline. Rather, they increased or stalled for many years, producing declining or stagnating life expectancy. A notable decline in life expectancy in the Soviet Union occurred during the 1960s. It continued for more than two decades, followed by an increase in the 1980s. These life expectancy reversals, shared with Central Europe, contrast sharply with trends of steadily increasing life expectancy found in other countries of Europe, Japan, and the United States during the same period. In the 1990s, further declines in life expectancy were reported for the NIS, driven largely by an extremely high incidence of premature death among the middle-aged adult population, particularly males. In 1993, adult males in the northern states of the NIS (Russia, Ukraine, and the Baltics) experienced mortality rates comparable to those of India in 1990 or Guatemala in 1960. In contrast with India or Guatemala, however, where the majority of excess adult mortality is attributable to

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--> communicable diseases, the main causes of excess adult mortality in the European NIS are cardiovascular disease and injuries. This volume describes in depth these reversals in the health of the NIS populations. Specifically, what are the trends, and what causes them to change? What, if anything, can be done about the adverse trends noted above? Chapters 2 through 6 examine the evidence for declining life expectancy in the NIS to determine the magnitude of the decline and the extent to which it is attributable to statistical rather than substantive issues. These chapters explore the nature of the decline—the extent to which it represents a new and sudden change in health conditions or the continuation of an existing trend, whether it is produced by change in one disease pattern or in several, whether it has affected all age groups or selected subpopulations, and whether it has affected all of the states equally. Chapters 7 through 14 examine possible causes for the large number of excess deaths in the NIS. They focus on three key health behaviors—alcohol consumption, tobacco consumption, and diet—and describe preventive health interventions in these three areas that have proven effective in other industrialized countries. Thus, the volume is organized to present a logical progression from mortality patterns by age, sex, and cause of death, to risk factors, to interventions, rather than an exhaustive treatment of any one topic. This volume brings together the perspectives of several fields of the health and social sciences. Demography, epidemiology, political science, economics, public health, nutrition sciences, and other disciplines all have a contribution to make to our understanding of health changes in populations and to the identification of control measures to mitigate premature mortality. Consolidation of these various perspectives can serve as an important aid to decision makers, who often find it difficult and time-consuming to absorb the main conclusions of scientific research from one discipline, let alone several. Furthermore, cross-disciplinary analysis often identifies new hypotheses, research needs, and information gaps, leading to different findings from those obtained by a single discipline. Understanding mortality profiles in the NIS and what is producing them is important for at least four reasons. First, there is genuine interest in reducing the suffering and losses of those who die prematurely and their families. Second, economic development in the region is probably hindered by the premature loss of working adults. Third, the NIS experience undoubtedly offers lessons that can help other middle-income countries avoid the re-emergence of premature death. And finally, it is to be hoped that information and knowledge will stimulate more research and action from decision makers to address the problems examined in this volume. Contributions of the Volume Assessment of mortality trends in the NIS is much more complex than a straightforward reading of reported death rates. The richness of the papers in the

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--> first part of this volume lies in their effort to disaggregate the mortality problem across the NIS; to apply a diversity of perspectives, methodologies, and measures; and to seek a variety of patterns and comparisons. In the past, information on the demographic and epidemiological dynamics in the NIS has been largely restricted; it was almost completely suppressed between 1975 and 1986. Access to such information increased with the opening up of Soviet society in the mid-1980s. Since that time, however, there has been an increasing awareness of the use of nonstandard definitions, classifications, and methods to estimate demographic parameters in the former Soviet Union. These unusual aspects of mortality data for the NIS have given rise to serious questions about the reliability and validity of the reported levels, trends, and causes of death in the NIS—questions that are addressed in several papers in the volume. In addition to the above complications, the age and sex profiles of mortality in most of the European NIS are quite distinctive. Those profiles, characterized by low to moderate levels of infant and child mortality and relatively high levels of adult mortality, are not common elsewhere in the world. Therefore, they are addressed in several of the chapters. Causes of death underlying the profiles are examined in detail for Russia, where the needed data are available. The profiles of the northern NIS are not well represented in standard models of mortality in use throughout the world, making it difficult to use standard demographic models to assess the quality of mortality data for these countries, as well as to choose a model for estimating the number of years of life lost to premature mortality. Epidemiological analysis of causes of death provides essential information on the characteristics of health status changes. Yet while the analysis of noncommunicable diseases suggests clues about lifestyles, it provides only a partial view of health priorities as it reflects immediate and not underlying or contributing causes. Another limitation of mortality analyses is that they fail to capture the sizable losses of healthy life due to disability. The paucity of information on disability and other nonfatal health losses in the NIS prevented authors in this volume from addressing that aspect of the problem. Underlying the immediate causes of death are proximate determinants or risk factors that need to be analyzed. In general, cause-of-death analysis leads to interventions centered around medical care to reduce the case fatality of diseases or prevent complications of chronic diseases. Analysis of proximate determinants, on the other hand, suggests preventive interventions to reduce the incidence of disease. The second half of this volume is focused on some key proximate determinants of mortality in the NIS. The legacy from the Soviet Union included a widespread medical care system in which there was almost universal coverage, but disease prevention and health promotion, particularly as related to noncommunicable diseases and injury, remained a relatively low priority. The health policy and planning implications of mortality patterns in the NIS have only recently begun to be widely analyzed. There is a particular need for reliable information to guide policy choices within the international health com-

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--> munity during the present transition of the NIS from centrally planned to market economies. An important contribution of the second half of this volume is to draw on the successes of the member countries of the Organization for Economic Cooperation and Development (OECD) in using various preventative measures to control the causes of death that dominate particularly in the European NIS. This volume highlights the problem of premature death among the adult male populations of the European NIS, resulting largely from trends in cardiovascular disease and injuries. The Central Asian NIS economies are at a different stage of the epidemiological transition, with high infant and child mortality and problems common to poor countries. The papers in the second half of the volume are only partially applicable to the concerns of Central Asia, since they do not address the issue of high infant and child mortality. However, problems, measures, and solutions to control infant and child mortality are relatively well known, and we have avoided repeating those well-known lessons here. Readers interested in such measures should refer to the child survival literature (Jamison et al., 1993). Understanding the causes and determinants of adult mortality in the NIS and assessing priorities for their control is extremely valuable for the NIS, but is also important for other parts of the world. Neighbors in Central Europe share many of the problems of adult mortality in the NIS. There is also evidence to suggest that Central Asian countries might soon experience increases in cardiovascular disease and injuries, posing the problems of high adult mortality found in the European countries of the region. Greater worldwide experience in learning how to control influential risk factors and avoid increases in premature mortality might provide valuable lessons for countries not yet at this epidemiological stage of increasing adult mortality. It may be noted that two factors that could partially explain high rates of premature death—the environment and the health care system—had to be excluded from this volume because of time and space limitations. Environmental pollution is a serious problem in the NIS, producing premature deaths mainly through an increase in some cancers, congenital malformations, and respiratory diseases. The conclusions of the volume would be unlikely to change with the availability of good data on the level of premature death that can be attributed to environmental pollution; at the same time, however, such premature death may be significant, particularly in some cities where air pollution and radioactive exposure have been greatest. For example, an estimated 3 percent of the total mortality in the Czech Republic can be attributed to air pollution (World Bank, 1993). Yet claims about cancer and congenital malformation due to environmental pollution in the NIS still need to be extensively evaluated. To illustrate the point, initial work carried out by the U.S. Centers for Disease Control shows a level of mortality due to congenital malformations in Russia, Belarus, and Ukraine similar to that found in Scotland, a country not known for high levels of environmental pollution (R. Hartford, personal communication, 1994).

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--> With regard to the health care system, the deterioration in male adult mortality in the 1970s and early 1980s coincided with a vast expansion and improvement in the health infrastructure of the Soviet Union; the improvements made in the health care system at that time could only ameliorate the existing negative trends. The most recent rise in adult mortality, on the other hand, has coincided with a sharp decline in the quality of medical care and possibly some problems of access to resources (World Bank, 1996). Mortality due to both injuries and cardiovascular disease is sensitive to the availability and quality of emergency care. Cardiovascular disease may also be influenced by declines in the control of high blood pressure. Moreover, a lack of drugs and some other consumables used for diagnosis and treatment, and sometimes energy shortages as well, has resulted in a serious deterioration in the quality of care. However, additional research is required to ascertain the impact of changes in the health care system on mortality trends in the NIS. Context: Places, People, and Transition Both before and since the breakup of the Soviet Union, the region has had significant global economic and political influence. Apart from being a world superpower for decades and one of the two main strongholds of communism, the former Soviet Union occupied a vast share of the earth's habitable land and contained the world's third-largest population, after China and India. Less well recognized were its achievements in improving the standard of living of its population and the equitable distribution of income and resources among socioeconomic groups. Despite its inefficiencies, the Soviet welfare system achieved universal coverage of basic education and health care (World Bank, 1996). Today, the influence of the NIS remains globally significant. From a historical perspective, many of the states that emerged from the Soviet Union in the early 1990s have been independent states before. Nonetheless, we use the generic term ''New Independent States" in this volume because alternative terms exclude some of the countries or reference the past. In Figure 1-1, a map depicts the 15 neighboring states of the NIS that span Europe and Asia. Table 1-1 lists the countries included in the NIS and shows which are encompassed by other terms commonly used to refer to groupings of countries in the region. Table 1-2 shows information on some key demographic, economic, and social indicators for the NIS. The size of Russia, Ukraine, and Kazakstan, together with their older age population structure, makes averages on many of these indicators for the NIS similar to the patterns in Europe generally, obscuring the different health profile of the Central Asian states. As to income, it is difficult to measure the purchasing power of the NIS countries. Available figures on income per capita are typically converted to U.S. currency based on the exchange rate; this approach underestimates the real value of income in these countries,

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--> Figure 1-1 New Independent States and surrounding countries.

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--> where the prices of services and nonimported goods are much lower than in industrialized and other middle-income countries. The Russian population, for example, had an average income per capita in 1990 equivalent to $8,000 U.S. dollars when corrected for local prices, but less than $3,500 when expressed in exchange rate dollars. The income differences both among and within countries are quite significant. Table 1-2 shows an income per capita for Tajikistan of $350 and levels below $1,000 for all the Central Asian republics, whereas the Baltic countries, Ukraine, and Russia all have an income per capita of $1,300 to $2,700. After correction for local prices, the real income differences are maintained, but with levels three to four times higher than those reported in Table 1-2. Table 1-2 also shows health expenditures per capita for the year 1990. Compared with countries of similar income per capita, health expenditures are low in most of the NIS. In the first four years of the present decade, health expenditures declined between 30 and 60 percent in most of the NIS (Klugman and Sheiber, 1996). Despite these two facts, however, the health infrastructure and personnel of the NIS are in excess supply as compared with the OECD countries (World Bank, 1993). Historically, the countries that comprise the NIS have not been considered developing countries. Today, there remains hesitation to classify individual NIS countries as either developed or developing. When comparing mortality rates and other health outcomes, analysts need a reference population. In most of this volume, the authors have chosen to use the mortality profiles of developed countries to assess the levels and trends in the NIS. This approach is useful for at least three reasons: first, decision makers and analysts from the NIS compare their countries with European countries and the United States; second, the economic integration of the vast majority of the NIS will be with OECD countries; and third, the NIS real income per capita and the network of social services are closer to those of the developed than the developing countries. The Central Asian republics, Armenia, and Azerbaijan are to some extent an exception. Although their social service networks cover almost all the population, their income per capita and health indicators are closer to those of some low-middle-income countries. Furthermore, their capacity to respond to the health challenges of the transition is as weak as that of low-middle-income countries. The ethnic composition of the NIS is by no means homogeneous. Many authors in this volume suggest ethnic differences in health behavior as an explanation for differing mortality profiles or trends. The Central Asian countries are composed mainly of Asian ethnic groups (Turks, Kyrgyz, Kazaks, Uzbeks, and others). The large majority of Russians are ethnic Russians, descendants of the Slavs, but numerous ethnic minorities also inhabit the land. The Baltics, Belarus, and Ukraine are all generally inhabited by one majority ethnic group, but also several other European ethnic groups. In Kazakstan and Kyrgyz in 1991, Russians composed 38 and 22 percent of the population, respectively, but since then emigration has significantly reduced these percentages. Ethnicity is to a certain

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--> TABLE 1-1 Geographic Designations for Country Categories Utilized in This Volume   New Independent States (NIS) Commonwealth of Independent States (CIS) Former Socialist Economies (FSE) Country       Former Soviet Union       Russia x x x Estonia x   x Latvia x   x Lithuania x   x Azerbaijan x   x Armenia x   x Georgia x x x Tajikistan x x x Turkmenistan x x x Uzbekistan x x x Kyrgyz x x x Kazakstan x x x Moldova x x x Belarus x x x Ukraine x x x Eastern Europe       Albania     x Bulgaria     x Czechoslovakia     x Hungary     x Poland     x Romania     x Yugoslavia     x a Former Socialist Economies of Europe (FSEE) is a designation by the World Bank (1993), but it is not used in this volume. extent associated with religious beliefs. Asian ethnic groups are largely Muslim; ethnic Russians are largely Russian Orthodox; and the rest, by and large, are mainly Moslem, Protestant, Roman Catholic, or Jewish. All the NIS countries are now passing through a profound transition. Several dimensions of everyday life have changed since the breakup of the Soviet Union, including the political system, social benefits, and income levels, among others. In the 1990s, all the states are experiencing the worst economic crisis recorded in

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-->     NIS Regions   Former Socialist Economies of Europe (FSEE)a Central Asian Baltic Trans-Caucasian Other Europe Russia x       x Estonia x   x     Latvia x   x     Lithuania x   x     Azerbaijan       x   Armenia       x   Georgia       x   Tajikistan   x       Turkmenistan   x       Uzbekistan   x       Kyrgyz   x       Kazakstan   x       Moldova x       x Belarus x       x Ukraine x       x Eastern Europe           Albania x         Bulgaria x         Czechoslovakia x         Hungary x         Poland x         Romania x         Yugoslavia x         peacetime, albeit with differing intensities. Overall income per capita and production (mainly industrial) dropped from 30 to 50 percent in the first five years of this decade. This decline is far larger than that experienced by eastern European countries in the past ten years and by developing countries during the debt crisis of the 1980s. Not surprisingly, expenditures on social services have declined in a way parallel to income, leading to greater health risks that are discussed later in this chapter.

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--> TABLE 1-2 Demographic, Economic, and Social Indicators in the NIS in the 1990s Country Population, 1994 (millions) Population 60 years old and over, 1990 (percent) GNP per capita, 1994 (U.S. dollars) GDP growth rate. 1994 (percent) Armenia 3.7 11 670 3 Azerbaijan 7.5 9 500 -22 Belarus 10.4 18 2,160 -22 Estonia 1.5 — 2,820 6 Georgia 5.4 16 — -28 Kazakstan 16.8 10 1,110 -25 Kyrgyz 4.5 9 610 -27 Latvia 2.5 — 2,290 0 Lithuania 3.7 16 1,350 2 Moldova 4.4 11 870 -22 Russia 148.4 17 2,640 -13 Tajikistan 5.8 6 350 -15 Turkmenistan 4.4 6 — -16 Ukraine 51.9 19 1,570 -24 Uzbekistan 22.4 6 950 -5   Source: World Bank (1993, 1996). Analyzing Premature Death in the NIS Trends and Immediate Causes Life expectancy trends in the NIS have not followed those of other industrialized countries. From the post-World War II period to the mid-1960s, mortality levels in the Soviet Union fell rapidly, approaching levels in the United States and Europe. Death rates in the Soviet Union and in Eastern Europe then stagnated for 15 years or so, with periods of little improvement and even a reversal in life expectancy at birth. Over the decade of the 1980s, life expectancy increased again in the region, only to start reversing again by the end of the decade in many states. This slowdown, especially for males, contrasts with the situation in other industrialized nations, where life expectancy over the last three decades increased by 5 to 7 years (see Figure 1-2). These trends in population survival in the NIS have been described in the literature. The papers of this volume confirm them and provide more detail on the countries and population groups most affected. Variations in life expectancy among national populations in the twentieth century have been a function primarily of variations in child mortality, but most of the reversals of life expectancy in Russia during the past 25 years have been

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--> Country Life expectancy at birth, 1994 (years) Infant mortality rate, 1994 (per 1,000 live births) Male adult death rate, 1990 (per 1,000 population) Health expenditures, 1994 (percent of GDP) Health expenditures per capita, 1990 (U.S. dollars) Armenia 71 5 20 4.2 152 Azerbaijan 69 25 24 4.3 98 Belarus 69 13 27 3.2 157 Estonia 70 15 — — — Georgia 73 18 22 4.5 152 Kazakstan 68 27 29 4.4 154 Kyrgyz 68 29 27 5.0 118 Latvia 68 16 — — — Lithuania 69 14 28 3.6 159 Moldova 68 23 27 3.9 143 Russia 64 19 30 3.0 157 Tajikistan 67 41 19 6.0 100 Turkmenistan 66 46 27 5.0 125 Ukraine 68 14 27 3.3 131 Uzbekistan 70 28 23 5.9 116 due largely to changes in adult mortality (predominantly among males). The chapter by Shkolnikov, Meslé, and Vallin examines trends in cause of death in Russia, which contains approximately half of the population of the NIS, for the period 1970 to 1993. The authors make a particularly noteworthy contribution in their necessary and painstaking reconstruction of cause-of-death categories in use during various time periods in the former Soviet Union to gain consistency and conformity with international standards. For their analysis, they break the time period of interest down into phases of increasing and decreasing mortality, paying particular attention to the important increases since 1987. They find the predominant role of increasing cardiovascular disease among males, and to a lesser extent among females, to be the notable feature of the long-term trends, while they find the predominant role of injury-related deaths to be the main explanatory factor in the shorter-term volatility in mortality levels since the mid-1980s. What has commonly been regarded as an understatement of neoplasm as a cause of death in Russia is reinterpreted by these authors as a late arrival of the cancer epidemic in Russia as compared with other European populations. One of the most notable features of the life expectancy trend in Russia is its strong relationship with injuries and poisoning as causes of death. During the 1970s, a decline in life expectancy corresponded with an increase in deaths from

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--> heart disease mortality are overshadowed by the negative effects with regard to both injuries and cardiovascular disease (Jackson and Klotsky, 1996). As pointed out by Shkolnikov and Nemtsov, the anti-alcohol campaign undertaken by the Gorbachev government in the 1980s revealed the important role of alcohol abuse in cardiovascular and injury mortality in Russia. During the campaign, over the period 1984-1987, life expectancy increased for males by 3.2 years and for females by 1.3 years. This is an impressive gain that has taken at least a decade in other developed countries. The impact was most pronounced in the reduction of mortality due to injuries, poisoning, and some cardiovascular disease among adult males. Changes in mortality due to respiratory and digestive diseases were also noted, but were less sensitive to the effects of the campaign. No major change occurred in rates of death due to neoplasm during the period. The results presented in this volume are consistent with current knowledge on the association between alcohol and mortality. Alcohol abuse is very likely one of the main reasons for the high percentage of people worldwide with arterial hypertension, according to the MONICA studies. Russia has some of the highest proportions of individuals with high blood pressure—40 percent for males and 30 percent for females (Williams and Martin, 1994). Hypertension is a leading cause of ischemic heart disease and hemorrhagic stroke (Poulter and Sever, 1992), the two most common cardiovascular diseases in the NIS. Alcohol consumption has a "J"-shaped relationship with ischemic heart disease; that is, abstainers and heavy drinkers have a greater risk of ischemic heart disease than moderate drinkers. But even in moderate amounts, alcohol consumption has been found to be associated with hemorrhagic stroke. The association has been found with both binge drinking and recent alcohol intoxication; although this finding has been best studied among Finnish young adults, the results have been found elsewhere (Camargo, 1989). Shkolnikov and Nemtsov point out that alcohol is the only risk factor among the three considered in this volume to show a correlation with cardiovascular mortality trends. Furthermore, alcohol and tobacco are the risk factors that differ most between men and women. This volume presents structured arguments suggesting that a large part of the increased mortality in the NIS is probably due to alcohol. The anti-alcohol campaign was motivated largely by productivity losses due to alcohol abuse. Studies based in the United States also reveal that alcohol abuse is generally responsible for large productivity losses to society (Sindelar. 1994). Such losses—including greater absenteeism, reduced on-the-job performance, and increased work-related accidents and injuries—represent by far the largest component of the costs of alcohol abuse. Indirect costs associated with alcohol-related morbidity and mortality are also quite large, relative to the direct costs associated with treatment and support for alcohol abusers. Policy instruments for reducing alcohol-related costs have been evaluated in the United States. It is clear that no one policy dominates others in effectiveness, and that the combined effects of multiple policies have still not eliminated this

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--> TABLE 1-6 Selected U.S. Policies to Control Alcohol Abuse Delineated by Type of Public Policy Taxes and Price Policies    Taxes on wine, beer, and liquor (tax equally on ethanol; tax more on the more socially costly, less on more regressive types of alcohol)    In cases of state monopolies, higher prices on alcohol    Import quotas and tariffs Regulations    Alcohol Control       Minimum drinking age       Restrictions on the number, type, hours, and location of sales premises       Prohibition       Designation of areas as dry    Control of the alcohol-related costs       Drunk driving laws and penalties    Mass media and information on alcohol       Warning labels       Bans on advertising alcohol    Liability for alcohol-related problems       Dram shop laws       Criminalization of drunkenness       Driving-under-the-influence laws    Control of complementary activities       Compulsory seat belt use       Speed limit laws       Minimum driving age       Mandatory driver education Subsidization and Enhancement of Treatment       Mandatory treatment, or option of treatment or incarceration       Subsidized treatment       Professional standards for treatment       Managed care       Triage       Publicly provide care       Training of professionals       Subsidized treatment research   SOURCE: Sindelar (1994). persistent problem. A list of selected U.S. policies by type of intervention is presented in Table 1-6. Prevention policies that have been shown to be effective include drunk driving laws and a minimum drinking age of 21 for reducing drunk driving and related accidents. Higher taxes have been shown to result in lower alcohol consumption in the United States, particularly among the young because of their relatively lower income. However, the applicability of these approaches to the NIS is speculative at this point. Better knowledge on the effectiveness of

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--> various policies will emerge only when the NIS countries start experimenting; small pilot projects will shed light on the complex interaction among policies, sociocultural preferences, commercial interests, and adult behavior. Controlling Tobacco Consumption The chapters by Lopez, Prokhorov, and Pierce address the problem of tobacco consumption. In the Soviet Union in the 1980s, approximately half the adult men smoked, compared with less than 15 percent of the women. By comparison, in the United States in 1987, around 31 percent of men and 26 percent of women smoked. According to Prokhorov and Pierce, survey data indicate that smoking appears to be increasing among adult males in Russia—from 53 percent in 1985 to 67 percent in 1992—and also among adolescents. Lopez points out that in the other NIS countries, rough estimates indicate the highest per adult yearly consumption of cigarettes to be in Armenia, Turkmenistan, Moldova, Georgia, and Ukraine. Prokhorov and Pierce also note that in recent years, transnational tobacco companies have expanded their role in the NIS. At the same time, tobacco promotion and advertising have increased, a development Prokhorov suggests is particularly noticeable in promotions and is directed to youth. Pierce documents the powerful impact of advertising on the smoking habits of the American public over time, with specific targeting measures quickly showing up in smoking prevalence among the targeted groups. He notes that susceptibility to advertising is a strong determinant of starting behavior. His observations echo the perception of Prokhorov regarding the acute susceptibility of the NIS market, which has not previously been exposed to these powerful marketing tools, combined with the tendency in the NIS to imitate the poor health habits of the West. Applying a new methodology (Peto et al., 1994) that examines impact across a range of causes of death, Lopez presents calculations of smoking-attributable mortality that suggest smoking claims many lives through lung cancer, but claims up to two to three times more lives from other diseases, such as coronary heart disease and stroke. According to the estimates presented, in one group of NIS countries—Armenia, Belarus, Estonia, Kazakstan, Latvia, Lithuania, the Russian Federation, and Ukraine—about 25 to 30 percent of all male deaths are currently due to smoking, and roughly 40 percent of deaths among men of middle age. The remaining countries can be considered as being at an intermediate or earlier stage of their tobacco epidemics, with proportionate mortality of 6 to 20 percent attributable to smoking. According to Pierce, regulations that control smoking among confirmed smokers have been shown to be effective in the United States and other developed countries. Quitting smoking is a time-dependent process, with success increasing with repeated attempts. Public control of tobacco use decreases levels

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--> of addiction among smokers, thereby contributing to greater chances for success in quitting. Prokhorov points out that the countries of the former Soviet Union have a disappointing history of tobacco control programs, which have been poorly planned and implemented, short-lived, and ineffective. Involvement of health care providers in tobacco control activities is a common first step in other countries that have succeeded in controlling the tobacco epidemic. However, smoking prevalence among health care providers in the NIS, especially among males, is very high, partly as a result of high tolerance for smoking in those countries. Although medical professionals are often seen as a major influence in tobacco control programs, further research is needed to determine whether medical professionals in the NIS are appropriately positioned to assume that role. The beginnings of a tobacco control movement in the NIS are evident. Prokhorov reports priorities formulated by NIS experts during the recent Ninth World Conference on Tobacco and Health. These include reducing smoking prevalence among health professionals and involving them in tobacco control activities, developing cost-effective interventions for different populations, introducing controls regulating the toxicity of tobacco products, and promoting the establishment and development of voluntary organizations for tobacco control. Pierce notes that bans on tobacco advertising have been considered in Russia, but enthusiasm for this approach may be expected to wane with the entry of the transnational tobacco companies into the market. Support for tobacco control is needed among both health professionals and the general public. Evidence suggests the need to build awareness of the link between smoking and health based on local evidence, in order to produce a galvanizing effect similar to that of the 1963 Surgeon General's report in the United States. Based on the experience of other countries, pricing strategies may also be a key component of tobacco control, consisting of small increases at regular intervals to avoid the emergence of a black market. Improving Diet Diet is one of the major determinants of cardiovascular disease. Diets high in polyunsaturated fat, total fat, and salt are strongly associated with cerebrovascular disease and ischemic heart disease, two of the most important causes of premature death in the NIS. The chapter by Popkin et al. documents a dramatic transformation in diet in the Soviet Union that occurred over the period 19601989: per capita consumption of cereals and breads declined greatly, and consumption of red meat, sugar, and dairy products increased. These changes appear to have been largely supply driven. At present, problems of a high-fat diet and obesity are common among adults in Russia and even in Kyrgyz, which is one of the poorest countries of the NIS, while chronic energy deficiency does not appear to be a major adult health problem. Although dietary changes occurred in Russia

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--> between 1992 and 1993, the Russian population continues to consume a moderately high-protein and high-fat diet. The chapter by Pearson and Patel draws on the international research literature to demonstrate that consumption of fat, especially from animal sources, can be markedly altered on a nationwide basis, and that population-wide dietary change is linked specifically with declines in cardiovascular disease. The chapter by Puska documents a comprehensive program in neighboring Finland to bring about population-wide dietary change. Although many population-based programs have been described in the literature, the Finnish program is particularly relevant to the NIS because of the common characteristics shared by the North Karelian people and Estonians and other NIS populations: binge drinking, high alcohol consumption per capita, high intake of animal fat, and similar genetic makeup. In the early 1970s, Finland was faced with serious noncommunicable disease epidemics, a situation comparable to that of Russia and other northern NIS countries today. Finnish men had extremely high rates of coronary heart disease. High rates of cancer also existed, and there was high mortality from all causes of death. A national preventive demonstration program, the North Karelia project, was instituted to decrease mortality and morbidity rates from cardiovascular and other chronic diseases, particularly among middle-aged males, and to promote general health among the population. Important risk factors included smoking, high serum cholesterol, and high blood pressure levels, the latter two likely related to a diet high in saturated fats. The project targeted changes in lifestyle behavior and its determinants. It was integrated into the existing health service structure, and broad community participation was key. Overall costs associated with the project have been modest. Careful evaluation studies have been carried out. In 20 years, the project has been associated with a marked reduction in target risk factors, and with a more than 50 percent reduction in cardiovascular disease mortality rates among the middle-aged population and a decrease in overall mortality of about 40 percent. Health researchers and personnel from Finland are now actively involved in collaboration with groups in Estonia and the Republic of Karelia, Russia, to plan and implement health intervention activities applying the lessons of the Finnish project. According to the chapter by Pearson and Patel, lessons learned from dietary change programs in the United States may also be useful to the NIS. Several institutions are generally involved in such change, using a variety of strategies. Governmental policy clearly plays a role in the establishment of nutritional goals for the population. For example, in market economies, production of food by the agricultural sector and by food manufacturers has been dictated largely by profitability and consumer demand, unless manipulated by subsidies or production quotas. Thus Pearson and Patel suggest that creation of demand for low-fat foods may be an important role for governmental, voluntary, and health-related organizations.

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--> Pearson and Patel note that numerous studies have examined the health benefits and cost savings of a variety of health promotion/disease prevention interventions at works sites and schools, reporting generally positive results. Evaluations of community intervention programs have examined the ability of mass media to influence population-wide eating behaviors, with results showing reductions in targeted risk factors. However, not all of the media involved need be national in scope. Rather, smaller-scale activities, such as production of pamphlets and brochures by local organizations, have an advantage in that they tailor the message to the local population and are generally less expensive than broader-scale efforts. It is important to note that endorsement of the health professional community is essential in supporting any national or local campaigns to change nutritional behavior. Multiple Risk Factors Measuring the number of deaths attributable to risk factors for noncommunicable diseases and injuries is an essential step toward the design of feasible and effective control policies. But serious methodological and measurement problems lead to imperfect results with most estimates of attributable mortality due to alcohol, tobacco, and diet, except for estimates based on longitudinal studies. The lag time between exposure to a risk factor and the development of a cardiovascular disease is between 10 and 15 years; most of the concurrent analyses of risk factors and cardiovascular mortality are thus rough approximations of the real relationship. For example, in the case of lung cancer, today's exposure to tobacco will be related to deaths in 2015-2020. Another problem is that the attributable mortality due to a specific risk factor is often influenced by the prevalence of other risk factors. Measuring the attributable mortality for a single risk factor thus often leads to overestimates of its influence. Moreover, the risk associated with a specific factor may not be the same in all countries, particularly when that risk is affected by individual behaviors. This is the case with the relationship between alcohol consumption and mortality due to homicides and traffic accidents. Table 1-7 presents estimates of the prevalence of multiple risk factors for a selected group of NIS countries (Nienssen et al., 1994). The prevalence of cigarette smoking, high blood pressure, high cholesterol, and obesity is presented for Kazakstan, Russia, and Lithuania, and compared with that in Poland, The Netherlands and all the Formerly Socialist Economies (see Table 1-1). Men in Lithuania and Russia show a higher prevalence of smoking, blood pressure, and high cholesterol than those in The Netherlands. Women in the three NIS countries show a higher prevalence of all the risk factors, except smoking, than women in The Netherlands. Nienssen et al. also estimate attributable mortality, adapting a model developed for The Netherlands. Despite the absence of alcohol abuse in that model, the results show that 30-36 percent of the adult mortality among men

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--> TABLE 1-7 Prevalence of Health Determinants in Three NIS Countries, Poland, The Netherlands, and the Former Socialist Economies (FSE) By Sex (0.5-rounded percentages)   Current Smoker High Blood Pressure High Cholestrol Obesity Men Kazakstan 59.0 16.0 13.5 NA Russia 49.5 26.0 20.0 12.5 Lithuania 41.5 20.0 32.5 22.5 Poland 60.0 30.5 18.5 20.2 Netherlands 40.0 18.0 16.0 13.0 FSE 53.0 26.0 13.0 14.5 Women Kazakstan 1.0 16.0 13.5 NA Russia 11.0 24.0 13.0 38.0 Lithuania 4.5 21.5 32.5 48.1 Poland 28.0 25.5 18.5 31.0 Netherlands 27.0 9.0 13.0 16.0 FSE 11.5 24.0 14.5 38.0   SOURCE: Niessen et al. (1994). in the three NIS countries studied can be attributed to smoking, high blood pressure, high cholesterol, and obesity, the largest effect being that of smoking on cardiovascular disease. For women, the mortality that can be attributed to these factors is 14 percent for Kazakstan, 22 percent for Lithuania, and 27 percent for Russia. These estimates are useful for identifying the main risk factors and their order of magnitude. However, to design and implement disease control programs, more accurate information is needed, an issue to which we now turn. Research and Information Needs Problems of missing and poor-quality data for assessing mortality trends and causes of death in the NIS are noted throughout this volume. In the Central Asian countries, measurement of basic levels of mortality leaves much to be desired, little is known about death rate trends, and baseline information is lacking. There is also a great need for reliable information on infant and child mortality levels in these states. Either rapid assessment techniques for measuring infant mortality or use of standard demographic methodology to measure infant and child mortality indirectly in future health surveys and censuses would serve to address the deficiencies in reported levels of mortality

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--> from the vital registration system and aid the assessment of trends in the future. At the same time, improvement of the vital registration system is essential in the medium term. The impact of chronic diseases and injuries on mortality among the total NIS population is evident from data already available in the NIS. Information on associated risk factors in the NIS is limited, and population surveys on chronic disease risk factors, health behaviors, and related determinants are needed in many of the NIS countries. Broader social and economic institutional factors may account for a substantial portion of the changes in health outcomes in the NIS. Little is known about the extent to which those changes are due to the general economic crisis, inflation, unemployment, and declining social support, in addition to deterioration in health programs, medical services, and public sanitation. These factors affect both the design of intervention strategies and estimation of the likely payoff of interventions, and thus need further exploration. Health care priorities based on the burden of premature death need to be complemented by information on the effectiveness of public health and clinical interventions (Tengs, 1994). Health expenditures, particularly those made with public funds, ideally should be based on cost-effectiveness, feasibility of alternative programs, and population preferences in relation to health benefits. Information on the effectiveness and cost of public health interventions to control alcohol abuse, hypertension, tobacco consumption, excess animal fat consumption, and obesity needs to be collected and analyzed. The influential role of injuries in losses to society, not only in Russia, but in both the northern and southern NIS, is noted in several chapters in this volume. Data used to support the analyses presented here take account only of losses due to mortality; losses from disability have not been estimated, yet these losses are sometimes thought to be double costs—in both productivity loss and increased costs of societal support for a disabled population. There is a great need for epidemiological studies on injuries to provide initial direction for appropriate control measures. Various types of data collection that have proven useful in the development of injury prevention and control strategies have been suggested by Graitcer (1994). These include accurate national vital records and traffic databases, population-based surveillance systems to collect information on the impact of nonfatal injuries, risk factor surveys on population behavior and injury experiences, and cohort and case-control surveys to learn more about specific injury causes and risk groups. Such studies should be large and specific enough to provide direction in developing injury prevention and control measures that would be tested in small-scale projects and conducted on an ongoing basis so their effectiveness could be evaluated. Evidence from international experience reported here suggests that education and communication can be effective tools in improving diet and controlling alcohol and tobacco use, albeit with some mixed results, and that for control of

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--> risk factors, raising awareness is an essential first step. Health professionals play a pivotal role in the implementation of behavior modification in other countries. Further assessment of their potential role in the future control of chronic disease in the NIS is needed, though qualified by information on health behaviors and levels of influence of the medical professional community in these settings. Planning of health interventions must incorporate knowledge of social and cultural norms, governmental practices, the local economic situation, and the local political will, although experience from other countries can be used to formulate a set of possibilities. Obstacles to positive health change include economic and political problems, but also population attitudes. Further exploration of the potential for change is an open area of research, with one possibility being the use of pilot projects. The experience of the North Karelia project in Finland indicates that a pilot demonstration program can be a strong tool for fostering national chronic disease prevention and health promotion. Such a program provides development and testing of approaches, offers demonstration and training for national purposes, draws the attention of the media, attracts politicians, and provides a visible practical reference for what can be done. It is a useful approach under situations of scarce resources and multiple problems, and may be applicable to the needs of the NIS. Finally, it is to be noted that mortality measures significantly underestimate the burden of ill health on a population, as they do not accurately reflect morbidity conditions or losses suffered through disability. For a thorough assessment of the impact of poor health the NIS, research on the impact of chronic disease and injuries on disability in the NIS is needed to inform health priorities and assist in identifying appropriate control measures. References Camargo, C.A. 1989 Moderate alcohol consumption and stroke: The epidemiologic evidence. Stroke 20(12):1611-1626. Coale, A.J., and P. Demeny 1966 Regional Model Life Tables and Stable Populations. Princeton, NJ: Princeton University Press. Coale, A.J., P. Demeny, and B. Vaughan 1983 Regional Model Life Tables and Stable Populations, second ed. New York: Academic Press. Cook, P 1990 The social costs of drinking. In The Negative Social Consequences of Alcohol Use. Oslo: Norwegian Ministry of Health and Social Affairs. Frenk. J., J.L. Bobadilla, J. Sepulveda, and M. Lopez Cervantes 1989 Health transition in middle income countries: New challenges for health care. Health Policy and Planning 4(1):29-39.

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--> Gavaler, J.S., and A.M. Arria 1994 Increased susceptibility of women to alcoholic liver disease: Artifactual or real? Pp. 122-133 in P.M. Hall, ed., Alcoholic Liver Disease, Pathology and Pathogenesis, second ed. London: Edward Arnold. Graitcer, P. L 1994 Injury Prevention and Control in the NIS: What Do We Need and What Would Work? Paper presented at the Workshop on Adult Health Priorities and Policies in the New Independent States. November 17-18. National Research Council. Washington, D.C. Jackson, R., and A. Klatsky 1996 Paper presented at the 1996 Joint Scientific Meeting of the Research Society on Alcoholism and the International Society for Biomedical Research on Alcoholism. June 22-27. Washington, D.C. Jamison, D.T., W.H. Mosley, A.R. Measham, and J.L. Bobadilla, eds. 1993 Disease Control Priorities in Developing Countries. New York: Oxford University Press. Klugman J., and G. Sheiber 1996 A Survey of Health Reform in Central Asia. A World Bank background paper prepared for the World Bank/Economic Development Institute Senior Policy Seminar. Ashgabad, Turkmenistan. Komarov Y.P., S.P. Ermakov, and V.G. Semyonova 1994 Loss of Working Potential in the New Independent States. Paper presented at the Workshop on Mortality and Disability in the New Independent States, September 8-9. National Research Council, Washington, D.C. 1996 Loss of Working Potential in the New Independent States. Unpublished revisions to paper presented at the Workshop on Mortality and Disability in the New Independent States . September 8-9. National Research Council, Washington, D.C. Niessen. Louis W., Pieter G.N. Kramers, and Rudolph Hoogenveen 1994 Proximate Determinants in the New Independent States: Attributable mortality Based on an Integrated Approach followed for The Netherlands. Paper presented at the Workshop on Adult Health Priorities and Policies in the New Independent States. November 17-18. National Research Council, Washington, D.C. Peto, R., A.D. Lopez, J. Boreham, M. Thun, and C. Heath, Jr. 1994 Mortality from Smoking in Developed Countries 1950-2000. Oxford: Oxford University Press. Poulter, N.R., and P.S. Sever 1992 Interventions in high risk groups: Blood pressure. Pp. 325-342 in M. Marmot and P. Elliot. eds., Coronary Health Disease Epidemiology: From Aetiology to Public Health. Oxford: Oxford University Press. Sindelar, J.L. 1994 Alcohol-related Policies in the United States and Their Applicability to the New Independent States. Paper presented at the Workshop on Adult Health Priorities and Policies in the New Independent States. November 17-18. National Research Council, Washington, D.C. Tengs T. 1994 The Cost-Effectiveness of Strategies to Prevent Premature Death in the Former USSR: Is United States Data Relevant? Paper presented at the Workshop on Adult Health Priorities and Policies in New Independent States. November 17-18. National Research Council, Washington, D.C. Tulchinsky, T.H., and E.A. Varavikova 1996 Addressing the epidemiological transition in the former Soviet Union: Strategies for health system and public health reform in Russia. American Journal of Public Health 86(3):313-320.

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--> Williams, O.D., and I. Martin 1994 Mortality and Other Outcomes, Risk Factors, and Links with Death Registration Data in NIS Epidemiological Study Sites. Paper presented at the Workshop on Mortality and Disability in the New Independent States. September 8-9. National Research Council, Washington, D.C. World Bank 1993 World Development Report 1993: Investing in Health. New York: Oxford University Press. 1996 World Development Report 1996: From Plan to Market. New York: Oxford University Press. World Health Organization 1965 International Statistical Classification of Diseases and Related Health Problems. IXth Revision. Geneva. 1994 Health in Europe: The 1993/1994 Health for All Monitoring Report. Who regional publications, European series, no. 56. Copenhagen: World Health Organization.