Why has Russian health collapsed?

The health care collapse in the former Soviet Union is old news, less well known is the contrast between Russia and Poland:

…another Slavic nation with a traditional affection for vodka — Poland — is experiencing one of the greatest improvements in health ever known. The difference tells a story of how democracy has transformed the center of Europe in the past 15 years — and how it has failed in Russia.

Start with the figures. In the early 1980s life expectancies in Soviet Russia and Communist Poland were roughly similar, and both were starting to get worse. Cancer and cardiovascular disease were beginning a rapid rise, in lock step with their prime causes: smoking and alcoholism.

Two decades later, Poland’s life expectancy for men, at 70, has risen by four years since the collapse of communism and now is more than 10 years longer than that of Russian men. In Poland, cardiovascular disease has fallen by 20 percent in a decade, while in Russia, it has risen by 25 percent. Sudden deaths from accidents and other external causes have fallen 19 percent in Poland, while in Russia the rate has soared to an unprecedented level. Poland’s rate of HIV infection is one of the lowest in Europe; Russia has one of the world’s highest rates of new infection.

Polish researcher Witold Zatonski has an explanation for this difference:

…he has boiled his answer down to a simple slogan: “Democracy is healthier.” “It’s the only way to explain what has happened,” he said during a recent visit to Washington. “It turns out that the free-market economy and a free political debate correlate directly with good health in Eastern and Central Europe.”

I was incredulous when I first read this, apparently I was not the only one:

That conclusion used to be doubted by some of Zatonski’s colleagues, both in Poland and in the West. After all, democracy brought Poland freedom for cigarette and alcohol advertising, Western brands, and a parliament presumably susceptible to special interests. Tobacco companies spent $100 million a year on marketing to Poles in the 1990s.

Remarkably, though, all that money and influence have been outweighed by the other products of a free society, especially independent civic organizations and media that promote knowledge and open debate about health issues.

It is well known from happiness surveys (see the work of Bruno Frey) that people are happier in democracies, so maybe there is a link to health as well, even after adjusting for income.

What about the comparative statics?

In addition to Poland, the Czech Republic, Hungary and other newly democratic states have recorded dramatic gains in health. But Ukraine and Belarus, which have followed Russia’s political course of far more restricted freedom, have seen their health measures decline. The Baltic states of Latvia, Lithuania and Estonia, which were once republics of the Soviet Union, at first shared Russia’s downward spiral; but since 1995, as they have built Western-style democracy, they have reversed the trend and now follow Poland’s path.

Here is a comprehensive paper with data and cross-country comparisons. From this excellent piece I learned the following:

1. Health in Belarus has continued to decline. Since Belarus has stayed largely communist, the country may serve as a possible control for where Soviet health was headed before communism fell.

2. In Russia, many of the biggest negative health changes have come for the 18-34 group, not for the elderly.

3. In the CIS countries, injuries and violence account for a quarter of all deaths about men aged 25-64; this is six times higher than the death rate from Western Europe.

4. Homicide and suicide rates in CIS countries exceed those for the West by about 20 times.

5. In Russia, deaths from all external causes correlate closely with deaths from alcohol poisoning.

6. Men of low educational background have been to most vulnerable to bad health.

7. Russian life expectancy has declined but it actually improved during the 1994-8 period and has moved with economic crises.

Here is some additional information on mortality trends in Eastern Europe, here is another related link. Zatonski has a longer essay, which I do not currently have access to.

The bottom line: Here is what I used to think: “I blamed the Russian health collapse on the loss of relative status for the elderly. While market reforms have increased aggregate wealth, this has been mostly for the young. Older people have lost their grip on power, and suffered psychologically through their loss of international relative status as well. They lost the will to live and died early.”

Here is what I now think: “Russian young and middle-aged men have found few useful institutional supports during the transition. They’ve gone crazy with drinking and violence.” That being said, I don’t think we have sorted out the relative importance of economic and political factors.