Russia is different…

Martin McKeeLondon School of Hygiene and Tropical

Medicine &

European Observatory on Health Systems and Policies

Dubai, January 2006

The challenge…

“I cannot forecast to you the action of Russia.  It is a riddle, wrapped in a mystery, inside an enigma “

Winston Churchill

Death of a nation

50

55

60

65

70

75

1970 1980 1990 2000

male

female

years

Life expectancy at birth

Percentage variation in myocardial infarction explained by nine risk factors

0 20 40 60 80 100

Central and eastern Europe

South America

Australia and New Zealand

South Asia

China

Overall

Western Europe

Southeast Asia and Japan

Middle East

Africa

North America

Source: INTERHEART

… and this is among survivors: In former Soviet Union, twice as many cardiac deaths are sudden

Ischaemic heart disease over time

11.5

12

12.5

13

13.5

14

14.5

15

15.5

We

d

Th

urs Fri

Sa

t

Su

n

Mo

n

Tu

es

% o

f to

tal

we

ek

ly d

ea

ths

0

100

200

300

400

500

600

700

1980 1985 1990 1995 2000 2005

male

female

Age standardised death ratesper 100,000

Deaths among men aged 35-45 from IHD

Could alcohol play a role?Trends in life expectancy at birth

Source: WHO

anti-alcoholcampaign begins

rise in illegal production

collapse

of USSR

Life expectancy at birth (years)

female

male

55

60

65

70

75

1970 1980 1990 2000

Variation in the life expectancy decrease for men across regions of European Russia

Walberg, McKee et al., 1998

7

0

10

20

30

40

50

60

70

80

0 5 10 15 20

% fall in male life expectancy

sum

of h

iring

s an

d re

dund

anci

es/1

,000

em

ploy

ees

Association between labour turnover in 1993/4 and fall in life expectancy 1990-94

Contribution of deaths from different causes and at different ages to differences in life expectancy in

best and worst regions

-1

0

1

1

2

2

3

3

0 1-14 15-34 35-64 65+

Other Alcohol relatedInjuriesRespiratory diseasesInfectious diseasesOther NeoplasmsResp. cancerCerebro vascularCardio vascular

Years o

f life lo

st/ gain

ed

Age group

And what about health care?

Death rate from avoidable mortality in UK and Russia similar in 1965, when little could be done

Gap began to widen in 1970s, and has continued to do so since 0

100

200

300

400

500

600

700

1965 1975 1985 1995

Year

deat

hs/1

00,0

00

Russia

UK

The Soviet health system A great success, at

first But funded

according to the “residual” principle – what was left after everything else

It just failed to adapt to modern health care“If communism does not destroy the louse, the louse will destroy communism”

Lenin

Chronic disease: the critical challenge

0

5

10

15

20

25

30

1980 1985 1990 1995 2000

ArmeniaAzerbaijanBelarusGeorgiaKazakhstanKyrgyzstanRepublic of MoldovaRussian FederationTajikistanTurkmenistanUkraineUzbekistan

Age standardised death rate, Diabetes mellitus, per 100,000

Patients speak: interviews with patients living with diabetes in Kyrgyzstan “It was fine in the old times but now it is worse, …” “What is the point of going to the health centre if nothing is

available, no equipment…. I always go to the city endocrinology dispensary for blood and urine tests even it is more difficult and expensive for me.”

“Our health centre is mainly closed and I never know when it is open.”

“I live far away from the city in a small village where the health centre doesn’t have insulin. I am worried that I won’t get insulin for a few days or even a week because we don’t have a car to go to the rayon (district) health centre and we need to wait until someone in the village goes there.”

Hopkinson, Balabanova, McKee & Kutzin, 2004

The Izhevsk Family Study

Vologda region

Arkhangelsk region

Nenets autonomous district

Republic of Komi

Kirov regionKomi-Permyatzky autonomous district

Perm region

Tver region

Yaroslavl region

Ivanovo region

Nizhny Novgorod region

Kostroma regionVladimir region

Republic of Mariy ElChuvash republic

Tula regionOryol region

Rostov regionVolgograd regionSaratov region

Penza regionTambov region

Lipetzk regionRyazan region

Republic of Mordovia

Ulyanovsk region

Samara region

Republic of TatarstanUdmurt republic

Chelyabinsk regionKurgan region

Sverdlovsk region

Yamalo-Nenetz autonomous district

Khanty-Mansi autonomous district

Tyumen region

Tomsk region

Republic of Khakasia

Kemerov region

Krasnoyarsk region

Evenki autonomous district

Taimyr (Dolgano-Nenetz) autonomous district

Irkutsk region

Ust-Ordynsky Buryat autonomous district

Chita region

Khabarovsk territory

Russian FederationRussian Federation

MoscowMoscow UdmurtiaUdmurtia

Izhevsk = 0.65 millionIzhevsk = 0.65 million Udmurtia = 1.6 millionUdmurtia = 1.6 millionRussia = 143 millionRussia = 143 million

Investigators:London:Dave LeonMartin McKeeSusannah TomkinsIzhevskNikolai KiryanovLyudmilla SubarovaRostockVladimir ShkolnikovEvgeniy Andreev

The Izhevsk Family Study Case control study 1700 cases (men dying between ages 25 and 54)

and 1700 controls Information obtained on cases from proxy

informants (family members) Information on controls from the controls

themselves and from proxies Supplemented with detailed information from

police, narcology service, social services, and autopsy data

Important questions without answers What proportion of all deaths are caused by

alcohol abuse ? How big is the problem of deaths due to toxic

impurities ? Whether deaths from causes not obviously

related to alcohol are in fact due to alcohol abuse?

How big is the problem of problem drinking in the population ?

How strongly is it related to social and economic characteristics ?

Drinking in Russia What is being drunk?

Vodka Surrogate spirits Alcohol containing medicines Samogon (moonshine)

8% of healthy controls drink substances not intended for drinking!

How is it drunk Heavy episodic consumption Zapoi – a Russian word meaning

getting so drunk that you withdraw from social interaction for several days

12% of controls report zapoi

Vodka: a selection

Samogon

Surrogate spirits

Alcohol containing medicines

How much ethanol?

0

10

20

30

40

50

60

70

80

90

100

Vodka

1

Vodka

2

Vodka

3

Vodka

4

Vodka

5

Vodka

6

Vodka

7

Vodka

8

Vodka

9

Surro

gate

1

Surro

gate

2

Surro

gate

3

Surro

gate

4

Med

icine

1

Med

icine

2

Med

icine

3

Med

icine

4

Med

icine

5

alco

hol c

once

ntra

tion

v/v%

Correlates of alcohol abuse (in live controls)

0

5

10

15

20

25

30

35

Ever drinksurrogates

Zapoi

%

Employed

Unemployed

0

2

4

6

8

10

12

14

16

Ever drinksurrogates

Zapoi

%

Higher

Specialised/ professional

Secondary

All case mortality according to frequency of surrogate drinking (relative to never surrogates)

M

orta

lity

odds

rat

io

40.0 20.0 10.0 5.0 2.5 1.25

OR1 Adjusted for age OR2 Adjusted for age and smoking OR3 Adjusted for age and education OR4 Adjusted for age, smoking and education

Frequency of surrogate drinking

OR

1O

R2

OR

3O

R4

Every day 5-6 times perweek

3-4 times perweek

1-2 times perweek

1-3 times permonth

A few times ayear

…and by cause (adjusted for smoking and education)

1 10 100

1-3 times per month or less

1-2 times per w eek

3-4 times per w eek

5-6 times per w eek

Daily

odds ratio (relative to never/ almost never drinking surrogates)

Alcohol-related causes Other causes All causes

Some more detail

1

10

100

1000

Cance

r 

Trans

port

injur

ies

Cereb

rova

scular

dise

ase

Isch

emic

hear

t dise

ase

Suicid

e

Homici

de

Exter

nal c

ause

s

Infe

ctio

us d

isease

Drownin

g

Exces

sive n

atur

al co

ld

Respir

ator

y dise

ase 

Acute

alco

hol po

isoning

Alcoholi

c car

diomyo

path

y

Alcoholi

c live

r cirr

hosis

Men

tal d

isord

ers

Odd

s ra

tio

Surrogates or ordinary drinking?All cause mortality

0

0.5

1

1.5

2

Daily or almostdaily

1-4 time per week1-3 times amonth or less

Never or almostnever

Adj surrogate drinking Adj age

Beer

00.511.522.533.544.55

Daily or almostdaily

1-4 time per week1-3 times amonth or less

Never or almostnever

Adj surrogate drinking Adj age

Wine

00.511.522.533.544.55

Daily or almostdaily

1-4 time per week1-3 times amonth or less

Never or almostnever

Adj surrogate drinking Adj age

Spirits

0

5

10

15

20

Daily or almostdaily

1-4 time perweek

1-3 times amonth or less

Never or almostnever

Adj frequent drinking beer/wine/spirits Adj age

Surrogates

Of course it is absolute rather than relative risk we are concerned with: The scale of the problem in

men of working age (25-54 years) 18% of deaths are due to causes that are certified

by a doctor as being directly caused by alcohol (e.g. alcoholic cirrhosis and alcohol poisoning)

A minimum of 20% of deaths from all other causes attributable to alcohol abuse (e.g. surrogates and/or zapoi)

Total burden = 18% + 20% = 38% of all deaths due to alcohol abuse (does not include effect of “normal” drinking)

Do these findings help us to understand what happened in Russia in early 1990s? Life expectancy

dropped markedly But not all causes of

death affected to same extent

Almost no change in cancer, but large changes in some other causes

0 1 2 3 4 5 6 7 8

cancers

other respiratory

circulatory diseases

infectious diseases

all causes

injuries & violence

alcohol related

pneumonia

Ratio of death rates in 1994 to those in 1987: men aged 40-44

Cause-specific mortality odds ratios for surrogate vs non-surrogate drinkers in the Izhevsk Family Study compared with relative changes in age-standardised mortality rates among men aged 25-54 in Russia 1994/1991

Mental disorders

0

1

2

3

4

5

6

0 5 10 15 20 25 30 35 40

1994

/199

1

Pearson r = 0.93

0

1

2

3

4

5

6

0 5 10 15 20 25 30 35 40Mortality ORs for surrogate drinking

Rat

io a

ge-s

tnda

rdis

ed R

ussi

an m

orta

lity

rat

es

Pearson r = 0.93

A mechanism?

Social and economic factors

(pace of transition)

Death

(un) conventionalrisk factors

stress

Healthcare

Back to alcohol: the cirrhosis belt

Age standardised death rate chronic liver disease & cirrhosis, age 0-64/100,000

1996

<70<56<42<28<14No data

Min: 00

10

20

30

40

50

60

70

80

1980 1985 1990 1995 2000

Hungary

Romania

EU average

Source: WHO

What else is being drunk elsewhere? Cane spirit (Latin America/ Africa)

Fruit brandies (eastern Europe)

1: internal standard2: methanol3: ethanol4: 2-butanol5: 1-propanol6: isobutanol7: 1-butanol8: isoamyl alcohol

1

3

1

2

3

4

5

6 7 8

A

B

MoonshineHoochArrackWhat else?Nascimento, Cardoso, Neto, Franco & Farias, 1998

Szűcs, Sárváry, McKee, Ádány, 2005

A night out in Tallinn…

0 20 40 60 80 100

MedicineMedicineMedicineMedicine

AftershaveAftershaveAftershaveAftershaveAftershaveAftershaveAftershaveAftershaveSamogonSamogonSamogonSamogonSamogonSamogonSamogonSamogonSamogon

Fire lighting fuelFire lighting fuel

alcohol v/v%

What is going on? In Russian cities, a significant number of people

drink surrogate alcohols Probably different in rural areas, where the

equivalent is samogon (home produced) Surrogates twice as strong and 1/3 the price – i.e.

six times cheaper for a given volume of alcohol Observed effects may be that once someone

crosses threshold to regular surrogate consumption, price barrier essentially disappears

However, where home produced spirits drunk, possibility of additional toxic organ damage

Implications for PURE? Russia is different, but maybe not so

different Even in the exceptions, identifiable

biological risk factors are likely to be very important

Look beyond beer, wine and spirits Don’t forget the impact of health care