Russia is different

1
Russia is different

• Martin McKee
• London School of Hygiene and Tropical Medicine
• European Observatory on Health Systems and
  Policies
• Dubai, January 2006

2
The challenge

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

3
Death of a nation
Life expectancy at birth
4
Percentage variation in myocardial infarction
explained by nine risk factors
and this is among survivors In former Soviet
Union, twice as many cardiac deaths are sudden
Source INTERHEART
5
Ischaemic heart disease over time
Deaths among men aged 35-45 from IHD
Age standardised death rates per 100,000
6
Could alcohol play a role? Trends in life
expectancy at birth
75
female
anti-alcohol
70
campaign begins
Life expectancy at birth (years)
male
65
60
55
1970
1980
1990
2000
Source WHO
7
Variation in the life expectancy decrease for men
across regions of European Russia
Walberg, McKee et al., 1998
7
8
Association between labour turnover in 1993/4 and
fall in life expectancy 1990-94
9
Contribution of deaths from different causes and
at different ages to differences in life
expectancy in best and worst regions
Other
Alcohol related
Years of life lost/ gained
Injuries
Respiratory diseases
Infectious diseases
Other Neoplasms
Resp. cancer
Cerebro vascular
Cardio vascular
Age group
10
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

11
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
12
Chronic disease the critical challenge
Age standardised death rate, Diabetes mellitus,
per 100,000
Armenia
Azerbaijan
Belarus
Georgia
Kazakhstan
Kyrgyzstan
Republic of Moldova
Russian Federation
Tajikistan
Turkmenistan
Ukraine
Uzbekistan
13
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 doesnt have insulin. I
  am worried that I wont get insulin for a few
  days or even a week because we dont 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

14
The Izhevsk Family Study
Udmurtia
Investigators London Dave Leon Martin
McKee Susannah Tomkins Izhevsk Nikolai
Kiryanov Lyudmilla Subarova Rostock Vladimir
Shkolnikov Evgeniy Andreev
Moscow

Izhevsk 0.65 million Udmurtia 1.6
million Russia 143 million
15
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

16
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 ?

17
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

18
Vodka a selection
19
Samogon
20
Surrogate spirits
21
Alcohol containing medicines
22
How much ethanol?
23
Correlates of alcohol abuse (in live controls)
24
All case mortality according to frequency of
surrogate drinking (relative to never surrogates)






40.0
OR1 Adjusted for age



OR2 Adjusted for age and smoking


OR3 Adjusted for age and education



OR1
OR4 Adjusted for age, smoking and education

OR2
OR3

OR4
20.0






10.0

Mortality odds ratio





5.0






2.5






1.25


Every day
5-6 times per
3-4 times per
1-2 times per
1-3 times per
A few times a

week
week
week
month
year


Frequency of surrogate drinking

25
and by cause (adjusted for smoking and education)
26
Some more detail
27
Surrogates or ordinary drinking?All cause
mortality
28
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)

29
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

Ratio of death rates in 1994 to those in 1987
men aged 40-44
30
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
6
6
5
5
Mental disorders
Pearson r 0.93
Pearson r 0.93
4
4
1994/1991
3
3
Ratio age-stndardised Russian mortality rates
2
2
1
1
0
0
0
5
10
15
20
25
30
35
40
0
5
10
15
20
25
30
35
40
Mortality ORs for surrogate drinking
31
A mechanism?
Social and economic factors (pace of transition)
(un) conventional risk factors
Health care
stress
Death
32
Back to alcohol the cirrhosis belt
Age standardised death rate chronic liver disease
cirrhosis, age 0-64/100,000
Source WHO
33
What else is being drunk elsewhere?

• Cane spirit (Latin America/ Africa)
• Fruit brandies (eastern Europe)

Moonshine Hooch Arrack What else?
Nascimento, Cardoso, Neto, Franco Farias, 1998
Szucs, Sárváry, McKee, Ádány, 2005
34
A night out in Tallinn
35
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

36
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
• Dont forget the impact of health care