Commentary: Reflections on ‘The Health Crisis in the USSR’

It seems hard to believe that a quarter century has passed since the publication of my essay ‘The Health Crisis in the USSR’1—but it is gratifying to see that the essay still has an audience, and still more gratifying to know that the audience includes readers of the calibre that this journal attracts. Since the editors have kindly invited me to comment on this essay's more-or-less silver anniversary, a few reminiscences may be in order about its origins and the controversy it initially elicited—as well as an afterthought or two about the essay's central arguments. At the time ‘The Health Crisis in the USSR’ appeared, I was a graduate student, just finishing a fellowship at the Rockefeller Foundation, and beginning what was to be an unusually long and happy visiting fellowship with the Harvard Center for Population Studies. I was working on, well, practically anything but my dissertation. In early 1979, while finishing my master's work, I had published a series of essays in the New York Review of Books (subsequently fashioned into a monograph2) on the new post-Mao revelations about China's highly qualified progress against material poverty in the decades 1949–78. I regarded myself back then as a well-wisher of 'socialist experiments' the world around; the growing availability of quantitative evidence by which to judge results against claims under Marxism-Leninism was, at least to me, an irresistible invitation to evaluate the social and economic performance of Communist regimes empirically (if not necessarily dispassionately). Late in 1979, newly ensconced at the Rockefeller Foundation, I stumbled across what seemed to me an utterly arresting fact, offered almost as a throw-away comment in a US Congress Joint Economic Committee (JEC) compendium on the soviet economy. A study on Soviet manpower prospects in that volume happened to mention that reported infant mortality rates in the USSR had increased sharply in the early 1970s; that the reported trends were curious and unexpected; and that they deserved much closer scrutiny. That anomalous development, of course, seemed to me to confute just about everything I thought I understood about social performance in industrialized societies not at war. The mystery deepened as I probed a little further and learnt that age-specific death rates had been rising for Soviet adults since the early 1960s. By the mid 1970s, an upsurge in reported death rates was evident not only among males of almost all working ages but also for many working-age female cohorts. These discoveries, for me, were just too fascinating—and disturbing—to be set aside. I looked up the telephone number of one of the co-authors of that JEC study (this was before the era of the fax machine, much less the Internet!) and soon found myself on the line with Dr Murray Feshbach of the US Census Bureau. In a manner at once gruff and endearing, Murray informed me that he was at work on a study on the phenomenon of rising infant mortality in the Soviet Union, and that if I wanted answers to the questions I was peppering him with, I just might want to read that study closely once it came out. Little did he know! Murray's resulting publication3 (co-authored with Christopher Davis, then with the University of Birmingham) would serve as both springboard and anchor for the exploration in the essay reprinted here. 'The Health Crisis in the USSR' was quite a challenge to write. Attempting to understand, even in the most general of terms, how it could be that an urbanized and literate population—and not just any population, but the citizenry of a global superpower!—should suffer sustained health reversals during a period of ostensible economic advance and material progress required, for starters, the checking at the door of some basic assumptions about the ways that modern societies, economies, and government policies were supposed to operate. Presenting a plausible explanation of the factors and relationships responsible for the quite literally sickening situation in the Soviet Union forced me to hypothesize about constellations of proximate variables and underlying causes with which I had absolutely no intuitive familiarity. Without exactly knowing it, I was being inducted into an exercise in epidemiological reasoning: an investigation that was perforce interdisciplinary, and one that, in Dr W.H. Frost's famous description of the epidemiological approach, would entail the 'orderly arrangement [of established facts] into chains of inference which extend more or less beyond the bounds of direct observation'.4 This took time to sort out and think through. Furthermore, because I had not taken any courses on Russian history or Soviet politics at university, there was a fairly imposing amount of background reading to work my way into. Readers may judge for themselves as to how I fared at this self-directed tutorial. Upon publication, 'The Health Crisis in the USSR' elicited considerable comment in both popular and professional media. Twenty-five years later, what may be most pertinent to recount are the objections and critiques in demographic and public health journals that were to appear in response to the essay. One thrust contended, with lesser or greater sophistication,5,6 that the ostensible rise in Soviet infant mortality was largely, or perhaps even entirely, artifactual: as one study put it, 'our thesis is that the evidence for any real increase in infant mortality in the Soviet Union after 1971 is weak'.6 Thanks to a variety of uncertainties—including under-registration of births and infant deaths in the USSR, somewhat idiosyncratic and apparently changing procedures for defining 'live birth' in the Brezhnev era, differences in vital registration coverage and procedures from one Soviet republic to the next, but most of all the stubborn lack of openness of the Soviet statistical system, which for almost a decade simply stopped publishing the offending infant mortality data—one could shoot for the Anglo-American courtroom standard of 'reasonable doubt' in attempting to dismiss the evidence of rising infant mortality rates in Soviet Russia and the rest of the USSR back in the Soviet years. Things are a bit different now: since the end of the Soviet Communism, researchers in both West and East have been able to offer independent reconstructions of Soviet era demographic trends, drawing upon vastly more information than was publicly available before the end of the Cold War. Among the most painstaking of these efforts is surely the mortality estimates for the Russian Federation (RF) in 'The Human Mortality Database' (the project directed by Professor John Wilmoth of the University of California, Berkeley and Dr Vladimir Shkolnikov of the Max Planck Institute for Demography).7 The Human Mortality Database estimates for infant mortality trends in the RF are presented in Figure 1. These numbers depict an all-too-real increase in RF infant mortality rates between 1971 and 1976. The Human Mortality Database also provides estimates for the former Soviet territories of Latvia and Lithuania—and for both of these republics, infant mortality is calculated to have risen markedly during the 1970s. In the light of additional new evidence, court is now adjourned. Infant Mortality in Russia (Both Sexes Combined), 1959–2001. Source: Human Mortality Database. University of California, Berkeley and Max Planck Institute for Demographic Research. Available at www.mortality.org (accessed on May 22, 2006). A second thrust proposed to explain—or to explain away—what a friend and colleague termed 'the seeming paradox of increasing mortality in a highly industrialized nation'.8 In one rendition, rising adult mortality in the Soviet Union was to be understood in terms of 'cohort effects': that is to say, as a sort of infelicitous echo from World War II on a generation that had been subjected as youths or children to the extraordinary privation and suffering of the Great Patriotic War.8 In another, increases in age-adjusted Soviet mortality were described in proximate terms as a consequence of rises in death rates from cardiovascular disease (CVD)—an entirely normal phenomenon that attends successful industrialization, it was maintained, and in all likelihood one that would soon adopt the downward trend already apparent in other industrialized countries.9,10 They were plausible objections, but as we can now see in retrospect, wrong on just about all main counts. While the 'cohort effect' might in theory help to explain essentially transient increases in age-specific adult mortality affecting particular (pre-World War II) birth years in the USSR, it would be rather less convincing when it came to explaining why 30-somethings born a decade after World War II should have higher mortality levels in the 1980s than their counterparts did back in the 1960s—even though that earlier cohort had endured the stresses of World War II. As for CVD mortality, age-standardized Soviet rates by the late 1970s were higher than anything that would ever be seen in the Western world—and with scarcely any interruption, they continued their terrible climb throughout the remainder of the Soviet era. Looking back at the arguments and hypotheses presented in 'The Health Crisis in the USSR', I should point to one longer term issue that I believe I got more or less 'right' and another that I would now say I got quite wrong. The former was my utilization of secular increases in age-standardized morality not only as instantiation of public health crises but also as a marker for systemic crisis and regime fragility in predominantly industrialized societies. Sustained increases in age-standardized mortality did not only afflict the USSR: they were characteristic of all of Soviet Bloc Europe, and Yugoslavia as well. Epidemiologists may be especially suited to mull over the following fact: all Communist regimes that reported secular rises in age-adjusted mortality have collapsed, while all those where secular mortality has continued to decline (China, Cuba, Vietnam) are still with us, after a fashion, in the here and now.11 As to what I got wrong: though I did not fully spell it out, my working hypothesis was that the health crisis in the USSR was very much a perverse construct of Soviet totalitarianism—and that the health crisis in territories under Soviet sway would consequently attenuate or terminate with the end of Soviet Communism. I was therefore unprepared to witness the 'demographic shocks after Communism' that I documented (among other places) in Eastern Germany: in the New Federal States, life expectancy was to fall by about a year in 1990/91, despite the huge increase in living standards and the great improvement in medical care that attended reunification.12 In Eastern Germany, the post-Communist downturn in health was brief. The situation looks very different in Russia. Almost a decade and a half after the end of Soviet rule, life expectancy is almost a year and a half lower for females than at the end of Gorbachev's tenure; for males, it is almost four and a half years lower (see Figure 2). Today's health crisis, in other words, is even more severe than the one that gripped Soviet Russia during the Cold War. Moreover, the 'cohort mortality analysis' favored by some during the Cold War era for examining the USSR's health troubles suggests that contemporary Russia's mortality crisis will not be quickly or easily reversed. Whereas in Japan (for example) male death rates at any given age have declined regularly and often dramatically over the course of the 20th century in accordance with the year in which one was born, in Russia male death rates are by and large highest for the cohort born most recently (see Figures 3 and 4). Under such circumstances, it may be an impressive accomplishment for contemporary Russians simply to re-attain health levels registered by their parents, who lived under Soviet Communism. Life Expectancy at Birth: Russian Federation, 1958/59–2004. Source: The Demographic Yearbook of Russia: 2005 Statistical Handbook, State Committee of the Russian Federation on Statistics (Goskomstat of Russia), Moscow, 2005, Table 2.6; The Demographic Yearbook of Russia: 2002 Statistical Handbook, State Committee of the Russian Federation on Statistics (Goskomstat of Russia), Moscow, 2002, Table 2.6 The Demographic Yearbook of Russia: 1993 Statistical Handbook, State Committee of the Russian Federation on Statistics (Goskomstat of Russia), Moscow, 1993, Table 2.5. Male Mortality in Japan by Birth Cohort: 1920–70. Source: Human Mortality Database. University of California, Berkeley and Max Planck Institute for Demographic Research. Available at www.mortality.org (accessed on June 12, 2006). Male Mortality in Russia by Birth Cohort: 1920–70. Source: Human Mortality Database. University of California, Berkeley and Max Planck Institute for Demographic Research. Available at www.mortality.org (accessed on June 8, 2006). Clearly, Russia's public health agonies are not yet over. Just how we explain the respective contributions in this ongoing tragedy of polity, political culture, and other factors may be the occasion today for a provocative essay by another graduate student searching for distraction from his or her thesis work.

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