or Russia and its people, the nightmare of Soviet totalitarianism has come to
an end, only to be followed by a phenomenon much more familiar in Russian history: a
"time of troubles." And although this current "time of troubles" is
surely less brutal for ordinary Russians than the original "Time of Troubles"
preceding the accession of the Romanov dynasty likely milder, indeed, than the
other "times of troubles" during the intervening four centuries
todays episode shares with all its predecessors an overarching and indeed defining
characteristic: a sudden, dramatic, and, from a Russian nationalist standpoint,
distressing enfeeblement of the Russian state.
In barely a decade, Moscow has plummeted from the status of an imperial
superpower to a condition of astonishing geopolitical weakness. To be sure, Soviet might,
resting as it did upon the grotesque arrangements of a special tyranny, may be said to
have been in some sense abnormal. Even so, with todays spectacle in which the
Russian states role in international affairs is so conspicuously diminished as to
seem at times negligible it would appear that the pendulum has swung toward
another, almost equally unnatural, extreme.
The symptoms of the Russian Federations newly limited
capabilities for influencing international events (or for that matter, events within its
own borders) are both diverse and abundant. Politically, some would argue, the very
existence in Russia of a constitutional democracy any constitutional
democracy should be regarded as a triumph in itself. Perhaps so, but in Russia
today, "real existing constitutional democracy" is, at least for now, an
essentially moribund edifice. Its wax museum president; its simultaneously fractious and
paralyzed legislature; its fictitious, "Dead Souls" approach to taxation and
budgeting; its "federalism" of local unaccountability and central government
decay; its largely ineffectual judiciary: In all, the Russian political system is at
present poorly suited to effecting decisions, mobilizing resources, or applying
an economic standpoint, Russias weaknesses are manifest. Although ambiguities
surround both old Soviet economic statistics and the new Russian statistics, official data
strongly suggest that the Russian Federations economy today is amazingly small. In
1997, total reported exports of goods and services were almost identical in Russia
(population: nearly 150 million) and Sweden (population: 9 million). (Russias trade
ledgers are probably distorted by under-reporting, but her true export revenues may still
not have matched those of such miniature countries as Singapore and Belgium.1) At official exchange rates, Russias estimated GNP in 1997 just barely exceeded $400 billion thus
ranking slightly above Australias ($380 billion). "Purchasing power
parity" (PPP) adjustments alter the picture only to a degree: By that benchmark,
according to World Bank calculations, Russias 1997 economy would have been about as
big as Spains, although smaller than Canadas or Indonesias. If accurate,
those World Bank estimates would have meant that per capita output in 1997 was actually
lower in Russia than in such places as Lebanon or Peru.2 All
of these figures, furthermore, refer to Russian conditions before the August 1998
collapse of the countrys finances, since which time the countrys economic
performance has only worsened.
Then there is the matter of military strength. Since the collapse of
communism, Moscows has evidently all but evaporated. Where the Red Army once
entertained global ambitions, the Russian Armys conventional forces now find
containing an insurrection in a small region within the nations borders to be an
almost overwhelming challenge. The dismal performance of the Russian Army in Chechnya
attests to no less; the very fact that the military campaign to suppress Chechen rebels
had to last nearly two years speaks for itself.
So straitened are Russias current circumstances that the Western
world has implicitly, but almost totally, redefined the nature of the external security
problem it expects to confront from the Russian state. No longer is that problem perceived
to center upon Moscows ability to project power abroad. Instead, it is believed to
emanate primarily from the potential consequences of Russian internal political decay and
military decline: the sell-off of military hardware to rising powers like China, or of
nuclear technology to would-be proliferators like Iran; weakened controls over the
governments arsenal of weapons of mass destruction; or internal convulsions with
international repercussions. To the extent that Western governments today perceive a
"Russian threat," it is not because they regard Moscow as an intentional
menace, but rather because they see it as an unintentional menace, a burden.
Many observers both within Russia and outside it take as self-evident
the proposition that Russias current condition of extreme weakness virtual
prostration is only temporary, and will be corrected. Emblematic of this view is
this assertion by Sergei Rogov, director of Moscows Institute of the USA and Canada:
"Sooner or later, Moscow will again be a major international player."3
The sorts of developments that would be necessary for a Russian
geopolitical recovery are easy enough to identify. They would include such things as
coalescence of a rule of law, a policy-competent central government, creation of an
attractive "business climate," and reinvigoration of the leadership and
institutions of the armed forces. Many of these qualities, however, involve historical
changes that could require correspondingly historical time spans to enact and all
of them are of course dependent upon unforeseeable, unreliable contingency. For these
reasons alone, Russias international comeback could be a very slow and gradual
affair under the best of circumstances.
Yet even such a qualified prognosis for a Russian comeback may prove to
be overly optimistic, because it does not take into account a factor that could prove
critical to an eventual Russian recovery. That factor is the health of the Russian people.
Illness and mortality trends do not typically play a great role in
world affairs. In Russia today, however, the nations health conditions have become
so degraded that it is possible to imagine these constituting an independent, and perhaps
significant, constraint upon Moscows prospects for re-attaining Great Power status.
Russias ongoing crisis in public health and "crisis" is hardly too
strong a word is historically unprecedented: No industrialized country has ever
before suffered such a severe and prolonged deterioration during peacetime. Given its
particular characteristics, Russias health decline promises to be especially
difficult to reverse. Such health trends augur ill for the Russian economy and it
is economic power that must ultimately underwrite any sustained resumption of
international influence for Russia.
Thus, "unnatural" as Russias current weakness is held
to be in many quarters, there is a real possibility that the countrys startlingly
adverse health trends will consign it to further relative economic and political decline
for as much as another generation.
Anatomy of a health crisis
USSRs departure from the world stage was remarkably peaceful, the collapse of the
Soviet system nevertheless brought on a veritable explosion of mortality in Russia.
Between 1989-91 (the last years of Soviet rule) and 1994, crude death rates in Russia shot
up by 40 percent.4
Though the mortality situation has improved somewhat since then, crude
death rates in Russia in the first half of 1998 were still nearly 30 percent higher than
they had been in the USSRs final years.5 This mortality
shock (in tandem with a concomitant sudden drop in fertility levels) has pushed Russia
into a continuing population decline for the first time since World War II. At the moment,
Russias deaths are exceeding its births by well over half about 700,000 a
the fact has gone largely unrecognized, the loss of life from this quiet crisis in Russia
has been a catastrophe of historic proportions. The dimensions of the catastrophe are
suggested by estimates from the World Health Organization (WHO).6
WHO has prepared "age standardized" death rates for Russia and many other
countries. (These "standardized" rates differ from the crude rates in that they
control for population aging and other such phenomena.) Against the benchmark of 1987
a relatively good year for personal survival in the old Soviet era
"excess mortality" in Russia during the four years 1992-95 would have amounted
to nearly 1.8 million deaths. To put that figure in perspective: For the four years of
World War I, the military death count for the Russian Empire is generally placed at 1.7
million.7 And WHO has not yet published "age
standardized" death rates for Russia for the years 1996-98; when it does, we are
likely to find that Russias "excess mortality" in the 1992-98 period alone
exceeded 3 million deaths.
The abrupt worsening of Russian health conditions since the end of the
communist era is all the more noteworthy because health trends in the fin-de-regime
USSR were themselves so very poor. From the end of the World War II to roughly 1960, the
Soviet system presided over a swift and dramatic improvement in Union-wide health levels;
by 1960, in fact, life expectancy at birth in Russia proper had caught up with
Americas, and was poised to exceed it. Just at that juncture, however, Russia began
to experience broad health setbacks. Death rates began to rise first among
middle-aged men, then for a steadily spreading number of male and female age groups. Even
infant mortality reportedly went up.
Initially, Soviet authorities responded to these unfavorable findings
by suppressing information about them; with Gorbachevs glasnost policy, this veil of
statistical secrecy was lifted. Official figures revealed that overall life expectancy for
Russia was no higher in the late 1980s than it had been in the early 1960s and that
for adults, life expectancy was actually somewhat lower than it had been a quarter century
After decades of stagnation, and now recent, unmerciful retrogression,
Russias health profile no longer remotely resembles that of a developed country; in
fact, it is worse in a variety of respects than those of many Third World countries. In
1997 the most recent year for which such estimates are available overall
life expectancy in Russia was thought to be somewhat under 67 years. That would have been
lower than Russias life expectancy four decades before but it would also be
distinctly lower than the life expectancies today of such spots as Mauritius, Ecuador, or
Azerbaijan. Mexico, for all its travails and troubles in the 1990s, now enjoys a life
expectancy estimated to be over six years higher than Russias.9
Throughout most of Latin America and the Caribbean and a growing number
of countries in Asia, women can now expect to live longer than their Russian counterparts.
But survival prospects are especially poor for Russian men. According to the most recent
figures available life expectancy at birth for males in Russia today hovers around 61.10 That ranks below the corresponding current estimates for such
places as Egypt, Indonesia, or Paraguay.11
Among Russian men, moreover, health conditions are particularly bad for
those of working age. In Australia today, by way of example, a 15-year-old boy would,
under current survival patterns, stand about an 80 percent chance of living to age 65. In
the Russian Federation, by contrast, barely 40 percent of those same 15-year-olds would
make it to 65. Although its records are limited to countries with relatively complete
death registration since World War II, the WHO database cannot provide another instance of
such bleak survival odds for "able-bodied" men even men from the African
island of Mauritius in the late 1950s enjoyed better prospects than todays Russians.12
For every subsidiary age group from 15 to 65, death rates for Russian
men today are frighteningly high. Youth may be the prime of life but Russian men in
their late teens and early 20s currently suffer higher death rates than American men 20
years their senior.13 For their part, Russian men in their
40s and 50s are dying at a pace that may never have been witnessed during peacetime in a
society distinguished by urbanization and mass education. Death rates for men in their
late 40s and early 50s, for example, are over three times higher today in Russia than in
Mexico. To approximate the current mortality schedule for Russian middle-aged men, one has
to look to India the India, that is, of the early 1970s, rather than the much
healthier India that we know today.14
ow is the
Russian health disaster to be explained? The troubling fact is that international public
health authorities have yet to come to any general agreement about the particular causes
of Russias health crisis much less an understanding of the precise magnitude
of the tolls being exacted. Reviewing available evidence three years ago, Dr. Lincoln Chen
of the Harvard School of Public Health and colleagues concluded that "the root causes
of the Russian health crisis remain uncertain." Our understanding of the upsurge in
Russias death rates has not advanced dramatically since then.
Yet, although we may not be able to account conclusively for the roots
of Russias health crisis, we may nevertheless obtain important clues about its
nature from the countrys death statistics. Apart perhaps from infant deaths,
mortality registration has been reasonably complete in Russia since at least the 1960s.
And Russian statistics also classify deaths according to reported causes. While
cause-of-death statistics are never perfect, and may be more than ordinarily problematic
for Russia, they do at least offer the most reliable hints as to what is ailing the
The first thing to note is what is not apparent in the
statistics. Many medical specialists within Russia itself, for example, would strongly
agree with Georgetown Universitys Murray Feshbach that "environmental issues
lurk behind much of the [Russian] public health problem."15
The Soviet systems appalling destruction of nature its casual and wanton
poisoning of air, land, and water has already been grimly documented, most notably
by Feshbach himself.16
what fells forests or slays wildlife does not always necessarily kill people. If, for
example, severe air pollution were exacting a particular toll on the Russian people, we
might reasonably expect to find evidence of extraordinary respiratory afflictions
but Russias death rate attributed to diseases of the respiratory system has
reportedly declined slightly since the early 1980s, and is currently lower than in
such countries as the Bahamas, Ireland, or Singapore. By the same token, while there is
little doubt that radiation and other potentially deadly mutagens have been handled
recklessly by the USSR (and now by the Russian Federation), the death rates attributed to
cancer in Russia today have changed little for a decade or more and in fact are
essentially indistinguishable from those reported in such countries as the U.S., the UK,
Germany, or France.17
The human cost of Russias "ecocide," to be sure, may
yet prove horrendous; but if we are to judge that cost by available mortality data, such a
dire verdict cannot yet be rendered.
Then there is the question of communicable disease. In recent years,
Russia has suffered outbreaks of typhus, typhoid, and cholera; diphtheria is reportedly
rampant; and the identified incidence of tuberculosis, which has more than doubled since
1990, is by WHO definitions now formally epidemic.
That Russia today should be so manifestly incapable of coping with
contagious diseases so routinely controlled and suppressed in so many other regions of the
world is surely suggestive of a breakdown in the countrys public health system
and perhaps indicative as well of upheaval within its social structure. But the
impact of epidemic disease per se on Russias health decline is easy to exaggerate.
In 1995, deaths attributed to infectious and parasitic diseases comprised less than 2
percent of Russias overall age-standardized death rate; while the level was almost
four times as high as (say) Swedens, that discrepancy accounted for less than
one-fiftieth of the overall mortality gap between the two countries. On the countrys
current mortality schedules, Russians face only about a 2 percent chance of eventually
dying from a communicable disease 98 percent will die from something else.
Obviously, then, the principal constituents of Russias health disaster would seem to
But where? To go by cause-of-death statistics, the overwhelming
majority of excess Russian deaths by comparison both with Western countries today,
and with Russia itself in earlier years would seem to fall in two categories:
"cardio-vascular disease" (or CVD: heart attacks, strokes, and the like) and
"accidents and adverse effects" (injuries including suicide and murder
cause-of-death statistics are to be believed, the world has never before seen anything
like the epidemic of heart disease that rages in Russia today. For men and women alike,
the standardized death rate in Russia today attributed to CVD alone is higher than the
death rate in the U.S. for all causes combined. And although men the world over are
prone to distinctly higher death rates from heart disease than women, Russias female
CVD mortality rate is currently roughly twice as high as the male rates in such countries
as Canada, Italy, and Spain. In the West, CVD mortality peaked in the late 1950s and
1960s, and subsequently declined substantially. In Russia, however, already unrivaled
rates have continued to climb.
As for deaths from "external causes," medical statistics have
never before documented a plague of the proportions that wracks Russia today. The United
States is widely regarded as a violence- and injury-prone society. Yet the U.S. death rate
attributed to injuries and poisonings currently stands at only half of the reported
Russian rate of the Brezhnev and Gorbachev years and Russias rate has doubled
again since then. At this juncture, despite the enormous worldwide disparity between men
and women in deaths from violent causes, the mortality rate ascribed to injury and
poisoning is higher for Russias women than it is for Americas men.
Russian men, for their part, have no peers in succumbing to deadly
injuries. Although the Russian male mortality rate from "external causes" was
reportedly significantly lower in 1995 than it had been in 1994, it was nevertheless
nearly three times higher than in Mexico or Venezuela, and over half again as high as in
Colombia a country then convulsed by drug warlords and unchecked narco-terrorism.
Under prevailing cause-of-death patterns, a baby boy in Russia in 1995 stood almost a 1 in
4 chance of eventually dying from some sort of external trauma; in Britain, to provide
some sense of contrast, the corresponding risk would have been about 1 in 30.18
How to explain modern Russias extraordinary disposition for
injuries and cardiovascular disease? The upsurge in deaths due to external trauma is
surely influenced, after a fashion, by broad social trends from the ongoing Russian
"transition." It is much easier now than in the past, for example, for Russians
to buy a car and by extension, to kill themselves on the roads. By the same token,
with the virtual collapse of police authority and the corresponding rise of "mafiya
capitalism," Russian citizens are more likely now than in the past to die from
a much narrower sense, however, Russias epidemic of deaths from external trauma is
intimately linked to its staggering consumption of hard spirits. The heavy vodka drinking
for which the USSR was so notorious has been replaced in post-Communist Russia by an even
more extreme regimen of national alcohol abuse. Contemporary Russias thirst for
vodka, indeed, is almost impossible for Westerners to imagine. According to a 1993
national household survey, for example, over 80 percent of Russian men were drinkers and
their alcohol intake reportedly averaged nearly 600 grams per day.19
That would be the equivalent of over five bottles of vodka a week, every week. And since
these figures were self-reported, they may have been underestimates. Other contemporary
studies suggested that the average level of alcohol consumption for the entire
Russian adult population men and women together exceeded 400 grams per day:
that is to say, three bottles a week. Since 1993 alcohol consumption may have declined,
but Russian drinking patterns have hardly moderated.20
Those patterns have deadly consequences. In 1996, over 35,000 Russians
died from accidental alcohol poisoning. (America is not exactly a country of teetotalers,
yet in the United States a country with almost twice Russias population
the corresponding figure averages about 300 persons a year.21)
Extraordinarily heavy drinking is also implicated in Russias explosion of deadly
injuries, for many of the fatal falls, crashes, suicides, and murders in Russia today are
thought to occur while the victim (or perpetrator) is drunk.22
Alcohol abuse surely also plays a role in Russias surfeit of
deaths from coronary disease, since binge drinking is associated with CVD mortality.23 But other aspects of the Russian lifestyle undoubtedly contribute
to the problem. Heavy smoking (prevalent in Russia today) contributes strongly to the risk
of CVD as do lack of exercise, diets too heavy in fatty foods, and obesity, all of
which are rife among the Russian populace. At work together, these risk factors may
disproportionately heighten vulnerability to cardiovascular threats.
In addition, there is evidence that attitudes, outlook, and stress
(what clinicians now term "psycho-social variables") may also affect
susceptibility to CVD. Although such data are tentative and must be treated with
considerable care, there are indications that the incidence of clinically defined
"depression" may be rather greater in Russia today than among other, Western
European, populations.24 And in a major recent study of
Russian health conditions, researchers concluded that health risks were strongly
associated with the perception that one had little control over ones own life.25 Association, of course, does not establish causality but it
raises the possibility that the profound and apparently deepening pessimism about personal
circumstances widely reflected in an array of opinion polls and surveys is among the
determinants underlying Russias fearsome levels of cardiovascular death.
If a better medical system were currently in place, Russias death
rate from CVD would doubtless be reduced. That CVD epidemic, however, speaks to much more
than the failure of a particular public health sector. For the risks that are resulting in
these unparalleled levels of cardiovascular mortality are strongly behavioral, and perhaps
also attitudinal, in nature. They are representative of, and appear to be deeply ingrained
within, the current Russian lifestyle. Until these behaviors and attitudes call
them "ways of life" change radically, it will be correspondingly
difficult to change the health risks they generate in any appreciable manner.
Prospects for recovery
people are not the only urbanized, educated populace in our era to experience sudden
upward spikes in mortality, or precipitous and unexpected declines in general levels of
health. At least four other countries Spain (1936-39), Western Germany (1943-46),
Japan (1944-45), and South Korea (1950-53) record cruel plunges in countrywide life
expectancy around the middle of the twentieth century.
Merely to note those dates, however, is to see a contrast between these
cases and the case of Russia. The mortality crises in Spain, Western Germany, Japan, and
South Korea were direct consequences of wars or civil war. Each of those mortality crises
proved transient. In the four war-riven states, health recovery commenced spontaneously
with the cessation of fighting. In each case, life expectancy at birth quickly recovered
to pre-disaster levels. Thereafter, brisk tempos of further health progress ensued
almost as if disaster had never struck.
The most remarkable instance of such post-disaster health progress is
undoubtedly Japans. In 1944-45, male life expectancy at birth in Japan had been
driven down essentially to Neolithic levels (under 25 years). Yet barely three decades
later in the late 1970s Japan was estimated to enjoy virtually the highest
male life expectancy in the world.
Can Russia hope for an analogous revitalization of health trends in the
decades immediately ahead? From todays vantage point, such an outcome would seem
unlikely. Remember: The Russian crisis has erupted in a country in a formal state of
peace.26 In origin, duration, and character, Russias
mortality crisis is fundamentally different from those others. And in every respect,
Russias distinctions portend both greater difficulties in re-attaining previous
health conditions and a more limited scope for exacting health gains after that status
quo ante is finally reached. Paradoxically, even if Russias health recovery were
to begin immediately or were discovered to be already underway the
particulars of the countrys health crisis suggest that Russias international
health ranking might nevertheless continue to decline for another several decades.
as the Spanish Civil War, World War II, and the Korean War all were, moreover, the
demographic toll that each of those catastrophes imposed appears to have had surprisingly
limited impact on the health of the crises survivors. Recent estimates by
demographers, for example, suggest that World War II and its repercussions cost Western
German women born in 1920, who were exposed directly to the destruction and privation of
that terrible defeat, an average of only about six months of life expectancy.27
No similar presumption can obtain for Russia. To the contrary: Given
the prolonged period of health stagnation and decay before the recent Russian health
crisis, and the indications that Russias pattern of excess deaths may be partly or
even largely related to accumulated lifestyle-related risks, there is every reason to
expect the burden of this crisis to continue to weigh heavily upon the Russian people even
after its most acute phase has passed.
Two specific features of Russias current patterns of death and
disease argue especially strongly against the likelihood of a speedy health turnaround.
The first has to do with the countrys current cause-of-death
structure the particular types of fatal illnesses, in other words, that are
killing people in modern Russia. For Russias deadly ailments, by and large, are
afflictions that tend inherently to be more resistant than others to immediate medical
interventions, and less amenable than others to significant short-run control.
The point can be illuminated by contrasting cause-of-death patterns in
contemporary Russia and post-war Japan (see Figure 1). In 1995, Russias overall
age-standardized death rate was just about the same as Japans had been in the early
1950s. The composition of the two countries death rates, however, was dramatically
In postwar Japan, infectious and communicable disease was a vastly
greater threat to public health than it is in Russia today. Death rates from respiratory
illnesses (among them, pneumonia and influenza) were over two-thirds higher than in
contemporary Russia, and mortality from tuberculosis (a major killer in Japan during those
years) was fully seven times higher. Fortunately for the Japanese, those were diseases
that could be rapidly and inexpensively suppressed by newly invented medicines and fairly
basic public hygiene measures. In the face of these sustained interventions, declines in
death rates were immediate and dramatic. In just the 10 years between the early 1950s and
the early 1960s, for example, Japans TB death rate fell by 63 percent.
In Russia today, the principal causes of death CVD and
injury/poisoning together account for two-thirds of the nations mortality.
Death rates from CVD are nearly twice as high for modern Russians as they were for postwar
Japanese; death rates for injury and poisoning, over three times higher. And unfortunately
for Russia, these are not the sorts of deaths that can be easily prevented through
inexpensive prophylactic health policies.
In theory, an injury prevention strategy could bring quick benefits. In
practice, such a strategy would be daunting to enact in Russia today. It would have to
induce tremendous behavioral changes on the part of the Russian people most
important, a radical drop in the prevalence of heavy drinking. Given Russias
seemingly unique passion for vodka, eliciting sustained declines in alcohol consumption
would not be easy. Nor would it be inexpensive. In addition to the direct costs of an
anti-alcohol campaign, there could be major revenue implications for the state, for
traditionally the Russian budget has been almost as dependent upon liquor as have the
Unlike sudden injuries, CVD typically is the culmination of a lifetime
of insults visited upon the cardiovascular system. With heart disease, in a real sense,
todays "bills" cover "debts" accumulated over long periods in
the past. For this reason, trends in deaths from heart disease in any country can never
turn on a dime. Even with sensible, well-funded medical policies and wholesale popular
embrace of a more "heart-healthy" lifestyle none of which conditions
obtain in todays Russia the control and reduction of CVD death rates tends to
be a relatively gradual affair. And, of course, it is now known that heredity plays a
significant role in cardiovascular risk. Some researchers speculate that such hereditary
risk factors may be disproportionately concentrated in particular ethnic populations.29 If there should happen to be a hereditary predisposition to CVD
for some non-trivial fraction of the Russian population, reductions in cardiovascular
mortality would presumably prove that much more difficult to achieve.
second, related, reason we should not expect speedy improvement in Russian health
conditions is that Russias health trends today embody a large measure of what might
be termed "negative momentum." In Spain, Western Germany, Japan, and South
Korea, local health conditions had been progressively improving for decades before their
respective cataclysmic upheavals; when the conflicts that triggered their mortality crises
came to a close, the survivors and their descendants continued upon already-established
paths of national health advance. In Russia, by contrast, health conditions have been
stagnating in fact, worsening for over three decades.
To appreciate just how much "negative momentum" lies within
contemporary Russian health trends, one might compare death rates for Russia proper in
1994 and, say, 1964. For men 15 years of age and older, death rates were higher in 1994
than they had been 30 years earlier for most age groups, in fact, far higher. For
men in their early 30s, mortality levels were twice as high for 1994 as for 1964; for men
in their early 50s, they were almost two and a half times as high. The situation was only
somewhat better for women. For them, death rates were worse than they had been three
decades earlier for all groups 25 and older; for women in their 30s, 40s, and 50s, death
rates typically had jumped by about half from 1964 to 1994.
These health setbacks mean that, at any given age, Russian adults are
dying at a tempo that had been observed back in the 1960s only among distinctly older age
groups. In 1994, the trend reached its nadir, with the absolute death rate for Russian men
in their late 20s, for example, matching the death rate for men in their early 40s
in 1964. While mortality rates have improved somewhat since the annus horribilus of
1994, Russian men, according to the latest data available, are nevertheless today dying at
a pace reported by counterparts fully 10 years their elder back in the 1960s; for a number
of female age groups, the differential remains at five years or more.
If death rates provide an accurate reflection of general health
conditions for a country like Russia, it would seem that the Russian population as a whole
has been growing progressively frailer in recent times that irrespective of
chronological age, todays men and women alike are in a real sense more
"elderly" than were their counterparts in their parents generation.
Under such circumstances, simply re-attaining within the next 20 years
the health levels Russia "enjoyed" in the 1960s will be no mean feat; indeed, it
will require far-reaching changes in both lifestyle and environment for the country as a
whole. The 50-year-olds in Russia 20 years hence are the 30-year-olds of Russia today
and by many indications, these particular 30-year-olds are strikingly less healthy
than their predecessors a few decades earlier. The same may be said of most of the current
Russian cohorts male and female alike that will compose the majority of the
Russian population, and the great majority of the Russian labor force, 20 years from now.
Modest as the goal may sound, getting back to the status quo ante is an ambitious
health goal for Russia today one that, quite possibly, may not be accomplished for
In its latest round of world demographic projections, the United
Nations World Population Division proposes an overall life expectancy of just over 70 for
Russia for the years 2010-15 just over 65 for men; just over 75 for women.30 These life expectancy projections are a bit more optimistic than
those of the Russian State Statistical Committee (Goskomstat)31
whose estimates, in turn, may prove to be overly optimistic for reasons already
mentioned. But even taken at face value, their implications are arresting, as Figure 2
If the U.N. projections prove correct, for example, male life
expectancy in Russia in 2010-15 will be barely higher than it was back in the early 1960s
that is to say, half a century earlier. Moreover, during Russias prolonged
bout of stagnation, health conditions in most of the rest of the world have been gradually
improving and are projected to continue to improve in the future. Thus
Russias international health standing is envisioned as declining for decades to come
even after the countrys health recovery has commenced.
In the early 1990s after the onset of Russias current,
acute mortality crisis life expectancy for the country as a whole is estimated to
have been almost five years higher than in the collectivity the U.N. terms the "less
developed regions" (low-income Asia, Africa, and Latin America). Twenty years from
now, by these projections, overall life expectancy in Russia would be only about two years
higher. Life expectancy for Russian men would be ever so slightly lower than the overall
male average for those regions.
In starker terms: In the Western hemisphere, to go by these
projections, only Bolivia, Guatemala, and Haiti would have a lower male life expectancy
than Russias own 20 years hence. Russias overall life expectancy would be
lower than those of such Asian countries as China, Indonesia, Iran, and Vietnam. Male life
expectancy would be lower in Russia than in India or Pakistan and would be just
about the same in Russia and Bangladesh.
Projections of this sort, of course, must be treated with caution. In
the event, the ones just cited may overestimate Third World health progress: A terrible
epidemic, war, or other disaster may depress life expectancy far below the future levels
anticipated. But that caveat holds equally for projections of health progress within the
Russian Federation. Though they can hardly be presumed to foretell the future, these
projections emphasize just how easy it will be in the years ahead for Russian health
conditions to slip further down into the ranks of the Third World and how
extraordinarily hard it will be to forestall such an eventuality.
Poor health and economic power
Russias health prognosis is indeed as gloomy as it seems, mortality and disease will
pose major obstacles to economic development in Russia for decades to come.
In our era, the wealth of nations lies in their human resources. Land,
commodities like oil, and even physical property have all been making a steadily
diminishing contribution to economic output over the course of the modern age. A
debilitated, unhealthy Russia is utterly unlikely to be capable of maintaining a highly
productive economic system. Rather, Russias continuing relative decline in
international health rankings is likely to be accompanied by a continuing relative decline
in her international economic standing. Given Russias prospective health problems,
its economy 20 years hence may look even smaller by comparison with others than it does
Internationally, the correspondence between health and productivity is
a strong one, as may be seen in Figure 3. No matter whose statistics one chooses or what
time period one examines, countries with higher levels of life expectancy tend to have
higher levels of per capita output and the ones with lower output tend also to have
poorer levels of health.
The relationship between health and economic productivity is of course
vastly more complicated than can be depicted in a simplified graphic. For one thing,
health improvements are often themselves consequences of productivity improvement: Higher
incomes permit populations to purchase better medical care, and to adopt lifestyles that
reduce the threats of ill health and death.32 Conversely,
improvements in health may have productivity-enhancing properties that come into play only
over the long run33 properties that a point-in-time
snapshot like Figure 3 is incapable of representing.
Nevertheless, the fact remains that, at any given time, a
countrys level of life expectancy turns out to be quite a good predictor of its
level of income. There are, of course, certain countries for which such predictions
consistently veer off the mark, but even in those cases, the deviations are readily
United States, for example, "overperforms" economically its income level
is always higher than would be predicted solely on the basis of its health attainment.
That differential may be understood in terms of the added productivity made possible by
our technological pre-eminence, our corporate/managerial advantages, and our cadre of
highly trained specialists. Conversely, China is an "underperformer"
economically there, per capita output is always lower than the countrys life
expectancy per se would predict. But given Chinas technological backwardness and the
still problematic nature of its "institutional infrastructure" (markets, laws,
and the like), it is hardly surprising that human resources should be less productive in
China than they might be elsewhere.
For the Russian Federation today, life expectancy happens to be a
rather good predictor of productivity. Russias per capita GNP, in other words, is
just about what one would guess from its level of life expectancy; by some comparisons, in
fact, Russias output levels look slightly better than one would predict on
the basis of health alone. That should be sobering news for Moscow, for it suggests that
the countrys current economic weakness is not so much an aberration attendant to its
ongoing "transition process" as it is a fact connected closely with the
countrys extraordinarily high levels of mortality and illness. Unless Russia can
hope to emerge as a U.S.-style "overperformer," its future economic and health
progress will be closely linked.
For all the reasons we have already seen, health progress in Russia
over the next several decades may well be painfully slow. Just what would this portend for
the Russian economy?
One way of thinking about the question would be to compute illustrative
GNPs for Russia and other countries on the basis of todays international
relationships between health and productivity, but using the numbers for life expectancy
and population size that are projected for, say, two decades from now. Obviously, this
will be a highly imperfect approach, but it may nonetheless prove useful in gleaning an
impression of what lies ahead.
Although current U.N. demographic projections envision a total Russian
population smaller 20 years from now than it is today, they also anticipate life
expectancy to be somewhat better. Using crude, health-based "predictors," such a
future Russia could be assigned a real GNP of a little over a trillion present U.S.
dollars. Taken at face value, that total would imply consequential economic progress for
Russia in the years ahead a respectable pace of GNP growth averaging, say, 2.5
percent per year.
But the world is a moving target and much of the world may be moving
more rapidly than Russia in the decades ahead. Certainly health-based
"predictors" of economic performance would suggest as much. The same methods
that depict a future Russia with a trillion-dollar economy 20 years from now, for example,
can be used to conjure up a Turkish economy of equal or even greater size. Similar
calculations portray a Russia virtually encircled in Asia by larger economies: Not just
Korea, Japan, China, and India, as today, but also Pakistan and Iran all could have
economies at least as large as Russias own.
illustrative approach, indeed, suggests that Russias international economic ranking
could drop steadily over the coming 20 years, notwithstanding an envisioned measure of
national health recovery and economic progress. At the moment, Russias economy is
probably the worlds thirteenth or fourteenth in terms of overall size.34 Crude, health-based calculations imply that it might possibly be
as low as, say, twentieth two decades from now.
What would it mean to be the worlds twentieth largest economy 20
years from now? We might get some sense of the geopolitical ramifications by considering
the worlds twentieth largest economy today. The World Bank provides PPP adjusted
estimates of national output for 1997; though these should not be taken as precise, they
offer at the least a sense of scale.
Consider Thailand or Australia. Neither of them would have been the
worlds twentieth largest economy in 1997 they were both almost certainly too
big for that. Instead, visualize something in the vicinity of Argentina or South Africa:
With the power of the Dutch economy, or the South African economy, or
the Argentine economy at its disposal, a radical or revisionist state could today cause
tremendous difficulties for its neighbors, its region, and arguably even the entire
international community. It could be a nuisance, a headache, or (if left unchecked) a
predatory menace. But no matter what its international disposition, no matter how shrewd
and ruthless its statesmen, a country with an economy the size of Argentinas today
could not hope to lay claim to Great Power status. The gap between that ambition and the
resources necessary to realize it would simply be too great.
What holds for Argentina today may obtain for the Russian Federation
tomorrow. A less peaceable, more militant Russian state than the one we know today could
easily be a source of tensions and a cause of troubles that the international community
currently does not have to contend with, and naturally would prefer not to. But if the
Russian Federations relative economic standing continues to slip in the decades
ahead, genuine Great Power status will drift ever further from the grasp of Moscow,
irrespective of the priorities, ideology, or skill of its leadership. Russias
potential for mobilizing national power is severely impaired today by the sickness of its
people and sickness looks to be an even more crippling constraint on Russian power
over the generation to come.
An unhealthy Great Power?
t is, of
course, possible to argue that Russias current trends in sickness and death will not
necessarily impede the countrys comeback on the world stage. At least two such
objections deserve consideration.
The first would hold that the economic costs of Russias health
crisis are not nearly as grave as has been suggested here. Consider a possible
counterargument by analogy. Some recent econometric research on the repercussions of the
international AIDS epidemic, for example, has concluded that this pestilence, gruesome as
its human consequences may be, has had only a negligible impact on economic growth and
output even in AIDS-ravaged areas of sub-Saharan Africa.35
Using similar reasoning and a similar econometric framework, one new study estimates that
the total costs of Russias mortality crisis are surprisingly low: only 0.3
percentage points a year knocked off the countrys economic growth rate.36 That would be a drag on economic growth, to be sure, but only a
relatively minor one: by implication, Russias burden of disease might not be nearly
so onerous as to prevent the countys ascendance as a major global economic power
and thus, a major political power in the decades immediately ahead.
gainsaying the sophisticated modeling techniques being marshaled here, one can make two
points about this type of objection. First, it is quite possible that estimates of a
negligible economic cost for the sub-Saharan AIDS epidemic are actually quite wrong,
drawing as those models did on much more preliminary information about a scourge that now
is radically depressing life expectancies in countries across the entire sub-Sahara.37 Second, the debilitating illnesses and afflictions pressing down
life expectancy in the Russian Federation today would appear to be distributed much more
broadly over the populace than would be an AIDS epidemic of equal lethality; if so, the
economic impact of the Russian-style health retrogression could be commensurately greater.
A second kind of objection asserts that, however weakened, the Russian
populace remains a force to be reckoned with in world affairs due to its formidable
potential on the field of battle. Edward N. Luttwak offered a variant of this argument
almost 15 years ago, when he warned readers against "Delusions of Soviet
. . . [D]runkenness is no doubt pervasive in the[ir] . . . armed
forces. But the Russians have always been great drinkers. Drunk they defeated Napoleon,
and drunk again they defeated Hitlers armies and advanced all the way to Berlin.38
Yet this objection, too, now appears overtaken by certain events.
Operation Desert Storm may have offered us a glimpse of the next face of war: the hi-tech,
information-intensive arrangements that currently travel under the banner of the
"revolution in military affairs." While this nascent "revolution" may
not invest the armies that embrace it with invincibility, it looks nonetheless to confer
upon them tremendous advantages over their "pre-revolutionary" opponents. That
being the case, what are its implications for Russian military might?
A debilitated Russian populace is unlikely to support a
"revolution in military affairs" worthy of the name. In a sick country, amassing
the requisite corps of soldier/specialists to conduct high-technology warfare may be a
challenge in itself. (Brave and regimented drunkards may have succeeded in marching on
Paris and Berlin in the past, but they would fare rather less creditably today in, say,
high-precision aerial combat.) More important, though, a debilitated Russian populace will
be hard-pressed to finance the far-reaching expenditures and investments that a meaningful
"revolution in military affairs" would demand.
If Russia cannot support a full-fledged "revolution in military
affairs" in the next decades, it may still be able to field a large conventional
force a force that would perhaps enjoy overwhelming capabilities by comparison with
a number of neighboring states. But such an armed force would have little capacity for
projecting military power far beyond its borders or against Great Power adversaries39 no matter how courageous or casualty-tolerant the Russians
happened to be.
Too sick to matter?
at the end of the Soviet era the Russian Federation contained the
worlds fifth largest population. By 2020, according to U.N. projections,
Russias population will be no larger than ninth. In the late 1980s, Russias
life expectancy, though lower than Europes, Japans, or Americas, was
nonetheless higher than Asias or Latin Americas; 20 years from now, according
to U.N. projections, Russias life expectancy would be lower than those of 125 of the
188 countries and territories assayed and as we have seen, even this may turn out
to be an optimistic assessment.
In the Soviet era, Russia was the sick man of Europe. Today, it is also
the sick man of Asia. This illness does not look to be quick in passing. If the
humanitarian implications of Russias health crisis are pressing, the strategic
implications also appear to be inescapable.
Russias well-wishers like the Russian people themselves
should hope for a speedy establishment of civil society, a sturdy rule of law, and
sound, steady economic policies for the Russian Federation. They should also pray for
enlightened public health measures to tackle the countrys terrible health situation
(a program, incidentally, to which not one of Russias many political parties
at this time is yet committed).
Russias imagined antagonists, for their part, should not base
their fears and apprehensions on the specter of a rapidly reviving "Great Power"
Russia. As orderlies at medical institutions around the world can attest, even a weakened
patient must be treated with care if he is seized by delirium. But it looks as if Russia
is going to be in bed for a long, long time.
--Nicholas Eberstadt is a visiting scholar at the American Enterprise Institute and
a researcher at the Harvard Center for Population and Development Studies.
1 Derived from International Monetary Fund, International
Financial Statistics, vol. 51, no. 1 (January 1999); U.N., World Population
Prospects: The 1998 Revision (New York: U.N. Population Division, forthcoming).
2 World Bank, World Development Report 1998/99 (New
York: Oxford University Press, 1998): pp. 190-191.
3 James Meek, "U.S. Views Russian Bear As Largely
Declawed," Washington Times (27 January 1999): p. A18.
4 Goskomstat of Russia, The Demographic Yearbook of Russia
1995 (Moscow: Goskomstat, 1996): p. 19.
5 Derived from The Demographic Yearbook of Russia 1995
and U.N. Monthly Bulletin of Statistics, March 1999, vol. 53, no. 3, p. 10.
6 World Health Organization, World Health Statistics Annual
(Geneva: WHO), various editions.
7 Anthony Bruce, An Illustrated Companion to the First World
War (London: Michael Joseph Ltd., 1989): p. 86.
8 For more details, see Vladimir Shkolnikov, France Meslé, and
Jacques Vallin, "La Crise Sanitaire en Russie: Tendences récentes de
lespérance de vie et des causes de décès de 1970 à 1993," Population
(Paris, 1995): nos. 4-5, pp. 907-943; Jose-Luis Bobadilla, Christine A. Costello, and
Faith Mitchell, eds., Premature Death in the New Independent States (Washington,
D.C.: National Academy Press, 1997).
9 World Health Statistics Annual 1996.
10 Zdavookhraneniye Rossiyskoy Federatsii 1999, no. 1
pp. 3-18; translated as "State Report on Public Health in 1997" in U.S. Foreign
Broadcast Information Service (hereafter FBIS), FBIS-SOV-1999-0405 (14 August 1999).
11 World Bank, World Development Report 1998/99 (New
York: Oxford University Press, 1998): pp. 192-193.
12 World Health Statistics Annual, 1993 and 1996
14 Ibid.; U.N. Population Division, Model Life
Tables for Developing Countries (New York: U.N., 1983).
15 Murray Feshbach, "Dead Souls," Atlantic
Monthly (January 1999): pp. 26-27.
16 For example, Murray Feshbach and Alfred Friendly, Jr., Ecocide
in the USSR: Health and Nature under Siege (New York: Basic Books, 1992); Murray
Feshbach, editor-in-chief, Environmental and Health Atlas of Russia (Moscow: Paims
Publishing House, 1995).
17 World Health Statistics Annual 1996.
18 Data in preceding paragraphs drawn from World Health
Statistics Annual, various editions.
19 David A. Leon et al., "Huge Variation in Russian
Mortality Rates 1984-94: Artefact, Alcohol, or What?," The Lancet, no. 9075,
vol. 350 (9 August 1997): pp. 383-388.
21 Zdravookhraneniye Rossiyskoy Federatsii (May-June
1998) no. 3, translated as "Russia: State Report on Public Health (Part 1),"
FBIS-TEN-98-341 (7 December 1998), electronic version; National Center for Health
Statistics, Vital Statistics of the United States 1992, vol. 2, part A
(Hyattsville, Md.: U.S. Department of Health and Human Services, Public Health Service,
1996): p. 206.
22 See Laurent Chenet et al., "Deaths from Alcohol and
Violence in Moscow: Socio-Economic Determinants," European Journal of Population,
vol. 14, no. 1 (1998): pp. 19-37.
23 See Laurent Chenet et al., "Alcohol and Cardiovascular
Mortality in Moscow: New Evidence of a Causal Association," Journal of
Epidemiology and Community Health, vol. 52, no. 12 (December 1998): pp. 772-774.
24 See, for example, Tony Charman and Irina Pervova,
"Self-Reported Depressed Mood in Russian and UK Schoolchildren: A Research
Note," Journal of Child Physchology and Psychiatry, vol. 37, no. 7 (1996): pp.
25 Martin Bobak et al., "Socioeconomic Factors, Perceived
Control and Self-Reported Health in Russia. A Cross-sectional Survey," Social
Science and Medicine, vol. 47, no. 2 (July 1998).
26 The Chechnyan rebellion does not alter this assessment. If
Chechnyan combat cost 50,000 deaths, as is commonly suggested, those losses would amount
to less than 2 percent of Russias "excess mortality" for 1992-98.
27 Charlotte Hoehn, "Kohortensterblichkeit unter
besonderer Berücksichtigung der Weltkriege," in Reiner Hans Dinkel, Charlotte Hoehn,
and Rembrandt D. Scholz, eds., Sterblichkeitsentwicklung unter besonderer
Berücksichtigung des Kohortsansatzes (Munich: Harald Boldt Verlag, 1996).
28 In the late 1980s, alcohol sales may have accounted for 12
percent of all Soviet state revenues and the fraction may have been even higher in
earlier years. See Stephen White, Russia Goes Dry: Alcohol, State, and Society
(New York: Cambridge University Press, 1996); Vladimir G. Treml, Alcohol in the USSR: A
Statistical Study (Durham, N.C.: Duke University Press, 1982).
In April 1992 the Russian Federation relinquished the states monopoly on liquor
sales; at the end of 1998, however, it reimposed that monopoly. See Dmitry Dukachayev,
"Vodka Monopoly Returns," Current Digest of the Post-Soviet Press, vol.
50, no. 30 (1998): p. 4.
29 R.S. Houlston et al., "Genetic Epidemiology of
Differences in Low-Density Lipoprotein (LDL) Cholesterol Concentration: Possible
Involvement at the Apolipoprotein B Gene Locus in LDL Kinetics," Genetic
Epidemiology, vol. 7, no. 3 (1990): pp. 199-210.
30 World Population Projects: The 1998 Revision.
31 "INTERFAX Statistical Report," vol. 7, issue 33,
no. 308 (14 August 1998); reprinted as "Russia: INTERFAX Statistical Report, 8-14
August 1998," FBIS-SOV-98-226 (14 August 1998), electronic version.
32 Lant Pritchett and Lawrence H. Summers, "Wealthier Is
Healthier," Journal of Human Resources, vol. 31, no. 4 (1996): pp. 841-868.
33 Robert W. Fogel, "Economic Growth, Population Theory
and Physiology: The Bearing of Long-Term Processes on the Making of Economic Policy,"
American Economic Review, vol. 84, no. 3 (1994): pp. 369-396.
34 World Development Report 1998/99.
35 David E. Bloom and Ajay S. Mahal, "Does the AIDS
Epidemic Threaten Economic Growth?" Journal of Econometrics, vol. 77, no. 1
(1997): pp. 105-127.
36 David E. Bloom and Pia Malaney, "Macroeconomic
Consequences of the Russian Mortality Crisis," World Development, vol. 26, no.
11 (1998): pp. 2073-2085.
37 According to the U.N. Population Divisions most
recent estimates, for example, life expectancy at birth in Botswana fell by almost 14
years between the early and the late 1990s.
38 Edward N. Luttwak, "Delusions of Soviet
Weakness," Commentary (January 1985): pp. 32-33.
39 Even if Russia cannot institutionalize its own full-fledged
RMA, it may be able to react with some effectiveness against RMAs by other states with
what Gen. John Reppert had described as "asymmetric responses" strategies
and techniques for disrupting its opponents information systems, for instance. See
John C. Repport, BG USA (Ret.), "The Russian Military and New Approaches to
Warfare," unpublished paper, Workshop on Russian Military Innovation, SAIC Strategic
Assessment Center, McLean, Va. (12 January 1999).