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Public health in eastern Europe
PUBLIC HEALTH: RUSSIA
'ealth crises in Russia Public h e a l t h in e a s t e r n the soleprovider of safety nets for the population, had been dominate discussion fuelled largely by state exports .about public health in of natural resources. Manueastern Europe. Their impact Andrei K Demine facturing, and therefore the urges policy response with, in labour force, ~uas only of the words of Rudyard Kipling, secondary importance. Nevertheless, social security of "1 million hows, 2 million wheres, and 7 million whys". Soviet citizens--put aside its quantity and quality--was Health-related issues used to be state secret until 1985. more comprehensive compared with that in western From 1992 onwards, the President ordered publication of countries. Destruction of this social system, which was the State Report on population health on a yearly basis. regarded as an intrinsic part of the totalitarian state, Relevant statistics were declassified legally in 1993. Russia had been losing many people in the 20th century provided resources for reform. "Shock therapy" (ie, the liberalisation of prices) wiped due to the war with Japan, savings. Abolition of the state World War I, the civil war monopoly on foreign trade, after the 1917 October natural resources, and Revolution, forced collectalcohol turnover, and the ivism of peasants, hunger unfair privatisation of during industrialisation, and state property created a the Stalinist repression. Over de-industrialised, export25 million people died in oriented privatised economy World War II. beneficial only to a slnaU Average life expectancy part of the population and increased during 1947-64 to certain forces of globalto up to 64 years among isation. Privatisation failed to men and 73 years among substitute the Soviet-state w o m e n - - a level similar to safety nets and most of the that in westem countries. population did not have the Since then health trends have At the front line of Russia's public-health crisis economic potency to recreate diverged. and procreate. Personal In the late 1960s, an excess income now in purchase-power parity is equal to that in the of deaths over births started among the rural population of USA in 1897, a third of citizens live below the poverty nine regions of central Russia. By 1977-78, life expectancy level, and the average monthly salary is US$74. Most among rural men fell to 58 years. About 900 000 people depend on their gardens. One third of salaries is premature deaths were prevented in 1985-87, which was generated in the "grey" sector--the so-called shadow attributed to initiatives such as the campaign against economy. 8"5 million are unemployed. Payment of foreign alcoholism, with a gain in life expectancy of up to 64.9 and debts absorbs a considerable portion of the gross domestic 74.6 years, in men and women, respectively. But familyproduct. friendly programmes, implemented in the late 1980s, could An excess of deaths over births parallels, though lags not prevent the excess of deaths over births that started in behind, these changes. A shrinking population is leading to November, 1991, before the dissolution of the USSR. its absolute deficit. Russia must prevent depopulation, first The overall health decline from 1964 to 1991 is of all in Siberia and the Far East to ensure its own survival explained by sacrificing social issues to military demands and stability. The global security r01e of Russia, during the "Cold" War. The dissolution of the USSR and acknowledged by its G8 membership, also necessitates a the shift away from a bipolar world crashed "Soviet healthy population size similar to that of the USA. civilisation" as a global phenomenon with profound Responses include family-friendly policies, and strategies repercussions for public health in eastem Europe. Burn-out of working-age men due to to promote health and immigration. Three players shape psychoactive-substance social security: the state, private enterprises, and society. The capacity of the latter two is currently compromised. abuse, a falling number of births, re-emergence of Therefore, the state will have to play the decisive part in breaking the vicious circle of poverty, disease, premature sexually transmitted disdeaths, and depopulation. Support for society and eases, tuberculosis, and incentives for the private sector should be legislated. other infections became Revenues from exports and competitive sectors of the typical for the transition economy should be redistributed to social security and to period. Births went down by employment initiatives, which in turn would raise incomes two-thirds in 1988-94 and life expectancy fell to 57-6 of private households. In February, 2000, the State Statistical Committee years in men. After an forecasted a decline of the population by 2016 by increase to 61"3 and then 11"6 million from its current 145.6 million. President 72.9 years during 1994-98, Vladimir Putin in his speech to National Parliament on July it declined again in 1999. 8, 2000, started his review of the most pressing issues Russia is facing a relative Russia is facing, with citing a forecast on population surplus and an absolute decline. In his words, the survival of the nation would be shortage of population. endangered if this trend persists. The President's policy The economy and aimed at strengthening of the state creates necessary industry, and with it the prerequisites to a resolution of our public-health crisis. state social programmes as
H
s49
Europe
T h e Lancet Perspectives • 356 • D e c e m b e r . 2000
'ealth crises in Russia Public h e a l t h in e a s t e r n the soleprovider of safety nets for the population, had been dominate discussion fuelled largely by state exports .about public health in of natural resources. Manueastern Europe. Their impact Andrei K Demine facturing, and therefore the urges policy response with, in labour force, ~uas only of the words of Rudyard Kipling, secondary importance. Nevertheless, social security of "1 million hows, 2 million wheres, and 7 million whys". Soviet citizens--put aside its quantity and quality--was Health-related issues used to be state secret until 1985. more comprehensive compared with that in western From 1992 onwards, the President ordered publication of countries. Destruction of this social system, which was the State Report on population health on a yearly basis. regarded as an intrinsic part of the totalitarian state, Relevant statistics were declassified legally in 1993. Russia had been losing many people in the 20th century provided resources for reform. "Shock therapy" (ie, the liberalisation of prices) wiped due to the war with Japan, savings. Abolition of the state World War I, the civil war monopoly on foreign trade, after the 1917 October natural resources, and Revolution, forced collectalcohol turnover, and the ivism of peasants, hunger unfair privatisation of during industrialisation, and state property created a the Stalinist repression. Over de-industrialised, export25 million people died in oriented privatised economy World War II. beneficial only to a slnaU Average life expectancy part of the population and increased during 1947-64 to certain forces of globalto up to 64 years among isation. Privatisation failed to men and 73 years among substitute the Soviet-state w o m e n - - a level similar to safety nets and most of the that in westem countries. population did not have the Since then health trends have At the front line of Russia's public-health crisis economic potency to recreate diverged. and procreate. Personal In the late 1960s, an excess income now in purchase-power parity is equal to that in the of deaths over births started among the rural population of USA in 1897, a third of citizens live below the poverty nine regions of central Russia. By 1977-78, life expectancy level, and the average monthly salary is US$74. Most among rural men fell to 58 years. About 900 000 people depend on their gardens. One third of salaries is premature deaths were prevented in 1985-87, which was generated in the "grey" sector--the so-called shadow attributed to initiatives such as the campaign against economy. 8"5 million are unemployed. Payment of foreign alcoholism, with a gain in life expectancy of up to 64.9 and debts absorbs a considerable portion of the gross domestic 74.6 years, in men and women, respectively. But familyproduct. friendly programmes, implemented in the late 1980s, could An excess of deaths over births parallels, though lags not prevent the excess of deaths over births that started in behind, these changes. A shrinking population is leading to November, 1991, before the dissolution of the USSR. its absolute deficit. Russia must prevent depopulation, first The overall health decline from 1964 to 1991 is of all in Siberia and the Far East to ensure its own survival explained by sacrificing social issues to military demands and stability. The global security r01e of Russia, during the "Cold" War. The dissolution of the USSR and acknowledged by its G8 membership, also necessitates a the shift away from a bipolar world crashed "Soviet healthy population size similar to that of the USA. civilisation" as a global phenomenon with profound Responses include family-friendly policies, and strategies repercussions for public health in eastem Europe. Burn-out of working-age men due to to promote health and immigration. Three players shape psychoactive-substance social security: the state, private enterprises, and society. The capacity of the latter two is currently compromised. abuse, a falling number of births, re-emergence of Therefore, the state will have to play the decisive part in breaking the vicious circle of poverty, disease, premature sexually transmitted disdeaths, and depopulation. Support for society and eases, tuberculosis, and incentives for the private sector should be legislated. other infections became Revenues from exports and competitive sectors of the typical for the transition economy should be redistributed to social security and to period. Births went down by employment initiatives, which in turn would raise incomes two-thirds in 1988-94 and life expectancy fell to 57-6 of private households. In February, 2000, the State Statistical Committee years in men. After an forecasted a decline of the population by 2016 by increase to 61"3 and then 11"6 million from its current 145.6 million. President 72.9 years during 1994-98, Vladimir Putin in his speech to National Parliament on July it declined again in 1999. 8, 2000, started his review of the most pressing issues Russia is facing a relative Russia is facing, with citing a forecast on population surplus and an absolute decline. In his words, the survival of the nation would be shortage of population. endangered if this trend persists. The President's policy The economy and aimed at strengthening of the state creates necessary industry, and with it the prerequisites to a resolution of our public-health crisis. state social programmes as
H
s49
Europe
T h e Lancet Perspectives • 356 • D e c e m b e r . 2000