- Email: [email protected]
Response to letter from S.V. Jargin
p u b l i c h e a l t h 1 2 7 ( 2 0 1 3 ) 1 9 1 e1 9 2
Available online at www.sciencedirect.com
Public Health journal homepage: www.elsevier.com/puhe
Authors response
Response to letter from S.V. Jargin We are very pleased to respond to Dr Jargin’s letter commenting upon our article ‘Changing trends of diseases in Eastern Europe: closing the gap’.1 Russia, and Eastern Europe, need an intensified discussion on how to understand and close the health gap that divides these countries from the countries of Western Europe. Launching such a debate was one of the goals of the article, as well as of the report ‘Closing the health ski’s team.2,3 gap in the European Union’ prepared by Dr Zaton Dr Jargin offers a few remarks regarding our article, in particular he makes reference to our analysis of the health situation in Russia. We pointed out that Russia is one of the few countries in the world where life expectancy at birth in both sexes has not increased in the last half century. In the early 1960s, it reached 69 years, while at the end of the first decade of the 21st Century, it stood at 67 years.3 The health disaster in Russia began in the early 1960s, during the high point of Communism. Its causes must be sought in the socioeconomic policies of the countries of the Soviet Bloc, which stood in stark contrast with the science-based health policies (e.g. tobacco and alcohol control) which started being adopted by Western countries at this time. In our work, we singled out vodka binge drinking as the key proximal cause of the Russian health disaster.1,3 It is difficult to disagree with the first part of Dr Jargin’s letter regarding potential misclassification and overdiagnosis of cardiovascular diseases in Russia and much of postCommunist Eastern Europe. This phenomenon, particularly of the death statistics, is described in a number of scientific studies, but surely much more research on the topic is needed, especially robust studies conducted by local scientists. It is especially important as the biological effect on the cardiovascular system may be different in cases of moderate consumption (‘Mediterranean’ style of drinking) than in cases of binge drinking to the point of severe intoxication.2,4 However, instances of such misclassification do not directly address the huge problem of premature mortality and its causes in Russia. In the second part of his letter, Dr Jargin proposed that ‘insufficient availability of modern health care’ might play a more important role in explaining premature mortality in today’s Russia than the high levels of alcohol consumption. He also offers the paradoxical explanation that the catastrophic levels of binge drinking in Russia during the collapse of the
DOI of original article: http://dx.doi.org/10.1016/j.puhe.2012. 11.003.
Soviet Union in the 1990s were a result of Gorbachev’s antialcohol campaign. Since the early 1990s, a hypothesis emerged that one of the main reasons for the huge premature mortality fluctuations among young and middle-aged inhabitants of Eastern Europe, especially Russia, is the high level of vodka binge drinking.2,3,5e9 This was initially met with disbelief or rejection, with many colleagues maintaining that alcohol can, in fact, have a positive overall effect on life expectancy in Eastern as well as Western Europe, through a putative protective influence on the main cause of mortality: ischaemic heart disease. However, in the last decade, after a series of epidemiological studies, a general consensus has formed on the key role of alcohol in the high premature mortality rates in Russia and other vodka binge drinking countries of the region.1 It must be remembered that the roots of the East European alcohol health disaster lie in the early years of the Soviet Bloc, and not in the time of its collapse. The development of the key phenomena destructive to health began in the 1950s and 1960s. For example: consumption of alcohol increased in Poland between 1950 and the early 1980s from 4 l/adult/year to 12 l/adult/year; while consumption of cigarettes increased from 1065 cigarettes/adult/year to 2648 cigarettes/adult/year; the highest level of consumption in the world at the time. The case was similar in all countries of the Eastern Bloc. These developments resulted in a situation rarely encountered during times of peace: every year, the mortality of young and middle-aged adults, especially men, increased, and the life expectancy after 15 years of age declined.3 This was happening at the same time as the number of doctors and hospital beds was growing in the Eastern Bloc, exceeding the numbers in OECD countries in the 1990s.10 We must remember that premature mortality of young and middle-aged adult (15e59 years) males in Russia, among the highest in the world during the collapse of the Soviet Union in the 1990s, remains amongst the highest today. It is currently higher not only in the countries of Western Europe with widely available modern health care, but also higher than that in China, India and sub-Saharan African countries.11 It is also important to remember that infant mortality, a good indicator of the functioning of health care, declined steadily in Russia during the 1990s, and is currently almost at single-digit levels. In this respect, Russia is firmly entrenched in the group of welldeveloped countries, which is not the case if we look at adult and middle-aged male mortality. While improvements in health care are always desirable, it seems that it is in evidence-
192
p u b l i c h e a l t h 1 2 7 ( 2 0 1 3 ) 1 9 1 e1 9 2
based public health policy (and potentially the introduction of the Health in All Policy approach present in Western Europe) that an avenue for solving Russia’s 60-year-old health crisis should be sought (Semashko’s ‘universal health system’ with full medicalization model vs Lalonde ‘health fields’ and Dalgren, Whitehead social health concepts).3,12e15 Evidence and science-based public health policy is still more a challenge than reality in all post-Communist countries, including the current members of the European Union, and drastic and decisive action is required. I fully agree with the last sentence in Dr Jargin’s letter e international collaboration is the key for closing the health gap dividing Russia and Eastern Europe from the Western countries e and we hope that future scientific endeavours can help to contribute meaningfully to this.
9.
10. 11. 12.
13. 14.
references
ski WA, Bhala N. Changing trends of diseases in Eastern 1. Zaton Europe: closing the gap. Public Health 2012;126:248e52. ski W. Closing the health gap in European union. Warsaw: 2. Zaton Cancer Epidemiology and Prevention Division, Maria Sk1odowska-Curie Memorial Cancer Center and Institute of Oncology. Available at: http://www.hem.waw.pl/; 2008 [last accessed 01.10.12]. ski WA. Epidemiological analysis of health situation 3. Zaton development in Europe and its causes until 1990. Ann Agric Environ Med 2011;18:194e202. 4. Bagnardi V, Zatonski W, Scotti L, La Vecchia C, Corrao G. Does drinking pattern modify the effect of alcohol on the risk of coronary heart disease? Evidence from a meta-analysis. J Epidemiol Community Health 2008;62:615e9. ski W. The health of the Polish population. Public Health 5. Zaton Rev Isr 1995;23:139e56. ski W, Boyle P. Commentary. Health transformations in 6. Zaton Poland after 1988. J Epidemiol Biostat 1996;1:183e97. ski W. Alcohol and health: what is good for the French 7. Zaton may not be for the Russians. J Epidemiol Community Health 1998;52:766e7. ski W, Jha P. The health transformation in Eastern Europe 8. Zaton after 1990: a second look. Warsaw: Cancer Center and Institute of Oncology. Available at: http://www.hem.waw.pl/files/The_
15.
Health_Transformation_in_Eastern_Europe_after_1990_-_A_ Second_Look.pdf; 2000 [last accessed 27.11.12]. czuk M, Boffetta P, Powles J, Rehm J, Sulkowska U, Man Popova S, et al. Alcohol accounts for a high proportion of premature mortality in central and eastern Europe. Int J Epidemiol 2007;36:458e67. Feachem R. Health decline in Eastern Europe. Nature 1994; 367:313e4. Murray C, Lopez A. Global and regional cause-of-death patterns in 1990. Bull World Health Organ 1994;72:447e80. Health and Medical Administration. Public health and medical administration. In: Red medicine: socialized health in Soviet Russia. Garden City, NY: DoubleDay, Doran & Company, Inc. Available at: http://www.marxists.org/archive/newsholme/ 1933/red-medicine/ch16.htm; 1933 [last accessed 27.11.12]. Lalonde M. A new perspective on the health of Canadians; a working document. Ottawa: Information Canada; 1974. Dahlgren G, Whitehead M. Policies and strategies to promote social equity in health. Stockholm: Institute for Future Studies. Available at: http://www.framtidsstudier.se/wp-content/ uploads/2011/01/20080109110739filmZ8UVQv2wQFShMRF6 cuT.pdf; 1991 [last accessed 27.11.12]. Terris M. Restructuring and accelerating the development of the Soviet health service: preliminary observations and recommendations. J Public Health Policy 1988;9:537e43.
ski* W. Zaton Department of Cancer Epidemiology & Prevention, Cancer Center and Institute of Oncology, 5 Roentgena Str., 02-781 Warsaw, Poland N. Bhala Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK *Corresponding author. Tel./fax: þ48 22 643 92 34. ski) E-mail address: [email protected] (W. Zaton Available online 20 December 2012 0033-3506/$ e see front matter ª 2012 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.puhe.2012.11.004
Available online at www.sciencedirect.com
Public Health journal homepage: www.elsevier.com/puhe
Authors response
Response to letter from S.V. Jargin We are very pleased to respond to Dr Jargin’s letter commenting upon our article ‘Changing trends of diseases in Eastern Europe: closing the gap’.1 Russia, and Eastern Europe, need an intensified discussion on how to understand and close the health gap that divides these countries from the countries of Western Europe. Launching such a debate was one of the goals of the article, as well as of the report ‘Closing the health ski’s team.2,3 gap in the European Union’ prepared by Dr Zaton Dr Jargin offers a few remarks regarding our article, in particular he makes reference to our analysis of the health situation in Russia. We pointed out that Russia is one of the few countries in the world where life expectancy at birth in both sexes has not increased in the last half century. In the early 1960s, it reached 69 years, while at the end of the first decade of the 21st Century, it stood at 67 years.3 The health disaster in Russia began in the early 1960s, during the high point of Communism. Its causes must be sought in the socioeconomic policies of the countries of the Soviet Bloc, which stood in stark contrast with the science-based health policies (e.g. tobacco and alcohol control) which started being adopted by Western countries at this time. In our work, we singled out vodka binge drinking as the key proximal cause of the Russian health disaster.1,3 It is difficult to disagree with the first part of Dr Jargin’s letter regarding potential misclassification and overdiagnosis of cardiovascular diseases in Russia and much of postCommunist Eastern Europe. This phenomenon, particularly of the death statistics, is described in a number of scientific studies, but surely much more research on the topic is needed, especially robust studies conducted by local scientists. It is especially important as the biological effect on the cardiovascular system may be different in cases of moderate consumption (‘Mediterranean’ style of drinking) than in cases of binge drinking to the point of severe intoxication.2,4 However, instances of such misclassification do not directly address the huge problem of premature mortality and its causes in Russia. In the second part of his letter, Dr Jargin proposed that ‘insufficient availability of modern health care’ might play a more important role in explaining premature mortality in today’s Russia than the high levels of alcohol consumption. He also offers the paradoxical explanation that the catastrophic levels of binge drinking in Russia during the collapse of the
DOI of original article: http://dx.doi.org/10.1016/j.puhe.2012. 11.003.
Soviet Union in the 1990s were a result of Gorbachev’s antialcohol campaign. Since the early 1990s, a hypothesis emerged that one of the main reasons for the huge premature mortality fluctuations among young and middle-aged inhabitants of Eastern Europe, especially Russia, is the high level of vodka binge drinking.2,3,5e9 This was initially met with disbelief or rejection, with many colleagues maintaining that alcohol can, in fact, have a positive overall effect on life expectancy in Eastern as well as Western Europe, through a putative protective influence on the main cause of mortality: ischaemic heart disease. However, in the last decade, after a series of epidemiological studies, a general consensus has formed on the key role of alcohol in the high premature mortality rates in Russia and other vodka binge drinking countries of the region.1 It must be remembered that the roots of the East European alcohol health disaster lie in the early years of the Soviet Bloc, and not in the time of its collapse. The development of the key phenomena destructive to health began in the 1950s and 1960s. For example: consumption of alcohol increased in Poland between 1950 and the early 1980s from 4 l/adult/year to 12 l/adult/year; while consumption of cigarettes increased from 1065 cigarettes/adult/year to 2648 cigarettes/adult/year; the highest level of consumption in the world at the time. The case was similar in all countries of the Eastern Bloc. These developments resulted in a situation rarely encountered during times of peace: every year, the mortality of young and middle-aged adults, especially men, increased, and the life expectancy after 15 years of age declined.3 This was happening at the same time as the number of doctors and hospital beds was growing in the Eastern Bloc, exceeding the numbers in OECD countries in the 1990s.10 We must remember that premature mortality of young and middle-aged adult (15e59 years) males in Russia, among the highest in the world during the collapse of the Soviet Union in the 1990s, remains amongst the highest today. It is currently higher not only in the countries of Western Europe with widely available modern health care, but also higher than that in China, India and sub-Saharan African countries.11 It is also important to remember that infant mortality, a good indicator of the functioning of health care, declined steadily in Russia during the 1990s, and is currently almost at single-digit levels. In this respect, Russia is firmly entrenched in the group of welldeveloped countries, which is not the case if we look at adult and middle-aged male mortality. While improvements in health care are always desirable, it seems that it is in evidence-
192
p u b l i c h e a l t h 1 2 7 ( 2 0 1 3 ) 1 9 1 e1 9 2
based public health policy (and potentially the introduction of the Health in All Policy approach present in Western Europe) that an avenue for solving Russia’s 60-year-old health crisis should be sought (Semashko’s ‘universal health system’ with full medicalization model vs Lalonde ‘health fields’ and Dalgren, Whitehead social health concepts).3,12e15 Evidence and science-based public health policy is still more a challenge than reality in all post-Communist countries, including the current members of the European Union, and drastic and decisive action is required. I fully agree with the last sentence in Dr Jargin’s letter e international collaboration is the key for closing the health gap dividing Russia and Eastern Europe from the Western countries e and we hope that future scientific endeavours can help to contribute meaningfully to this.
9.
10. 11. 12.
13. 14.
references
ski WA, Bhala N. Changing trends of diseases in Eastern 1. Zaton Europe: closing the gap. Public Health 2012;126:248e52. ski W. Closing the health gap in European union. Warsaw: 2. Zaton Cancer Epidemiology and Prevention Division, Maria Sk1odowska-Curie Memorial Cancer Center and Institute of Oncology. Available at: http://www.hem.waw.pl/; 2008 [last accessed 01.10.12]. ski WA. Epidemiological analysis of health situation 3. Zaton development in Europe and its causes until 1990. Ann Agric Environ Med 2011;18:194e202. 4. Bagnardi V, Zatonski W, Scotti L, La Vecchia C, Corrao G. Does drinking pattern modify the effect of alcohol on the risk of coronary heart disease? Evidence from a meta-analysis. J Epidemiol Community Health 2008;62:615e9. ski W. The health of the Polish population. Public Health 5. Zaton Rev Isr 1995;23:139e56. ski W, Boyle P. Commentary. Health transformations in 6. Zaton Poland after 1988. J Epidemiol Biostat 1996;1:183e97. ski W. Alcohol and health: what is good for the French 7. Zaton may not be for the Russians. J Epidemiol Community Health 1998;52:766e7. ski W, Jha P. The health transformation in Eastern Europe 8. Zaton after 1990: a second look. Warsaw: Cancer Center and Institute of Oncology. Available at: http://www.hem.waw.pl/files/The_
15.
Health_Transformation_in_Eastern_Europe_after_1990_-_A_ Second_Look.pdf; 2000 [last accessed 27.11.12]. czuk M, Boffetta P, Powles J, Rehm J, Sulkowska U, Man Popova S, et al. Alcohol accounts for a high proportion of premature mortality in central and eastern Europe. Int J Epidemiol 2007;36:458e67. Feachem R. Health decline in Eastern Europe. Nature 1994; 367:313e4. Murray C, Lopez A. Global and regional cause-of-death patterns in 1990. Bull World Health Organ 1994;72:447e80. Health and Medical Administration. Public health and medical administration. In: Red medicine: socialized health in Soviet Russia. Garden City, NY: DoubleDay, Doran & Company, Inc. Available at: http://www.marxists.org/archive/newsholme/ 1933/red-medicine/ch16.htm; 1933 [last accessed 27.11.12]. Lalonde M. A new perspective on the health of Canadians; a working document. Ottawa: Information Canada; 1974. Dahlgren G, Whitehead M. Policies and strategies to promote social equity in health. Stockholm: Institute for Future Studies. Available at: http://www.framtidsstudier.se/wp-content/ uploads/2011/01/20080109110739filmZ8UVQv2wQFShMRF6 cuT.pdf; 1991 [last accessed 27.11.12]. Terris M. Restructuring and accelerating the development of the Soviet health service: preliminary observations and recommendations. J Public Health Policy 1988;9:537e43.
ski* W. Zaton Department of Cancer Epidemiology & Prevention, Cancer Center and Institute of Oncology, 5 Roentgena Str., 02-781 Warsaw, Poland N. Bhala Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK *Corresponding author. Tel./fax: þ48 22 643 92 34. ski) E-mail address: [email protected] (W. Zaton Available online 20 December 2012 0033-3506/$ e see front matter ª 2012 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.puhe.2012.11.004