Russia is different…

1. Russia is different… Martin McKee London School of Hygiene and Tropical Medicine & European Observatory on Health Systems and Policies Dubai, January 2006

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

3. 75 female 70 65 male years 60 55 50 1970 1980 1990 2000 Death of a nation Life expectancy at birth

4. Percentage variation in myocardial infarction explained by nine risk factors … and this is among survivors: In former Soviet Union, twice as many cardiac deaths are sudden Source: INTERHEART

5. 15.5 15 700 14.5 male 600 % of total weekly deaths 14 500 13.5 13 400 female 12.5 300 12 200 11.5 100 Fri Sat Sun Wed Mon Tues Thurs 0 1980 1985 1990 1995 2000 2005 Ischaemic heart disease over time Deaths among men aged 35-45 from IHD Age standardised death rates per 100,000

6. collapse of USSR rise in illegal production Could alcohol play a role? Trends in life expectancy at birth 75 female anti-alcohol 70 campaign begins Life expectancy at birth (years) male 65 60 55 1970 1980 1990 2000 Source: WHO

7. Variation in the life expectancy decrease for men across regions of European Russia Walberg, McKee et al., 1998 7

8. 80 70 60 50 redundancies/1,000 employees sum of hirings and 40 30 20 10 0 0 5 10 15 20 % fall in male life expectancy Association between labour turnover in 1993/4 and fall in life expectancy 1990-94

9. 3 3 2 2 1 1 0 0 1-14 15-34 35-64 65+ -1 Contribution of deaths from different causes and at different ages to differences in life expectancy in best and worst regions Other Alcohol related Years of life lost/ gained Injuries Respiratory diseases Infectious diseases Other Neoplasms Resp. cancer Cerebro vascular Cardio vascular Age group

10. And what about health care? • Death rate from avoidable mortality in UK and Russia similar in 1965, when little could be done • Gap began to widen in 1970s, and has continued to do so since

11. The Soviet health system • A great success, at first • But funded according to the “residual” principle – what was left after everything else • It just failed to adapt to modern health care “If communism does not destroy the louse, the louse will destroy communism” Lenin

12. 30 25 20 15 10 5 0 1980 1985 1990 1995 2000 Chronic disease: the critical challenge Age standardised death rate, Diabetes mellitus, per 100,000 Armenia Azerbaijan Belarus Georgia Kazakhstan Kyrgyzstan Republic of Moldova Russian Federation Tajikistan Turkmenistan Ukraine Uzbekistan

13. Patients speak: interviews with patients living with diabetes in Kyrgyzstan • “It was fine in the old times but now it is worse, …” • “What is the point of going to the health centre if nothing is available, no equipment…. I always go to the city endocrinology dispensary for blood and urine tests even it is more difficult and expensive for me.” • “Our health centre is mainly closed and I never know when it is open.” • “I live far away from the city in a small village where the health centre doesn’t have insulin. I am worried that I won’t get insulin for a few days or even a week because we don’t have a car to go to the rayon (district) health centre and we need to wait until someone in the village goes there.” Hopkinson, Balabanova, McKee & Kutzin, 2004

14. Nenets autonomous district Arkhangelsk region Taimyr (Dolgano-Nenetz) autonomous district Tver region Vologda region Yaroslavl region Russian Federation Republic of Komi Kostroma region Ivanovo region Vladimir region Yamalo-Nenetz autonomous district Tula region Oryol region Ryazan region Kirov region Lipetzk region Nizhny Novgorod region Komi-Permyatzky autonomous district Republic of Mariy El Republic of Mordovia Tambov region Chuvash republic Penza region Khanty-Mansi autonomous district Perm region Udmurt republic Ulyanovsk region Republic of Tatarstan Sverdlovsk region Evenki autonomous district Volgograd region Saratov region Samara region Rostov region Tyumen region Chelyabinsk region Krasnoyarsk region Kurgan region Khabarovsk territory Tomsk region Irkutsk region Kemerov region Chita region Republic of Khakasia Ust-Ordynsky Buryat autonomous district The Izhevsk Family Study Udmurtia Investigators: London: Dave Leon Martin McKee Susannah Tomkins Izhevsk Nikolai Kiryanov Lyudmilla Subarova Rostock Vladimir Shkolnikov Evgeniy Andreev Moscow Izhevsk = 0.65 million Udmurtia = 1.6 million Russia = 143 million

15. The Izhevsk Family Study • Case control study • 1700 cases (men dying between ages 25 and 54) and 1700 controls • Information obtained on cases from proxy informants (family members) • Information on controls from the controls themselves and from proxies • Supplemented with detailed information from police, narcology service, social services, and autopsy data

16. Important questions without answers • What proportion of all deaths are caused by alcohol abuse ? • How big is the problem of deaths due to toxic impurities ? • Whether deaths from causes not obviously related to alcohol are in fact due to alcohol abuse? • How big is the problem of problem drinking in the population ? • How strongly is it related to social and economic characteristics ?

17. Drinking in Russia • What is being drunk? • Vodka • Surrogate spirits • Alcohol containing medicines • Samogon (moonshine) • 8% of healthy controls drink substances not intended for drinking! • How is it drunk • Heavy episodic consumption • Zapoi – a Russian word meaning getting so drunk that you withdraw from social interaction for several days • 12% of controls report zapoi

18. Vodka: a selection

19. Samogon

20. Surrogate spirits

21. Alcohol containing medicines

22. How much ethanol?

23. Correlates of alcohol abuse(in live controls)

24. All case mortality according to frequency of surrogate drinking (relative to never surrogates) 40.0 OR1 Adjusted for age OR2 Adjusted for age and smoking OR3 Adjusted for age and education OR1 OR4 Adjusted for age, smoking and education OR2 OR3 OR4 20.0 10.0 Mortality odds ratio 5.0 2.5 1.25 Every day 5-6 times per 3-4 times per 1-2 times per 1-3 times per A few times a week week week month year Frequency of surrogate drinking

25. …and by cause (adjusted for smoking and education)

26. Some more detail

27. Surrogates or ordinary drinking?All cause mortality

28. Of course it is absolute rather than relative risk we are concerned with: The scale of the problem in men of working age (25-54 years) • 18% of deaths are due to causes that are certified by a doctor as being directly caused by alcohol (e.g. alcoholic cirrhosis and alcohol poisoning) • A minimum of 20% of deaths from all other causes attributable to alcohol abuse (e.g. surrogates and/or zapoi) • Total burden = 18% + 20% = 38% of all deaths due to alcohol abuse (does not include effect of “normal” drinking)

29. Do these findings help us to understand what happened in Russia in early 1990s? • Life expectancy dropped markedly • But not all causes of death affected to same extent • Almost no change in cancer, but large changes in some other causes Ratio of death rates in 1994 to those in 1987: men aged 40-44

30. Cause-specific mortality odds ratios for surrogate vs non-surrogate drinkers in the Izhevsk Family Study compared with relative changes in age-standardised mortality rates among men aged 25-54 in Russia 1994/1991 6 6 5 5 Mental disorders Pearson r = 0.93 Pearson r = 0.93 4 4 1994/1991 3 3 Ratio age-stndardised Russian mortality rates 2 2 1 1 0 0 0 0 5 5 10 10 15 15 20 20 25 25 30 30 35 35 40 40 Mortality ORs for surrogate drinking

31. A mechanism? Social and economic factors (pace of transition) (un) conventional risk factors Health care stress Death

32. 80 70 Hungary 60 50 40 30 Romania 20 EU average 10 0 <70 1980 1985 1990 1995 2000 <56 <42 <28 <14 No data 1996 Min: 0 Back to alcohol: the cirrhosis belt Age standardised death rate chronic liver disease & cirrhosis, age 0-64/100,000 Source: WHO

33. What else is being drunk elsewhere? • Cane spirit (Latin America/ Africa) • Fruit brandies (eastern Europe) Moonshine Hooch Arrack What else? Nascimento, Cardoso, Neto, Franco & Farias, 1998 Szűcs, Sárváry, McKee, Ádány, 2005

34. A night out in Tallinn…

35. What is going on? • In Russian cities, a significant number of people drink surrogate alcohols • Probably different in rural areas, where the equivalent is samogon (home produced) • Surrogates twice as strong and 1/3 the price – i.e. six times cheaper for a given volume of alcohol • Observed effects may be that once someone crosses threshold to regular surrogate consumption, price barrier essentially disappears • However, where home produced spirits drunk, possibility of additional toxic organ damage

36. Implications for PURE? • Russia is different, but maybe not so different • Even in the exceptions, identifiable biological risk factors are likely to be very important • Look beyond beer, wine and spirits • Don’t forget the impact of health care