European Centre on Health of Societies in Transition, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK. E-mail: martin.mckee{at}lshtm.ac.uk
It has almost become a cliché to talk of winners and losers in the transition to democracy in the former Soviet Union. Like the men in grey suits (the arms dealers) who did well out of the First World War, some have seen their fortunes improve beyond their wildest dreams. Some of the most extreme examples are in Russia where a small group of oligarchs effectively appropriated the assets of the state for their own private gain. At the same time, many of their compatriots have seen once secure jobs disappear, or more often continue but with payment in arrears or not at all, recalling the old joke that communism was where you pretend to work and we pretend to pay you.
It is not just at the level of individuals that there have been winners and losers. Some of the newly independent countries that emerged from the Soviet Union have also fared better than others. The most tragic examples are Tajikistan, Moldova, and the countries of the Caucasus, which have been wracked by wars. Others escaped this fate but, as in Belarus and Turkmenistan, were denied the promise of democratic reform as the former communist leaders reinvented themselves, installing regimes that were at least as repressive as those in the communist era. But some have, on the surface at least, done well. The three Baltic states are already members of NATO and they stand on the brink of European Union membership. They have stable democratic structures and have aligned their laws with those in Western Europe.
Yet there is a paradox. A visitor to a large Finnish owned supermarket in Tallinn, the capital of Estonia, could be forgiven for thinking he or she was in Helsinki. However, Estonias health statistics more closely resemble those of Russia, and indeed until 1998 the trajectory of life expectancy in Russia and Estonia was almost parallel (Figure 1). Estonia (in common with its Baltic neighbours) is at last achieving sustained improvements in health. But is everyone gaining to the same extent? By taking advantage of data from the 2000 census, Leinsalu et al. have shown us that even in Estonia, which has fared relatively well, transition has also brought winners and losers.1
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It is possible to gain valuable insights from the authors analysis by cause of death. It is apparent that even in the best educated group gains have been uneven. Deaths from ischaemic heart disease have fallen extremely rapidly, at a rate that questions once again our understanding of the aetiology of this disease. It is increasingly clear that traditional explanatory models, largely derived from studies such as that in Framingham, do not predict mortality well in many other populations,2 and nor do they predict the changes that have been seen in Eastern Europe in the last decade. In countries where the potential scope for prescribing expensive statins is enormous there is an urgent need to understand better the inter-related roles played by lipids and by other dietary components, in particular fruit and vegetables.3
This very large decline in deaths from ischaemic heart disease tends to obscure the fact that deaths from alcoholic liver cirrhosis, alcohol poisoning, and homicide have all increased, even among the best educated. While in each case the absolute numbers are still small, the relative increases have been very substantial, with, for example, a more than doubling of the death rate from homicide. The role of alcohol is, once again in this region, all too apparent.4
Yet when we seek explanations for the widening gap in life expectancy, as the authors note, the picture is complex. Some causes, such as lung cancer, clearly have their origins in the period before transition.5 Others, such as homicides and deaths from infectious diseases clearly reflect contemporary circumstances. The authors identify many possible factors, including impoverishment and differences in timely access to effective health care. Their identification of the importance of alcohol has clear and immediate implications for policy. But otherwise these findings raise as many questions as they answer. Premature death is often the final step in a long sequence of events, with scope to prevent progression at many stages, from social and economic change through primary prevention to medical care. This paper suggests that there are numerous failures along the way. One immediate step to a better understanding would be to trace the pathways that these individuals have followed to identify what went wrong and why. This approach can identify problems that would otherwise remain invisible, as was seen in a study that looked at the circumstances leading to death among young people with diabetes in Ukraine,6 or in one that looked at those being murdered in Russia.7
While the health consequences of transition in this region will, over time, continue to provide much information that will help us to understand the determinants of disease (and in doing so will prevent the uncritical application of research conducted on populations where the pattern of risk factors is quite different) there is a need for other methods that provide some answers now. And of course, political action to strengthen social safety nets and to redistribute resources need not wait for epidemiological research.
This paper is an extremely valuable first step in reaching a population diagnosis in Estonia. It will now be important to follow up the numerous questions it raises to understand why so many Estonians are still dying prematurely. One obvious next step, albeit one that may be controversial, would be to look for any differences in the experiences of ethnic Estonians and Russians in Estonia. It will also be important for those working in other former Soviet republics to repeat the exercise to see whether their situation is different, and, if so, in what ways and why.
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2 Hense H-W, Schulte H, Löwel H, Assmann G, Keil U. Framingham risk function overestimates risk of coronary heart disease in men and women from Germanyresults from MONICA Augsburg and the PROCAM cohorts. Eur Heart J 2003;24:93745.
3 McKee M, Perry I. Ischaemic heart disease: more than just lipids? Eur J Public Health 2002;12:24142.
4 McKee M, Pomerleau J, Robertson A et al. Alcohol consumption in the Baltic Republics. J Epidemiol Community Health 2000;54:36166.
5 Shkolnikov V, McKee M, Leon D, Chenet L. Why is the death rate from lung cancer falling in the Russian Federation? Eur J Epidemiol 1999;15:20306.[CrossRef][ISI][Medline]
6 Telishevska M, Chenet L, McKee M. Towards an understanding of the high death rate among young people with diabetes in Ukraine. Diab Med 2001;18:39.[CrossRef][ISI][Medline]
7 Chervyakov VV, Shkolnikov VM, Pridemore WA, McKee M. The changing nature of murder in Russia. Soc Sci Med 2002;55:2132.[CrossRef][ISI][Medline]