Russia is different
This presentation is the property of its rightful owner.
Sponsored Links
1 / 36

Russia is different… PowerPoint PPT Presentation


  • 42 Views
  • Uploaded on
  • Presentation posted in: General

Russia is different…. Martin McKee London School of Hygiene and Tropical Medicine & European Observatory on Health Systems and Policies Dubai, January 2006. The challenge…. “I cannot forecast to you the action of Russia.  It is a riddle, wrapped in a mystery, inside an enigma “

Download Presentation

Russia is different…

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript


Russia is different

Russia is different…

Martin McKee

London School of Hygiene and Tropical Medicine

&

European Observatory on Health Systems and Policies

Dubai, January 2006


The challenge

The challenge…

  • “I cannot forecast to you the action of Russia.  It is a riddle, wrapped in a mystery, inside an enigma “

    Winston Churchill


Death of a nation

75

female

70

65

male

years

60

55

50

1970

1980

1990

2000

Death of a nation

Life expectancy at birth


Percentage variation in myocardial infarction explained by nine risk factors

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


Ischaemic heart disease over time

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


Russia is different

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


Russia is different

Variation in the life expectancy decrease for men across regions of European Russia

Walberg, McKee et al., 1998

7


Association between labour turnover in 1993 4 and fall in life expectancy 1990 94

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


Russia is different

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


And what about health care

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


The soviet health system

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


Chronic disease the critical challenge

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


Patients speak interviews with patients living with diabetes in kyrgyzstan

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


The izhevsk family study

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


The izhevsk family study1

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


Important questions without answers

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 ?


Drinking in russia

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


Vodka a selection

Vodka: a selection


Samogon

Samogon


Surrogate spirits

Surrogate spirits


Alcohol containing medicines

Alcohol containing medicines


How much ethanol

How much ethanol?


Correlates of alcohol abuse in live controls

Correlates of alcohol abuse(in live controls)


All case mortality according to frequency of surrogate drinking relative to never surrogates

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


And by cause adjusted for smoking and education

…and by cause (adjusted for smoking and education)


Some more detail

Some more detail


Surrogates or ordinary drinking all cause mortality

Surrogates or ordinary drinking?All cause mortality


Russia is different

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)


Do these findings help us to understand what happened in russia in early 1990s

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


Russia is different

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


A mechanism

A mechanism?

Social and

economic factors

(pace of transition)

(un) conventional

risk factors

Health

care

stress

Death


Back to alcohol the cirrhosis belt

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


What else is being drunk elsewhere

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


A night out in tallinn

A night out in Tallinn…


What is going on

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


Implications for pure

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


  • Login