Vodka, the Elixir of Life ….. and Death

1. Vodka, the Elixir of Life….. and Death Cultural, economic and health aspects of alcohol use in Russia April 27, 2010 Ellis L. Rolett, M.D. Dartmouth Medical School

2. Churches, ikons, crosses, bells, Painted whores and garlic smells, Vice and vodka every place – This is Moscow’s daily face - Olearius, Travels, 1647 Vodka, the Elixir of Life….. and Death Smith & Christian, 1984

3. Without vodka the Russian people simply cannot live. It is their elixir of life, the living water, the universal cure. - Y. Georg, 1858 Vodka, the Elixir of Life….. and Death Christian, 1990

4. Vodka - a cultural context (1) “Russia's hard drinking is not a purely physiological phenomenon - it is, rather, psychological and social. Drinking to the Russians is something like Buddhism to the Indians or Confucianism to the Chinese. It is a kind of a national religion.” - AleksandrZinovyev Moscow News, №33 8/23/2007

5. Vodka - a cultural context (2) “When the Russian is born, when he marries or dies, when he goes to court or is reconciled, when he makes a new acquaintance or parts from an old friend, when he negotiates a purchase or sale, realizes a profit or suffers a loss – every activity is copiously baptized with vodka….The Russian spends his entire life from cradle to grave, bathing and swimming in this drunken sea.” – speaker at the All-Russian Congress on the Struggle against Alcoholism, 1914 Transchel, 2006

6. Negotiating a sale Ukraine, 2008

7. Russia

8. Alcohol - a cultural staple Alcohol beverages were and are tightly interwoven into the fabric of Russian life. Two Russian customs add to the problem of alcohol consumption: a) a vodka bottle once opened, must be finished b) a shot glass of vodka must be downed in one gulp Binge drinking is rampant. 40% of male drinkers and 11% of female drinkers consume ≥ 7 drinks on a typical drinking day. Garrett, 2000; R. Room, Int J Epidemiol 2005

9. Back in Time: Cultural History • Communal intoxication was a key social custom among ancient Slavic tribes. • Norsemen who conquered Kievan Rus in 9th C introduced a more violent drinking style. • Vodka became central to social interaction and the economy, especially among peasants. • Taverns and cheap vodka in late 19th C eroded communal control over individual drinking. • Drinking to get drunk became the norm. Segal, 1990; Transchel, 2006

10. Liquor taxes (1) Smith and Christian, 1984

11. Liquor taxes (2) Smith and Christian, 1984

12. Early Twentieth Century History 1900-1914 - 90% of alcohol consumed is vodka. Binge drinking is a common pattern 1905 - Battle of Tsushima, Russo-Japanese War “Who defeated the Russians? The Japanese did not conquer, but alcohol triumphed, alcohol, alcohol.” – German war correspondent. 1914 - Prohibition is instituted by the Czar to counter drunkenness in the military as Russia prepares for WW I. In part this contributes to the Bolshevik takeover in 1917: the loss of revenue from alcohol taxes makes it difficult for the government to feed Russian workers, and bread riots ensue. White, 1996; Herlihy, 2002

13. Communist Takeover • Engels argued that alcoholism resulted from economic exploitation of workers. • Trotsky: “The very nearest future will be a period of a heroic struggle with alcohol. If we do not stamp out alcoholism, beginning with cities, then we will drink up socialism and drink up the October Revolution.” • Lenin: “Vodka and other narcotics will draw us back to capitalism, rather than forward to Communism.” • Stalin equated alcoholism with capitalism. With overthrow of capitalism, alcoholism was no longer regarded as a societal problem, rather as individual criminal behavior. Segal, 1990; Transchel, 2006

14. A Change of Soviet Leadership! • 1985 - General Secretary Chernenko dies of cirrhosis of the liver. • Mikhail Gorbachev takes his place. • Two months later Central Committee adopts resolution titled ‘On Measures to Overcome Drunkenness and Alcoholism’. White, 1996; Herlihy, 2002

15. Official statistics on alcohol published after a lapse of 26 years • Younger onset of heavy drinking, average age 19. • Increase in heavy drinking among women and juveniles. • 90% of women drinking regularly in 1984 => rising incidence of FAS. • Eight-fold increase in per capita alcohol consumption between 1940 and 1984. White, 1996

16. Official statistics (continued) • Staggering consequences to the economy • decreased productivity, • decline in health of the population • decreased military preparedness • at least half of the armed forces are heavy drinkers or alcoholics White, 1996

17. The Gorbachev Anti-Alcohol Campaign (1) • Nationwide anti-alcohol campaign launched in 1985. • Restrictions imposed on alcohol sales, many liquor stores are closed. • Official drinking age raised from 18 to 21. • Government alcohol production is cut in half, and prices are increased. • Over 1 million private stills are destroyed. White, 1996; Herlihy, 2002

18. The Gorbachev Anti-Alcohol Campaign (2) “Waiting for opening time, 1988” White, 1996

19. The Gorbachev Anti-Alcohol Campaign (3) • Compulsory treatment of alcoholics • Removal of alcohol abusers from public office and employment. • Expulsion of alcohol abusers from the Communist Party. White, 1996; Herlihy, 2002

20. The Gorbachev Anti-Alcohol Campaign: Positive Outcomes • Life expectancy rose 3 years for men, 1 year for women. • Overall mortality down 15% between 1984 and 1986. • Accidental deaths down one-third. • Heart disease deaths down 13%. • Alcohol poisoning deaths down over 50%. • Birth rate increased. • Divorce rate decreased. • Absenteeism and crime down 30%. White, 1996; Nemtsov, 2005

21. The Gorbachev Campaign: Adverse Consequences • Drinkers find alternatives to alcohol: colognes, industrial spirits, etc. • Sugar sales skyrocket as homebrewing takes off. White, 1996

22. The Gorbachev Campaign Ends In October 1988, after three years, the Central Committee rescinds the reforms because of • increased home brewing • loss of government revenues Garrett, 2000; Herlihy, 2002

23. Alcohol in the Post-communist Transitional Economy 1991 - Boris Yeltsin is elected president of Russia 1992 - State monopoly on alcohol production is ended.

24. Alcohol in the Post-communist Transitional Economy (cont.) • 1992 – Massive importation of foreign liquor. • 1993 - Russia overtakes France as the world’s heaviest drinking nation. • Average male consumes a bottle of vodka every 2 days • Major adverse health and societal consequences • 1994 - 50% of alcohol sales are illicit. • 70% of alcohol sold by street traders is dangerous White, 1996

25. Bootleg liquor sale on the street Ryan, 1995

26. Magnitude of the Problem • Estimated numbers of alcoholics in 2007 • 7 million men (official statistics), but may well be twice as high • mainly men • Average per capita annual consumption of pure alcohol • Russia: • 18 L (10 L legal, 8 L illegal) across entire population • Equivalent to 60 bottles of spirits for every man, woman, and child • WHO standard for dependency: 8 L • Estimates of alcohol related deaths and alcohol poisonings vary widely Pravda, 11/9/2006; The Times, 4/13/2007

27. Risk Factors for Alcohol Abuse • Disease of males. • Male coping strategy • Normative pattern of male socializing • Economic and social dislocation. • Lower economic strata • Unemployment • Lack of job satisfaction • Weak family structure • Less well educated • Low self-esteem • Geographic isolation and far northern location White, 1996; Carlson, 2000; Leon, 2007; Denisova, 2010

28. Health Consequencesof binge drinking & acute intoxication • Poisonings • Illicit alcohol • Alcohol substitutes • Accidents and violence • Automobile and industrial accidents • Domestic violence • Suicide • Homicide • Cardiovascular • Arrhythmias • Acute myocardial infarction

29. Alcohol and Pregnancy • Survey conducted 1999-2000, St. Petersburg. • 88% of nonpregnant and 34% of pregnant women had had alcohol within the preceding 30 days. • 16% of nonpregnant and 2.5% of pregnant women had “binged” at least once in the preceding 30 days. • 60% reported drinking when they knew they were pregnant. • 75% of women who drank during pregnancy were aware that alcohol consumption during pregnancy could cause birth defects. • Wine and beer were the preferred alcoholic beverages of both groups. Kristjanson, Alcohol Clin Exp Res, 31: 299, 2007

30. Global Distribution of Alcohol Consumption and Drinking Patterns 1Liters of pure alcohol per resident age 15 and above, annually 2Range 1-4, with 4 being most detrimental Rehm, Eur Addiction Research 2003

31. Type of Alcohol Consumed: 2000 NBER Oct 2004

32. Moscow Scene 2008

33. Alcohol Surrogates Counterfeit Vodka Kills Russians by the Score Moscow, 1 Nov 2006, Reuters “Thousands of Russians have been poisoned by counterfeit vodka laced with toxic household agents, and hundreds have died from acute liver failure.” When Vodka is Your Poison (“Yellow Death”) By John Sweeney, March 10, 2007, BBC News, Russia “Thousands of Russians may have been poisoned by bootleg alcohol containing a medical disinfectant (Extrasept) causing drinkers' skin to turn yellow because of acute toxic hepatitis.”

34. Alcohol Surrogates http://www.guardian.co.uk/world/2007/jun/15/russia.science

35. United Nations Report 2008 • Life expectancy among Russian males is 59 years, on a par with underdeveloped African countries. • Projected population decline is from current 142 M to 100 M by 2050. • Compared to countries with similar economic development, among working-age population mortality is 3-5 times higher for men and twice as high for women. UN in Russia: Demographic Policy in Russia, 2008

36. United Nations Report 2008 (cont.) • Causes include alcoholism, smoking, industrial and automobile accidents, suicide, poor nutrition, and lack of health care. • Annual death estimates: • Alcohol 425,000 • Smoking 330,000 • - Industrial accidents 180,000 • - Traffic accidents 40,000 • Alcohol-related deaths in Russia are 6 times higher for men and 5 times higher for women than in Europe. UN in Russia: Demographic Policy in Russia, 2008

37. Drunken Nation: Russia’s Depopulation Bomb Nicholas Eberstadt, World Affairs, Spring 2009 In 2007, Russia ranked 164 of 226 nations in life expectancy. Major causes of premature mortality were cardiovascular disease (CVD) and accidental deaths. • CVD mortality was almost 4 times higher than in Western Europe. • Injuries and poisonings were over 5 times higher than in Western Europe. • Alcohol abuse was a major contributor to both of the above, especially among younger males. Demographics

38. Dissolution of USSR Eberstadt 2005

39. Eberstadt 2005

40. Male Life Expectancy NBER Oct 2004

41. Eberstadt, 2005

42. Eberstadt, 2005 Eberstadt, 2005

43. Eberstadt, 2005

44. Mortality men ages 35-39 (1980-2005) Russia Latvia Hungary Estonia Poland Czech Republic http://demoscope.ru/weekly/2009/0363/img/l_graf03.gif

45. Eberstadt, 2005

46. Life Expectancy: Summary Substantial changes in alcohol consumption accounted for most of the changes in life expectancy in the Soviet Union and Russia during the 1980s and 1990s. D.A. Leon et al. (1997) The Lancet 350: 383

47. Summary (1) • Alcohol plays a highly symbolic role in Russian culture. • It functions as a means of social interaction, commemoration of significant events, and escape from unfulfilling existence. • Binge drinking is deeply ingrained in Russian society, especially among workers and those living in rural areas.

48. Summary (2) • Hazardous drinking patterns (binging, surrogates, illicit alcohol) are pervasive. • Russia is facing a demographic crisis. • It has the lowest male life expectancy in the developed world. • Alcohol abuse is a major contributor to both of the above.

49. New Anti-Alcohol Campaign

50. New Anti-Alcohol Campaign • Main features under consideration: • Specialized life-improvement centers for alcoholics, smokers and obese persons • Nationwide PR campaign • Restriction of alcohol sales to youth • Increase in price of vodka • Crackdown on producers of illegal alcohol • Stay tuned!