Premature Death in the New Independent States (1997) / Chapter Skim
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Premature Death in the New Independent States: Overview
Premature Death in the New Independent States: Overview
Pages 1-33
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experienced mortality rates comparable to those of India in 1990 or Guatemala in 1960. In contrast with India or Guatemala, however, where the majority of excess adult mortality is attributable to 1
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Chapters 7 through 14 examine possible causes for the large number of excess deaths in the NIS. They focus on three key health behaviors alcohol consumption, tobacco consumption, and diet and describe preventive health interventions in these three areas that have proven effective in other industrialized countries.
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The profiles of the northern NIS are not well represented in standard models of mortality in use throughout the world, making it difficult to use standard demographic models to assess the quality of mortality data for these countries, as well as to choose a model for estimating the number of years of life lost to premature mortality. Epidemiological analysis of causes of death provides essential information on the characteristics of health status changes.
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There is also evidence to suggest that Central Asian countries might soon experience increases in cardiovascular disease and injuries, posing the problems of high adult mortality found in the European countries of the region. Greater worldwide experience in learning how to control influential risk factors and avoid increases in premature mortality might provide valuable lessons for countries not yet at this epidemiological stage of increasing adult mortality.
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The most recent rise in adult mortality, on the other hand, has coincided with a sharp decline in the quality of medical care and possibly some problems of access to resources (World Bank, 1996~. Mortality due to both injuries and cardiovascular disease is sensitive to the availability and quality of emergency care.
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Many authors in this volume suggest ethnic differences in health behavior as an explanation for differing mortality profiles or trends. The Central Asian countries are composed mainly of Asian ethnic groups (Turks, Kyrgyz, Kazaks, Uzbeks, and others)
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(FSE) Europe (F Former Soviet Union Russia x x x x Estonia x x x Latvia x x x Lithuania x x x Azerbaijan x x Armenia x x Georgia x x x Tajikistan x x x Turkmenistan x x x Uzbekistan x x x Kyrgyz x x x Kazakstan x x x Moldova x x x x Belarus x x x x Ukraine x x x x Eastern Europe Albania x x Bulgaria x x Czechoslovakia x x Hungary x x Poland x x Romania x x Yugoslavia x x aFormer Socialist Economies of Europe (FSEE)
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This decline is far larger than that experienced by eastern European countries in the past ten years and by developing countries during the debt crisis of the 1980s. Not surprisingly, expenditures on social services have declined in a way parallel to income, leading to greater health risks that are discussed later in this chapter.
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. ANALYZING PREMATURE DEATH IN THE NIS Trends and Immediate Causes Life expectancy trends in the NIS have not followed those of other industrialized countries.
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They find the predominant role of increasing cardiovascular disease among males, and to a lesser extent among females, to be the notable feature of the long-term trends, while they find the predominant role of injury-related deaths to be the main explanatory factor in the shorter-term volatility in mortality levels since the mid1980s. What has commonly been regarded as an understatement of neoplasm as a cause of death in Russia is reinterpreted by these authors as a late arrival of the cancer epidemic in Russia as compared with other European populations.
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Injury increases in the late 1980s were due to increases in motor vehicle accidents and homicides, while those in the l990s are attributable to increases in suicide, homicide, and accidental poisoning by alcohol. These recent changes and their relationship with alcohol consumption are examined in depth by Shkolnikov and Nemtsov in this volume.
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The two extreme profiles summarize the predominant profiles in the NIS, found in geographically contiguous countries: the first has moderate child mortality and high adult male mortality, whereas the second has high child mortality and moderate adult mortality. The first profile characterizes Russia, the Baltic states, other European countries, and Kazakstan, and the second is typical in the other Central Asian states, Azerbaijan, and Armenia.
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In the NIS outside of Russia, rural populations generally have higher death rates than their urban counterparts; the exception is males in the Central Asian states, where there is reason for suspicion about the quality of mortality statistics, especially in rural areas. In the southern NIS countries, loss of life due to infectious diseases is primarily a rural phenomenon, while loss of life due to degenerative diseases and injuries is greater among the urban than rural populations of these states.
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Murray and Bobadilla, on the other hand, used a model life table to estimate the maximum potential length of life, introduced a 3 percent discount rate (per year) for the stream of life lost in the future, and weighted the value of years lost at different ages.
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The states in the European region show a profile dominated by noncommunicable diseases and injuries, but the states in Central Asia show a mixed profile including communicable diseases, noncommunicable diseases, and injuries, a pattern reflected in the age-sex profiles discussed previously. In the European region, two-thirds of potential years of life lost is due to noncommunicable diseases.
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When one considers the capacity of the health care system, respiratory disease, considered to be largely manageable by existing health care, becomes a higher priority for preventing loss of working potential, while perinatal and congenital causes decrease in importance. Top health care priorities for many of the northern NIS are injury and cardiovascular disease, while those for the Central Asian states are respiratory disease, infectious and parasitic diseases, and injury.
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These anomalies include higher mortality rates in urban than rural areas and an apparent "crossover" in mortality at older ages, favoring rural areas, which they ascribe to age exaggeration among the rural population. They also base their assessment of data quality in the Central Asian states on comparisons with age patterns of mortality in Russia and Latvia, where the quality of mortality data appears better, and with patterns of age misreporting in data among the same ethnic groups in Xinjiang, China.
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A1though their estimates are not free of problems, they estimate coverage of death registration to be over 95 percent in most states, with registration in the Central Asian states being more in the 85 to 95 percent range. Corrections of infant and child mortality and older adult mortality are also evaluated by Shkolnikov, Mesle, and Vallin for Russia.
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The second part of this volume explores prospects for preventing premature death in the NIS by reducing alcohol abuse, controlling tobacco consumption, and improving diet. These three areas were chosen because of their demonstrated relationship to cardiovascular disease and injuries in other countries of the world, and thus their probable relevance to the mortality profile of the northern NIS.
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However, the chapter by Treml points out that mortality rates due to alcohol poisoning in Russia are extremely high relative to those of other developed countries. Shkolnikov and Nemtsov also observe that alcohol consumption has generally been higher in Russia and the Baltic states than in the other NIS countries.
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, the two most common cardiovascular diseases in the NIS. Alcohol consumption has a "J"-shaped relationship with ischemic heart disease; that is, abstainers and heavy drinkers have a greater risk of ischemic heart disease than moderate drinkers.
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Prevention policies that have been shown to be effective include drunk driving laws and a minimum drinking age of 21 for reducing drunk driving and related accidents. Higher taxes have been shown to result in lower alcohol consumption in the United States, particularly among the young because of their relatively lower income.
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Lopez points out that in the other NIS countries, rough estimates indicate the highest per adult yearly consumption of cigarettes to be in Armenia, Turkmenistan, Moldova, Georgia, and Ukraine. Prokhorov and Pierce also note that in recent years, transnational tobacco companies have expanded their role in the NIS.
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Improving Diet Diet is one of the major determinants of cardiovascular disease. Diets high in polyunsaturated fat, total fat, and salt are strongly associated with cerebrovascular disease and ischemic heart disease, two of the most important causes of premature death in the NIS.
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In 20 years, the project has been associated with a marked reduction in target risk factors, and with a more than 50 percent reduction in cardiovascular disease mortality rates among the middle-aged population and a decrease in overall mortality of about 40 percent. Health researchers and personnel from Finland are now actively involved in collaboration with groups in Estonia and the Republic of Karelia, Russia, to plan and implement health intervention activities applying the lessons of the Finnish project.
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But serious methodological and measurement problems lead to imperfect results with most estimates of attributable mortality due to alcohol, tobacco, and diet, except for estimates based on longitudinal studies. The lag time between exposure to a risk factor and the development of a cardiovascular disease is between 10 and 15 years; most of the concurrent analyses of risk factors and cardiovascular mortality are thus rough approximations of the real relationship.
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In the Central Asian countries, measurement of basic levels of mortality leaves much to be desired, little is known about death rate trends, and baseline information is lacking. There is also a great need for reliable information on infant and child mortality levels in these states.
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The impact of chronic diseases and injuries on mortality among the total NIS population is evident from data already available in the NIS. Information on associated risk factors in the NIS is limited, and population surveys on chronic disease risk factors, health behaviors, and related determinants are needed in many of the NIS countries.
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Further exploration of the potential for change is an open area of research, with one possibility being the use of pilot projects. The experience of the North Karelia project in Finland indicates that a pilot demonstration program can be a strong tool for fostering national chronic disease prevention and health promotion.
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Kramers, and Rudolph Hoogenveen 1994 Proximate Determinants in the New Independent States: Attributable mortality Based on an Integrated Approach followed for The Netherlands. Paper presented at the Workshop on Adult Health Priorities and Policies in the New Independent States.
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Martin 1994 Mortality and Other Outcomes, Risk Factors, and Links with Death Registration Data in NIS Epidemiological Study Sites. Paper presented at the Workshop on Mortality and Disability in the New Independent States.
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