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Johnson's Russia List
 

 

June 6, 1999    
This Date's Issues: 3327 3328


Johnson's Russia List
#3328
6 June 1999
davidjohnson@erols.com

********

Policy Review
June & July 1999, No. 95
Published by The Heritage Foundation, Washington DC 
http://www.policyreview.com/jun99/eberstadt.html

Russia: Too Sick to Matter?
By NICHOLAS EBERSTADT 
Nicholas Eberstadt is a visiting scholar at the American Enterprise
Institute and a researcher at the Harvard Center for Population and
Development Studies.
[footnotes not reproduced here]

For Russia and its people, the nightmare of Soviet totalitarianism has come
to an end, only to be followed by a phenomenon much more familiar in
Russian history: a "time of troubles." And although this current "time of
troubles" is surely less brutal for ordinary Russians than the original
"Time of Troubles" preceding the accession of the Romanov dynasty — likely
milder, indeed, than the other "times of troubles" during the intervening
four centuries — today’s episode shares with all its predecessors an
overarching and indeed defining characteristic: a sudden, dramatic, and,
from a Russian nationalist standpoint, distressing enfeeblement of the
Russian state. 

In barely a decade, Moscow has plummeted from the status of an imperial
superpower to a condition of astonishing geopolitical weakness. To be sure,
Soviet might, resting as it did upon the grotesque arrangements of a
special tyranny, may be said to have been in some sense abnormal. Even so,
with today’s spectacle — in which the Russian state’s role in international
affairs is so conspicuously diminished as to seem at times negligible — it
would appear that the pendulum has swung toward another, almost equally
unnatural, extreme.

The symptoms of the Russian Federation’s newly limited capabilities for
influencing international events (or for that matter, events within its own
borders) are both diverse and abundant. Politically, some would argue, the
very existence in Russia of a constitutional democracy — any constitutional
democracy — should be regarded as a triumph in itself. Perhaps so, but in
Russia today, "real existing constitutional democracy" is, at least for
now, an essentially moribund edifice. Its wax museum president; its
simultaneously fractious and paralyzed legislature; its fictitious, "Dead
Souls" approach to taxation and budgeting; its "federalism" of local
unaccountability and central government decay; its largely ineffectual
judiciary: In all, the Russian political system is at present poorly suited
to effecting decisions, mobilizing resources, or applying governmental will. 

>From an economic standpoint, Russia’s weaknesses are manifest. Although
ambiguities surround both old Soviet economic statistics and the new
Russian statistics, official data strongly suggest that the Russian
Federation’s economy today is amazingly small. In 1997, total reported
exports of goods and services were almost identical in Russia (population:
nearly 150 million) and Sweden (population: 9 million). (Russia’s trade
ledgers are probably distorted by under-reporting, but her true export
revenues may still not have matched those of such miniature countries as
Singapore and Belgium.1) At official exchange rates, Russia’s estimated GNP
in 1997 just barely exceeded $400 billion — thus ranking slightly above
Australia’s ($380 billion). "Purchasing power parity" (PPP) adjustments
alter the picture only to a degree: By that benchmark, according to World
Bank calculations, Russia’s 1997 economy would have been about as big as
Spain’s, although smaller than Canada’s or Indonesia’s. If accurate, those
World Bank estimates would have meant that per capita output in 1997 was
actually lower in Russia than in such places as Lebanon or Peru.2 All of
these figures, furthermore, refer to Russian conditions before the August
1998 collapse of the country’s finances, since which time the country’s
economic performance has only worsened.

Then there is the matter of military strength. Since the collapse of
communism, Moscow’s has evidently all but evaporated. Where the Red Army
once entertained global ambitions, the Russian Army’s conventional forces
now find containing an insurrection in a small region within the nation’s
borders to be an almost overwhelming challenge. The dismal performance of
the Russian Army in Chechnya attests to no less; the very fact that the
military campaign to suppress Chechen rebels had to last nearly two years
speaks for itself. 

So straitened are Russia’s current circumstances that the Western world has
implicitly, but almost totally, redefined the nature of the external
security problem it expects to confront from the Russian state. No longer
is that problem perceived to center upon Moscow’s ability to project power
abroad. Instead, it is believed to emanate primarily from the potential
consequences of Russian internal political decay and military decline: the
sell-off of military hardware to rising powers like China, or of nuclear
technology to would-be proliferators like Iran; weakened controls over the
government’s arsenal of weapons of mass destruction; or internal
convulsions with international repercussions. To the extent that Western
governments today perceive a "Russian threat," it is not because they
regard Moscow as an intentional menace, but rather because they see it as
an unintentional menace, a burden.

Many observers both within Russia and outside it take as self-evident the
proposition that Russia’s current condition of extreme weakness — virtual
prostration — is only temporary, and will be corrected. Emblematic of this
view is this assertion by Sergei Rogov, director of Moscow’s Institute of
the USA and Canada: "Sooner or later, Moscow will again be a major
international player."3 

The sorts of developments that would be necessary for a Russian
geopolitical recovery are easy enough to identify. They would include such
things as coalescence of a rule of law, a policy-competent central
government, creation of an attractive "business climate," and
reinvigoration of the leadership and institutions of the armed forces. Many
of these qualities, however, involve historical changes that could require
correspondingly historical time spans to enact — and all of them are of
course dependent upon unforeseeable, unreliable contingency. For these
reasons alone, Russia’s international comeback could be a very slow and
gradual affair under the best of circumstances.

Yet even such a qualified prognosis for a Russian comeback may prove to be
overly optimistic, because it does not take into account a factor that
could prove critical to an eventual Russian recovery. That factor is the
health of the Russian people. 

Illness and mortality trends do not typically play a great role in world
affairs. In Russia today, however, the nation’s health conditions have
become so degraded that it is possible to imagine these constituting an
independent, and perhaps significant, constraint upon Moscow’s prospects
for re-attaining Great Power status. Russia’s ongoing crisis in public
health — and "crisis" is hardly too strong a word — is historically
unprecedented: No industrialized country has ever before suffered such a
severe and prolonged deterioration during peacetime. Given its particular
characteristics, Russia’s health decline promises to be especially
difficult to reverse. Such health trends augur ill for the Russian economy
— and it is economic power that must ultimately underwrite any sustained
resumption of international influence for Russia. 

Thus, "unnatural" as Russia’s current weakness is held to be in many
quarters, there is a real possibility that the country’s startlingly
adverse health trends will consign it to further relative economic and
political decline for as much as another generation.

Anatomy of a health crisis

Although the USSR’s departure from the world stage was remarkably peaceful,
the collapse of the Soviet system nevertheless brought on a veritable
explosion of mortality in Russia. Between 1989-91 (the last years of Soviet
rule) and 1994, crude death rates in Russia shot up by 40 percent.4

Though the mortality situation has improved somewhat since then, crude
death rates in Russia in the first half of 1998 were still nearly 30
percent higher than they had been in the USSR’s final years.5 This
mortality shock (in tandem with a concomitant sudden drop in fertility
levels) has pushed Russia into a continuing population decline for the
first time since World War II. At the moment, Russia’s deaths are exceeding
its births by well over half — about 700,000 a year.

Although the fact has gone largely unrecognized, the loss of life from this
quiet crisis in Russia has been a catastrophe of historic proportions. The
dimensions of the catastrophe are suggested by estimates from the World
Health Organization (WHO).6 WHO has prepared "age standardized" death rates
for Russia and many other countries. (These "standardized" rates differ
from the crude rates in that they control for population aging and other
such phenomena.) Against the benchmark of 1987 — a relatively good year for
personal survival in the old Soviet era — "excess mortality" in Russia
during the four years 1992-95 would have amounted to nearly 1.8 million
deaths. To put that figure in perspective: For the four years of World War
I, the military death count for the Russian Empire is generally placed at
1.7 million.7 And WHO has not yet published "age standardized" death rates
for Russia for the years 1996-98; when it does, we are likely to find that
Russia’s "excess mortality" in the 1992-98 period alone exceeded 3 million
deaths.

The abrupt worsening of Russian health conditions since the end of the
communist era is all the more noteworthy because health trends in the
fin-de-regime USSR were themselves so very poor. From the end of the World
War II to roughly 1960, the Soviet system presided over a swift and
dramatic improvement in Union-wide health levels; by 1960, in fact, life
expectancy at birth in Russia proper had caught up with America’s, and was
poised to exceed it. Just at that juncture, however, Russia began to
experience broad health setbacks. Death rates began to rise — first among
middle-aged men, then for a steadily spreading number of male and female
age groups. Even infant mortality reportedly went up.

Initially, Soviet authorities responded to these unfavorable findings by
suppressing information about them; with Gorbachev’s glasnost policy, this
veil of statistical secrecy was lifted. Official figures revealed that
overall life expectancy for Russia was no higher in the late 1980s than it
had been in the early 1960s — and that for adults, life expectancy was
actually somewhat lower than it had been a quarter century earlier.8 

After decades of stagnation, and now recent, unmerciful retrogression,
Russia’s health profile no longer remotely resembles that of a developed
country; in fact, it is worse in a variety of respects than those of many
Third World countries. In 1997 — the most recent year for which such
estimates are available — overall life expectancy in Russia was thought to
be somewhat under 67 years. That would have been lower than Russia’s life
expectancy four decades before — but it would also be distinctly lower than
the life expectancies today of such spots as Mauritius, Ecuador, or
Azerbaijan. Mexico, for all its travails and troubles in the 1990s, now
enjoys a life expectancy estimated to be over six years higher than Russia’s.9

Throughout most of Latin America and the Caribbean and a growing number of
countries in Asia, women can now expect to live longer than their Russian
counterparts. But survival prospects are especially poor for Russian men.
According to the most recent figures available life expectancy at birth for
males in Russia today hovers around 61.10 That ranks below the
corresponding current estimates for such places as Egypt, Indonesia, or
Paraguay.11

Among Russian men, moreover, health conditions are particularly bad for
those of working age. In Australia today, by way of example, a 15-year-old
boy would, under current survival patterns, stand about an 80 percent
chance of living to age 65. In the Russian Federation, by contrast, barely
40 percent of those same 15-year-olds would make it to 65. Although its
records are limited to countries with relatively complete death
registration since World War II, the WHO database cannot provide another
instance of such bleak survival odds for "able-bodied" men — even men from
the African island of Mauritius in the late 1950s enjoyed better prospects
than today’s Russians.12

For every subsidiary age group from 15 to 65, death rates for Russian men
today are frighteningly high. Youth may be the prime of life — but Russian
men in their late teens and early 20s currently suffer higher death rates
than American men 20 years their senior.13 For their part, Russian men in
their 40s and 50s are dying at a pace that may never have been witnessed
during peacetime in a society distinguished by urbanization and mass
education. Death rates for men in their late 40s and early 50s, for
example, are over three times higher today in Russia than in Mexico. To
approximate the current mortality schedule for Russian middle-aged men, one
has to look to India — the India, that is, of the early 1970s, rather than
the much healthier India that we know today.14

Uncertain origins

How is the Russian health disaster to be explained? The troubling fact is
that international public health authorities have yet to come to any
general agreement about the particular causes of Russia’s health crisis —
much less an understanding of the precise magnitude of the tolls being
exacted. Reviewing available evidence three years ago, Dr. Lincoln Chen of
the Harvard School of Public Health and colleagues concluded that "the root
causes of the Russian health crisis remain uncertain." Our understanding of
the upsurge in Russia’s death rates has not advanced dramatically since then. 

Yet, although we may not be able to account conclusively for the roots of
Russia’s health crisis, we may nevertheless obtain important clues about
its nature from the country’s death statistics. Apart perhaps from infant
deaths, mortality registration has been reasonably complete in Russia since
at least the 1960s. And Russian statistics also classify deaths according
to reported causes. While cause-of-death statistics are never perfect, and
may be more than ordinarily problematic for Russia, they do at least offer
the most reliable hints as to what is ailing the country today.

The first thing to note is what is not apparent in the statistics. Many
medical specialists within Russia itself, for example, would strongly agree
with Georgetown University’s Murray Feshbach that "environmental issues
lurk behind much of the [Russian] public health problem."15 The Soviet
system’s appalling destruction of nature — its casual and wanton poisoning
of air, land, and water — has already been grimly documented, most notably
by Feshbach himself.16 

But what fells forests or slays wildlife does not always necessarily kill
people. If, for example, severe air pollution were exacting a particular
toll on the Russian people, we might reasonably expect to find evidence of
extraordinary respiratory afflictions — but Russia’s death rate attributed
to diseases of the respiratory system has reportedly declined slightly
since the early 1980s, and is currently lower than in such countries as the
Bahamas, Ireland, or Singapore. By the same token, while there is little
doubt that radiation and other potentially deadly mutagens have been
handled recklessly by the USSR (and now by the Russian Federation), the
death rates attributed to cancer in Russia today have changed little for a
decade or more — and in fact are essentially indistinguishable from those
reported in such countries as the U.S., the UK, Germany, or France.17 

The human cost of Russia’s "ecocide," to be sure, may yet prove horrendous;
but if we are to judge that cost by available mortality data, such a dire
verdict cannot yet be rendered.

Then there is the question of communicable disease. In recent years, Russia
has suffered outbreaks of typhus, typhoid, and cholera; diphtheria is
reportedly rampant; and the identified incidence of tuberculosis, which has
more than doubled since 1990, is — by WHO definitions — now formally
epidemic. 

That Russia today should be so manifestly incapable of coping with
contagious diseases so routinely controlled and suppressed in so many other
regions of the world is surely suggestive of a breakdown in the country’s
public health system — and perhaps indicative as well of upheaval within
its social structure. But the impact of epidemic disease per se on Russia’s
health decline is easy to exaggerate. In 1995, deaths attributed to
infectious and parasitic diseases comprised less than 2 percent of Russia’s
overall age-standardized death rate; while the level was almost four times
as high as (say) Sweden’s, that discrepancy accounted for less than
one-fiftieth of the overall mortality gap between the two countries. On the
country’s current mortality schedules, Russians face only about a 2 percent
chance of eventually dying from a communicable disease — 98 percent will
die from something else. Obviously, then, the principal constituents of
Russia’s health disaster would seem to lie elsewhere.

But where? To go by cause-of-death statistics, the overwhelming majority of
excess Russian deaths — by comparison both with Western countries today,
and with Russia itself in earlier years — would seem to fall in two
categories: "cardio-vascular disease" (or CVD: heart attacks, strokes, and
the like) and "accidents and adverse effects" (injuries — including suicide
and murder — and poisonings).

If cause-of-death statistics are to be believed, the world has never before
seen anything like the epidemic of heart disease that rages in Russia
today. For men and women alike, the standardized death rate in Russia today
attributed to CVD alone is higher than the death rate in the U.S. for all
causes combined. And although men the world over are prone to distinctly
higher death rates from heart disease than women, Russia’s female CVD
mortality rate is currently roughly twice as high as the male rates in such
countries as Canada, Italy, and Spain. In the West, CVD mortality peaked in
the late 1950s and 1960s, and subsequently declined substantially. In
Russia, however, already unrivaled rates have continued to climb.

As for deaths from "external causes," medical statistics have never before
documented a plague of the proportions that wracks Russia today. The United
States is widely regarded as a violence- and injury-prone society. Yet the
U.S. death rate attributed to injuries and poisonings currently stands at
only half of the reported Russian rate of the Brezhnev and Gorbachev years
— and Russia’s rate has doubled again since then. At this juncture, despite
the enormous worldwide disparity between men and women in deaths from
violent causes, the mortality rate ascribed to injury and poisoning is
higher for Russia’s women than it is for America’s men. 

Russian men, for their part, have no peers in succumbing to deadly
injuries. Although the Russian male mortality rate from "external causes"
was reportedly significantly lower in 1995 than it had been in 1994, it was
nevertheless nearly three times higher than in Mexico or Venezuela, and
over half again as high as in Colombia — a country then convulsed by drug
warlords and unchecked narco-terrorism. Under prevailing cause-of-death
patterns, a baby boy in Russia in 1995 stood almost a 1 in 4 chance of
eventually dying from some sort of external trauma; in Britain, to provide
some sense of contrast, the corresponding risk would have been about 1 in
30.18

How to explain modern Russia’s extraordinary disposition for injuries and
cardiovascular disease? The upsurge in deaths due to external trauma is
surely influenced, after a fashion, by broad social trends from the ongoing
Russian "transition." It is much easier now than in the past, for example,
for Russians to buy a car — and by extension, to kill themselves on the
roads. By the same token, with the virtual collapse of police authority and
the corresponding rise of "mafiya capitalism," Russian citizens are more
likely now than in the past to die from free-lance criminality. 

In a much narrower sense, however, Russia’s epidemic of deaths from
external trauma is intimately linked to its staggering consumption of hard
spirits. The heavy vodka drinking for which the USSR was so notorious has
been replaced in post-Communist Russia by an even more extreme regimen of
national alcohol abuse. Contemporary Russia’s thirst for vodka, indeed, is
almost impossible for Westerners to imagine. According to a 1993 national
household survey, for example, over 80 percent of Russian men were drinkers
and their alcohol intake reportedly averaged nearly 600 grams per day.19
That would be the equivalent of over five bottles of vodka a week, every
week. And since these figures were self-reported, they may have been
underestimates. Other contemporary studies suggested that the average level
of alcohol consumption for the entire Russian adult population — men and
women together — exceeded 400 grams per day: that is to say, three bottles
a week. Since 1993 alcohol consumption may have declined, but Russian
drinking patterns have hardly moderated.20 

Those patterns have deadly consequences. In 1996, over 35,000 Russians died
from accidental alcohol poisoning. (America is not exactly a country of
teetotalers, yet in the United States — a country with almost twice
Russia’s population — the corresponding figure averages about 300 persons a
year.21) Extraordinarily heavy drinking is also implicated in Russia’s
explosion of deadly injuries, for many of the fatal falls, crashes,
suicides, and murders in Russia today are thought to occur while the victim
(or perpetrator) is drunk.22

Alcohol abuse surely also plays a role in Russia’s surfeit of deaths from
coronary disease, since binge drinking is associated with CVD mortality.23
But other aspects of the Russian lifestyle undoubtedly contribute to the
problem. Heavy smoking (prevalent in Russia today) contributes strongly to
the risk of CVD — as do lack of exercise, diets too heavy in fatty foods,
and obesity, all of which are rife among the Russian populace. At work
together, these risk factors may disproportionately heighten vulnerability
to cardiovascular threats. 

In addition, there is evidence that attitudes, outlook, and stress (what
clinicians now term "psycho-social variables") may also affect
susceptibility to CVD. Although such data are tentative and must be treated
with considerable care, there are indications that the incidence of
clinically defined "depression" may be rather greater in Russia today than
among other, Western European, populations.24 And in a major recent study
of Russian health conditions, researchers concluded that health risks were
strongly associated with the perception that one had little control over
one’s own life.25 Association, of course, does not establish causality —
but it raises the possibility that the profound and apparently deepening
pessimism about personal circumstances widely reflected in an array of
opinion polls and surveys is among the determinants underlying Russia’s
fearsome levels of cardiovascular death.

If a better medical system were currently in place, Russia’s death rate
from CVD would doubtless be reduced. That CVD epidemic, however, speaks to
much more than the failure of a particular public health sector. For the
risks that are resulting in these unparalleled levels of cardiovascular
mortality are strongly behavioral, and perhaps also attitudinal, in nature.
They are representative of, and appear to be deeply ingrained within, the
current Russian lifestyle. Until these behaviors and attitudes — call them
"ways of life" — change radically, it will be correspondingly difficult to
change the health risks they generate in any appreciable manner. 

Prospects for recovery

The Russian people are not the only urbanized, educated populace in our era
to experience sudden upward spikes in mortality, or precipitous and
unexpected declines in general levels of health. At least four other
countries — Spain (1936-39), Western Germany (1943-46), Japan (1944-45),
and South Korea (1950-53) — record cruel plunges in countrywide life
expectancy around the middle of the twentieth century.

Merely to note those dates, however, is to see a contrast between these
cases and the case of Russia. The mortality crises in Spain, Western
Germany, Japan, and South Korea were direct consequences of wars or civil
war. Each of those mortality crises proved transient. In the four war-riven
states, health recovery commenced spontaneously with the cessation of
fighting. In each case, life expectancy at birth quickly recovered to
pre-disaster levels. Thereafter, brisk tempos of further health progress
ensued — almost as if disaster had never struck. 

The most remarkable instance of such post-disaster health progress is
undoubtedly Japan’s. In 1944-45, male life expectancy at birth in Japan had
been driven down essentially to Neolithic levels (under 25 years). Yet
barely three decades later — in the late 1970s — Japan was estimated to
enjoy virtually the highest male life expectancy in the world.

Can Russia hope for an analogous revitalization of health trends in the
decades immediately ahead? From today’s vantage point, such an outcome
would seem unlikely. Remember: The Russian crisis has erupted in a country
in a formal state of peace.26 In origin, duration, and character, Russia’s
mortality crisis is fundamentally different from those others. And in every
respect, Russia’s distinctions portend both greater difficulties in
re-attaining previous health conditions and a more limited scope for
exacting health gains after that status quo ante is finally reached.
Paradoxically, even if Russia’s health recovery were to begin immediately —
or were discovered to be already underway — the particulars of the
country’s health crisis suggest that Russia’s international health ranking
might nevertheless continue to decline for another several decades.

Devastating as the Spanish Civil War, World War II, and the Korean War all
were, moreover, the demographic toll that each of those catastrophes
imposed appears to have had surprisingly limited impact on the health of
the crises’ survivors. Recent estimates by demographers, for example,
suggest that World War II and its repercussions cost Western German women
born in 1920, who were exposed directly to the destruction and privation of
that terrible defeat, an average of only about six months of life
expectancy.27 

No similar presumption can obtain for Russia. To the contrary: Given the
prolonged period of health stagnation and decay before the recent Russian
health crisis, and the indications that Russia’s pattern of excess deaths
may be partly or even largely related to accumulated lifestyle-related
risks, there is every reason to expect the burden of this crisis to
continue to weigh heavily upon the Russian people even after its most acute
phase has passed.

Two specific features of Russia’s current patterns of death and disease
argue especially strongly against the likelihood of a speedy health
turnaround.

The first has to do with the country’s current cause-of-death structure —
the particular types of fatal illnesses, in other words, that are killing
people in modern Russia. For Russia’s deadly ailments, by and large, are
afflictions that tend inherently to be more resistant than others to
immediate medical interventions, and less amenable than others to
significant short-run control.

The point can be illuminated by contrasting cause-of-death patterns in
contemporary Russia and post-war Japan (see Figure 1). In 1995, Russia’s
overall age-standardized death rate was just about the same as Japan’s had
been in the early 1950s. The composition of the two countries’ death rates,
however, was dramatically different. 

In postwar Japan, infectious and communicable disease was a vastly greater
threat to public health than it is in Russia today. Death rates from
respiratory illnesses (among them, pneumonia and influenza) were over
two-thirds higher than in contemporary Russia, and mortality from
tuberculosis (a major killer in Japan during those years) was fully seven
times higher. Fortunately for the Japanese, those were diseases that could
be rapidly and inexpensively suppressed by newly invented medicines and
fairly basic public hygiene measures. In the face of these sustained
interventions, declines in death rates were immediate and dramatic. In just
the 10 years between the early 1950s and the early 1960s, for example,
Japan’s TB death rate fell by 63 percent.

In Russia today, the principal causes of death — CVD and injury/poisoning —
together account for two-thirds of the nation’s mortality. Death rates from
CVD are nearly twice as high for modern Russians as they were for postwar
Japanese; death rates for injury and poisoning, over three times higher.
And unfortunately for Russia, these are not the sorts of deaths that can be
easily prevented through inexpensive prophylactic health policies. 

In theory, an injury prevention strategy could bring quick benefits. In
practice, such a strategy would be daunting to enact in Russia today. It
would have to induce tremendous behavioral changes on the part of the
Russian people — most important, a radical drop in the prevalence of heavy
drinking. Given Russia’s seemingly unique passion for vodka, eliciting
sustained declines in alcohol consumption would not be easy. Nor would it
be inexpensive. In addition to the direct costs of an anti-alcohol
campaign, there could be major revenue implications for the state, for
traditionally the Russian budget has been almost as dependent upon liquor
as have the Russian people.28

Unlike sudden injuries, CVD typically is the culmination of a lifetime of
insults visited upon the cardiovascular system. With heart disease, in a
real sense, today’s "bills" cover "debts" accumulated over long periods in
the past. For this reason, trends in deaths from heart disease in any
country can never turn on a dime. Even with sensible, well-funded medical
policies and wholesale popular embrace of a more "heart-healthy" lifestyle
— none of which conditions obtain in today’s Russia — the control and
reduction of CVD death rates tends to be a relatively gradual affair. And,
of course, it is now known that heredity plays a significant role in
cardiovascular risk. Some researchers speculate that such hereditary risk
factors may be disproportionately concentrated in particular ethnic
populations.29 If there should happen to be a hereditary predisposition to
CVD for some non-trivial fraction of the Russian population, reductions in
cardiovascular mortality would presumably prove that much more difficult to
achieve.

A second, related, reason we should not expect speedy improvement in
Russian health conditions is that Russia’s health trends today embody a
large measure of what might be termed "negative momentum." In Spain,
Western Germany, Japan, and South Korea, local health conditions had been
progressively improving for decades before their respective cataclysmic
upheavals; when the conflicts that triggered their mortality crises came to
a close, the survivors and their descendants continued upon
already-established paths of national health advance. In Russia, by
contrast, health conditions have been stagnating — in fact, worsening — for
over three decades.

To appreciate just how much "negative momentum" lies within contemporary
Russian health trends, one might compare death rates for Russia proper in
1994 and, say, 1964. For men 15 years of age and older, death rates were
higher in 1994 than they had been 30 years earlier — for most age groups,
in fact, far higher. For men in their early 30s, mortality levels were
twice as high for 1994 as for 1964; for men in their early 50s, they were
almost two and a half times as high. The situation was only somewhat better
for women. For them, death rates were worse than they had been three
decades earlier for all groups 25 and older; for women in their 30s, 40s,
and 50s, death rates typically had jumped by about half from 1964 to 1994. 

These health setbacks mean that, at any given age, Russian adults are dying
at a tempo that had been observed back in the 1960s only among distinctly
older age groups. In 1994, the trend reached its nadir, with the absolute
death rate for Russian men in their late 20s, for example, matching the
death rate for men in their early 40s in 1964. While mortality rates have
improved somewhat since the annus horribilus of 1994, Russian men,
according to the latest data available, are nevertheless today dying at a
pace reported by counterparts fully 10 years their elder back in the 1960s;
for a number of female age groups, the differential remains at five years
or more.

If death rates provide an accurate reflection of general health conditions
for a country like Russia, it would seem that the Russian population as a
whole has been growing progressively frailer in recent times — that
irrespective of chronological age, today’s men and women alike are in a
real sense more "elderly" than were their counterparts in their parents’
generation.

Under such circumstances, simply re-attaining within the next 20 years the
health levels Russia "enjoyed" in the 1960s will be no mean feat; indeed,
it will require far-reaching changes in both lifestyle and environment for
the country as a whole. The 50-year-olds in Russia 20 years hence are the
30-year-olds of Russia today — and by many indications, these particular
30-year-olds are strikingly less healthy than their predecessors a few
decades earlier. The same may be said of most of the current Russian
cohorts — male and female alike — that will compose the majority of the
Russian population, and the great majority of the Russian labor force, 20
years from now. Modest as the goal may sound, getting back to the status
quo ante is an ambitious health goal for Russia today — one that, quite
possibly, may not be accomplished for years.

In its latest round of world demographic projections, the United Nations
World Population Division proposes an overall life expectancy of just over
70 for Russia for the years 2010-15 — just over 65 for men; just over 75
for women.30 These life expectancy projections are a bit more optimistic
than those of the Russian State Statistical Committee (Goskomstat)31 —
whose estimates, in turn, may prove to be overly optimistic for reasons
already mentioned. But even taken at face value, their implications are
arresting, as Figure 2 demonstrates.

If the U.N. projections prove correct, for example, male life expectancy in
Russia in 2010-15 will be barely higher than it was back in the early 1960s
— that is to say, half a century earlier. Moreover, during Russia’s
prolonged bout of stagnation, health conditions in most of the rest of the
world have been gradually improving — and are projected to continue to
improve in the future. Thus Russia’s international health standing is
envisioned as declining for decades to come — even after the country’s
health recovery has commenced.

In the early 1990s — after the onset of Russia’s current, acute mortality
crisis — life expectancy for the country as a whole is estimated to have
been almost five years higher than in the collectivity the U.N. terms the
"less developed regions" (low-income Asia, Africa, and Latin America).
Twenty years from now, by these projections, overall life expectancy in
Russia would be only about two years higher. Life expectancy for Russian
men would be ever so slightly lower than the overall male average for those
regions.

In starker terms: In the Western hemisphere, to go by these projections,
only Bolivia, Guatemala, and Haiti would have a lower male life expectancy
than Russia’s own 20 years hence. Russia’s overall life expectancy would be
lower than those of such Asian countries as China, Indonesia, Iran, and
Vietnam. Male life expectancy would be lower in Russia than in India or
Pakistan — and would be just about the same in Russia and Bangladesh. 

Projections of this sort, of course, must be treated with caution. In the
event, the ones just cited may overestimate Third World health progress: A
terrible epidemic, war, or other disaster may depress life expectancy far
below the future levels anticipated. But that caveat holds equally for
projections of health progress within the Russian Federation. Though they
can hardly be presumed to foretell the future, these projections emphasize
just how easy it will be in the years ahead for Russian health conditions
to slip further down into the ranks of the Third World — and how
extraordinarily hard it will be to forestall such an eventuality.

Poor health and economic power

If Russia’s health prognosis is indeed as gloomy as it seems, mortality and
disease will pose major obstacles to economic development in Russia for
decades to come. 

In our era, the wealth of nations lies in their human resources. Land,
commodities like oil, and even physical property have all been making a
steadily diminishing contribution to economic output over the course of the
modern age. A debilitated, unhealthy Russia is utterly unlikely to be
capable of maintaining a highly productive economic system. Rather,
Russia’s continuing relative decline in international health rankings is
likely to be accompanied by a continuing relative decline in her
international economic standing. Given Russia’s prospective health
problems, its economy 20 years hence may look even smaller by comparison
with others than it does today.

Internationally, the correspondence between health and productivity is a
strong one, as may be seen in Figure 3. No matter whose statistics one
chooses or what time period one examines, countries with higher levels of
life expectancy tend to have higher levels of per capita output — and the
ones with lower output tend also to have poorer levels of health.

The relationship between health and economic productivity is of course
vastly more complicated than can be depicted in a simplified graphic. For
one thing, health improvements are often themselves consequences of
productivity improvement: Higher incomes permit populations to purchase
better medical care, and to adopt lifestyles that reduce the threats of ill
health and death.32 Conversely, improvements in health may have
productivity-enhancing properties that come into play only over the long
run33 — properties that a point-in-time snapshot like Figure 3 is incapable
of representing. 

Nevertheless, the fact remains that, at any given time, a country’s level
of life expectancy turns out to be quite a good predictor of its level of
income. There are, of course, certain countries for which such predictions
consistently veer off the mark, but even in those cases, the deviations are
readily explicable. 

The United States, for example, "overperforms" economically — its income
level is always higher than would be predicted solely on the basis of its
health attainment. That differential may be understood in terms of the
added productivity made possible by our technological pre-eminence, our
corporate/managerial advantages, and our cadre of highly trained
specialists. Conversely, China is an "underperformer" economically — there,
per capita output is always lower than the country’s life expectancy per se
would predict. But given China’s technological backwardness and the still
problematic nature of its "institutional infrastructure" (markets, laws,
and the like), it is hardly surprising that human resources should be less
productive in China than they might be elsewhere.

For the Russian Federation today, life expectancy happens to be a rather
good predictor of productivity. Russia’s per capita GNP, in other words, is
just about what one would guess from its level of life expectancy; by some
comparisons, in fact, Russia’s output levels look slightly better than one
would predict on the basis of health alone. That should be sobering news
for Moscow, for it suggests that the country’s current economic weakness is
not so much an aberration attendant to its ongoing "transition process" as
it is a fact connected closely with the country’s extraordinarily high
levels of mortality and illness. Unless Russia can hope to emerge as a
U.S.-style "overperformer," its future economic and health progress will be
closely linked.

For all the reasons we have already seen, health progress in Russia over
the next several decades may well be painfully slow. Just what would this
portend for the Russian economy?

One way of thinking about the question would be to compute illustrative
GNPs for Russia and other countries on the basis of today’s international
relationships between health and productivity, but using the numbers for
life expectancy and population size that are projected for, say, two
decades from now. Obviously, this will be a highly imperfect approach, but
it may nonetheless prove useful in gleaning an impression of what lies ahead.

Although current U.N. demographic projections envision a total Russian
population smaller 20 years from now than it is today, they also anticipate
life expectancy to be somewhat better. Using crude, health-based
"predictors," such a future Russia could be assigned a real GNP of a little
over a trillion present U.S. dollars. Taken at face value, that total would
imply consequential economic progress for Russia in the years ahead — a
respectable pace of GNP growth averaging, say, 2.5 percent per year.

But the world is a moving target and much of the world may be moving more
rapidly than Russia in the decades ahead. Certainly health-based
"predictors" of economic performance would suggest as much. The same
methods that depict a future Russia with a trillion-dollar economy 20 years
from now, for example, can be used to conjure up a Turkish economy of equal
or even greater size. Similar calculations portray a Russia virtually
encircled in Asia by larger economies: Not just Korea, Japan, China, and
India, as today, but also Pakistan and Iran — all could have economies at
least as large as Russia’s own.

This illustrative approach, indeed, suggests that Russia’s international
economic ranking could drop steadily over the coming 20 years,
notwithstanding an envisioned measure of national health recovery and
economic progress. At the moment, Russia’s economy is probably the world’s
thirteenth or fourteenth in terms of overall size.34 Crude, health-based
calculations imply that it might possibly be as low as, say, twentieth two
decades from now. 

What would it mean to be the world’s twentieth largest economy 20 years
from now? We might get some sense of the geopolitical ramifications by
considering the world’s twentieth largest economy today. The World Bank
provides PPP adjusted estimates of national output for 1997; though these
should not be taken as precise, they offer at the least a sense of scale.

Consider Thailand or Australia. Neither of them would have been the world’s
twentieth largest economy in 1997 — they were both almost certainly too big
for that. Instead, visualize something in the vicinity of Argentina or
South Africa: perhaps Holland.

With the power of the Dutch economy, or the South African economy, or the
Argentine economy at its disposal, a radical or revisionist state could
today cause tremendous difficulties for its neighbors, its region, and
arguably even the entire international community. It could be a nuisance, a
headache, or (if left unchecked) a predatory menace. But no matter what its
international disposition, no matter how shrewd and ruthless its statesmen,
a country with an economy the size of Argentina’s today could not hope to
lay claim to Great Power status. The gap between that ambition and the
resources necessary to realize it would simply be too great. 

What holds for Argentina today may obtain for the Russian Federation
tomorrow. A less peaceable, more militant Russian state than the one we
know today could easily be a source of tensions and a cause of troubles
that the international community currently does not have to contend with,
and naturally would prefer not to. But if the Russian Federation’s relative
economic standing continues to slip in the decades ahead, genuine Great
Power status will drift ever further from the grasp of Moscow, irrespective
of the priorities, ideology, or skill of its leadership. Russia’s potential
for mobilizing national power is severely impaired today by the sickness of
its people — and sickness looks to be an even more crippling constraint on
Russian power over the generation to come.

An unhealthy Great Power?

It is, of course, possible to argue that Russia’s current trends in
sickness and death will not necessarily impede the country’s comeback on
the world stage. At least two such objections deserve consideration.

The first would hold that the economic costs of Russia’s health crisis are
not nearly as grave as has been suggested here. Consider a possible
counterargument by analogy. Some recent econometric research on the
repercussions of the international AIDS epidemic, for example, has
concluded that this pestilence, gruesome as its human consequences may be,
has had only a negligible impact on economic growth and output — even in
AIDS-ravaged areas of sub-Saharan Africa.35 Using similar reasoning and a
similar econometric framework, one new study estimates that the total costs
of Russia’s mortality crisis are surprisingly low: only 0.3 percentage
points a year knocked off the country’s economic growth rate.36 That would
be a drag on economic growth, to be sure, but only a relatively minor one:
by implication, Russia’s burden of disease might not be nearly so onerous
as to prevent the county’s ascendance as a major global economic power —
and thus, a major political power — in the decades immediately ahead.

Without gainsaying the sophisticated modeling techniques being marshaled
here, one can make two points about this type of objection. First, it is
quite possible that estimates of a negligible economic cost for the
sub-Saharan AIDS epidemic are actually quite wrong, drawing as those models
did on much more preliminary information about a scourge that now is
radically depressing life expectancies in countries across the entire
sub-Sahara.37 Second, the debilitating illnesses and afflictions pressing
down life expectancy in the Russian Federation today would appear to be
distributed much more broadly over the populace than would be an AIDS
epidemic of equal lethality; if so, the economic impact of the
Russian-style health retrogression could be commensurately greater.

A second kind of objection asserts that, however weakened, the Russian
populace remains a force to be reckoned with in world affairs due to its
formidable potential on the field of battle. Edward N. Luttwak offered a
variant of this argument almost 15 years ago, when he warned readers
against "Delusions of Soviet Weakness":

. . . [D]runkenness is no doubt pervasive in the[ir] . . . armed forces.
But the Russians have always been great drinkers. Drunk they defeated
Napoleon, and drunk again they defeated Hitler’s armies and advanced all
the way to Berlin.38 

Yet this objection, too, now appears overtaken by certain events. Operation
Desert Storm may have offered us a glimpse of the next face of war: the
hi-tech, information-intensive arrangements that currently travel under the
banner of the "revolution in military affairs." While this nascent
"revolution" may not invest the armies that embrace it with invincibility,
it looks nonetheless to confer upon them tremendous advantages over their
"pre-revolutionary" opponents. That being the case, what are its
implications for Russian military might? 

A debilitated Russian populace is unlikely to support a "revolution in
military affairs" worthy of the name. In a sick country, amassing the
requisite corps of soldier/specialists to conduct high-technology warfare
may be a challenge in itself. (Brave and regimented drunkards may have
succeeded in marching on Paris and Berlin in the past, but they would fare
rather less creditably today in, say, high-precision aerial combat.) More
important, though, a debilitated Russian populace will be hard-pressed to
finance the far-reaching expenditures and investments that a meaningful
"revolution in military affairs" would demand. 

If Russia cannot support a full-fledged "revolution in military affairs" in
the next decades, it may still be able to field a large conventional force
— a force that would perhaps enjoy overwhelming capabilities by comparison
with a number of neighboring states. But such an armed force would have
little capacity for projecting military power far beyond its borders or
against Great Power adversaries39 — no matter how courageous or
casualty-tolerant the Russians happened to be.

Too sick to matter?

A decade ago — at the end of the Soviet era — the Russian Federation
contained the world’s fifth largest population. By 2020, according to U.N.
projections, Russia’s population will be no larger than ninth. In the late
1980s, Russia’s life expectancy, though lower than Europe’s, Japan’s, or
America’s, was nonetheless higher than Asia’s or Latin America’s; 20 years
from now, according to U.N. projections, Russia’s life expectancy would be
lower than those of 125 of the 188 countries and territories assayed — and
as we have seen, even this may turn out to be an optimistic assessment.

In the Soviet era, Russia was the sick man of Europe. Today, it is also the
sick man of Asia. This illness does not look to be quick in passing. If the
humanitarian implications of Russia’s health crisis are pressing, the
strategic implications also appear to be inescapable. 

Russia’s well-wishers — like the Russian people themselves — should hope
for a speedy establishment of civil society, a sturdy rule of law, and
sound, steady economic policies for the Russian Federation. They should
also pray for enlightened public health measures to tackle the country’s
terrible health situation (a program, incidentally, to which not one of
Russia’s many political parties at this time is yet committed).

Russia’s imagined antagonists, for their part, should not base their fears
and apprehensions on the specter of a rapidly reviving "Great Power"
Russia. As orderlies at medical institutions around the world can attest,
even a weakened patient must be treated with care if he is seized by
delirium. But it looks as if Russia is going to be in bed for a long, long
time.

********



 

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