11 Former Soviet Union Hserv 482

Learning Objectives describe the health achievements of countries of the Soviet Union from its origins to its demise discuss possible reasons for the decline of health in countries of the former Soviet Union STUDENT IMPRESSIONS/EXERIENCES?

Trends for population health in the Former Soviet Union? Comparisons with USA for life expectancy –1900 –1960 –1980 –1996 TRENDS

Shkolnikov Population

Shkolnikov Population

Soviet History Tsarist period 1400s to Revolution, Golden Age ( ) Stalin consolidation era ( ) Great Patriotic War (1941-5) Khrushchev ( ) Gorbachev era ( ) on

Tsarist period 1400s to 1917 tight control, an imperial bulwark against liberal and democratic ideas of Europe Royal Family and church ruled ruthlessly over illiterate peasantry rigorous censorship serfdom abolished in 1861 to forestall more radical social changes early 20th century, urban factories and universities a breeding ground for radical opposition inspired by socialists and anarchists

1917 Revolution, led by urban intellectuals peasants seized land, workers took over factories, soldiers deserted takeover by Lenin led to Soviet Union (“bread, land and peace”) Bolsheviks Mensheviks –larger faction in Second Congress of the Russian Social Democratic Workers' Party (1903) –Sided with Lenin and became Russian Communist Party

Socialism oriented towards creation of social order in which : there is maximum feasible quantity of access for all human beings –to economic resources –to knowledge –to political power minimum possible domination exercised by any individual or social group over any others FREE ASSOCIATION OF PRODUCERS

Marx: path to a socialist society –through class conflict arising from class inequality –which leads to class consciousness –the path is by revolution need to abolish private ownership of property Marx in Soho play by Howard Zinn

Communism: Process of class conflict, revolutionary struggle resulting in victory for proletariat and … establishment of classless socialist society with –abolition of private ownership, and –means of production and subsistence belonging to the community (may not be socialism)

1917 Revolution results nationalized industry under workers control destroyed former class system abolished private ownership of land when property of nobility taken over abolished rank in military

Golden Age ( ) major powers hostile to USSR, –Churchill recommended ‘strangling Bolshevik baby in its cradle’ –counter-revolutionary war supported by 21 countries, finally ended in 1921 –economy crippled, people war-weary Bolsheviks fell back to authoritarian tactics, demands for local control suppressed 1920s adopted some market freedoms for peasants to deal with catastrophic fall in food production Lenin died in 1924, leading to fight for power characterized by intense debate, flowering of arts, literature, music & gains in public health

Stalin consolidation era ( ) five year plans stressing –fast industrialization (production increased rapidly) –urbanization –collectivization of agriculture (production faltered) moderately well-off peasant families (petty capitalists) had their property seized, deported to labor camps or executed (5 to 10 million)

Stalin consolidation era ( ) purges of bureaucracy after making confessions Gulag: system of concentration camps, –largest employer in Europe no control devolved to people (Stalinism) –command economy –police state repression –military buildup created system of hierarchical privilege

Class system began under Stalin working class –promised housing, wages, safety, but never got it "you pretend to work, we'll pretend to pay you" rural peasants –worse off than serfs used to be in many cases nomenklatura (Communist Party Elite) –special privileges –purloined state property –exercised patronage

Great Patriotic War (1941-5) Lost 7.5 million soldiers, 6-8 million civilians, 25 million left homeless People pulled together, –popular fondness for Stalin emerged Occupation of Eastern Europe from Turkish border to Baltic led to Soviet Union with 15 republics

Khrushchev ( ) labor camps shut down, some prisoners freed, censorship eased, socialism optimism surfaced Red Army crushed anti-Stalinism revolution in Hungary 1956 Sputnik in 1957 boosted people’s self-esteem and USSR expected to overtake the west

USSR: similar to Stalin without the brutality widespread corruption, absenteeism, alcoholism –growth of nomenklatura, consolidating their privileged position and discouraging change profound sense of disillusionment especially for older generations whose idealism and faith in system had declined economic growth declined

USSR: dissenters harassed, imprisoned, exiled, or sent to mental hospitals military interventions in Czechoslovakia, Afghanistan, comparable to US in Vietnam and Central America –huge spending on military might Cold War: –carved up world between 2 ‘superpowers’ increasingly educated citizenry attempts at economic reforms in 1960s halted by bureaucracy consumer dissatisfaction –shortages and quality of goods increased

Gorbachev era ( ) allowed free speech, new ideas circulated, sparked struggle for greater democracy –hundreds of independent organizations and political clubs open, contested elections for government posts democratically elected parliament

Gorbachev era ( ) allowed limited free-market economy –free-market economy and political choices not compatible with state-controlled economics and Soviet style communism Gorbachev said he wouldn’t intervene in internal politics of Eastern Europe –people overturned their communist governments, through civil unrest “Communism” incapable of inducing “reform” Nationalism grew in Soviet republics

Accomplishments of Russia and FSU revered rulers brought suffering down upon people (Ivan the Terrible, Peter the Great, Stalin) Stalin inherited country that was primary casualty of WW I and bequeathed to successors a superpower –doubled production of coal and steel –tripled output of cement and industrial goods –increased pool of skilled labor by order of magnitude ALL HIGHER RATES OF INCREASE THAN THE WEST

Accomplishments during Stalin era few revolts, Stalin era spiritually satisfying for those who survived, in spite of the violent deaths between 1940 and million lives lost in wars, equal number in purges life expectancy rose from 44 when he took power to about 62 when he died

Stalin death’s led to intense elation, Socialist Utopia within striking distance, –ascetic dedication of Revolution married to Consumerism 10 years later: no progress after self-sacrifice –people stranded without faith, Effect of media in portraying “good life” in west Russian’s deprived of this “good life” –US in 60s and 70s was preoccupied with revolts in cities, Vietnam War, women’s movement, etc. didn’t notice USSR was grinding down productivity not improving state projects: > 40% abandoned in 1975 cf 1.7% in 1965 –“economic sabotage” perhaps 20% in 1980 –since early 1950s per capita alcohol sales rose five fold, and with home brew, could be much higher

Attitudes towards Stalin 1942: MAN OF THE YEAR, Time magazine –Winston Churchill, Averill Harriman others dined with him NYT front page headline March 6, 1953 on Stalin's death made no mention of purges or gulag, instead wrote that his death "brought to an end the career of one of the great figures of modern times-- a man whose name stands second to none as the organizer and builder of the great state structure the world knows as the Soviet Union"

Soviet achievements to 1960 focus on heavy industry and military weapons production –Space Program (was ahead of USA initially) Sputnik 1957 and space program putting first person into orbit 1961 first manned orbiting spacecraft in 1964 US had better technology except for heavy payload rockets –Consumer production limited to mostly food and housing economic growth from 1950 to 1960 was faster than Western Europe and USA –productivity peaked with Khrushchev ( ) exports: armaments, oil, gas and gold

Economic growth dropped since mid-1960s Slipped below OECD rivals in 1970s, with increased public (military) investment coming from goods and services economy ("reforms") –when Stalin died in 1953, living standards were considered lower than under Czar Nicholas II, –yet there were strong consumer expectations that no succeeding leader could fulfill (not Khrushchev, nor Brezhnev nor Kosygin). Responses imported grain from adversaries to feed people (Seattle elevators) produced consumer goods such as refrigerators cut back on health services

After Stalin's death glue holding USSR together in the late 70s, early 80s was –secret police and army –black market –political privilege restrictive and highly sophisticated

social cohesion lack of trust in system –absenteeism, drunkenness on job USSR was guided by a Russian minority, personality cult Russian ethos (collective reserve of strength) “beat your son and he will comfort you in old age” –advice given by monk Sylvester, confessor to Ivan the Terrible Sayings –“whom I love, I beat” –“happiness without suffering is incomplete” –“don’t argue with misfortune, suffer” –Dostoevsky “fundamental spiritual need of Russian people is... for suffering, perpetual and insatiable, everywhere and in everything”

Responses to Productivity decline tax alcohol –might awaken masses, and also cut government spending elsewhere for lack of revenue –Yet by late 1980s, alcohol consumption declined, and alcohol-related deaths dropped

Health Achievements in FSU 1897 life expectancy ~30 years (Imperial Russia), IMR ~250, US life expectancy then about s, 30s great improvements, but data collection poor

Health during cold war, improvements continued late 1950s –life expectancy ~68 slightly greater than in US, –IMR lower than Italy, or Austria health in Central Asian republics of USSR better than Iran, Pakistan, Afghanistan

Health to around 1970, “communism is good for poverty removal and for health" Amartya Sen for equivalent GNP/capita, health was better in ‘communist’ countries

life expectancy stagnation/decline began in 60s, 70s in different degrees in different areas –remarkable since it was difficult to push life expectancy down in 20th century –UK gains during two world wars –France gained during WW I

Reasons for health decline not health care system, –which was always small in comparison to Western Europe and US (3-4 % of GNP and declining over time, –numbers of people hospitalized declined cardiology clinic in Moscow was on the fifth floor, no elevator “second economy” = bribery, tips works against the neediest

Health in countries of the former Soviet Union declined MUCH more after 1991 with the breakup bulk of health decline occurred in middle-aged adults, not infants –Steepest decline in urban and most economically developed areas –(where economies changed most rapidly) Social Chernobyl SHOCK THERAPY

Andreev IJE

How aware are Russian’s of this catastrophe? About as aware as Americans of their poor health relative to other countries, nor of our decline in relative health since 1960 Typical of structural violence –No outcry! cf. Rwanda genocide, or Holocaust –"no pain, no gain, need stay course of reforms"

Life Expectancy Declines in 20th C. Wars –Spain –West Germany –Japan Male life expectancy that year was 25, but by 1977 was highest –South Korea Sub-Saharan Africa from 1990s onward Russia alone 1.8 million excess deaths – about 3 million excess deaths WW I Russian deaths were 1.7 million Former Soviet Union toll more than 15 million deaths

INFORMAL TRUST Social cooperation necessary for people to secure enough to avoid becoming destitute –only one in 8 earns enough from official job to meet basic needs but most get through without borrowing or spending savings, using unofficial economies (subsistence agriculture, barter economy, second job, tips, bribes, foreign remittances –NEGOTIABLE CREATIVE EXCHANGES: after passing exams to graduate need "pay" teacher parents of sick child told might be dead next week, unless you get expensive "extra treatment" taxi driver stopped on way to airport with foreign fare, fined $100 for "being drunk" Russians’ help friends without expecting money –“A hundred friends are worth more than a hundred rubles” –sometimes strangers oblige without being paid, and thereby enlarging their own network of people upon whom they can call for help some day

MAFIA CAPITALISM Robber Capitalism Russian Mafia exploits cash-rich individuals –Has distracted attention from cash-free economies that depend on social cooperation

ECONOMIES IN RUSSIA Two economies for every family –official economy with wage or pension –social economies in which goods and services produced, exchanged, consumed without money changing hands (11% of Russian hh exist solely on social economy) –Also “uncivil” economy for a third of Russian hh, with shadow economy or extra-legal or illegal (also called “second economy” before 1990) most vulnerable groups (poorest) least affected by this uncivil economy, and rely on official economy, and hence most at risk supply greatly exceeds demand here, about 17% of Russian hh rely on this economy along with official economy

Making Transition Work for Everyone: Poverty and Inequality in Europe and Central Asia, World Bank 2001

eSilver medial in Billionaire Olympics

Hierarchy and Fall in Life Expectancy Data on 71 regions from Russian state statistics committee, including income surveys, adjusted for changes in consumer price index, using Robin Hood index (Gini more sensitive to extremes) Male life expectancy fall from 1990 to 1994 (nadir) Fall associated with labor turnover and RH index and associated less with mean hh income in 1990

Davey Smith 1996

Marmot & Bobak BMJ 2000

Association of Labor Turnover and Fall in Men's Life expectancy

Making Transition Work for Everyone: Poverty and Inequality in Europe and Central Asia, World Bank 2001 Social Monitor 2003 Innocenti

Making Transition Work for Everyone: Poverty and Inequality in Europe and Central Asia, World Bank 2001 Social Monitor 2003 Innocenti

Central Asia Human Development Report 2005

Making Transition Work for Everyone: Poverty and Inequality in Europe and Central Asia, World Bank 2001 Social Monitor 2003 Innocenti

16 nations, 169,776 people

SCF State of the World's Mothers 2004 In Phillips County,Arkansas, the birth rate among teenage girls in 2000 was 127 births per 1,000 w omen aged 15 to 19 - a rate higher than in 94 developing countries. A fifth of 20-yr old women who gave birth in the US gave birth did so in their teens

Marmot, Lancet 05

Summary Former Soviet Union made remarkable health gains until the 1960s Population health declined since then, as social capital eroded Most vulnerable groups in the decline were single middle-aged men and to a lesser extent single women Political structures have profound impacts on health outcomes (structural violence) Most people are ignorant of these issues, although major world forces have paid lip service in the past (Benjamin's Law)

Creative Destruction "Any reform must be disruptive on an historically unprecedented scale. An entire world must be discarded, including all its economic and most of its social and political institutions." –Create Middle America on the Volga –If you can't make money from it, don't do it 'The essential fact about capitalism' Joseph Schumpeter jobs living standards entire industries health lives MEDIUM-LEVEL NUCLEAR ATTACK