1. Сравнительный анализ тенденций смертности в странах бывшего Советского Союза Л.А. Гаврилов Н.С.Гаврилова Университет Чикаго

2. GDP per capita at current prices (dollars) in Russia and other countries Country1990200020102012 Russia384017681061814178 China34793243756070 Kazakhstan18491266938012455 Ukraine174663729623872 Belarus1835104458186726 Finland27852235284409845741 Bulgaria2350161364597004 Mexico3815658289169795 Source: http://data.un.orghttp://data.un.org

3. IndicatorRussiaKazakhstan Infant mortality per 1000 live births7.428 Total fertility rate (mean number of children per woman) 1.72.6 Percent of persons 65+ years of age137 Life expectancy: Men64 Women7674 Proportion of urban population, %7455 Demographic Indicators of Russia and Kazakhstan Source: Population Reference Bureau. 2013 World Population Data Sheet.

4. Ожидаемая продолжительность жизни в России, Китае и Индии Россия ГодМужчиныЖенщины 199262.073.8 199358.971.9 199457.671.2 199760.872.9 200058.871.7 201264.675.9 Китай201373.077.377.3 Индия201366.468.7

5. Изменение продолжительности жизни в России после 1964 года

6. Россия и Казахстан имеют сходную картину изменения смертности за последние 20 лет

9. 1992 – реформы Гайдара Катастрофический рост цен Разрешен обмен валюты Разрешены все виды бизнесов Приватизация всего Теперь Российские СМИ называют эти реформы “печально известные”

10. Кризис ВВП в странах Закавказья

11. Эффект реформ Гайдара на ОПЖ в России ОПЖ мужчин упала с 63.8 лет в 1990 до 57.4 лет в 1994. ОПЖ женщин упала с 74.3 лет в 1990 до 71.1 лет в 1994

12. Депопуляция в России или “Русский крест”

13. Обратное изменение смертности Ситуация, когда обычные временные тенденции снижения смертности идут вспять (смертность растет со временем). Наблюдается в странах Африки (пандемия СПИДА), Восточной Европе и странах постсоветского пространства, включая Россию. Обратное изменение смертности в странах б.СССР наблюдается преимущественно у мужчин, у которых основной всплеск смертности происходит в возрасте 35- 55 лет. Наиболее сильный рост смертности наблюдается от насильственных причин и несчастных случаев среди рабочих и малообразованных групп населения

14. Вклад основных классов причин смерти в формирование ОПЖ при рождении у мужчин Источник – В.Юмагузин, Demoscope Weekly, N 485-486, 2011

15. 1998 – новый экономический кризис 28 августа 1998 года во время свободного падения российских биржевых индексов, правительство России объявило дефолт по своим облигациям и прекратило обмен рубля на иностранную валюту. Вкладчики потеряли существенную часть накоплений в банках

16. Кризис 1998 года остановил снижение смертности в России

17. Russian President on Demographic Situation in Russia (Address to Russian Parliament, May 10, 2006) Demographic problem is "the most urgent problem of modern Russia" Demographic situation is "critical" "We talked at lot on this topic but did little." Government is "too slow with unacceptable bureaucracy in resolving the problem" Suggested 10+ year program with three priorities: -- to decrease mortality -- effective migration policy -- to increase fertility

18. Рост ожидаемой продолжительности жизни в России после 2003 года Источник – В.Юмагузин, Demoscope Weekly, N 485-486, 2011

19. Russian President on How to Decrease Mortality (Address to Russian Parliament, May 10, 2006) Program to prevent traffic accidents and improve road safety (high penalties for drunk driving) To eradicate production and import of alcohol surrogates (poisoned alcohol) National Project "Health" focused on prevention and treatment of cardiovascular diseases, and other major causes of death. Smoking ban in public places High taxes on hard liquors

20. Вклад основных классов причин смерти в формирование ОПЖ, 1990-2009 Источник – В.Юмагузин, Demoscope Weekly, N 485- 486, 2011

21. Переходный период сопровождался небывалым ростом насилия, преступности и смертности от убийств

22. Преднамеренные убийства в России и США

23. Тенденции смертности от убийств лиц молодого и среднего возраста в России Данные статистики смертности России МужчиныЖенщины

24. Традиционно высокое потребление алкоголя возросло в 1990-х годах

25. Age Profiles of Mortality from Accidental Poisoning by Alcohol Data from Russian Vital Statistics MalesFemales

26. Снижение качества алкоголя во время рыночных реформ In 1992 state monopoly on alcohol sales was abolished Self-production of alcohol became not profitable but over 20% of alcohol sales included technical alcohol Sample control tests showed that proportion of below quality standards alcohol was 5.6% in 1992 and 30.4% in 1994 Imported alcohol had even lower quality: 67.2% below quality standards

27. Суррогаты алкоголя Alcohol surrogates – non-food liquids containing ethanol (polishing liquids, perfume, pharmaceutical tinctures, etc.) Alcohol surrogates are cheap, so they are attractive to poor persons. May be the only source of ethanol for impoverished persons. 47% of men who used surrogates were unemployed. Only 13% of men not used surrogates were unemployed

28. Потребление крепких напитков и продолжительность жизни

29. Социальный состав молодых мужчин (16-39 лет), умерших в 2004 году в Кировской области Иванова и др., Demoscope

30. Можно предположить, что рост смертности в 90-х годах определялся преимущественно: Расширением базы маргинализированных слоев населения (все больше людей оказалось вовлеченными в эти группы) Ускоренным ростом смертности в социально дезадаптированных группах населения

31. Маргинализация смертности сопровождается возвратом старых инфекций

32. Туберкулез и сифилис в России 1990-1999

33. Распространенность сифилиса в Казахстане на 100000 населения (1991-1999)

34. Образование предохраняет от преждевременной смертности мужчины 20-69лет, Россия Источник: Shkolnikov et al., SSM, 1998

35. Особенности недавнего роста ожидаемой продолжительности жизни Наибольший прирост в рабочих возрастах (15-64) Основные улучшения в смертности от причин, непосредственно связанных с потреблением алкоголя, несчастными случаями и респираторными заболеваниями Эти улучшения могут быть связаны с мерами по контролю за алкогольной продукцией, принятыми в 2005г.

36. Current trends in life expectancy in Moscow and some Eastern European countries

37. Что происходило в других странах постсоветского пространства Прибалтийские страны – в целом положительная динамика смертности Славянские страны – стагнация продолжительности жизни, улучшение в последние несколько лет Страны Закавказья – позитивная динамика, но возможны проблемы качества данных Страны Средней Азии – в целом положительная динамика, но странные флуктуации ОПЖ в последние годы в некоторых странах (качество данных?)

38. Ожидаемая продолжительность жизни в странах б.СССР в 2012, Мужчины

39. ОПЖ в странах б.СССР в 2012, Женщины

40. Продолжительность жизни в Беларуси, России и Украине. Мужчины

41. Продолжительность жизни в Беларуси, России и Украине. Женщины

42. Продолжительность жизни в Казахстане, Кыргызстане и Узбекистане. Мужчины

43. Продолжительность жизни в Казахстане, Кыргызстане и Узбекистане. Женщины

44. Ethnic Differentials in Mortality

45. Based on the Study of Ethnic Differentials in Adult Mortality in Kyrgyzstan Michel Guillot (PI), University of Wisconsin-Madison Natalia Gavrilova, University of Chicago Tetyana Pudrovska, University of Wisconsin-Madison Demography, 2011, 48(3): 1081-1104

47. Background on Kyrgyzstan Former Soviet republic; became independent in 1991 Population: 5.2 million (2006) Experienced a severe economic depression after break-up of Soviet Union GNI per capita = 440 USD; 28 th poorest country in the world (2005) 48% of population below national poverty line (2001)

48. 2008 Workshop, Bishkek

49. Workshop in Almaty, 2011

50. Ethnic Groups in Kyrgyzstan Native Central Asian groups: Kazakh, Kyrgyz, Tajik, Turkmen, Uzbek (Sunni Muslims) Slavs: Russian, Ukrainian, Bielorussian Kyrgyzstan, 1999 census: Central Asians: 79% of pop. (Kyrgyz 65%) Slavs: 14% of pop. (Russian 12%)

51. Recorded trends in adult mortality (20-60 years)

52. Mortality paradox? Soviet period: Russians/Slavs occupied dominant positions in the socio-economic structure of Central Asian societies (Kahn 1993)

53. Mortality paradox? Slavic females more educated than Central Asian females (1989 and 1999 censuses) Slavic males: educational advantage not so clear – varies by age (1989 and 1999 censuses) Slavic households less poor than Central Asians (1993 World Bank poverty survey) Infant mortality lower among Slavs (Soviet and post-Soviet period)

54. Proportion of individuals with post-secondary education, by age and ethnicity, in 1989 census. Females

55. Mortality paradox? Slavic females more educated than Central Asian females (1989 and 1999 censuses) Slavic males: educational advantage not so clear – varies by age (1989 and 1999 censuses) Slavic households less poor than Central Asians (1993 World Bank poverty survey) Infant mortality lower among Slavs (Soviet and post-Soviet period)

56. Proportion of individuals with post-secondary education, by age and ethnicity, in 1989 census. Males.

57. Mortality paradox? Slavic females more educated than Central Asian females (1989 and 1999 censuses) Slavic males: educational advantage not so clear – varies by age (1989 and 1999 censuses) Slavic households less poor than Central Asians (1993 World Bank poverty survey) Infant mortality lower among Slavs (Soviet and post-Soviet period)

59. Mortality paradox? Slavic females more educated than Central Asian females (1989 and 1999 censuses) Slavic males: educational advantage not so clear – varies by age (1989 and 1999 censuses) Slavic households less poor than Central Asians (1993 World Bank poverty survey) Infant mortality lower among Slavs (Soviet and post-Soviet period)

60. IMR by ethnicity, 1958-2003, Kyrgyzstan

61. Data Unpublished population and death tabulations since 1959 collected from local archives Individual census records – 1999 Individual death records – 1998- 1999 obtained from national statistical office

64. Possible explanations for mortality paradox Data artifacts Migration effects (esp. 1989-99) Cultural effects

65. Data artifacts? Could the lower recorded mortality among Central Asian adults be due to lower data quality among them (coverage of deaths, age misreporting)?

66. Migration effects? 1/3 of Russian population has left Kyrgyzstan since 1991 Could the increased disparity between Russian and Kyrgyz adult mortality be due to selective migration (healthy migrant effect)?

67. Cultural effects? Culture may affect mortality in various ways:  individual health and lifestyle behaviors (e.g., diet, smoking, alcohol, use of preventive care)  family structure and social networks (denser social networks may produce lower stress levels and better health) Could different cultural practices among Slavs and Central Asians explain the observed mortality differentials?

68. Data artifacts? Intercensal estimates of death registration coverage above age 60 (Guillot, 2004): 90+ % as early as 1959 in urban areas coverage in rural areas was low initially (~50%) but caught up with urban areas in 1980s Total population: 92% for 1989-99 period Adult deaths (20-59) usually better reported than deaths 60+

70. Health selection?

71. Cohort-specific changes in educational attainment, Males, 1989-99

72. Cohort-specific changes in educational attainment, Females, 1989-99

73. Cultural effects? Analysis of causes of death by ethnicity, 1998-99 Calculations based on micro-data Deaths: vital registration (1998-99) Exposure: census (March 1999) Ages 20-59 Ethnicity: Central Asians vs. Slavs ~20,000 death records; ~2.2 million census records

74. Age-standardized Death Rates at working ages (per 100000), 1998-99, by cause and ethnicity, Males

75. Contribution of causes of death to the difference in life expectancy at working ages ( 40 e 20 ) between Slavs and Central Asians Males (total difference = 2.90 years)

76. Age-standardized Death Rates at working ages (per 100,000). Detailed Injuries, Males

77. Age-standardized Death Rates at working ages (per 100,000), 1998-99, by cause and ethnicity, Females

78. Contribution of causes of death to the difference in life expectancy at working ages ( 40 e 20 ) between Slavs and Central Asians Females (total difference =.28 years)

79. Age-standardized Death Rates at working ages (per 100,000) Detailed Injuries, Females

80. Alcohol-related Causes of Death (Chronic alcoholism, Alcohol psychoses, Alcohol cirrhosis of the liver, Accidental poisoning by alcohol) Age-standardized Death Rates at working ages (per 100,000)

81. Multivariate analysis Do ethnic mortality differentials at adult ages remain once we account for differences in education and urban/rural residence? Negative binomial regression Dependent variable: deaths from all causes; deaths by major cause (7) Explanatory variables: exposure, dummy variables for age, ethnicity, urban/rural residence, education (3 cat.) Males and Females analyzed separately Model 1: age, ethnicity Model 2: age, ethnicity, education, residence

82. Males, all causes of death

83. Risk Ratio Slavs/CA Males

84. Risk Ratio Slavs/CA Females NS

85. Conclusions Excess mortality among adult Slavs (Soviet and post-Soviet period) is not likely due to data artifacts or migration effects Excess mortality due to important ethnic differences in cause-specific mortality – alcohol and suicide in particular Differences remain unexplained by education or residence

86. Conclusions Role of cultural characteristics? Alcohol tied to cultural practices (“culture of alcohol” among Russians; Impact of Islam for Central Asians) Denser social networks and stronger social support among Central Asian ethnic groups?

87. Divergent paths for adult mortality in Russia and Central Asia: Evidence from Kyrgyzstan Guillot, M, Gavrilova, N, Torgasheva, L, Denisenko, M. PLOS ONE, 2013, 8(10): e75314, DOI: 10.1371/journal.pone.0075314 Further developments

88. Study of autopsies in Barnaul during 1990-2004 (Zaridze et al., 2009) Among 5732 autopsied men aged 35- 69 years who were reported to have died from circulatory diseases 49% had alcohol detected in their blood and in 21% concentration of ethanol was 4g/l and higher (lethal dose) Of 5880 autopsied men aged 35-69 years who were reported to have died from injuries 76% had alcohol in their blood and in 38% concentration of ethanol was 4g/l and higher

89. Trends in Life Expectancy: Men

90. Trends in Life Expectancy: Women

91. 40 M 20 (Russia) – 40 M 20 (Kyrgyzstan), 1979-2009, all causes and strongly alcohol related causes

92. Ethnicity, russification and excess mortality in Kazakhstan Ethan J. Sharygin and Michel Guillot. Vienna Yearbook of Population Research 2013 (Vol. 11), pp. 213–237 Further developments (2)

93. Сравнительная смертность русских и казахов 1999

94. Модель 1 контр.по возрасту и области. Модель 2 дополнительно контр. на тип поселения и образование. Экспоненты коэффициентов. Негативные биномиальные регрессии числа умерших по русской национальности для разных причин смерти, Казахстан 1998-1999

95. Framework for Understanding Health Crisis in Russia vs. Central Asia RussiaKyrgyzstan (Central Asia?) Infant mortality DeclinedStalled Adult mortality Large increaseModerate increase Explanatory framework Greater importance of detrimental adult health behaviors Greater importance of health care deterioration

96. Acknowledgements National Statistical Committee of the Kyrgyz Republic Zarylbek Kudabaev, Orozmat Abdykalykov, Liudmila Torgashova, Larissa Mimbaeva, Elena Komandirova and Mikhail Denisenko NICHD: R03 HD38752, R01 HD045531