Introduction

The health of people in the former Soviet countries deteriorated dramatically after the collapse of the Soviet Union, although the first signs of deterioration were already visible in the second half of the 1980s. Some improvements have been observed in recent years, but health indicators in many post-Soviet countries have not yet reached the levels of the late 1980s. This chapter provides an overview of mortality and morbidity patterns in the 12 countries of the former Soviet Union considered in this volume. It then describes key risk factors for health in the region, focusing on alcohol consumption; tobacco use; obesity, nutrition and physical activity; and water and sanitation.

Life expectancy and mortality

Life expectancies in the countries of the former Soviet Union lag far behind those in western Europe. The divergence started in the 1960s, when life expectancy in the Soviet Union began to stagnate (Andreev et al., 2003; Mackenbach, 2013). Notable but short-lived improvements occurred in the late 1980s, linked to President Gorbachev’s anti-alcohol campaign (Leon et al., 1997). However, life expectancy declined dramatically in the first half of the 1990s, particularly for males. While there were large drops in life expectancy in Armenia in 1988 (as a result of a major earthquake in Spitak) and Tajikistan in 1993 (due to the civil war), even in countries unaffected by natural disaster or war declines were substantial. This was most pronounced in the Russian Federation, where male life expectancy fell by 6.2 years between 1990 and 1994, from 63.8 to just 57.6 years. Following the rouble crash in 1998, the fragile improvement up till then was arrested and life expectancy only began to improve again after 2006. Other countries in the region have followed a similar trend, with a marked decline in the first half of the 1990s, and a subsequent slow recovery. Some countries in the region are yet to reach the level of life expectancy they had more than 25 years ago (Fig. 2.1). While variation persists among countries, the region overall has the lowest life expectancy in Europe.

Fig. 2.1

Officially recorded life expectancy at birth, 1985–2012. Source: WHO, 2014.

However, officially reported data may overestimate the true life expectancies in many of these countries, in particular in central Asia and the south Caucasus, mainly due to an underreporting of infant and child mortality (Aleshina & Redmond, 2003), but also due to overestimates of population sizes that have been depleted by migration (Yeganyan et al., 2001). Table 2.1 shows WHO estimates of life expectancy in the region, which are substantially lower than values that some countries report officially.

Table 2.1

Official and estimated life expectancies, latest available year (in parentheses).

The main reason for the low life expectancy compared to western Europe is the very high burden of premature mortality, particularly in males of working age. In 2010 a 20-year old man in the Russian Federation had, given 2010 mortality rates, a 64% chance of reaching the age of 60 compared with a 91% chance in western Europe (Rechel et al., 2013). Another reason is infant mortality, which, at 11.2 per 1000 live births in the region as a whole in 2010, was almost three times higher than the EU average of 4 per 1000 live births (WHO, 2014). This is a particular concern in central Asia. Data from Demographic and Health Survey Program suggest that already high official rates (reported from all central Asian countries except Turkmenistan) underreport infant mortality, with survey results 1.4–3 times higher, depending on the country (DHS, 2012). In Kyrgyzstan, for example, estimates based on surveys and censuses exceeded routine vital registration figures by a factor of two until the early 2000s when, with the introduction of new live birth criteria, the gap between the two sources finally started closing (Guillot et al., 2013). Child mortality is also high, while maternal mortality reached an official rate of 47.5 maternal deaths per 100 000 live births in Kyrgyzstan in 2011, compared to a rate of 5.1 in the EU (WHO, 2014). Turkmenistan reported a maternal mortality rate of 3.8 per 100 000 live births in 2012 (WHO, 2014) but this, like many other health indicators reported from Turkmenistan, is hardly credible.

The main immediate causes of adult mortality are diseases of the circulatory system (most notably cardiovascular diseases), cancers and external causes such as injuries, violence and poisoning. Age-standardized death rates from diseases of the circulatory system were about three times higher in Kyrgyzstan (702 per 100 000 population), the Russian Federation (674) Ukraine (667) and the Republic of Moldova (659) in 2010–2012 than in the EU (212). The gap for males is particularly pronounced up to the age of 64, with death rates in the Russian Federation in 2010 (336 per 100 000 population) more than five times higher than in the EU (64 per 100 000) (WHO, 2014).

While deaths from all cancers are lower than in western Europe, there is substantial variation by type of cancer and gender. Thus, mortality from lung cancer among men is higher than in western Europe in the Russian Federation, Belarus, Ukraine, Kazakhstan and Armenia, while among women it is much lower in all post-Soviet countries, reflecting historically low smoking rates among women.

With the exception of the countries of the south Caucasus, death rates due to external causes of death in the region are also much higher than in western Europe, reaching 141 per 100 000 population in the Russian Federation in 2010, compared to 35 per 100 000 in the EU (WHO, 2014). Transport accidents are one of the leading causes, with double the rate of deaths in the region compared to the EU in 2010 (15.4 and 6.4 per 100 000, respectively). Interpersonal violence is also a leading cause; even after a substantial decline from very high levels in the 1990s it still remains well above levels in the EU. For example, in the Russian Federation in 2010 there were 20.5 male deaths from homicide and intentional injury per 100 000 population, compared to only 1.2 in the EU (WHO, 2014). There was also a dramatic increase in male suicides in the 1990s, particularly in the Russian Federation, Belarus, Kazakhstan and Ukraine, attributed to the stress of unemployment, impoverishment, rising inequalities, uncertainty and social alienation (Andreev et al., 2008). While suicide rates have declined in these countries in the intervening years, they remain 1.7 times higher than the EU average (WHO, 2014).

Morbidity

Although the overall burden of disease in the region is dominated by the noncommunicable diseases noted above, there is also a persisting threat from infectious disease, in particular HIV/AIDS and TB. Infection control was relatively successful in the Soviet Union but communicable disease surveillance, prevention and control systems were significantly weakened after the dissolution of the Soviet Union. New problems also emerged, most notably multidrug-resistant tuberculosis (MDR-TB) and HIV/AIDS.

In the 1990s TB incidence rates increased steeply in all countries of the region and progress in reducing them in the 2000s has been uneven, with some countries making noticeable improvements, but others still struggling (Fig. 2.2). Estimated incidence rates are even higher, reaching 193 per 100 000 population in Tajikistan in 2011, the highest rate in the WHO European Region (WHO, 2014). The reasons for the resurgence of TB are complex and include an initial collapse in services for detection and treatment, as well as, in some countries, the consequences of high levels of alcohol consumption, which increases susceptibility to infection and decreases compliance to treatment (Lonnroth et al., 2008). The high rate of incarceration is also a factor (Coker et al., 2006), with prisons being high-risk environments that act as incubators of disease (Stuckler et al., 2008), while treatment and prevention services in prisons tend to be underdeveloped, not only for TB, but also for a range of other conditions (Møller et al., 2005). Worryingly, a number of former Soviet countries have among the highest recorded rates of multidrug and extensively drug-resistant tuberculosis worldwide (Zignol et al., 2012), which are much more expensive and complicated to treat (WHO 2011b).

Fig. 2.2

Officially recorded TB incidence per 100 000 population, 1985–2012. Source: WHO, 2014.

HIV/AIDS is another major concern in the region. For several years, some of the former Soviet countries, including the Russian Federation and Ukraine, experienced the fastest growing HIV epidemics in the world, with the vast majority of reported infections attributed to injecting drug use (Field, 2004). However, most governments in the region have been slow to respond adequately to the problem (Field, 2004). The scale and scope of HIV programmes remain inadequate, in particular with regard to harm reduction measures, substitution treatment and antiretroviral treatment (Open Society Institute, 2008; UNAIDS, 2008). One of the major barriers to improving access to HIV prevention and treatment in the former Soviet countries is the predominance of a punitive approach to injecting drug use and people living with HIV (Bernitz & Rechel, 2006; Rechel, 2010). This approach is also reflected in the limited availability of antiretroviral treatment for people living with HIV. Coverage with harm reduction programmes remains low in many countries of the region and largely relies on external donors. Substitution treatment with buprenorphine or methadone remains illegal in the Russian Federation and unavailable in some other countries of the region. Harsh policies on drugs in many countries of the former Soviet Union have had particularly harmful consequences for access to HIV testing, counselling and harm reduction interventions (Sarang, Stuikyte & Bykov, 2007; Platt et al., 2013). In many countries of the region, official HIV incidence rates show an upward trend (Fig. 2.3) and HIV prevalence in 2010 was believed to be 1% or higher in the Russian Federation and Ukraine (UNAIDS, 2010).

Fig. 2.3

Officially recorded HIV incidence per 100 000 population, 1987–2012. Source: WHO, 2014.

The Global Burden of Disease study 2010 reported that mental and behavioural disorders accounted for around 9% of total disability-adjusted life-years (DALYs) in the region in 2010, rising to around 20% in the age group 10–35 years (IHME 2013). The main mental and behavioural disorders contributing to this burden are major depressive disorder (men and women, all ages) and alcohol use disorders (men, particularly aged 15–69) (IHME, 2013). However, data on mental disorders in the former Soviet countries remain extremely limited (Ferrari et al., 2013). A study on psychological distress indicated that the prevalence of high psychological distress had reduced across the region between 2001 and 2011, as the social and economic situation became more stable, but that socially and economically marginalized populations continued to bear the brunt of poor mental health in the region (Roberts, Abbott & McKee, 2012). Mental health services have also struggled to modernize and generally remain outdated, of poor quality and overly reliant on institutionalizing people with mental disorders (see Chapter 10).

Key risk factors

Health outcomes in the region have been heavily influenced by adverse underlying circumstances, particularly poverty, which is widespread in many parts of the region, and the rapid societal change in settings in which social safety nets were either absent or severely weakened (Walberg et al., 1998; Stuckler, King & McKee, 2009). However, while poverty levels generally stabilized and then declined somewhat over the 2000s, wide income inequalities have emerged, with severe consequences for the poorest and most vulnerable population groups. Key proximal risk factors behind the mortality and morbidity patterns include alcohol and tobacco use, with diet and activity levels also contributing to obesity and cardiovascular disease. Inadequate treatment and weak health policies also play a key role and are addressed in more detail in subsequent chapters of this volume.

Obesity, nutrition and physical activity

The available evidence suggests that rates of being overweight and obese are increasing in the region and are now comparable to countries in western Europe but not yet at the levels of the United States. While men are more likely to be overweight, women are more likely to be obese, which is in line with what is seen in other high and high-middle income countries (Huffman & Rizov, 2007; Sassi et al., 2009; Watson et al., 2013). In 2008, the highest prevalences of obesity among women – at around 30% – were seen in Azerbaijan, Armenia, the Russian Federation and the Republic of Moldova, while among men the highest rates – at around 20% – were in Kazakhstan, Belarus and the Russian Federation (Fig. 2.4). Projections suggest that further increases will take place, particularly among men (Huffman & Rizov, 2007; Rtveladze et al., 2012; WHO, 2014). The increasing trend in obesity has significant implications for diabetes and cardiovascular disease in the region and related health-care costs (Rtveladze et al., 2012).

Fig. 2.4

Prevalence of obesity in 2008, by gender and country (age-standardized). Source: WHO, 2013.

Increasing education (in males) appears to be a strong predictor of obesity in the region and this could potentially reflect the shift from manual to knowledge-based economies in the post-Soviet countries and the more sedentary nature of occupations requiring higher level educational qualifications (Watson et al., 2013). Higher alcohol intake is also associated with obesity among men in the region, consistent with the experience in western Europe (Swinburn et al., 2011; Watson et al., 2013) but this association is particularly important in the post-Soviet countries given the traditionally high rates of male alcohol consumption (WHO, 2011a).

In addition to reductions in physical activity related to increasingly sedentary occupations, dietary factors play a role. The diet in the region has been characterized as high in meat and fat and low in fruit and vegetables (although this varies and is somewhat less the case in the countries of central Asia and the south Caucasus). While overall availability of fruit and vegetables has increased substantially in the region since the mid-1990s (FAO, 2013; WHO, 2014), there appear to be slight reductions in the daily consumption of fruit and vegetables in a number of countries, including Georgia, Kyrgyzstan and the Republic of Moldova. These reductions are greater among poorer economic groups (Abe et al., 2013). Simultaneously, there may be a shift towards western diets – with a high content of fat and sugar – in the region.

Conclusion

After the major deterioration in health the post-Soviet countries experienced in the 1990s, there have been improvements in many health indicators through the 2000s. These include life expectancy, infant mortality, premature mortality and TB morbidity, with some improvements in risk behaviours such as hazardous alcohol consumption. Some alcohol and tobacco control policies have also been implemented in recent years in all countries, although to varying degrees and effectiveness. Despite these general improvements, major challenges for population health still remain, including low life expectancy compared to western European countries, large health disparities among different population groups, as well as alarming rates of MDR-TB.

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