Dead souls

The rumours about President Boris Yeltsin's health, or lack of it, which seep out of the Kremlin and keep Russia's political classes chattering, miss a bigger point. By the standards of his countrymen, Yeltsin is an old man. At 64, he has lived six years beyond the average life expectancy for Russian men. Most Russian males alive today will be lucky if they live long enough to receive a pension.

Between 1987 and 1994, the number of live births recorded in Russia halved, while the number of deaths soared. In 1993, 322,000 more Russians died than in 1992. That is an increase greater than the total American losses during the Second World War.

There is no obvious parallel for this in the modern world in time of either war or peace. In France during the First World War, life expectancy did not change. Nor did it in Japan, until the final year of the Second World War.



"The only country to have suffered a more serious setback in life expectancy was Pol Pot's Cambodia," wrote Nick Eberstadt, a demographer based at Harvard University, in a study published at the end of the 1980s, when Russian male life expectancy was still above 60. Eberstadt traces the slide back to pre-industrial standards of health to the years of stagnation.

At the turn of the century, the average Russian could expect to live about 30 years. By the time Stalin came to power, this had increased to 44 years. Despite the purges and the war, life expectancy had risen to 62 by the time of Stalin's death. By the late 1950s Soviet life expectancy had reached 69-higher than in the US, which had begun the century with a 17-year lead on Russia.

The reasonable conclusion must have seemed that Marxist-Leninism, as a form of social organisation which improved the lot of the majority, worked. And then it stopped working.

From 1974 onwards, Soviet statistical yearbooks began to omit even the most basic data on mortality and health. At the time it was widely assumed that the guardians of the system were embarrassed by the third world conditions of life in the central Asian republics of the Soviet Union. But now it seems likely that they were trying to conceal more worrying trends in the Slav heartland, where life expectancy peaked in the mid-1970s and then began to fall towards the end of that decade.

At first the rate of decline was glacial. It turned into an avalanche with the collapse of the Soviet Union, the rebirth of Russia in 1991, and the introduction of radical economic reform in 1992. But to what extent are these events linked to the collapse in life expectancy?

Most Russians assume they are intimately connected. They believe that more people are dying now because of the rise in violent crime and because the health care system has collapsed.

There is some truth in this. To take the health system first: under Soviet rule, the number of doctors grew each year, from a mere 8.2 per 10,000 people in 1940, to 45.2 per 10,000 in 1990. Not all of the doctors were well trained, and they did not always have access to basic equipment, but the average Soviet citizen did have access to free, if rudimentary, health care.

Now, even basic drugs can be scarce. "The shortage of medicines has led directly to an increase in the death rate," says Linda Bilmes, a consultant at the Boston Consulting Group, who is advising the Russian government on health care reform. In most drug categories, Russian production has been cut in half. Russian pharmaceutical companies produce only 35 per cent of the demand for cardiovascular drugs; even with imports, at least one-third of those who need cardiac drugs cannot obtain them.

The deterioration in health care is most obvious in almost any government hospital: appalling standards of hygiene, overcrowded wards, very few nurses, cancelled vaccination programmes, and a lack of essential supplies.

A symptom of how bad hospitals have now become is that the mother of a friend of mine died 18 months ago from something as simple as piles. She had been in pain for some time, but had told no one because she was scared stiff of going into hospital. By the time she was admitted, blood poisoning had set in. Still, she might have lived had the hospital had any antibiotics and the medical staff not decided to take the weekend off.

The state of Russia's hospitals is the result not of three years of reform, but decades of neglect. Any guesses about government spending under the Soviet system are fraught with difficulties-budgets were secret, and no one, not even the general secretary of the Communist party, knew what GDP was. However, attempts to piece together the evidence suggest that from 1970 onwards the Soviet system allocated a mere 4 per cent of GDP to health care. Most western countries spend between 8 per cent and 12 per cent of their output on health.

Improving the state of the Russian health system is complicated by privatisation. Under the Soviet system, most large enterprises ran free primary "polyclinics" for their employees and families, and even owned 10 per cent of the hospital beds in the country. These facilities tended to be better than average.

One of the best hospitals in Moscow belonged to ZiL, the huge conglomerate which produced limousines for the bosses. Now, the newly private enterprises are striving to become competitive. Some-such as ZiL-are virtually bankrupt. So they have stopped paying for hospital beds, or basic care-unless the government and the insurance funds reimburse them.

Making hospitals safe for patients will be as difficult as stopping the seemingly inexorable rise of violence. The number of recorded murders committed each year in Russia has risen from 21,100 in 1990, to 45,100 in 1993, the most recent year for which a detailed breakdown of causes of death is available. Even more people take their own lives: 56,100 committed suicide in 1993.

The suicide figure suggests that what is going on is more complicated than just new freedoms engendering a more violent and unstable society. Of the suicides in 1993, only 10,100 were women. Most of the male suicides were aged between 50 and 59. An astounding 118 out of every 100,000 men in that age group killed themselves in 1993. Another 52,800 men, most of them from this age group, died from alcohol-related diseases in the same year-perhaps merely a more prolonged form of suicide.

The suicides and alcohol-related deaths tell only part of the story. By far the biggest killer in Russia is cardiovascular disease. Its incidence might decrease if Russian men drank and smoked less, exercised more and could rely on an ambulance coming when a heart attack strikes.

But all these behaviour patterns, and the poor medical care, are less important than what is killing off a whole generation of Russian men-stress. It is hard for men in their 50s to find a place in the new Russia-a country where cabinet ministers are in their 30s and bankers barely out of school. The data for household incomes tells of a nation of Arthur Daleys on the make. By 1994, only 40.3 per cent of recorded household incomes came from wages; another 16 per cent came from social transfers; the rest-43.7 per cent-came from what the official statistics agency labels "incomes from property, private business and others."

Russian middle-aged women know how to cope. Most of them have had to work while bringing up children in a cramped apartment with little help from their husbands. They have taken the new Russian order in their stride. So have some older men. The lucky ones, who were in charge of some enterprise in 1992, privatised it and now call themselves capitalists. The less fortunate are either too old to learn the new ways or too young to retire. What is left to them is to sit at home in a dingy apartment, worrying, smoking, drinking, eventually keeling over from a heart attack.

Many Russian demographers believe, however, that the collapse of the public health service and the psychological factors at work in the new Russia do not completely explain what is happening. One hypothesis is that environmental devastation is also to blame.

The figures on birth defects lend credence to this. In Russia in 1990 the number of children per 10,000 live births who died before reaching their first birthday as a result of a serious birth defect was 388. By 1993 it had risen to 409; a year after that it had reached 436. (In the US the figure is less than 100.) More than 10 per cent of new born babies have serious birth defects, and up to 40 per cent of schoolchildren have chronic illnesses.

There is, however, some light amid the gloom. The rate of increase in the number of deaths has slowed: 295,400 people died in the first four months of this year, compared with 304,700 in the same period last year. But according to Eberstadt, even if the crisis is ending and Russia's economy begins to grow rapidly, it will take the country 25 years to reach west European life expectancy rates.

Too late for today's 50-year-olds. But the Russian attitude to death has changed little since Nikolai Gogol wrote 150 years ago that, "If a man has died, then he's dead."