Published June 26, 2017, in the Harvard Business Review. Reposted with permission.
In 2015 Princeton economists Anne Case and Angus Deaton published a stunning finding: The mortality rates for working-age white Americans have been rising since 1999. For mortality rates to rise instead of fall is extremely rare in developed countries except as a result of war or pandemic.
However, history does offer a recent example of a large industrialized country where mortality rates rose over an extended period: Russia in the decades before and after the Soviet Union’s collapse. Although there are important differences between the two phenomena, there are also sobering similarities.
From 1965 to 2005 the mortality rates for nonelderly Russian men and women rose by an average of 1.5% and 0.9%, respectively, per year. For children and the elderly, mortality remained relatively flat. In broad strokes, this event had three phases:
1. From 1965 to 1985 the mortality rate rose steadily as the Soviet economy failed to modernize and an increasing share of government spending shifted from social services to defense.
2. From 1985 to 1988 Mikhail Gorbachev’s anti-alcohol campaign made vodka and other spirits far more difficult for the average Soviet citizen to obtain. This coincided with a large, immediate decline in mortality, making it one of the most effective public health interventions in history.
3. From 1988 to 2005 the winding down of the anti-alcohol campaign coincided with the Soviet Union’s collapse and Russia’s fraught transition to capitalism. It is likely that these events contributed to mortality rates spiking upward again.
By 2005 adult Russian men were nearly twice as likely to die prematurely as they had been in 1965. Since then their mortality rate has fallen, but it remains exceptionally high for a relatively wealthy country.
There are many theories on what caused Russia’s mortality rate to rise for 40 years, but no simple answers. In a purely descriptive sense, death records tell us that four-fifths of the excess deaths were due to cardiovascular disease and accidents. While helpful, this doesn’t tell us why these deaths became so common. Alcohol clearly played an important role, as evidenced by the extraordinary effects of the anti-alcohol campaign. But to some degree alcohol consumption may reflect external conditions, with alcohol abuse acting as the mediator through which insecurity and stress in a population elevate death rates.
And there were obvious sources of insecurity and stress during this period in Russian history. First among them was the country’s political and economic transition from communism to capitalism. For the average Russian citizen, this transition meant the end of the government’s guarantee of housing, work, and a secure pension. Some experts have further argued that economic inequality — while always present during the Soviet years — became far more pronounced and apparent after the transition to capitalism. The collapse of the safety net, coupled with the widening gap between the haves and the have-nots, may have contributed to Russians’ sense of disempowerment and hopelessness that public surveys from this era reveal.
Ultimately, it may be a fool’s errand to try to trace the interwoven strands of cause and effect among culture, economics, politics, and individual behavior — not to mention concurrent degradations in Russia’s health system and environment. Safer to say, it was the historically unique combination of these factors that led to Russia’s health calamity and millions of premature deaths.
The similarities between the mortality rate increases in Russia and the United States are striking and troubling.
First, there are similarities between the affected populations. As in the United States, the Russian phenomenon occurred exclusively among working-age adults, not children or the elderly. In addition, the excess deaths in Russia appear concentrated among the less educated, and spared those with university degrees. The same is true today of the mortality crisis among U.S. whites.
Second, there are similarities in the causes of death driving the upsurge. Rampant substance abuse is a common factor in both countries — alcohol in Russia and opioids in the United States.
Finally, there are similarities in the economic and social contexts. Declines in low-skilled American workers’ wages, economic mobility, and financial security may echo the Soviet economy’s long decline and eventual restructuring. And as in Russia, surveys of white working-class Americans indicate a marked pessimism about the future.
However, despite these resemblances between the two countries’ experiences, there are important differences to bear in mind.
First, the level of mortality in the two countries is vastly different. Even today, adults in Russia face a risk of death more than twice as high as that in the United States. And so a 1% rise in the mortality rate reflects far more excess deaths.
Second, recent U.S. history contains no parallel to 20th–century Russia’s legacy of war and oppression. It is hard to imagine that this legacy was not at least partly responsible for Russians’ worsening health.
The similarities between the U.S. and Russian phenomena may be inexact in some respects but are still sobering. Fundamental societal events that affect the economic and social well-being of populations can have profound effects on a nation’s health. That influence seems to be mediated in diverse settings through substance abuse, and where political will exists (as it did in authoritarian Russia) it can be quickly, though perhaps not sustainably, reversed. The unfortunate recent parallels between American and Russian health experiences serve to further emphasize the importance of attending to the struggles of those falling victim to opioid abuse in the U.S. as well as other vulnerable populations.
