Сравнительный анализ тенденций смертности в странах бывшего Советского Союза Л.А. Гаврилов Н.С.Гаврилова Университет Чикаго GDP per capita at current prices (dollars) in Russia and other countries Country Russia China Kazakhstan Ukraine Belarus Finland Bulgaria Mexico Source: http://data.un.org.
Download ReportTranscript Сравнительный анализ тенденций смертности в странах бывшего Советского Союза Л.А. Гаврилов Н.С.Гаврилова Университет Чикаго GDP per capita at current prices (dollars) in Russia and other countries Country Russia China Kazakhstan Ukraine Belarus Finland Bulgaria Mexico Source: http://data.un.org.
Сравнительный анализ тенденций смертности в странах бывшего Советского Союза Л.А. Гаврилов Н.С.Гаврилова Университет Чикаго GDP per capita at current prices (dollars) in Russia and other countries Country 1990 2000 2010 2012 Russia 3840 1768 10618 14178 China 347 932 4375 6070 Kazakhstan 1849 1266 9380 12455 Ukraine 1746 637 2962 3872 Belarus 1835 1044 5818 6726 Finland 27852 23528 44098 45741 Bulgaria 2350 1613 6459 7004 Mexico 3815 6582 8916 9795 Source: http://data.un.org Demographic Indicators of Russia and Kazakhstan Indicator Russia Kazakhstan Infant mortality per 1000 live births 7.4 28 Total fertility rate (mean number of children per woman) 1.7 2.6 Percent of persons 65+ years of age 13 7 Men 64 64 Women 76 74 74 55 Life expectancy: Proportion of urban population, % Source: Population Reference Bureau. 2013 World Population Data Sheet. Ожидаемая продолжительность жизни в России, Китае и Индии Россия Год Китай Индия 1992 1993 1994 1997 2000 2012 2013 2013 Мужчины Женщины 62.0 58.9 57.6 60.8 58.8 64.6 73.0 66.4 73.8 71.9 71.2 72.9 71.7 75.9 77.3 68.7 Изменение продолжительности жизни в России после 1964 года мужчины женщины 69 Гайдаровские Анти-алкогольная реформы кампания 64 59 Дефолт 2003 2000 1997 1994 1991 1988 1985 1982 1979 1976 1973 1970 1967 54 1964 ожидаемая п.ж. 74 Россия и Казахстан имеют сходную картину изменения смертности за последние 20 лет 1992 – реформы Гайдара Катастрофический рост цен Разрешен обмен валюты Разрешены все виды бизнесов Приватизация всего Теперь Российские СМИ называют эти реформы “печально известные” Кризис ВВП в странах Закавказья Эффект реформ Гайдара на ОПЖ в России 76 ОПЖ мужчин упала с 63.8 лет в 1990 до 57.4 лет в 1994. 74 Life expectancy, years 72 70 68 66 ОПЖ женщин упала с 74.3 лет в 1990 до 71.1 лет в 1994 Women Men 64 62 60 58 56 1989 1990 1991 1992 1993 Calendar year 1994 1995 1996 Депопуляция в России или “Русский крест” Rate per 1000 population 30.0 Births, CBR Deaths, CDR 25.0 20.0 15.0 10.0 5.0 0.0 1950 1960 1970 1980 1990 2000 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 3555 лет. Наиболее сильный рост смертности наблюдается от насильственных причин и несчастных случаев среди рабочих и малообразованных групп населения Вклад основных классов причин смерти в формирование ОПЖ при рождении у мужчин Источник – В.Юмагузин, Demoscope Weekly, N 485-486, 2011 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 Кризис 1998 года остановил снижение смертности в России 74 72 Life expectancy, years 70 68 Women Men 66 64 62 60 58 56 1994 1996 1998 2000 2002 Calendar year 2004 2006 2008 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 Рост ожидаемой продолжительности жизни в России после 2003 года Источник – В.Юмагузин, Demoscope Weekly, N 485-486, 2011 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 Вклад основных классов причин смерти в формирование ОПЖ, 1990-2009 Источник – В.Юмагузин, Demoscope Weekly, N 485486, 2011 Переходный период сопровождался небывалым ростом насилия, преступности и смертности от убийств Recorded Intentional Homicide (completed) per 100,000 Преднамеренные убийства в России и США 24 22 Russia 20 18 16 14 12 10 8 United States 6 4 1988 1990 1992 1994 1996 Time, years 1998 2000 2002 Тенденции смертности от убийств лиц молодого и среднего возраста в России Данные статистики смертности России 25 90 80 45-49 45-49 Mortality Rate x 100,000 Mortality Rate x 100,000 20 70 60 20-24 50 40 15 20-24 10 5 30 20 1988 1990 1992 1994 1996 Year Мужчины 1998 2000 2002 0 1988 1990 1992 1994 1996 1998 Year Женщины 2000 2002 Традиционно высокое потребление алкоголя возросло в 1990-х годах Age Profiles of Mortality from Accidental Poisoning by Alcohol Data from Russian Vital Statistics 120 40 2001 1981 Mortality Rate x 100,000 Mortality Rate x 100,000 100 2001 80 60 1991 40 30 1981 20 1991 10 20 0 0 0 20 40 60 Age Males 80 100 0 20 40 60 Age Females 80 100 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 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 Потребление крепких напитков и продолжительность жизни Социальный состав молодых мужчин (16-39 лет), умерших в 2004 году в Кировской области Иванова и др., Demoscope 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 Маргинализация смертности сопровождается возвратом старых инфекций Туберкулез и сифилис в России 1990-1999 250 200 150 100 50 Tuberculosis 99 19 98 19 97 19 96 19 95 19 94 19 93 19 92 19 91 19 90 0 19 New Cases per 100,000 300 Syphillis Распространенность сифилиса в Казахстане на 100000 населения (1991-1999) 300 268.9 250 231.2 200 231.4 182.2 150 122.9 100 50 0 32.6 2.1 3.5 8.2 1991 1992 1993 1994 1995 1996 1997 1998 1999 Образование предохраняет от преждевременной смертности мужчины 20-69лет, Россия Источник: Shkolnikov et al., SSM, 1998 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. Current trends in life expectancy in Moscow and some Eastern European countries 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?) Ожидаемая продолжительность жизни в странах б.СССР в 2012, Мужчины Turkmenistan Russia Tajikistan Kazakhstan Uzbekistan Belarus Moldova Ukraine Kyrgyzstan Lithuania Latvia Georgia Armenia Estonia Azerbaijan 50.00 55.00 60.00 65.00 70.00 Ожидаемая продолжительность жизни, годы ОПЖ в странах б.СССР в 2012, Женщины Turkmenistan Tajikistan Uzbekistan Kazakhstan Moldova Kyrgyzstan Russia Ukraine Azerbaijan Belarus Armenia Latvia Georgia Lithuania Estonia 60.00 65.00 70.00 75.00 80.00 85.00 Продолжительность жизни в Беларуси, России и Украине. Мужчины Продолжительность жизни в Беларуси, России и Украине. Женщины Продолжительность жизни в Казахстане, Кыргызстане и Узбекистане. Мужчины Продолжительность жизни в Казахстане, Кыргызстане и Узбекистане. Женщины Ethnic Differentials in Mortality 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 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; 28th poorest country in the world (2005) 48% of population below national poverty line (2001) 2008 Workshop, Bishkek Workshop in Almaty, 2011 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%) Recorded trends in adult mortality (20-60 years) Kyrgyzstan, 40q20 0.30 0.10 0.20 q2060 0.10 0.20 q2060 0.30 0.40 Females 0.40 Males 1960 1970 1980 y ear 1990 2000 1960 1970 1980 y ear 1990 2000 russian ky rgy z russian ky rgy z slv cas slv cas Mortality paradox? Soviet period: Russians/Slavs occupied dominant positions in the socio-economic structure of Central Asian societies (Kahn 1993) 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) Proportion of individuals with post-secondary education, by age and ethnicity, in 1989 census. Females SLAVIC (Russian, Ukrainian, Belorussian), 1989 CENTRAL ASIAN (Kyrgyz, Uzbek), 1989 0.300 Proportion higher education 0.250 0.200 0.150 0.100 0.050 0.000 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 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) Proportion of individuals with post-secondary education, by age and ethnicity, in 1989 census. Males. SLAVIC (Russian, Ukrainian, Belorussian), 1989 CENTRAL ASIAN (Kyrgyz, Uzbek), 1989 0.250 Proportion higher education 0.200 0.150 0.100 0.050 0.000 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 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) 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) IMR by ethnicity, 1958-2003, Kyrgyzstan 30 20 10 IMR 40 50 Urban areas 1960 1970 1980 year Central Asians 1990 Slavs 2000 Data Unpublished population and death tabulations since 1959 collected from local archives Individual census records – 1999 Individual death records – 19981999 obtained from national statistical office Possible explanations for mortality paradox Data artifacts Migration effects (esp. 1989-99) Cultural effects Data artifacts? Could the lower recorded mortality among Central Asian adults be due to lower data quality among them (coverage of deaths, age misreporting)? 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)? 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? 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+ Kyrgyzstan, 40q20, Urban areas 0.30 0.20 0.10 0.10 0.20 q2060 0.30 0.40 Females 0.40 Males 1960 1970 1980 y ear 1990 2000 1960 1970 1980 y ear 1990 2000 russian ky rgy z russian ky rgy z slv cas slv cas Health selection? Russians in KG vs. Russia, 40q20 0.40 0.50 Females 0.10 0.20 0.30 q2060 0.30 0.20 0.10 q2060 0.40 0.50 Males 1960 1970 1980 y ear Russians in KG 1990 2000 Russia 1960 1970 1980 y ear Russians in KG 1990 2000 Russia Cohort-specific changes in educational attainment, Males, 1989-99 SLAVIC, 1989 SLAVIC, 1999 0.300 Proportion higher education 0.250 0.200 0.150 0.100 0.050 0.000 Age in 1989: 20-24 Age in 1999: 30-34 25-29 35-39 30-34 40-44 35-39 45-49 40-44 50-54 45-49 55-59 50-54 60-64 55-59 65-69 60-64 70-74 65-69 75-79 70-74 80-84 75-79 85-89 80-84 90-94 Cohort-specific changes in educational attainment, Females, 1989-99 SLAVIC, 1989 SLAVIC, 1999 0.300 Proportion higher education 0.250 0.200 0.150 0.100 0.050 0.000 Age in 1989: Age in 1999: 20-24 30-34 25-29 35-39 30-34 40-44 35-39 45-49 40-44 50-54 45-49 55-59 50-54 60-64 55-59 65-69 60-64 70-74 65-69 75-79 70-74 80-84 75-79 85-89 80-84 90-94 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 Age-standardized Death Rates at working ages (per 100000), 1998-99, by cause and ethnicity, Males Infectious/par. diseases - incl. TB Neoplasms CVD CA Slavs - incl. IHD Respiratory diseases Digestive diseases Injuries/poisoning Other causes 0 50 100 150 200 250 Contribution of causes of death to the difference in life expectancy at working ages (40e20) between Slavs and Central Asians Males (total difference = 2.90 years) 1.8 1.6 1.4 1.2 1.0 0.8 0.6 0.4 0.2 au se s O th e rc ju ri es In C V R D es pi ra to ry D is . D ig es t iv e D is . pl as m s N eo In fe ct io ns 0.0 ho m un de te rm in ed su ic id e . ic id ac e cid .p oi al so lo ni ng th er ac ci d. tra ca ns us po . rt ac ci ac de ci nt de s nt al dr ow ac c. ni ca ng us ./e ac le ct c. r.c m ec ur ha n. su ffo ca t. ot he r in ju ry ac ci d. po is on ./a lco h Age-standardized Death Rates at working ages (per 100,000). Detailed Injuries, Males 50 45 40 Slavs CA 35 30 25 20 15 10 5 0 Age-standardized Death Rates at working ages (per 100,000), 1998-99, by cause and ethnicity, Females Infectious/par. diseases - incl. TB Neoplasms CVD - incl. IHD Respiratory diseases Digestive diseases CA Slavs Injuries/poisoning Other causes 0 10 20 30 40 50 60 70 80 Contribution of causes of death to the difference in life expectancy at working ages (40e20) between Slavs and Central Asians Females (total difference = .28 years) 0.35 0.30 0.25 0.20 0.15 0.10 0.05 au se s O th e rc ju rie s In Di s. e es t iv CV D pl as m s Di s. Di g -0.10 Re sp ir a to ry In -0.05 Ne o fe ct io ns 0.00 . su ic id e .a cc id en t.c tra au ns s. po rt ac ci ac de ci nt d. s ca us e ac by c. fir ca e us ./e le ac ct ci r.c de ur nt al dr ow ni ng al lo o. ic id ac e ci d. po iso in ju ni ry ng un de te rm in ed ho m ac ci d. po is on ./a lco h Age-standardized Death Rates at working ages (per 100,000) Detailed Injuries, Females 9 8 7 Slavs CA 6 5 4 3 2 1 0 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) 50 45 CA Slavs 40 35 30 25 20 15 10 5 0 Males Females 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 Males, all causes of death In e s. ie s di s. di ju r es t iv Di g y Re sp ir a to r CV D pl as m s ns ca us es fe ct io Ne o In Al l Risk Ratio Slavs/CA Males 3.5 3.0 2.5 2.0 Model 1 1.5 Model 2 1.0 0.5 0.0 Risk Ratio Slavs/CA Females 3.5 3.0 2.5 2.0 Model 1 Model 2 1.5 NS NS 1.0 NS NS NS NS NS NS 0.5 au se s ie s O th e rc ju r In CV Re D sp ir a to ry Di s. Di ge st iv e Di s. pl as m s Ne o ns fe ct io In Al l C au se s 0.0 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 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? Further developments 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 Study of autopsies in Barnaul during 1990-2004 (Zaridze et al., 2009) Among 5732 autopsied men aged 3569 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 Trends in Life Expectancy: Men Russia Kyrgyzstan 65.00 63.00 61.00 59.00 57.00 55.00 19 80 19 82 19 84 19 86 19 88 19 90 19 92 19 94 19 96 19 98 20 00 20 02 20 04 20 06 20 08 20 10 Life expectancy 67.00 Calendar year Trends in Life Expectancy: Women Russia Kyrgyzstan 76.00 74.00 73.00 72.00 71.00 70.00 Calendar year 2010 2008 2006 2004 2002 2000 1998 1996 1994 1992 1990 1988 1986 1984 1982 69.00 1980 Life expectancy 75.00 40M20 (Russia) – 40M20 (Kyrgyzstan), 1979-2009, all causes and strongly alcohol related causes Further developments (2) Ethnicity, russification and excess mortality in Kazakhstan Ethan J. Sharygin and Michel Guillot. Vienna Yearbook of Population Research 2013 (Vol. 11), pp. 213–237 Сравнительная смертность русских и казахов 1999 Негативные биномиальные регрессии числа умерших по русской национальности для разных причин смерти, Казахстан 1998-1999 Модель 1 контр.по возрасту и области. Модель 2 дополнительно контр. на тип поселения и образование. Экспоненты коэффициентов. Framework for Understanding Health Crisis in Russia vs. Central Asia Russia Kyrgyzstan (Central Asia?) Infant mortality Declined Stalled Adult mortality Large increase Moderate increase Explanatory framework Greater importance Greater importance of of detrimental adult health care health behaviors deterioration 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