Health Expectancy in the Russian Federation: A New Perspective on the Health Divide in Europe
Andreev, Evgueni M., McKee, Martin, Shkolnikov, Vladimir M., Bulletin of the World Health Organization
It is increasingly recognized that an accurate view of a nation's health is inadequately captured by traditional measures such as life expectancy and infant mortality. Specifically, such measures underestimate the burden of discase that is attributable to chronic disabling disorders, such as mental health problems and the increasing number of physical diseases for which health care has postponed death but failed to restore normal functioning (1). Consequently, a concept of health expectancy has emerged in which overall life expectancy is partitioned into periods lived at different levels of health. The most common methods divide life expectancy into disability-free life expectancy and time lived with disability (2).
Although the need to move beyond the traditional measure of life expectancy is widely accepted, there are many unresolved issues, such as the means to measure and value states of health (3). For the present purposes, however, the use of a simple division of health into good and less than good makes it possible to examine the extent to which gains in life expectancy have been associated with a corresponding improvement in health while alive--a phenomenon known as compression of morbidity. This is becoming increasingly relevant to policymakers as the complex interrelationships between health and economic prosperity are becoming better understood (4) and as countries begin to see the scope for reducing the growth in health care expenditures by improving health (5).
Yet such comparisons have been limited, largely because of the lack of comparable data on disability. The landmark Global Burden of Disease study (6), which assessed the impact of selected diseases and risk factors on disability-adjusted life years, largely applied standard disability weightings to data on disease incidence and prevalence (7), and in many parts of the world these data were themselves estimated from other parameters (8). In particular, in die Russian Federation the only surveillance systems that can generate prevalence data cover cancer and tuberculosis, and even these systems are not without problems. The other potential source of data, the routine collection of invalidity data, has become highly problematic since the political transition in 1991 (9). The 2000 Global Burden of Disease study will, however, incorporate data from household surveys (10).
Over the past decade one of the greatest challenges faced by health researchers from many disciplines has been to understand the unprecedented changes in health, at least as measured by life expectancy, in the countries of the former Soviet Union during the 1980s and 1990s (11). Between 1987 and 1994, and since 1998, life expectancy at birth has declined in the Russian Federation and has been declining or stagnating in many of its neighbours, at a time when life expectancy has been improving steadily in the rest of Europe (12). Many aspects of this phenomenon are now relatively well understood, at least in relation to mortality. However, the contribution of various causes of death to overall mortality in the Russian Federation is different to that in western countries. Death rates from cancer in the Russian Federation and in western countries are relatively similar, so that cancer's share of the much higher total mortality in the Russian Federation is less than other causes; injuries and cardiovascular disease are much more important. But what can be said about the overall burden of disease in the Russian Federation population? On the one hand, many of the premature deaths are sudden, whether they are a result of injury or cardiovascular disease (13), and sudden cardiac death provoked by alcohol is especially common (14, 15). These causes might be expected to cause little preceding morbidity. On the other hand, levels of self-reported ill-health in the early 1990s were much higher than in the West, perhaps reflecting an unknown number of disabling but less frequently fatal conditions such as those due to poor mental health (16). …