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Paper confirms previous findings
- Martin McKee, Vladimir M Shkolnikov, Max Planck Institute for Demographic Research (1 October 2004)
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Another case for disability adjustment in life expectancy
- Udaya S mishra (6 October 2004)
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East-West health status gap: evidence against binge drinking as main determinant
- Ulrich Ronellenfitsch (11 October 2004)
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binge drinking and morbidity are not incompatible
- Martin McKee, Vladimir M Shkolnikov, Max Planck Institute for Demographic Research (18 October 2004)
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Similarity between papers and results
- Martin Bobak (17 March 2005)
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Martin McKee, Professor of European Public Health London School of Hygiene and Tropical Medicine, Vladimir M Shkolnikov, Max Planck Institute for Demographic Research
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Dear Editor, The paper by Bobak et al. on disability in Russia is an interesting and an important one. However we were very surprised by their statement under "What is already known about this topic" that "Disability levels in Russia have not been systematically studied". First, data on self-rated health have been reported for some years from the Russian Longitudinal Monitoring Study [1]. Second, in 2002 we published an article on ill-health and healthy life expectancy in the Russian Journal of Statistics [2] and in 2003 we published an extended, more detailed study on the same topic [3] in the Bulletin of the WHO. We used an almost identical methodology, comparing self-rated health and reported physical performance in Russia with those in countries of eastern Europe and western Europe. We are pleased to see that their results are entirely consistent with ours although rather surprised that our earlier published studies are not cited. We do, however, disagree with their statement that their findings are consistent with the WHO healthy life expectancy project. That project reports a male-female gap in healthy life expectancy of 11.5 years (52.8 versus 64.3 years) [4]. This figure for healthy life expectancy at birth would correspond to at least an 8-9-year gender gap at age 20. While Bobak et al. do not report healthy life expectancy, their figures for the prevalence of good or fair health or good physical performance show no large gender gap, again consistent with our findings. Computation of healthy life expectancy at age 20 from the table of age-specific prevalence of poor health in the paper by Bobak et al. produces figures of 34.5 and 35.7 years for men and women, respectively. This is an even smaller gender gap than in our estimates of 36.7 and 40.6 years for men and women respectively [3, p. 783]. We believe that there is an additional message from these findings. This concerns the plight of Russian women surviving into middle and old age, a group that, as we noted in our earlier study, suffers from both high levels of disability and a strong probability of widowhood. Until now they have had a limited degree of protection from the worst effects of the political transition by virtue of the social support system, which has provided many benefits in kind, a situation that is now under threat [4]. 1. URL: http://www.cpc.unc.edu/rlms/ (accessed 1st October 2004) 2. Andreev, E.M., Shkolnikov, V.M., McKee, M. 2002. Prodolzhitelnost zdorovoi zhizni. [Healthy life expectancy]. Voprosi Statistiki, 11, pp. 16 -21. 3. Andreev EM, McKee M, Shkolnikov VM. Health expectancy in Russia: a new perspective on the health divide in Europe. Bull WHO 2003; 81: 778-788. 4. URL: http://www3.who.int/whosis/hale/hale.cfm?path=whosis,hale&language=english (accessed 1st October 2004) 5. URL: http://news.bbc.co.uk/1/hi/world/europe/3530184.stm (accessed 1st October 2004) Competing interests: None declared |
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Udaya S mishra, Takemi Fellow, department of Population and International Health Harvard school of Public Health, 665, Huntington Avenue, Boston, MA 02115, USA
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This paper by Bobak et.al is an illustrative example of life expectancy figures being illusive and less reflective of the quality of life. Also, valuation of shorter or longer life expectancy in mortality terms is always misleading as it overlooks the valuation of illness or disability at any age during the life span. This paper argues for high levels of ill health and disability to be the reason behind its low life expectancy. However, ill health and disability are cumulative in nature and ought to be relatively more during later years of life. And hence, Russia’s life expectancy need to be undervalued further while Sweden’s needs to be over-valued before comparison. Competing interests: None declared |
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Ulrich Ronellenfitsch, PhD student University of Heidelberg, Dpt. of Tropical Hygiene and Public Health, 69120 Heidelberg, Germany
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Editor, Bobak et al. with their paper [1] show once again the dramatic extent of the gap in health status between Russia and Western Europe. The reasons for this gap are still not fully understood, but some authors claim to have identified so-called "binge drinking", the consumption of large amounts of alcohol at one particular occasion, as one of the crucial underlying risk factors [2]. One of the most interesting aspects of the study by Bobak et al. is that, in contrast to numerous other studies in the past, it uses not mortality but self-reported morbidity as an outcome. In line with two other studies, which employed similar indicators [3;4], the results show that not only men, but also women, in Russia and other Eastern European countries have a much poorer health status than their peers in the Western part of the continent. These findings clearly indicate that binge drinking alone cannot be the main determinant of the catastrophic health status found in both sexes in Russia. Since the frequency of binge drinking among women in Russia is reported to be considerably lower than among men [5], it can be excluded that this behaviour is causal for the East-West health status gap in women. Moreover, given the small extent of differences in survival without disability between the two sexes in the present study [1], it is also highly unlikely that binge drinking plays a crucial role in the demonstrated East-West differences in morbidity. To find out which other factors might cause this difference, it is indispensable to conduct longitudinal studies which assess potential risk factors as well as appropriate measures of morbidity and disability. 1. Bobak M, Kristenson M, Pikhart H, Marmot M. Life span and disability: a cross sectional comparison of Russian and Swedish community based data. BMJ 2004; 329: 767-70 2. Walberg P, McKee M, Shkolnikov V, Chenet L, Leon DA. Economic change, crime, and mortality crisis in Russia: regional analysis. BMJ 1998; 317: 312-8. 3. Carlson P. Self-perceived health in East and West Europe: another European health divide. Soc Sci Med. 1998;46:1355-66. 4. Andreev EM, McKee M, Shkolnikov VM. Health expectancy in the Russian Federation: a new perspective on the health divide in Europe. Bull WHO 2003; 81: 778-87. 5. Malyutina S, Bobak M, Kurilovitch S, Ryizova E, Nikitin Y, Marmot M. Alcohol consumption and binge drinking in Novosibirsk, Russia, 1985-95. Addiction 2001; 96: 987-95. Competing interests: None declared |
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Martin McKee, professor of European public health London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK, Vladimir M Shkolnikov, Max Planck Institute for Demographic Research
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As authors of papers arguing that (a) binge drinking is an important cause of premature mortality in Russia and (b) there are high levels of morbidity among Russian women, unlike Ulrich Ronellenfitsch we see no contradiction whatosever in these two findings. Furthermore we are unaware of anyone who has argued that “binge drinking alone” is “the main determinant of the catastrophic health status found in both sexes in Russia”. Population health is a complex matter, with factors acting at many levels, and over varying periods of time. Even a superficial examination of the mortality data makes it clear that there are many factors involved. We do, however, continue to believe that episodic heavy drinking has played an important role in the fluctuations in mortality observed in Russia since the mid 1980s and in particular deaths from sudden cardiac death and violence. Of course, this raises other questions, such as why people drink in this way and the effect this has on those around them, highlighting the folly of trying to reduce even this element of this human tragedy to a single headline. Competing interests: None declared |
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Martin Bobak, Reader University College London, WC1E 6BT
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Martin McKee and Vladimir Shkolnikov expressed a surprise that we did not cite their papers. We would like to clarify the situation. We did not know about their Russian paper until now [1]. We submitted our paper to BMJ before theirs in Bull WHO [2] was published, and we were not aware of their paper when we submitted the revision. We probably came across the paper, or at least its abstract, by the time of the proof reading but we did not pay sufficient attention to it to feel the need to re-reference our paper at that late stage. We agree that the papers and results are similar. We regret this unfortunate situation and we apologise to Andreev, McKee and Skolnikov for not citing their work. We emphasise that all work on our paper (study design, calculations, interpretation and writing up) was entirely independent from their study and that we did not omit a reference to their paper intentionally. Overall, the similarity between the findings is a good thing; since the two studies used entirely independent data (and partly different outcomes), it supports the validity of both results. 1. Andreev, E.M., Shkolnikov, V.M., McKee, M. 2002. Prodolzhitelnost zdorovoi zhizni. [Healthy life expectancy]. Voprosi Statistiki, 11, pp. 16 -21. 2. Andreev EM, McKee M, Shkolnikov VM. Health expectancy in Russia: a new perspective on the health divide in Europe. Bull WHO 2003; 81: 778- 788. Competing interests: None declared |
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