Life span and disability: a cross sectional comparison of Russian and Swedish community based data
BMJ 2004; 329 doi: https://doi.org/10.1136/bmj.38202.667130.55 (Published 30 September 2004) Cite this as: BMJ 2004;329:767All rapid responses
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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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
Similarity between papers and results
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
Competing interests: No competing interests