Russian mortality trends for 1991-2001: analysis by cause and regionBMJ 2003; 327 doi: https://doi.org/10.1136/bmj.327.7421.964 (Published 23 October 2003) Cite this as: BMJ 2003;327:964
All rapid responses
EDITOR: The deductions of Bobak and Marmot are highly likely to be
correct: “there is no direct evidence that alcohol caused the mortality
fluctuations” (1) reported annually in Russia (2). Except for such deaths
as the relatively small proportion (in Russia) due to alcoholic liver
disease, alcohol poisoning and transport accidents, alcohol rarely
compromises health in a direct fashion.
For most people, alcohol is self-administered as a psychotropic drug,
whose patterns of use interact with the social environment in which it is
used. Psychological and social harms associated with drinking accumulate,
typically, over a long period of time before they are seen as a “problem”
(3). Family breakdown, job loss, homelessness and public order offences
do not appear overnight, but patterns related to alcohol use are
discernible over populations, especially at times of wider change (4).
For example, when the old South West Thames health region asked me to
review HIV and drinking behaviour in 1991, we knew that alcohol did not
cause AIDS - but alcohol use was a significant factor in the spread and
progress of HIV-related disease. Currently my department is involved in
localised studies of domestic violence and of youth suicide: these health
problems are not directly caused by alcohol, but they do appear to relate
to cumulative histories of drinking in individuals and in groups. The
“underlying social problems” mentioned (1) interact with alcohol
histories, and socially isolating adult experiences like divorce, a
criminal record or homelessness may be predisposing to many pathologies
down the road....
That long term health impact of different alcohol histories was
tracked for decades by George Vaillant. He observed (5): “Alcohol abuse
-- unrelated to unhappy childhood -- consistently predicts unsuccessful
aging, in part because alcohol damages future social supports.”
1 Bobak M, Marmot M. How much did alcohol really contribute to the
mortality changes ? BMJ eletters/327/7421/964 13 November 2003.
2 Men T, Brennan P, Boffetta P, Zaridze D. Russian mortality trends
for 1991-2001: analysis by cause and region. BMJ 2003; 327: 964-966.
3 Caan W. Alcohol on the mind. In: Caan W, de Belleroche J (eds)
Drink, Drugs and Dependence. From science to clinical practice. London:
Routledge, 2002; 51-68.
4 Caan W. Coming together on alcohol and drugs: a capital idea.
Journal of Mental Health 2001; 10: 477-479.
5 Vaillant GE. Aging Well: Surprising Guideposts to a Happier Life
from the landmark Harvard Study of Adult Development. Boston: Little and
Brown, 2003 (paperback edition).
Competing interests: No competing interests
The Russian mortality crisis is a unique and fascinating phenomenon.
The paper by Men at al is very helpful in mapping the mortality trends and
drawing attention to the problem. We agree that there is an urgent need
for more research into the causes of the mortality crisis. Men et al
proposed that the mortality crisis is linked to the social changes during
transformation, and they speculated that alcohol is an important, or
indeed the major proximal cause of mortality in Russia.
We agree that alcohol played an important role in the changes in
changes in mortality from external causes and other causes directly
related to alcohol. However, the contribution of alcohol to the overall
mortality rates, both long-term and short-term, is less clear.
First, there is no direct evidence that alcohol caused the mortality
fluctuations. The evidence is largely indirect, based on the temporal
coincidence of mortality changes with Gorbatchov’s anti-alcohol campaign
and the collapse of the Soviet Union, and on loose extrapolations from
western data. The trends in drinking are uncertain. For example, the most
often cited estimates of alcohol consumption, by Nemtsov, are partly
derived from mortality rates; this can explain why these estimates
agree well with mortality trends. Other estimates should also be
considered. For example, the well designed and carefully executed MONICA
surveys in Novosibirsk showed a decline in heavy drinking over the period
of the steep increasing mortality in the early 1990s. Data from St
Petersburg  also showed a slight decline in proportion of heavy
drinkers between the 1980s and 1990s (calculations available on request).
Second, the mortality fluctuations were roughly similar in men and
women but there is overwhelming evidence that alcohol consumption has been
low in women.[2,4-6] If these data are correct, alcohol cannot explain the
mortality changes in women.
Third, if alcohol was responsible, then the mortality increase should
be steeper in drinkers, or the prevalence of heavy drinking should have
increased between the 1980s and 1990s. The St Petersburg data  suggest
that neither of these happened. The prevalence of heavy drinking declined
from 19% in the 1980s to 15% in the 1990s; the increase in mortality was
identical in heavy drinkers and others (48% and 49%, respectively); and
the relative risk of heavy drinkers vs. the others also remained identical
(1.43 in 1980s and 1.42 in the 1990s; calculations avaialble on request).
Leaving aside short-term mortality fluctuations, the evidence on long
-term effects of heavy and binge drinking does suggest some effect on
total and cardiovascular (CVD) mortality  but the relative risks are
too small to explain much of the high CVD mortality in Russian men and the
contribution would be negligible in women.
Alcohol as the major proximal cause of the mortality crisis would be
a simple explanation, and it would provide a reasonably specific target
for policy measures (though it is debatable whether measures focused on
alcohol can be effective without addressing the underlying social problems
first). The alcohol hypothesis might well turn out to be correct. However,
the evidence available at present does not justify such a conclusion.
1 Nemtsov A. Estimates of total alcohol consumption in Russia, 1980-
1994. Drugs & Alcohol Dependence 2000; 58:133-143.
2 Malyutina S, Bobak M, Kurilovitch S, Ryizova E, Nikitin Y, Marmot
M. Alcohol consumption and binge drinking in Novosibirsk, Russia, 1985-95.
Addiction 2001; 96:987-995.
3 Plavinski SL, Plavinskaya SI, Klimov AN. Social factors and
increase in mortality in Russia in the 1990s: prospective cohort study. Br
Med J 2003; 326:1240-1242.
4 Bobak M, McKee M, Rose R, Marmot M. Acohol consumption in a
national sample of the Russian population. Addiction 1999; 94:857-866.
5 Carlson P, Vagero D. The social pattern of heavy drinking in Russia
during transition. Evidence from Taganrog 1993. Eur J Public Health 1998;
6 Palosuo H, Uutela A, Zhravleva I, Lakomova N. Observations on the
use of alcohol in Helsinki and Moscow in the 1990s. In: Simpura J, Levin
BM, (Eds). Demystifying Russian drinking. Comparative studies from the
1990s. Helsinki: STAKES, 1997: 149-174.
7 Malyutina S, Bobak M, Kurilovitch S, Gafarov V, Simonova G, Nikitin
Y et al. Relation between heavy and binge drinking and all-cause and
cardiovascular mortality in Novosibirsk, Russia: a prospective cohort
study. Lancet 2002; 360:1448-1454.
Competing interests: No competing interests
This paper about Russian mortality after 1991 is very interesting in
so many ways. Here we can medically conclude that the dramatically change
of the economic centralized communist profile into an open-market one left
Russian people in poverty. And Reagan and Thatcher, at these dramatic
times, cannot help with one penny the suffered people of “Rodnaya Rus”,
nor even a symbolic Marshall plan…
But these events are connected with others in the world: after the
fall of URSS, Cuba Island was cutter off from Russia benefits, and, in
modern times, was the first country to expose an epidemic status
of...peripheral neuropathy! After thousands of people with the classic
symptoms presented at the neurology teams, the ENMG studies confirmed the
clinical picture and the explanation was: famine.Complex B deficiency,
measured in laboratory. With some months of intense use of capsules of
vitamins, the patients returned to normal status. This was publicated by
Machado et al in Neurology some years ago.
Alcohol consumption, loss of perspectives in the future, the
criminalization of Russia in 90’ (the so called “mafias”),famine in
Cuba…What a difference between the end of WWII and the USA help to Europe
(not for URSS,of course) and this kind of savage vengeance. The
globalization, the Washington Consensuses come after the fall of Berlin
wall, and now a lot of people in Americas (even in USA), Europe, Asia,
etc. are paying the account for what? The derogate of communism?
This is social medicine and neurology in real life, and in our
times. And, as said Otto Friederich, a Harvard professor of History,
deceased just in the Reagan-Gorbagachov meetings, in the title of his most
famous book, is “The End of the World”.
Competing interests: No competing interests