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Learning from the Russians

BMJ 2006; 333 doi: https://doi.org/10.1136/bmj.333.7561.267 (Published 27 July 2006) Cite this as: BMJ 2006;333:267

Re: Learning from the Russians

Alcohol consumption in the former Soviet Union (SU) has been a theme of extensive research despite the difficulties of obtaining valid statistics. The fact that the state, at various times, encouraged alcohol sales is known to the international community (1). Veiled propaganda of alcohol consumption was recognizable during the 1960-1980s (before the start of the anti-alcohol campaign in 1985) and took place also earlier (3); more details are in (2). Alcohol consumption at workplaces was not only tolerated but also visibly encouraged among workers, students and intelligentsia. Parties at workplaces were often initiated or indirectly inspired by the management, which was common also in medical, educational and scientific institutions. In such institutions, technical or medicinal alcohol was consumed, which was knowingly tolerated by the management. It was known and seen that the management purloined alcohol themselves. The ringleaders could be observed, who manipulated others towards drinking in excess while non-drinkers were stigmatized.
Treatment and prevention of alcoholism was inefficient, placebos and persuasion being usual methods (4). Aversion (emetic) therapy and repeatedly induced teturam-alcohol reactions were applied (5). Correctional centres, so-called work-and-treatment prophylactoriums, were in fact a form of detainment for 1-2 years for chronic alcoholics evading treatment, violating community order or working discipline (according to the official definition); while loopholes were left for the patients to obtain alcohol e.g. over the fence. There was business with teturam preparations for the implantation, having a placebo effect at best (6,7): the patients were persuaded about efficiency and paid for the implantation. Finally, the so-called ultra-rapid psychotherapy or stress-therapy of alcoholism, known in the former SU as the ‘coding’, should be mentioned. The method was started during the anti-alcohol campaign; it was criticized as unethical (8) because of mystification, intimidating verbal suggestion, and painful or unpleasant manipulations: spraying the throat with ethyl chloride, massage of the trigeminal nerve branches, sudden backwards movements of the patient’s head by the therapist (8-10). We have found no reports on complications, but injuries of the cervical spine could have happened. Modifications of the method included general anaesthesia (11). The method is used in the former SU for the treatment of alcohol and drug addiction now as before (12).
The anti-alcohol campaign (1985-88) was initially successful but ended with a failure. It was accompanied, along with a temporary decrease in the alcohol-related mortality (1), by numerous fatal cases because of the increased consumption of alcohol-containing surrogates and technical fluids. The quality of alcoholic beverages deteriorated during that period (13). After the campaign, the alcohol consumption increased again, with vodka forming a larger share in the total (14), having partly replaced wine (15). Retrospectively, it becomes clear that the anti-alcohol campaign (1985-88) was used for the same purpose: its failure and the recoil-effect was predictable and occurred when it was required. Massive alcohol consumption after the campaign facilitated the economical reforms of early 1990s. It is known that alcohol abusers can experience emotions of shame, guilt and have a low self-esteem (16), therefore being probably easier to manipulate and to command. Workers did not oppose privatizations of state-owned enterprises by former administrators and party functionaries partly due to their drunkenness, involvement in workplace theft and other illegal activities, e.g. use of equipment for private purposes, which was often tolerated by the management at that time.
After the anti-alcohol campaign (1985-88), the quality of alcoholic beverages deteriorated, but they have become easily available. However, recent governmental measures in Russia, limiting availability of alcohol, in particular, a prohibition of small (0.33l) beer cans, can contribute even today to alcohol consumption in higher doses. Another recent anti-alcohol measure – prohibition from the 1 January 2013 of beer selling between 23 p.m. and 8 a.m. sometimes results in purchasing larger amounts in advance with subsequent consumption. Prohibition of beer sales at small kiosks will probably have a similar effect in the places with no shops near at hand. There is an opinion that the latter measure would have no impact on the volume of beer sales (17). Superficial anti-alcohol measures of this kind and accompanying rhetoric are in fact distracting public attention from the problems, which the government does not tackle, among them corruption, the insufficient public health and social security systems.
According to the author’s observations, the pattern of alcohol consumption in Russia has been changing since approximately 2000, with the average amounts of consumed alcohol tending to decrease. During the Soviet time and the 1990s, many inebriated people could be seen in public places: drinking, sleeping, making noise, etc. In contrast with the past, there are almost no heavily drunk people in the streets today; even the marginalized are rarely seen drunk in public. Concomitantly, the pattern of alcohol consumption has been changing: less heavy binge drinking of vodka, partly replaced by the moderate consumption of beer (15). A similar tendency is also noticed in smaller towns and rural areas, favoured by the ongoing immigration from the regions with less widespread alcohol consumption, such as Middle Asia and the Caucasus, or explained by the fact that local alcoholics have “died out” with fewer successors. Other reasons for these changes have been discussed previously: the more responsible way of life under the conditions of the market economy, intimidation and crime against alcoholics and people with alcohol-related dementia, including appropriation of their residences and other property (18).
After the anti-alcohol campaign (1985-88), average life expectancy at birth decreased sharply, especially in men: by 1993 it had slumped to about 59 years (14), today being estimated to be 64 years (19). According to a widespread opinion, many Russian alcohol abusers do not live long enough to die of liver cirrhosis or its complications. Among the most frequent causes of death of alcoholics are bronchopulmonary diseases including chronic bronchitis, bronchopneumonia, pleural empyema, and tuberculosis (20-22). This is probably partly caused by the cold climate coupled with the limited availability of warm public houses for the people with low incomes, so that they often drink and loiter outdoors and can fall asleep in a cold place. Smoking is also likely to be a contributing factor.
Another cause of the relatively high mortality has been the poor quality of alcoholic beverages, in particular, consumption of counterfeit products and surrogates sold also in legally operating shops (13,23). During the anti-alcohol campaign, many poisonings were caused by alcohol-containing technical fluids. The quality of legally sold alcoholic beverages deteriorated during that period; after the campaign, poor-quality beverages were produced and sold en masse (23). Numerous cases of death after the ingestion of moderate amounts (24), with a relatively low blood alcohol level (23) were reported, obviously caused by the substances other than ethanol contained in the consumed products.
Furthermore, a relatively high mortality rate from cardiovascular diseases in Russia has been reported (25,26). A cause of the high registered cardiovascular mortality in the former SU is evident for anatomic pathologists. Since the Soviet time, autopsy has remained obligatory for all patients dying in hospitals; but the attitude towards post-mortem examinations has become less rigorous. Autopsies were often performed incompletely. If a cause of death is not entirely clear, it is usual to write on a death certificate: ‘Ischemic heart disease with cardiac insufficiency’ or a similar formulation. A tendency to overdiagnose cardiovascular diseases also exists for people dying at home and not undergoing autopsy. This is likely to be one of the causes of the increase in cardiovascular mortality, especially among men (27). It can be indirectly confirmed by the following statement: ‘Increases and decreases in mortality [have been] related to cardiovascular diseases (CVD), particularly to ‘other forms of acute and chronic ischemia’ and ‘atherosclerotic heart disease’, but not to myocardial infarction, the proportion of which in Russian CVD-related mortality is extremely low.’ (28) The explanation is evident: the diagnosis of myocardial infarction is usually based on clear clinical and/or pathological criteria, while entities such as ‘acute and chronic ischemia’ or ‘atherosclerotic heart disease’ can be used post mortem without strong evidence. The ‘extremely low’ (28) mortality of myocardial infarction in Russia indicates that many cases remain undiagnosed and untreated.
The role of alcohol as a cause of premature death cannot be denied, but this role was obviously more significant during the 1990s, when alcohol consumption increased as a recoil effect after the anti-alcohol campaign. The causative role of alcohol in Russian mortality rates was obviously exaggerated in some publications, e.g. (29), where “the enormous scale of alcohol-related mortality” was reiterated without mentioning the insufficient availability and quality of health care as another cause of premature death. There is a tendency in the Russian literature to exaggerate the topic alcohol abuse and its cause-effect relationship with mortality, especially from cardiovascular diseases, e.g. (20,21,23,29,30). In this way, responsibility for higher mortality rates, partly caused by the shortages of the health care system, is in a sense shifted onto the patients themselves: they allegedly suffered from self-inflicted diseases due to their excessive alcohol consumption.
For example, it was stated on the basis of a large autopsy study that all 654 deceased individuals classified as hard drinkers were diagnosed post mortem with cardiomyopathy; while in the majority of the patients diagnosed with chronic alcoholism (172 cases) the cardiomyopathy was graded as pronounced (21). According to the monograph (20), clinically significant cardiomyopathy was diagnosed in approximately 50% of habitual alcohol consumers. Accordingly, cardiomyopathy is used to explain for sudden death among alcohol consumers (21), while the factual cause could have been undiagnosed disease or poisoning (28). The tendency to exaggerate the cause-effect relationship between alcohol and the cardiovascular morbidity is relatively new in the Russian literature. An earlier epidemiological study reported that rates of cardiovascular diseases including hypertension were not significantly higher among excessively drinking men compared to the general male population (22).
Conclusion
Exaggeration of alcohol-related mortality tends to veil shortcomings of the health care system, with responsibility for the low life expectancy especially among men shifted onto the patients, that is, self-inflicted diseases caused by excessive alcohol consumption. The purpose of this Rapid Response is to draw attention to this and other problems related to the alcohol consumption, such as the instable quality of legally sold alcoholic beverages Russia, which have sometimes caused poisonings even after consumption in moderate doses, and crime against alcoholics and people with alcohol-related dementia aimed at appropriation of their immobile or other properly (31).
References
1. McKee M. Alcohol in Russia. Alcohol Alcohol 1999;34(6):824-9.
2. Jargin SV. On the causes of alcoholism in the former Soviet Union. Alcohol Alcohol 2010;45(1):104-5.
3. Pelipas VE, Miroshnichenko LD. Problems of the alcohol policy. In: Ivanets NN, Vinnikova MA. (Editors) Alcoholism. Moscow: MIA, 2011:817-51. (Russian)
4. Fleming PM, Meyroyan A, Klimova I. Alcohol treatment services in Russia: a worsening crisis. Alcohol Alcohol 1994;29(4):357-62.
5. Altshuler VB. Alcoholism. Moscow: GEOTAR-Media, 2010. (Russian)
6. Johnsen J, Mørland J. Depot preparations of disulfiram: experimental and clinical results. Acta Psychiatr Scand Suppl 1992;369:27-30.
7. Wilson A, Blanchard R, Davidson W, et al. Disulfiram implantation: a dose response trial. J Clin Psychiatry 1984;45(6):242-7.
8. Voskresenskii VA. Critical evaluation of ultra-rapid psychotherapy of alcoholism (concerning the article by A.R. Dovzhenko et al. "Ambulatory stress psychotherapy of alcoholics"). Zh Nevropatol Psikhiatr Im S S Korsakova 1990;90(9):130-2.
9. Dovzhenko AR, Artemchuk AF, Bolotova ZN, et al. Outpatient stress psychotherapy of patients with alcoholism. Zh Nevropatol Psikhiatr Im S S Korsakova 1988;88(2):94-7.
10. Lipgart NK, Goloburda AV, Ivanov VV. Once more about A.R. Dobzhenko's method of stress psychotherapy in alcoholism. Zh Nevropatol Psikhiatr Im S S Korsakova 1991;91(6):133-4.
11. Belokrylov IV, Agibalova TV, Rovenskikh IN. Psychotherapy of alcoholism technology. In: Ivanets NN, Vinnikova MA. (Editors) Alcoholism. Moscow: MIA, 2011:396-438 (Russian)
12. Torban M, Heimer R, Ilyuk RD, Krupitsky EM. Practices and attitudes of addiction treatment providers in the Russian Federation. Journal of Addiction Research & Therapy 2011; 2:104.
13. Jargin SV. Letter from Russia: minimal price for vodka established in Russia from 1 January 2010. Alcohol Alcohol 2010;45(6):586-8.
14. Ryan M. Alcoholism and rising mortality in the Russian Federation. BMJ 1995;310(6980):646-8.
15. WHO. Russian Federation. Global Information System on Alcohol and Health (GISAH), Geneva: World Health Organization, 2011.
16. Scherer M, Worthington EL, Hook JN, Campana KL. Forgiveness and the bottle: promoting self-forgiveness in individuals who abuse alcohol. J Addict Dis 2011;30(4):382-95.
17. MacFarlane S. Regulation of brewing in RF – one of the most strict. Beer and Beverages (Moscow) 2013;(1):48-9.
18. Jargin SV. Changing pattern of alcohol consumption in Russia. Adicciones 2013;25(4):356-7.
19. Rehm J. Russia: lessons for alcohol epidemiology and alcohol policy. Lancet 2014;383(9927):1440-2.
20. Vertkin AL, Zairat'iants OV, Vovk EI. Final diagnosis. Moscow: Geotar-Media, 2009. (Russian)
21. Paukov VS, Erokhin IuA. Pathologic anatomy of hard drinking and alcoholism. Arkh Patol 2004;66(4):3-9.
22. Kopyt NIa, Gudzhabidze VV. Effect of alcohol abuse on the health indices of the population. Zdravookhr Ross Fed 1977;(6):25-8.
23. Nuzhnyi VP, Kharchenko VI, Akopian AS. Alcohol abuse in Russia is an essential risk factor of cardiovascular diseases development and high population mortality (review). Ter Arkh 1998;70(10):57-64.
24. Govorin NV, Sakharov AV. Alkohol-related mortality. Tomsk: Ivan Fedorov, 2012. (Russian)
25. Zatonski WA, Bhala N. Changing trends of diseases in Eastern Europe: closing the gap. Public Health 2012;126(3):248-52.
26. Razvodovsky YE. Beverage-specific alcohol sale and cardiovascular mortality in Russia. J Environ Public Health 2010;2010:253853.
27. Zatonski W. The East-West Health Gap in Europe - what are the causes? Eur J Public Health 2007;17(2):121.
28. Davydov MI, Zaridze D G, Lazarev AF, et al. Analysis of mortality in Russian population. Vestn Ross Akad Med Nauk 2007;(7):17-27.
29. Nemtsov AV. Alcohol-related human losses in Russia in the 1980s and 1990s. Addiction 2002;97(11):1413-25.
30. Razvodovsky YE. Estimation of alcohol attributable fraction of mortality in Russia. Adicciones 2012;24(3):247-52.
31. Jargin SV. Alcohol consumption in Russia 1970-2014. LAP LAMBERT Academic Publishing, Saarbrücken, 2014. ISBN: 978-3-659-22952-7

Competing interests: No competing interests

01 June 2014
Sergei V. Jargin
researcher
Peoples' Friendship University of Russia
Clementovski per 6-82, Moscow