Transcript Factors driving the NCDI epidemic in CIS countries

Explanations of the East European Health Crises
and Implications for Health and Social Policy
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Conclusions
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Most current male deaths at working
age in CIS are avoidable by reducing
smoking and alcohol
Huge opportunity to prevent future
epidemic of smoking-related disease in
women in CIS
Improvements in health services
important for secondary prevention
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What is the problem ?
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Probability of a 20 year old
living to age 60 years in 2003
W Germany
England & Wales
Lithuania
Latvia
Women
Estonia
Men
Ukraine
Russia
Belarus
0
0.2
0.4
0.6
0.8
Source : www.mortality.org , calculations by VM Shkolnikov, Max Planck Institute
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4
Making the diagnosis - 1
Sharp fluctuations in mortality
in CIS
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Gradual improvement in life
expectancy in EU 1980-2005
85
EU - F
80
EU - M
75
70
65
60
Source : WHO HFA
2004
2002
2000
1998
1996
1994
1992
1990
1988
1986
1984
1982
1980
55
6
Sharp fluctuations in life
expectancy in CIS 1980-2005
85
80
75
CIS-F
70
65
CIS - M
60
Source : WHO HFA
2004
2002
2000
1998
1996
1994
1992
1990
1988
1986
1984
1982
1980
55
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Alcohol poisonings and life expectancy at birth
Russia (M+F) 1965-2006
60
R= - 0.94
Life expectancy
70
40
68
30
66
20
64
10
62
Alcohol poisoning
per 100,000
0
1965
Source : VM Shkolnikov
60
1975
1985
1995
2005
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Life expectancy, years
Death rate per 100,000
50
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Driver of fluctuations
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Alcohol is the most likely factor
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Very strong correlation of alcohol poisoning with
life expectancy for males AND females
Gorbachev anti-alcohol campaign
Causes most affected are those directly linked to
alcohol
Fluctuations least in CIS countries with lowest
burden of alcohol-related mortality
Smoking did not fluctuate and could NOT
produce these effects
Diet, exercise – little evidence
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Making the diagnosis - 3
The major problem is at
working ages
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Mortality increase is at working ages
(Males in Ukraine – typical of CIS)
25-64 years
125
75+ years
100
75
0-14 years
Source : WHO HFA
2005
2003
2001
1999
1997
1995
1993
1991
1989
1987
1985
1983
50
1981
Mortality relative to 1981
150
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Working age mortality
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Not pensioners, children or infants
even though they are socially and
economically most vulnerable
The problem must be behaviours that
are common at working ages
There is an iceberg of ill health and
disability among people who are the
wealth generators of society
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Making the diagnosis - 4
Non-communicable diseases and
injuries are dominant
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Deaths in Russia, aged 25-64 years, 2005
% distribution by cause of death
Men
Women
Other causes
Injuries
poisoning &
violence
Infections
Infections
Other causes
Cancer
Cancer
Injuries
poisoning &
violence
Circulatory
disease
Respiratory
disease
Source : WHO HFA
Respiratory
disease
Circulatory
disease
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Heart disease, injuries & cancer
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Alcohol key driver of injuries, poisonings
& violence (and possibly “heart disease”)
Smoking key modifiable factor for cancer
and heart disease
Primary prevention essential and feasible
Improved treatment important as well but essential to reduce number of people
seeking treatment through prevention
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Smoking
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Smoking causes more deaths from
cardiovascular disease than cancer
Deaths attributed to smoking
among all men in 2000, Russia
All cancers = 77,000
Cardiovascular disease = 148,000
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Source : http://www.deathsfromsmoking.net/
Smoking prevalence
Prevalence of smoking in Russia
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Very high prevalence
in men – even among
those who are higher
educated
Low, but rapidly
increasing smoking in
women
A tragedy as this is
one of very few areas
where the CIS has an
advantage over the
West
70
60
male
50
%
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40
30
female
20
10
0
1992
1994
1996
1998
Perlman et al. 2007
2000
2002
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What can be done about smoking ?
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Signing and ratifying FCTC
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Commitment
Information
Experience of active lobbying
Pooling knowledge and resources
Policy priorities
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Increasing taxation
Smoking in public places
Restrictions on advertising
Access to nicotine replacement therapy
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Alcohol
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Alcohol in the former Soviet Union
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Climate too cold for grapes
(except in South), so alcohol
prepared initially from honey
and later distilled from grain
Long cold winters offer few
other distractions
One of very few consumer
goods that could be produced
Explicit use of alcohol as tool
of state policy (under Czars
and Communists)
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To raise money
To keep population from revolting
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Frequency of heavy drinking
among men
35
30
25
20
15
10
5
All respondents
va
M
ol
do
ai
ne
U
kr
sia
us
R
st
an
rg
yz
an
za
Ky
kh
st
gi
a
Ka
G
eo
r
s
la
ru
Be
ia
0
m
en
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40
Ar
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2 litre or more of
beer
750 grams bottle
of wine or more
200 grams or
more of vodka or
strong spirits
(among those
sober enough to
answer question
and/or
remember)
episodes/ year
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What is being drunk?
Evidence from a typical Russian city
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The drinks
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Vodka
Surrogate spirits
Alcohol containing
medicines
Samogon (moonshine)
8% of healthy controls
drink substances not
intended for drinking!
How is alcohol drunk
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Heavy episodic
consumption
Zapoi – a Russian word
meaning getting so
drunk that you withdraw
from social interaction
for several days
12% of controls report
zapoi
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Vodka: a selection
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Samogon
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Surrogate spirits
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Alcohol containing medicines
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od
V ka
od 1
V ka
od 2
V ka
od 3
k
V a4
od
V ka
od 5
V ka
od 6
V ka
od 7
V ka
S od 8
ur ka
r
S oga 9
ur t
r e
S oga 1
ur t
r e
S oga 2
ur t
ro e
M ga 3
ed te
M ic in 4
ed e
M ic in 1
ed e
M ic in 2
ed e
M ic in 3
ed e
ic 4
in
e
5
V
alcohol concentration v/v%
How much ethanol?
100
90
80
70
60
50
40
30
20
10
0
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What is going on?
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In Russian cities, a significant number of people drink
surrogate alcohols
Probably different in rural areas, where the equivalent is
samogon (home produced)
Surrogates twice as strong and 1/3 the price – i.e. six
times cheaper for a given volume of alcohol
Observed effects may be that once someone crosses
threshold to regular surrogate consumption, price barrier
essentially disappears
However, where home produced spirits drunk, possibility
of additional toxic organ damage
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What can be done?
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Reduce initiation of hazardous drinking,
especially among young people
Prevent hazardous drinking, especially
among young people
Restrict the sale of surrogate alcohols
Reduce the risk of harm to those who
have been drinking
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Reduce initiation of hazardous drinking,
especially among young people
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Price
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Access
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Price is an important determinant of consumption
higher prices (taxes) reduce consumption
Fewer sales outlets, shorter opening hours
Controls on sales to young people: but must be
detected and deterred
Education
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Traditional negative messages are not effective
some other approaches, such as motivational
Interviewing, are promising.
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Restrict the sale of surrogate alcohols
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This is emerging as a key issue
Legislation already in place in Russia
since January 2006
The challenge now is to implement
and police the restrictions
comprehensively
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Reduce the risk of harm to those
who have been drinking
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Training for people who serve alcohol
Sanctions against sales outlets
identified as serving to people already
drunk (fines/ closure)
Training for police
Enforcement of drink-driving laws
 Care of people found drunk
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