Book Review

Russia's Torn Safety Nets: Health and social welfare during the transition

N Engl J Med 2000; 343:1424November 9, 2000

Article

Russia's Torn Safety Nets: Health and social welfare during the transition
Edited by Mark G. Field and Judyth L. Twigg. 314 pp. New York, St. Martin's Press, 2000. $49.95. ISBN: 0-312-22916-X

Russia has undergone a series of enormous social experiments in the past two decades. In 1985, Mikhail Gorbachev introduced the concepts of glasnost and perestroika to the Soviet Union, a monolithic state that was under rigid central control and surrounded by secrecy. Six years later, in the wake of an attempted coup, the Soviet Union was no more. An independent Russia, divested of its colonial possessions, experienced a political, social, and economic transition of staggering proportions. The demographic consequences were enormous. By 1994, life expectancy at birth for males had fallen to less than 58 years, which was almost 8 years less than life expectancy for males in 1987. The birth rate was only half what it had been a decade earlier. Perestroika had given way to katastroika.

Demographic changes on this scale are unprecedented in peacetime. Most observers simply could not accept that what was reported was genuine. This view was encouraged by the strong Soviet tradition of secrecy. In the 1930s, demographers were shot for drawing attention to the effects of Stalin's purges. In 1976, the Central Committee of the Communist Party established the Commission on the Non-Publication of Data and, soon afterward, ceased supplying demographic information to the World Health Organization.

Almost 10 years after the collapse of the Soviet Union, the scale of the demographic changes is no longer in question. But otherwise Russia remains shrouded in mystery. What processes are unfolding in Russia that can have these effects? And what can be done to reverse them?

Mark Field and Judyth Twigg have brought together contributors from various fields to illuminate the challenges facing Russia today. Together, they make a powerful case that although many aspects of the Soviet state, such as its labor camps, censorship, and inefficient systems of production, should be consigned to the history books, it did provide a basic safety net that protected most people from abject poverty. The transition to a capitalist economy has removed this safety net, leaving the Russian population at the mercy of the worst aspects of capitalism.

The first part of the book examines issues related to health. Field makes the important point that the mortality rate in Russia has two components. The first dates from the 1960s, when life expectancy had stopped increasing. He shows how this change coincided with the fallout from the Cuban missile crisis. A humiliated Russian leadership deposed Khrushchev and had increased military expenditures by a factor of 14 by the end of the decade.

Field dates the second phase from 1992, when both the birth rate and life expectancy began to plummet. These changes, he argues, were attributable to the breakup of the Soviet Union. Inflation eliminated the savings of many people, the institutions on which they depended were in crisis, and none of the existing rules seemed to apply. This argument is supported by evidence that the largest increases in the mortality rate occurred in regions experiencing the greatest economic change.

Field's analysis provides an excellent overview of what is known about the social determinants of demographic change in Russia, but by dating this change from 1992, Field ignores the impact of Gorbachev's 1985 anti-alcohol campaign. The campaign faltered in 1987, and the trend in life expectancy was reversed, returning to the earlier level at the beginning of the 1990s. The decline, which evoked widespread concern, can be seen as an acceleration of a preexisting trend, in which alcohol has been a central factor.

The next three chapters provide different perspectives on a health care system in crisis, one that is unable to adapt to the new political context. Twigg provides an excellent overview of the reality, as opposed to the rhetoric, of the Russian health insurance system, documenting its uneven implementation and lack of funding. Brown and Rusinova report on a survey in St. Petersburg showing that most people no longer understand how the system works and that fewer than 1 in 10 people are confident that they will receive the care they might need. Schecter shows that not only patients but also health professionals are unable to respond to the changing circumstances. The inability of Russian society to respond to the new challenges is exemplified by its inability to confront AIDS and illicit-drug use. Sex education has been absent from Soviet schools, and recent attempts to introduce it have fallen victim to a conservative alliance of religious and political groups. Few teachers or health professionals have the skills needed to carry out public health policies effectively. As a result, the incidence of AIDS infections is rocketing.

The second half of the book explores changes in the social policies of the Soviet era. In each case, the achievements may have been greatly exaggerated, but the basic protection these policies offered has disappeared. The Soviet view of women as equal citizens may have been somewhat illusory, but it did limit the now widespread exploitation of women and sexual harassment. The appearance of full employment in the Soviet era obscured the large numbers of people who were engaged in unproductive and meaningless work, but these people are left with nothing now that the facade has crumbled. Collectively, these chapters illustrate the challenges that Russia faces and also show how the legacy of the Soviet system is the main obstacle to effective responses.

This book contains a wealth of valuable information, but there are a few omissions that require comment. First, although each contributor draws extensively on the work of Russians, the inclusion of only one Russian contributor is striking. Second, the news from Russia is not all bad. Life expectancy at birth improved markedly between 1994 and 1998, although it still lags far behind life expectancy in the West and there are many reasons for continued concern. Finally, the last section of the book, on replacing the safety net, is somewhat thin. By focusing on American assistance to Russia, it ignores the large contributions made by other countries, as well as those made by many people in Russia itself.

Notwithstanding these minor reservations, this book is essential reading for anyone interested in health and social policy in this vast and still mysterious country.

Martin McKee, M.D.
London School of Hygiene and Tropical Medicine, London WC1E 7HT, United Kingdom