Abstract
Russia experienced a severe health crisis in the 1990s,
as reflected by a drop in life expectancy. It has been suggested in literature
that this poor state of health is likely to endure and will significantly
retard economic growth in the country. This paper uses evidence from other
former Communist countries and studies of income-health relationship across
economies to evaluate these claims. It concludes that the mortality increases
of 1988-94 and 1999-2000 were the effects, rather than causes, of the economic
recession. The state of health is unlikely to put a brake on future economic
growth.
Acknowledgements:
I thank Michael Ellman for his comments on an earlier
version of this paper and Luba Kontorovich for editing the text.
1. The post-Communist economic divergence
In the late 1980s Russia and its western neighbors had similar socio-economic
structures and levels of development [òåçèñ, âåñüìà
è âåñüìà íåî÷åâèäíûé è íåïîäòâåðæä¸ííûé, õîòÿ è î÷åíü ðàñïðîñòðàí¸ííûé],
yet in the 1990s their paths diverged. While some ex-Communist economies
experienced rapid growth after the early-1990s contraction, others, including
Russia, continued to shrink (Table 1). Explanations for this phenomenon,
initially put in terms of differences in macroeconomic policies, have shifted
to the quality of political institutions (e. g., corruption and the rule
of law), geographic location (Gallup & al., 1999, and Parshev, 2000,
pp. 9-104), and Russia’s imperial legacy (Kontorovich, 1996). Corruption,
lawlessness, and imperial institutions and attitudes, while not immutable,
are more difficult to change than a wrong fiscal or monetary policy. And
there is nothing one can do about a country’s geographic characteristics
(though changing technology may modify their economic impact). An analysis
of Russia’s recent lagging performance thus leads to an assessment of its
growth prospects.
[Table 1 here] (ê ñîæàëåíèþ, òàáëèöû âñå óäàëåíû, ïîñêîëüêó
áûëè èñïëîíåíû íåóäîáîâàðèìî)
Almost conterminously with its economic decline Russia experienced an
exceptionally severe health crisis, as expected life spans dropped by six
years in 1988-94 (Table 2). Other ex-Communist countries had smaller declines
in life expectancy, and a few had none (Table 3). [1] One may hypothesize
that Russia's more severe health crisis made its recession deeper than
elsewhere. If there is cause to believe that health problems will persist,
one may then also expect substandard economic growth in the future.
[Table 2 here]
Bloom and Malaney (1998, p. 2080) estimated the contribution of the
health crisis to the decline in Russian GDP in the 1990s to be very small.
Still they speculate that the “… Russian mortality crisis has the potential
to push health below a critical point into a vicious cycle, where declining
health leads to a decline in output, which further contributes to declining
health.” (ibid., p. 2081). Feschbach (1999, p. 27) attributes the high
level of mortality and morbidity in Russia in large part to ecological
problems, predicts a worsening situation, and states that as a result,
“long-term solutions to the country's political, economic, and military
problems will be inconceivable.”
[Table 3 here]
Eberstadt (1999, p. 12) agrees that the health crisis will be very difficult
to overcome but provides a different reason: the ‘inertia’ of unfavorable
mortality developments in the 1960s-1980s. Eberstadt uses a strong correlation
between life expectancy and GDP per capita across countries to forecast
Russia's
future GDP. He assumes that the correlation at a moment in time will
also hold over decades, so that if Russian life expectancy will improve
little, so will its national income (ibid., pp. 16-18).
This paper considers conjectures about the significance of the Russian
health crisis for the country's future economic performance. As is common
in the literature on health and the economy, I concentrate on only one
measurable aspect of health-mortality, as summarized by life expectancy
at birth. This makes comparisons over time and across countries easier.
By contrast, morbidity data cannot be reduced to one number and are less
reliable than those for mortality. It is assumed that mortality and morbidity
move together over time and across countries.
2. Why would high mortality in Russia persist?
For poor health to depress future Russian growth, as Eberstadt (1999) and
Feschbach (1999) suggest, the present state of health must persist into
the future. In the second half of the 20th century, mortality rates declined
in rich, poor, and middle-of-the-road countries on all continents (see,
e. g., Easterlin,
2000, pp. 12-13). Some powerful factors unique to Russia must exist
for it to be excluded from this universal trend.
2.1. The environment and a history of stagnant mortality rates
Feshbach (1999) suggested environmental pollution as one such factor. For
it to keep future mortality high, the following should hold:
a. air, water, and soil in Russia are contaminated more than
they are elsewhere;
b. this has driven Russian mortality rates to their present high level;
c. the pollutants are long-lived or continuously replenished and are
costly to clean up, and therefore will continue to effect health in the
coming years.
Whatever the merits of a. and c., point b. is definitely weak. The most
important causes of mortality increase of working age population in 1990-94
were accidents, poisonings, traumas, murders, suicides (Table 4). [2] These
'external' causes of death are totally unrelated to environmental pollution.
Circulatory diseases - the second largest contributor to mortality increase
- are more tenuously associated with health effects of pollution than other
possible causes of death.
Together these two groups of causes accounted for three quarters of
mortality increase in the early 1990s. Environmental pollution is not the
major cause of the present high mortality, as is generally recognized in
the literature. [3] Hence there is no reason why, barring a catastrophe,
ecological problems should bolster future mortality rates.
[Table 4 here]
Eberstadt (1999, p. 14) appeals to history in support of his argument
that Russian mortality rates are likely to stagnate in the coming decades.
In 1960-90, life expectancy increased in every other part of the world
but stagnated in Russia (Table 5). In fact, between the mid-1960s and the
late 1970s life expectancy in Russia declined by two years. Whatever forces
kept Russia from sharing in the world trend to longer life in the past
(and they are far from being understood) may well continue for another
couple of decades.
[Table 5 here]
The problem with this argument is that life expectancy stagnated between
1960 and 1990 in the East European region as a whole, including most Soviet
republics in Europe and the Warsaw Pact countries (Table 5). If there is
such a thing as inertia of poor health, it should operate not just in Russia
but also
throughout the rest of Eastern Europe. Yet Poland, the Czech Republic,
and Slovakia have shown rapid improvements in life expectancy in the 1990s,
clearly breaking with the stagnation of the previous three decades (Table
3). This shows that a history of stagnation is not sufficient grounds to
prevent future growth in life expectancy.
2.2. Mortality increases in 1988-94 and 1999-2000
Two recent episodes of increased mortality should be analyzed as potentially
signaling a bleak future for health in Russia. In 1988-94, life expectancy
for Russian males fell by 7.6 years and for females by 3.4 years (Table
2). Death rates among working age males increased by 50-100% (Table 6).
This may be the largest peacetime increase in mortality in the modern age.
However, smaller increases in mortality experienced by other countries
under similar circumstances help shed light on the Russian developments.
[Table 6 here]
Mortality increased in most East European countries after the collapse
of Communism (Table 3). As in Russia, the increase was more pronounced
for men than women. Declines in male life expectancy in the former Soviet
republics were 70%-90% of those in Russia. Declines in the ex-CMEA countries
were an order of magnitude smaller. Yet small changes in life expectancy
may hide substantial changes in death rates for particular age groups.
Thus, male life expectancy in Poland declined by 0.39 years from 1990 to
1991, while death rates increased by one third for the 10-14 age group,
by 8.5% for the 35-44 age group, and 6.8% for the 45-54 age group (Tables
3 and 7). In Slovenia, the decrease in male life expectancy between 1992
and 1993 was 0.27 years, yet death rates jumped 12% for the 20-24 age group,
21% for the 25-29 age group, and 12.5% for the 40-44 group (Tables 3 and
8). In East Germany the life expectancy decline was also small, but the
death rate for men aged 35-45 increased 30% in 1989-91 (Riphahn & Zimmerman,
1998, p. 49; Eberstadt, 1994, pp. 527-8).
[Table 7 here]
In 1995-98, male life expectancy in Russia regained 51% of its recent
loss (Table 2). Death rates among all age groups declined (Table 6). This
is common to all the ex-Communist countries listed in Table 3 except for
Belarus. In Slovenia, Poland, and Hungary, where the decline in life expectancy
was small and
recovery started early, life expectancy has already exceeded the pre-crisis
peak. While Russia experienced the largest decline in life expectancy,
it also bottomed out earlier than Ukraine, Belarus, and Lithuania, and
had a faster recovery than Estonia and Latvia. As a result, the number
of years of life expectancy lost between 1989 and 1998 in Russia was smaller
than in the other European ex-republics of the USSR. In 1989, male life
expectancy in Russia was lower than in all the other countries in Table
3. In 1997, Russia overtook Ukraine and closed part of the gap with the
other ex-republics (Table 9). Still, its lag behind ex-CMEA countries has
increased, in some cases rather dramatically.
[Table 8 here]
The list of countries suffering from the increase in mortality and the
timing of this increase leave little doubt that its causes lie in the collapse
of the old order. It is not a Russian, but rather post-Communist phenomenon,
with former Soviet republics being hit the hardest. The experience of other
countries shows that a post-Communist health crisis is reversible and hence
likely to be overcome by Russia, as well.
[Table 9 here]
This proposition sounds less credible now than it did a few years ago.
Before even recovering to its 1992 level, life expectancy in Russia declined
again in 1999 (Table 2). The decline continued in 2000, though at slower
pace. [4] While the data are not in yet, this second tour of post-Communist
mortality increase may well turn out to be an exclusively Russian phenomenon,
with at most one or two other former Soviet republics sharing in the misery.
[5] Would it then be a manifestation of a fundamental difference in health
conditions in Russia and elsewhere that will keep Russia lagging ever farther
behind in terms of life expectancy? To answer this question, we need to
examine the causes of mortality increase.
3. Relationship between health and income
3.1. Correlation and causation
Per capita income and life expectancy correlate strongly with each other
across countries at a point in time. [6] Eberstadt (1999, p. 18) uses this
fact to deduce the future level of income in Russia from its life expectancy,
which is assumed to change little from the present. There are several reasons
why this
correlation cannot be used in such a way.
Health-wealth relationship is the strongest for poor countries with
short-lived populations, and then levels off. [7] A logarithmic curve approximates
this relationship better than a straight line.[8] Using a straight line
instead, as Eberstadt does, exaggerates a slope applicable to Russia’s
level of income.
The relationship between health and income changes over time. In a sample
of more than 100 countries, levels of GDP per capita have been diverging
in 1960-1985 while life expectancy levels have been converging (Ingram,
1994, p. 327). The reason for this is that both life expectancy and income
depend on many other factors that change over time. [9] Technological change
shifts the income – life expectancy line upward as time passes (i.e., life
expectancy associated with a given level of income today is higher than
30 years ago).[10] Because of the public good property of technology, such
improvements need not correlate with income change.
The share of income spent on health services is another factor that
can modify income-health relationship. Sri Lanka had a life expectancy
at birth of 72 years in 1990, not far below the American 75.4 years, while
its GDP per capita was only about 12% of that in the US (IBRD, 1993, pp.
200, 296).[11] Below we will see how the process of urbanization in the
19th century pushed health and income in opposite directions. This means
that the straight line which Eberstadt (1999, p. 18) used to describe the
current relationship between health and income will not be the same several
decades from now, and therefore cannot be used for prediction.
Correlation between health and income does not tell us anything about
the direction of causation. One can construct examples when health determines
income, when income determines health, and when both are determined by
a third variable. There are microeconomic studies showing that in particular
situations one or another of these influences predominates (Smith, 1999,
pp. 149-65). But what about an “aggregate” relationship between health
and GDP across countries, the one used by Eberstadt (1999)?
Pritchett and Summers (1996) studied the relationship between changes
in GDP per capita and changes in health for a large sample of developing
countries in 1960-85. They used the method of instrumental variables (variables
that are closely associated with income, but in their nature can not be
influenced by health) to disentangle the interrelation of health and wealth.
They found that these variables closely correlate with health, i. e., the
main causation link runs from income to health, and not the other way around.
These results were obtained for infant mortality, child (under age 5) mortality,
and life expectancy at birth. The latter indicator was found to be less
sensitive to income than the former two, effect the authors ascribed to
poor data quality. Income (or wealth) and health also correlate in a cross
section of population within a country (Smith, 1999, pp. 146-7). Ettner
(1996) studied the relationship between income and several indicators of
morbidity for a cross-section of the US population using instrumental variables
method. Her results show that the predominant influence is from income
to health.
The correlation between life expectancy and income cannot be used to
predict the latter based on the former, because the causality runs in the
opposite direction.
3.2. Mechanisms of causation
The post-Communist health crises and the Russian mortality increase of
1999-2000 are examples of income change driving health change. The collapse
of the old order in one case and a financial crisis in the other, both
unrelated to mortality rates, drove down income, which, in turn, suppressed
life expectancy. The collapse of Communism and the 1998 financial crisis
here play the role of instrumental variables, enabling us to judge the
predominant direction of causality between two parallel processes. The
relationship between income and health across countries or in a cross section
of population (as discussed in the previous section) works through many
channels, some of which are poorly understood. It is common to think that
in this relationship, income stands for the degree of physical deprivation
and access to health care. This may be an important part of the relationship
at low income levels. However, income also correlates with health for a
group of equally wellfed white-collar workers using similar medical services
(Smith, 1999, p. 158-60). The post-Communist recession must have increased
mortality in Russia primarily through channels other than malnutrition
or lack of medical care. This is attested to by the data on the most vulnerable
age groups - the youngest and the oldest. Mortality rates of infants and
children did not increase at all in the 1990s, and that of the elderly
increased significantly less than that of working age people (Table 6).
The same applies a fortiori to the richer post-Communist countries. The
Great Depression in the US had a similar impact on mortality. While GNP
declined by 30.5% and bottomed out in 1933, life expectancy declined by
4.8 years in 1934-36 (US, 1960, p. 25 and US, 1975, p. 229). But infant
mortality did not increase at all (Table 10).
[Table 10 here]
A plausible mechanism for income - health relationship in the early
1990s post-Communist crises was proposed by (Shapiro, 1995, pp. 167-9).
[12] Rapid and massive social upheaval induced stress in individuals ill
prepared to cope with such change. Stress, in turn, exacerbated circulatory
diseases and selfdestructive behavior, such as heavy drinking. Accidents,
murders, and suicides are strongly correlated with alcohol consumption.
[13] This is consistent with the structure of mortality increase by cause
of death discussed above and shown in Table 4.
Income as a determinant of health works here not as a measure of command
over goods and services essential for a healthy life, but as a correlate
of personal status, prospects, self-respect, and any number of other hard-to-measure
variables. This is also apparently the role of income as determinant of
health in a cross section of the population in developed countries (Smith,
1999, p. 162-4). One might equally plausibly argue that the post-Communist
health crisis was the result of disintegration of a social order with its
roles, values, and other attributes. Income decline may then be taken as
a proxy for the depth of social disintegration, providing a continuous
measure for an otherwise ethereal category. If large declines in income
can, by inducing stress, cause mortality to increase, then the 1999-2000
drop in Russian life expectancy becomes predictable (see Kontorovich, 1998,
p. 23). While GDP decline in 1998 was relatively modest 4.6% (Table 1),
personal disposable income fell much more. In the fourth quarter of 1998
and the first two quarters of 1999 this variable was about 25% below similar
periods in 1997 and 1998 (Goskomstat, 2000, p. 84). It is not Russian mortality
that was unusually impervious to improvements, but the economy that was
unusually brittle and interrupted the recovery of life expectancy after
the 1988-94 plunge. [14] If this analysis is correct, and Russian economy
continues its healthy performance of 2000, then life expectancy has to
rebound in 2001.
3.3. Why there is no vicious cycle between growth and health
Bloom & Malaney (1998, p. 2081) hypothesized that when a decline in
income makes people less healthy, poor health may further suppress income.
Such a situation is unlikely because, as argued in the previous section,
the impact of these two variables on each other is not symmetrical. A large
decline in income does indeed hurt people's health and generates a positive
feedback. But the latter is small (as Bloom & Malaney themselves have
found for Russia). Other factors influencing economic growth easily outweigh
the impact of deteriorating health. In the previous section we examined
several cases when falling income drove down life expectancy. Let us examine
historic episodes when health deteriorated for “exogenous” reasons and
see what this did to growth. What matters in these examples is both the
magnitude of the mortality increase and its age composition. Post-Communist
health crisis has the maximum possible economic impact because it falls
mostly on working age people. A mortality increase that hit mostly children
and the elderly would have a much smaller economic effect in the short
run. If there are productivity differentials by sex in the economies concerned,
then the fact that the post-Communist crisis hits mostly men would also
be significant. In the 19th century the most advanced countries experienced
prolonged periods of rising mortality, usually attributed to urbanization
at a time when cities lacked adequate sanitation. In the US, life expectancy
at age ten was falling from about 1790 to 1850. This means that mortality
must have been increasing for the working age population. The height of
native-born American men, another indicator of the health status of working
age people, had been falling from 1830 to 1890. Yet real GDP per capita
in the US grew at an average annual rate of 1.2% in 1820-50, 1.5% in 1850-70,
and 1.6% in 1870-90 (Fogel & Costa, 1998, p. 57-9 and 61; Maddison,
1995, p. 196).
In Britain, falling life expectancy in the 1830s and 1840s did not stop
economic growth (Table 11). In fact, growth accelerated in the very decade
(1840s) when the decline in life expectancy was greatest. [15] It was in
urban centers that the growth of the English economy in the mid-19th century
was generated, and the cities also suffered the greatest setbacks in health.
Szreter and Mooney (1998, pp. 104-105) estimate that life expectancy at
birth in English cities with over 100,000 inhabitants declined from 35
years in the 1820s to 29 in the 1830s (a 17% drop), stayed at 30 years
through the 1840s, and did not regain its previous peak until well into
the 1860s. The relevance of this example is reduced by the fact that I
do not know the age distribution of this mortality increase.
[Table 11 here]
AIDS epidemic in sub-Saharan Africa, which disproportionately falls
on working age population, has so far had little effect on the economic
growth of the countries concerned (Bloom & Mahal, 1997; McNeil, 1998).
And the jury is still out on the economic impact of the Black Death (Bloom
& Malaney, 1998, p. 2074).
The recent health crises in ex-Communist countries also did not push
their economies into a downward spiral. The three Baltic countries, which
suffered a mortality crisis comparable in magnitude and in age-sex composition
to that of Russia, have been growing since 1995-96 at a respectable, and
in the case of Estonia, exceptional rate. Russia itself posted its first
significant gain in GDP in ten years in 1999, just as life expectancy declined.
GDP growth further accelerated to 7.7% in the first eleven months of 2000,
even as mortality kept increasing.
4. Health and growth in Russia
While the level of mortality in Russia has been unusually high, its changes
followed a pattern observed elsewhere. Russian mortality increased between
the mid-1960s and the late 1970s, as did mortality in other European Communist
countries and European Soviet Republics (for reasons that are not well
understood). Mortality in Russia increased again after the collapse of
Communism, as it did in most ex-Communist countries. Former Soviet republics
suffered deeper declines in life expectancy than the ex-CMEA countries,
as did Russia. Russia had the misfortune being a member of all of the afflicted
groups, and this goes a long way towards explaining its anomalous, from
a global point of view, health record.
Mortality increase after the collapse appears to be due to stress induced
by the social collapse and economic downturn. Change in GDP serves as a
convenient proxy for these dislocations. Decline in life expectancy in
the early 1990s is strongly correlated with the relative decline in GDP
across countries. [16] Former Soviet republics suffered a deep recession
and a large increase in mortality, while ex-CMEA countries saw a shallow
recession and a much smaller jump in death rates. The severity of the Russian
health crisis of the early 1990s was due to the comparatively deep economic
recession.
There are several reasons to believe that causation in these episodes
runs from recession to mortality increase and not the other way around.
Several studies have found that the relationship between health and income
on the macro level is asymmetric, with the stronger impact being the latter
on the former. Economic decline was caused by events (collapse of the Communist
system) that are clearly independent from change in mortality. There have
been other instances when an economic downturn caused by non-health related
events led to increased mortality, such as the Great Depression in the
US and the Russian financial crisis of 1998.
The sorry experience of the past does not predetermine continued stagnation
of life expectancy in Russia. Some of the countries with similar health
crises experiences overcame their post-Communist mortality increase and
have shown sustained improvements in life expectancy. Others appear well
on the way to doing so. Absent new severe economic shocks, life expectancy
shows the tendency to recover to pre-crisis levels. And as the economy
embarks on sustained growth, mortality is likely to start declining, as
it is everywhere else in the world. Yet even if this does not happen and
mortality in Russia stagnates, this will not stymie economic growth.
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Tables ;(óäàëåíû)