PSKOV, Russia - Olga Kudryavtseva, a cardiologist at the regional hospital,
does not expect Vladimir Bragin to return to work at the welding factory
of this northwest Russian town.
The 40-year-old father of two has already suffered two heart attacks,
and the pains in his chest suggest he is in imminent danger of a third.
Kudryavtseva says he is reaping the harvest of years of bad habits - two
packs of cigarettes a day since he was 15, no exercise, a diet of sausage
and sour cream and binge drinking up to eight pints of vodka a day.
His heart is so damaged that only a bypass operation could repair it
- and that is far beyond his means. "He will be an invalid," Kudryavtseva
said, out of earshot of the patient. "It's a very sad forecast."
He thinks differently. "I will work," he insists, sitting on the edge
of a sky-blue iron bed in the hospital that has been his home for almost
a month. "If I don't work, my family will not be able to survive."
Bragin's personal crisis is Russia's national disaster. Russian men
in their forties and fifties are dying at rates that some experts say are
unheard of for a developed nation in peacetime. In 1999, outside of
AIDS-swept Africa, only Haiti reported higher male mortality rates
than Russia.
The life expectancy of Russian men is 59 years, shorter than that of
men in three-fourths of the world's countries, including many less prosperous
nations such as Nicaragua and Vietnam. A typical Russian baby boy born
today is expected to live as long as a typical American boy was in 1931.
The implications for Russia's place in the world could be profound,
because healthy nations tend to be more productive. Nicholas Eberstadt,
a Russia expert with the American Enterprise Institute in Washington, says
Russia's burden of disease is likely to cripple its economy - and its hopes
of major
power status - for decades to come.
"The wealth of nations today is in people, not in what can be mined
or drilled from the ground," he said. "Russia's potential is seriously
impaired by the woeful state of the population's health."
The principal reason Russian men die so young is not poor medical care,
although many of Russia's hospitals are antiquated and spending on health
care is just a fraction of that in the West. More significant is the risk-prone
lifestyle of Russian men and the failure of doctors and government officials
to stress preventive health care - a Western mantra for three decades.
The leading cause of death for Russian and American men is the same:
circulatory, heart or cerebrovascular disease. But the risk of death is
far greater for Russian men, largely because of their lifestyles: three
times higher for heart or circulatory failure, and seven times higher for
cerebrovascular disease.
Almost two-thirds of Russian men smoke, compared to one-fourth of U.S.
men. Some researchers estimate that the typical Russian man drinks a pint
of pure alcohol every two days, compared to less than two pints a month
for the average American man or woman. Only 6 percent of Russians exercise
regularly. High-fat foods are so popular that some Russian restaurants
offer a chunk of salted pork fat as a stand-alone item.
Next to heart disease, violence and accidents claim the most Russian
men. More of them die every year of accidents, poisonings, drownings, homicides
and suicides than die of cancer. Alexander Pochinok, Russia's labor minister,
calls Russia's accident rate "unbelievable."
About 40,000 Russians - the equivalent of the population of McLean,
Va. - die every year of alcohol poisoning. In the United States, with nearly
twice Russia's population, alcohol poisoning kills only about 300 people
a year. Roughly 17,000 Russians drown annually, most of them drunken men,
a rate nine times higher than in the United States, where most drowning
victims are children.
Such statistics trace the impact of a decade of financial and social
upheaval. Russia has been sliding toward poor health since the mid-1960s,
but perestroika precipitated a dizzying plunge. Russia's overall death
rate jumped by almost a third in the past decade, mostly due to heart disease
and violent deaths. Health experts say the sudden loss of stability and
security simply drove some Russians over the edge.
But if capitalism has taken its toll, so did communism. Russians were
drilled for decades to believe that the state would take care of their
health, and that they need not do so. As a result, said Raphael Oganov,
director of Russia's National Research Center for Preventive Medicine,
Russians have continued to suffer from their bad habits while Westerners
started to correct theirs.
"In the Soviet Union, it was embarrassing to care about your health,"
Oganov said. "We were made to think that. The Ministry of Health was in
charge of your health. Your priority was to work for the society. If you
thought about your own health, people would call you an egoist."
Until the mid-1960s, the Soviet populace had no reason to mistrust the
Health Ministry. Life expectancies in the West and the Soviet Union differed
by only a few years. Both countries were waging the same
successful battle against infectious disease.
But the West moved on to a bigger, more expensive fight against chronic
and preventable illnesses such as heart disease and many forms of cancer.
Health-care spending grew by leaps and bounds, and so did the emphasis
on preventive health care.
Goskomstat, the Soviet Union's statistical agency, illustrated the political
leadership's head-in-the-sand reaction in its annual reports. When it became
clear in the 1970s that Westerners were living longer while
Soviet lifespans had stalled, mortality rates were no longer published.
President Mikhail Gorbachev's anti-alcohol campaign in the late 1980s
was a rare detour into the field of prevention. As vodka became more expensive
and harder to get, life expectancy rose sharply in just three years. But
when the campaign collapsed in the face of public fury, life expectancy
collapsed as well.
Russia's leaders now express more concern about the death rate, partly
because the country is losing population at a rapid clip. President Vladimir
Putin said last year that the prospect of an aging, dwindling
nation is a national security concern. United Nations population experts
predict that Russia's population will drop from 144.5 million to 104 million
in the next five decades. That would make Russia the world's
17th-most populous nation, instead of the sixth.
But early deaths are not the driving force behind Russia's population
loss. The real drain on population is a steep decline in the birth rate,
one of the lowest in the world. That is not a trend that political leaders
can easily influence. Nor is it unique to Russia.
To many experts, poor health presents a far bigger threat to Russia's
strength than fewer people. "There is not much difference between Russia
and other countries in terms of low birth rates," said Sergei Zakharov,
a population expert with the Russian Academy of Sciences. "This is a global
problem, and no one knows how to solve it. But the high mortality rate
and very short life expectancy are problems of Russia. We should concentrate
on them."
At least in some areas, Russia finally is focusing on them. A new law
bans cigarette sales to minors and restricts smoking in public places.
The Kremlin's budget for next year requests a 60 percent increase in doctors'
salaries.
Yuri Shevchenko, Russia's health minister, is an advocate of prevention.
"We need to develop in our people a feeling of responsibility for their
health. And what that means, besides everything else, is propaganda," he
said recently.
Last year, he arrived at a cabinet meeting with a blood pressure monitor,
offering to test his colleagues. Most of those who agreed tested high.
The other half fled out the door, said Oganov, who was there. The upshot:
Shevchenko obtained $1 million for a program to educate Russians about
the dangers of high blood pressure, from which 40 percent of them suffer.
But such programs are rare. Russia spends 2 to 3 percent of its gross
domestic product on health care, compared to 7 to 9 percent in Europe as
a whole. The public health system is ancient, inefficient and increasingly
financed by under-the-table payments. The World Health Organization recently
ranked it 130th in the world.
To reshape it toward prevention, said Julian Schweitzer, the World Bank's
Moscow director, "there has to be an impetus at the very top of the government
. . . a concerted effort for a very long period of time."
Bold measures so far are not in favor with Russian leaders. They have
shied away from the World Health Organization's recommendation of higher
cigarette taxes. A pack of Pall Malls or Winstons in Moscow costs just
50 cents, compared to $4.50 in a Washington vending machine. Russian cigarettes
cost even less.
Few dare to even suggest higher alcohol prices. A half-liter of vodka
costs just $1 in Moscow. As for beer, some Russians consider it a breakfast
drink. In the state's eyes, it is not even an alcoholic beverage.
In the end, raw capitalism may turn out to be one of the strongest forces
for good health. In today's Russia, being sick costs money. And with pensions
no more than a pittance, Russians are finding that disabling accidents
and chronic disease lead to a life of poverty, not a comfortable sinecure.
"The market economy makes people think about their health," said Oganov,
the preventive medicine expert. "People seem to start to understand that
their health means money."
In Pskov, a placid city of 200,000 near the Estonian border, Yuri Skripin,
a lanky 47-year-old, is well aware of that.
He jogs every morning. He doesn't smoke. He stays sober. He eats healthy
food. He is the first to say it: "I am not a typical Russian."
A pediatrics consultant at the regional health care office, he is out
of place in this town. Male life expectancy here is the lowest in the European
third of Russia.
The military industry that once sustained the town has shriveled, and
city officials say many of those who lost their jobs never found new ones.
The second-biggest employer now is the vodka factory. So many workers drink
at the local electric cable factory that managers offer hefty bonuses to
security guards who turn them in.
Exercise is not in vogue, as Skripin can attest. "When you walk down
the street with a bottle, no one looks twice," he said. "But when you are
jogging, they stare at you like some sort of strange creature."
If Russia were more stable, he argues, that attitude might change. "People
are accustomed to living in the present time, not planning for the long
run," he said.
At Pskov's regional hospital, Bragin, a balding, mustachioed welder,
is trying to think ahead. This time, when he felt chest pains, he went
to the doctor, even though, like many Russian men, he considers that a
sign of weakness. "I would never have gone this time, but I felt bad,"
he said, his half-buttoned black and white shirt stretched tight across
a roll of stomach fat.
He quit drinking six years ago but said he wonders "if I had been drinking,
maybe I wouldn't have had a heart attack." He still smokes, hiding his
habit from his wife.
As for the bypass operation that would give him a chance for an active
life, only about 10 Pskov patients a year can afford the procedure, which
costs about $6,000 in Moscow. More than 100 are on the list.
Bragin, who earned $40 a month at the welding factory, still hopes to
come up with the money somehow. "I will find a way out," he said.