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LETTER |
Paul Landsbergis is with the Department of Community and Preventive Medicine, Mount Sinai School of Medicine, New York, NY. Jurate Klumbiene is with the Kaunas University School of Medicine, Kaunas, Lithuania.
Correspondence: Requests for reprints should be sent to Paul Landsbergis, PhD, MPH, Department of Community and Preventive Medicine, Mount Sinai School of Medicine, Box 1043, One Gustave Levy Place, New York, NY 10029 (e-mail:paul.landsbergis{at}mssm.edu).
Weidner and Cain1 provide a valuable analysis of the trend toward decreasing life expectancy in Russia and portions of Eastern Europe since 1990. This decrease in life expectancy is primarily due to a dramatic increase in coronary heart disease (CHD) mortality among men, which increased by about 30% in Russia between 1990 and 2000.1 The authors discuss possible explanations, which include increasing psychosocial stress and income inequality, declining income, gender differences in coping, economic uncertainty, and inadequate health insurance, occurring within the context of enormous social and economic change. Other authors have described high rates of alcohol and tobacco consumption and poor nutrition in Russia.2
In Lithuania, CHD mortality patterns have been similar to those in Russia—an increase between 1988 and 1994, a decline between 1995 and 1998, and an upturn between 1999 and 2001. However, in contrast to Russia, rates in 2001 were lower than those in 1990 (unpublished data). As a result, life expectancy in Lithuania has increased since 1994, reaching 67.1 years for males and 77.4 years for females in 1999.3
A key piece of information is missing from Weidner and Cain’s article, that is, that CHD mortality has been increasing in Eastern Europe since the 1960s.4 For example, in Lithuania, the increase in CHD mortality among 25- to 64-year-olds between 1972 and 1987 was 75.5% for men and 27.9% for women.5 As a result, male life expectancy (at age 15) declined between 1970 and 1991 in Hungary, Poland, Romania, and Bulgaria.6,7 In the Soviet Union, male life expectancy declined between the mid-1960s and the mid-1980s, rose between 1985 and 1987 as alcohol consumption declined, and then fell between 1987 and 1994 as alcohol consumption rose.2
Explanations for the longer-term trend have been extensively discussed.2,6–10 One possible explanation is that the CHD epidemic simply occurred later in Eastern Europe than in Western Europe and was caused by increases in standard coronary risk factors.8 However, the decline in CHD mortality anticipated in the 1980s in Eastern Europe8,9 did not occur.
Other researchers have focused on factors related to the "failure of the political and economic system to satisfy population needs, both material and psychosocial"7 prior to 1989, which was exacerbated by the post-1989 declines in gross domestic product. Psychosocial stressors, such as lack of control, may have a direct effect on health "and may also be mediated by consumption of alcohol, smoking, unhealthy diet and violent behavior."7 Further research is needed to better understand the links between economic and social systems, economic and social change, psychosocial stressors, health behaviors, and resulting impacts on health.
References
1. Weidner G, Cain V. The gender gap in heart disease: lessons from Eastern Europe. Am J Public Health.2003;93:768–770.
2. Notzon F, Komarov Y, Ermakov S, Sempos C, Marks J, Sempos E. Causes of declining life expectancy in Russia. JAMA.1998;279:793–800.
3. Grabauskas V, Kalediene R. Tackling social inequality through the development of health policy in Lithuania. Scand J Public Health.2002;30(suppl 59):12–19.
4. Uemora K, Pisa Z. Trends in cardiovascular disease mortality in industrialized countries since 1950. World Health Stat Q.1988;41:155–178.[Medline]
5. Grabauskas V, Miseviciene I, Milasauskiene Z, Radisauskas R. Trends in coronary heart disease mortality and changes in risk factors among adult population in Lithuania. Eur Heart J.1990;11(suppl):881.
6. Bobak M, Marmot M. East-west health divide and potential explanations. In: Hertzman C, Kelly S, Bobak M, eds. East-West Life Expectancy Gap in Europe. Dordrecht, Netherlands: Kluwer Academic Publishers; 1996:17–44.
7. Bobak M, Marmot M. East-West mortality divide and its potential explanations: proposed research agenda. BMJ.1996;312:421–425.
8. Cooper R, Schaitzkin A. Recent trends in coronary risk factors in the USSR. Am J Public Health.1982;72:431–440.
9. Cooper R. Has the period of rising mortality in the Soviet Union come to an end? Int J Health Serv.1987;17:515–519.[ISI][Medline]
10. Hertzman C, Marmot M. The leading hypothesis and its discontents: a synthesis of evidence and outstanding issues regarding the east-west life expectancy gap. In: Hertzman C, Kelly S, Bobak M, eds. East-West Life Expectancy Gap in Europe. Dordrecht, Netherlands: Kluwer Academic Publishers; 1996:211–219.
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