Russia: Too Sick to Matter?

For Russia and its people, the nightmare of Soviet totalitarianism has come to an end, only to be followed by a phenomenon much more familiar in Russian history: a "time of troubles." And although this current "time of troubles" is surely less brutal for ordinary Russians than the original "Time of Troubles" preceding the accession of the Romanov dynasty — likely milder, indeed, than the other "times of troubles" during the intervening four centuries — today’s episode shares with all its predecessors an overarching and indeed defining characteristic: a sudden, dramatic, and, from a Russian nationalist standpoint, distressing enfeeblement of the Russian state.

In barely a decade, Moscow has plummeted from the status of an imperial superpower to a condition of astonishing geopolitical weakness. To be sure, Soviet might, resting as it did upon the grotesque arrangements of a special tyranny, may be said to have been in some sense abnormal. Even so, with today’s spectacle — in which the Russian state’s role in international affairs is so conspicuously diminished as to seem at times negligible — it would appear that the pendulum has swung toward another, almost equally unnatural, extreme.

The symptoms of the Russian Federation’s newly limited capabilities for influencing international events (or for that matter, events within its own borders) are both diverse and abundant. Politically, some would argue, the very existence in Russia of a constitutional democracy — any constitutional democracy — should be regarded as a triumph in itself. Perhaps so, but in Russia today, "real existing constitutional democracy" is, at least for now, an essentially moribund edifice. Its wax museum president; its simultaneously fractious and paralyzed legislature; its fictitious, "Dead Souls" approach to taxation and budgeting; its "federalism" of local unaccountability and central government decay; its largely ineffectual judiciary: In all, the Russian political system is at present poorly suited to effecting decisions, mobilizing resources, or applying governmental will.

From an economic standpoint, Russia’s weaknesses are manifest. Although ambiguities surround both old Soviet economic statistics and the new Russian statistics, official data strongly suggest that the Russian Federation’s economy today is amazingly small. In 1997, total reported exports of goods and services were almost identical in Russia (population: nearly 150 million) and Sweden (population: 9 million). (Russia’s trade ledgers are probably distorted by under-reporting, but her true export revenues may still not have matched those of such miniature countries as Singapore and Belgium.¹) At official exchange rates, Russia’s estimated GNP in 1997 just barely exceeded $400 billion — thus ranking slightly above Australia’s ($380 billion). "Purchasing power parity" (PPP) adjustments alter the picture only to a degree: By that benchmark, according to World Bank calculations, Russia’s 1997 economy would have been about as big as Spain’s, although smaller than Canada’s or Indonesia’s. If accurate, those World Bank estimates would have meant that per capita output in 1997 was actually lower in Russia than in such places as Lebanon or Peru.² All of these figures, furthermore, refer to Russian conditions before the August 1998 collapse of the country’s finances, since which time the country’s economic performance has only worsened.

Then there is the matter of military strength. Since the collapse of communism, Moscow’s has evidently all but evaporated. Where the Red Army once entertained global ambitions, the Russian Army’s conventional forces now find containing an insurrection in a small region within the nation’s borders to be an almost overwhelming challenge. The dismal performance of the Russian Army in Chechnya attests to no less; the very fact that the military campaign to suppress Chechen rebels had to last nearly two years speaks for itself.

So straitened are Russia’s current circumstances that the Western world has implicitly, but almost totally, redefined the nature of the external security problem it expects to confront from the Russian state. No longer is that problem perceived to center upon Moscow’s ability to project power abroad. Instead, it is believed to emanate primarily from the potential consequences of Russian internal political decay and military decline: the sell-off of military hardware to rising powers like China, or of nuclear technology to would-be proliferators like Iran; weakened controls over the government’s arsenal of weapons of mass destruction; or internal convulsions with international repercussions. To the extent that Western governments today perceive a "Russian threat," it is not because they regard Moscow as an intentional menace, but rather because they see it as an unintentional menace, a burden.

Many observers both within Russia and outside it take as self-evident the proposition that Russia’s current condition of extreme weakness — virtual prostration — is only temporary, and will be corrected. Emblematic of this view is this assertion by Sergei Rogov, director of Moscow’s Institute of the USA and Canada: "Sooner or later, Moscow will again be a major international player."³

The sorts of developments that would be necessary for a Russian geopolitical recovery are easy enough to identify. They would include such things as coalescence of a rule of law, a policy-competent central government, creation of an attractive "business climate," and reinvigoration of the leadership and institutions of the armed forces. Many of these qualities, however, involve historical changes that could require correspondingly historical time spans to enact — and all of them are of course dependent upon unforeseeable, unreliable contingency. For these reasons alone, Russia’s international comeback could be a very slow and gradual affair under the best of circumstances.

Yet even such a qualified prognosis for a Russian comeback may prove to be overly optimistic, because it does not take into account a factor that could prove critical to an eventual Russian recovery. That factor is the health of the Russian people.

Illness and mortality trends do not typically play a great role in world affairs. In Russia today, however, the nation’s health conditions have become so degraded that it is possible to imagine these constituting an independent, and perhaps significant, constraint upon Moscow’s prospects for re-attaining Great Power status. Russia’s ongoing crisis in public health — and "crisis" is hardly too strong a word — is historically unprecedented: No industrialized country has ever before suffered such a severe and prolonged deterioration during peacetime. Given its particular characteristics, Russia’s health decline promises to be especially difficult to reverse. Such health trends augur ill for the Russian economy — and it is economic power that must ultimately underwrite any sustained resumption of international influence for Russia.

Thus, "unnatural" as Russia’s current weakness is held to be in many quarters, there is a real possibility that the country’s startlingly adverse health trends will consign it to further relative economic and political decline for as much as another generation.

Anatomy of a health crisis

Although the USSR’s departure from the world stage was remarkably peaceful, the collapse of the Soviet system nevertheless brought on a veritable explosion of mortality in Russia. Between 1989-91 (the last years of Soviet rule) and 1994, crude death rates in Russia shot up by 40 percent.⁴

Though the mortality situation has improved somewhat since then, crude death rates in Russia in the first half of 1998 were still nearly 30 percent higher than they had been in the USSR’s final years.⁵ This mortality shock (in tandem with a concomitant sudden drop in fertility levels) has pushed Russia into a continuing population decline for the first time since World War II. At the moment, Russia’s deaths are exceeding its births by well over half — about 700,000 a year.

Although the fact has gone largely unrecognized, the loss of life from this quiet crisis in Russia has been a catastrophe of historic proportions. The dimensions of the catastrophe are suggested by estimates from the World Health Organization (WHO).⁶ WHO has prepared "age standardized" death rates for Russia and many other countries. (These "standardized" rates differ from the crude rates in that they control for population aging and other such phenomena.) Against the benchmark of 1987 — a relatively good year for personal survival in the old Soviet era — "excess mortality" in Russia during the four years 1992-95 would have amounted to nearly 1.8 million deaths. To put that figure in perspective: For the four years of World War I, the military death count for the Russian Empire is generally placed at 1.7 million.⁷ And WHO has not yet published "age standardized" death rates for Russia for the years 1996-98; when it does, we are likely to find that Russia’s "excess mortality" in the 1992-98 period alone exceeded 3 million deaths.

The abrupt worsening of Russian health conditions since the end of the communist era is all the more noteworthy because health trends in the fin-de-regime USSR were themselves so very poor. From the end of the World War II to roughly 1960, the Soviet system presided over a swift and dramatic improvement in Union-wide health levels; by 1960, in fact, life expectancy at birth in Russia proper had caught up with America’s, and was poised to exceed it. Just at that juncture, however, Russia began to experience broad health setbacks. Death rates began to rise — first among middle-aged men, then for a steadily spreading number of male and female age groups. Even infant mortality reportedly went up.

Initially, Soviet authorities responded to these unfavorable findings by suppressing information about them; with Gorbachev’s glasnost policy, this veil of statistical secrecy was lifted. Official figures revealed that overall life expectancy for Russia was no higher in the late 1980s than it had been in the early 1960s — and that for adults, life expectancy was actually somewhat lower than it had been a quarter century earlier.⁸

After decades of stagnation, and now recent, unmerciful retrogression, Russia’s health profile no longer remotely resembles that of a developed country; in fact, it is worse in a variety of respects than those of many Third World countries. In 1997 — the most recent year for which such estimates are available — overall life expectancy in Russia was thought to be somewhat under 67 years. That would have been lower than Russia’s life expectancy four decades before — but it would also be distinctly lower than the life expectancies today of such spots as Mauritius, Ecuador, or Azerbaijan. Mexico, for all its travails and troubles in the 1990s, now enjoys a life expectancy estimated to be over six years higher than Russia’s.⁹

Throughout most of Latin America and the Caribbean and a growing number of countries in Asia, women can now expect to live longer than their Russian counterparts. But survival prospects are especially poor for Russian men. According to the most recent figures available life expectancy at birth for males in Russia today hovers around 61.¹⁰ That ranks below the corresponding current estimates for such places as Egypt, Indonesia, or Paraguay.¹¹

Among Russian men, moreover, health conditions are particularly bad for those of working age. In Australia today, by way of example, a 15-year-old boy would, under current survival patterns, stand about an 80 percent chance of living to age 65. In the Russian Federation, by contrast, barely 40 percent of those same 15-year-olds would make it to 65. Although its records are limited to countries with relatively complete death registration since World War II, the WHO database cannot provide another instance of such bleak survival odds for "able-bodied" men — even men from the African island of Mauritius in the late 1950s enjoyed better prospects than today’s Russians.¹²

For every subsidiary age group from 15 to 65, death rates for Russian men today are frighteningly high. Youth may be the prime of life — but Russian men in their late teens and early 20s currently suffer higher death rates than American men 20 years their senior.¹³ For their part, Russian men in their 40s and 50s are dying at a pace that may never have been witnessed during peacetime in a society distinguished by urbanization and mass education. Death rates for men in their late 40s and early 50s, for example, are over three times higher today in Russia than in Mexico. To approximate the current mortality schedule for Russian middle-aged men, one has to look to India — the India, that is, of the early 1970s, rather than the much healthier India that we know today.¹⁴

Uncertain origins

How is the Russian health disaster to be explained? The troubling fact is that international public health authorities have yet to come to any general agreement about the particular causes of Russia’s health crisis — much less an understanding of the precise magnitude of the tolls being exacted. Reviewing available evidence three years ago, Dr. Lincoln Chen of the Harvard School of Public Health and colleagues concluded that "the root causes of the Russian health crisis remain uncertain." Our understanding of the upsurge in Russia’s death rates has not advanced dramatically since then.

Yet, although we may not be able to account conclusively for the roots of Russia’s health crisis, we may nevertheless obtain important clues about its nature from the country’s death statistics. Apart perhaps from infant deaths, mortality registration has been reasonably complete in Russia since at least the 1960s. And Russian statistics also classify deaths according to reported causes. While cause-of-death statistics are never perfect, and may be more than ordinarily problematic for Russia, they do at least offer the most reliable hints as to what is ailing the country today.

The first thing to note is what is not apparent in the statistics. Many medical specialists within Russia itself, for example, would strongly agree with Georgetown University’s Murray Feshbach that "environmental issues lurk behind much of the [Russian] public health problem."¹⁵ The Soviet system’s appalling destruction of nature — its casual and wanton poisoning of air, land, and water — has already been grimly documented, most notably by Feshbach himself.¹⁶

But what fells forests or slays wildlife does not always necessarily kill people. If, for example, severe air pollution were exacting a particular toll on the Russian people, we might reasonably expect to find evidence of extraordinary respiratory afflictions — but Russia’s death rate attributed to diseases of the respiratory system has reportedly declined slightly since the early 1980s, and is currently lower than in such countries as the Bahamas, Ireland, or Singapore. By the same token, while there is little doubt that radiation and other potentially deadly mutagens have been handled recklessly by the USSR (and now by the Russian Federation), the death rates attributed to cancer in Russia today have changed little for a decade or more — and in fact are essentially indistinguishable from those reported in such countries as the U.S., the UK, Germany, or France.¹⁷

The human cost of Russia’s "ecocide," to be sure, may yet prove horrendous; but if we are to judge that cost by available mortality data, such a dire verdict cannot yet be rendered.

Then there is the question of communicable disease. In recent years, Russia has suffered outbreaks of typhus, typhoid, and cholera; diphtheria is reportedly rampant; and the identified incidence of tuberculosis, which has more than doubled since 1990, is — by WHO definitions — now formally epidemic.

That Russia today should be so manifestly incapable of coping with contagious diseases so routinely controlled and suppressed in so many other regions of the world is surely suggestive of a breakdown in the country’s public health system — and perhaps indicative as well of upheaval within its social structure. But the impact of epidemic disease per se on Russia’s health decline is easy to exaggerate. In 1995, deaths attributed to infectious and parasitic diseases comprised less than 2 percent of Russia’s overall age-standardized death rate; while the level was almost four times as high as (say) Sweden’s, that discrepancy accounted for less than one-fiftieth of the overall mortality gap between the two countries. On the country’s current mortality schedules, Russians face only about a 2 percent chance of eventually dying from a communicable disease — 98 percent will die from something else. Obviously, then, the principal constituents of Russia’s health disaster would seem to lie elsewhere.

But where? To go by cause-of-death statistics, the overwhelming majority of excess Russian deaths — by comparison both with Western countries today, and with Russia itself in earlier years — would seem to fall in two categories: "cardio-vascular disease" (or CVD: heart attacks, strokes, and the like) and "accidents and adverse effects" (injuries — including suicide and murder — and poisonings).

If cause-of-death statistics are to be believed, the world has never before seen anything like the epidemic of heart disease that rages in Russia today. For men and women alike, the standardized death rate in Russia today attributed to CVD alone is higher than the death rate in the U.S. for all causes combined. And although men the world over are prone to distinctly higher death rates from heart disease than women, Russia’s female CVD mortality rate is currently roughly twice as high as the male rates in such countries as Canada, Italy, and Spain. In the West, CVD mortality peaked in the late 1950s and 1960s, and subsequently declined substantially. In Russia, however, already unrivaled rates have continued to climb.

As for deaths from "external causes," medical statistics have never before documented a plague of the proportions that wracks Russia today. The United States is widely regarded as a violence- and injury-prone society. Yet the U.S. death rate attributed to injuries and poisonings currently stands at only half of the reported Russian rate of the Brezhnev and Gorbachev years — and Russia’s rate has doubled again since then. At this juncture, despite the enormous worldwide disparity between men and women in deaths from violent causes, the mortality rate ascribed to injury and poisoning is higher for Russia’s women than it is for America’s men.

Russian men, for their part, have no peers in succumbing to deadly injuries. Although the Russian male mortality rate from "external causes" was reportedly significantly lower in 1995 than it had been in 1994, it was nevertheless nearly three times higher than in Mexico or Venezuela, and over half again as high as in Colombia — a country then convulsed by drug warlords and unchecked narco-terrorism. Under prevailing cause-of-death patterns, a baby boy in Russia in 1995 stood almost a 1 in 4 chance of eventually dying from some sort of external trauma; in Britain, to provide some sense of contrast, the corresponding risk would have been about 1 in 30.¹⁸

How to explain modern Russia’s extraordinary disposition for injuries and cardiovascular disease? The upsurge in deaths due to external trauma is surely influenced, after a fashion, by broad social trends from the ongoing Russian "transition." It is much easier now than in the past, for example, for Russians to buy a car — and by extension, to kill themselves on the roads. By the same token, with the virtual collapse of police authority and the corresponding rise of "mafiya capitalism," Russian citizens are more likely now than in the past to die from free-lance criminality.

In a much narrower sense, however, Russia’s epidemic of deaths from external trauma is intimately linked to its staggering consumption of hard spirits. The heavy vodka drinking for which the USSR was so notorious has been replaced in post-Communist Russia by an even more extreme regimen of national alcohol abuse. Contemporary Russia’s thirst for vodka, indeed, is almost impossible for Westerners to imagine. According to a 1993 national household survey, for example, over 80 percent of Russian men were drinkers and their alcohol intake reportedly averaged nearly 600 grams per day.¹⁹ That would be the equivalent of over five bottles of vodka a week, every week. And since these figures were self-reported, they may have been underestimates. Other contemporary studies suggested that the average level of alcohol consumption for the entire Russian adult population — men and women together — exceeded 400 grams per day: that is to say, three bottles a week. Since 1993 alcohol consumption may have declined, but Russian drinking patterns have hardly moderated.²⁰

Those patterns have deadly consequences. In 1996, over 35,000 Russians died from accidental alcohol poisoning. (America is not exactly a country of teetotalers, yet in the United States — a country with almost twice Russia’s population — the corresponding figure averages about 300 persons a year.²¹) Extraordinarily heavy drinking is also implicated in Russia’s explosion of deadly injuries, for many of the fatal falls, crashes, suicides, and murders in Russia today are thought to occur while the victim (or perpetrator) is drunk.²²

Alcohol abuse surely also plays a role in Russia’s surfeit of deaths from coronary disease, since binge drinking is associated with CVD mortality.²³ But other aspects of the Russian lifestyle undoubtedly contribute to the problem. Heavy smoking (prevalent in Russia today) contributes strongly to the risk of CVD — as do lack of exercise, diets too heavy in fatty foods, and obesity, all of which are rife among the Russian populace. At work together, these risk factors may disproportionately heighten vulnerability to cardiovascular threats.

In addition, there is evidence that attitudes, outlook, and stress (what clinicians now term "psycho-social variables") may also affect susceptibility to CVD. Although such data are tentative and must be treated with considerable care, there are indications that the incidence of clinically defined "depression" may be rather greater in Russia today than among other, Western European, populations.²⁴ And in a major recent study of Russian health conditions, researchers concluded that health risks were strongly associated with the perception that one had little control over one’s own life.²⁵ Association, of course, does not establish causality — but it raises the possibility that the profound and apparently deepening pessimism about personal circumstances widely reflected in an array of opinion polls and surveys is among the determinants underlying Russia’s fearsome levels of cardiovascular death.

If a better medical system were currently in place, Russia’s death rate from CVD would doubtless be reduced. That CVD epidemic, however, speaks to much more than the failure of a particular public health sector. For the risks that are resulting in these unparalleled levels of cardiovascular mortality are strongly behavioral, and perhaps also attitudinal, in nature. They are representative of, and appear to be deeply ingrained within, the current Russian lifestyle. Until these behaviors and attitudes — call them "ways of life" — change radically, it will be correspondingly difficult to change the health risks they generate in any appreciable manner.

Prospects for recovery

The Russian people are not the only urbanized, educated populace in our era to experience sudden upward spikes in mortality, or precipitous and unexpected declines in general levels of health. At least four other countries — Spain (1936-39), Western Germany (1943-46), Japan (1944-45), and South Korea (1950-53) — record cruel plunges in countrywide life expectancy around the middle of the twentieth century.

Merely to note those dates, however, is to see a contrast between these cases and the case of Russia. The mortality crises in Spain, Western Germany, Japan, and South Korea were direct consequences of wars or civil war. Each of those mortality crises proved transient. In the four war-riven states, health recovery commenced spontaneously with the cessation of fighting. In each case, life expectancy at birth quickly recovered to pre-disaster levels. Thereafter, brisk tempos of further health progress ensued — almost as if disaster had never struck.

The most remarkable instance of such post-disaster health progress is undoubtedly Japan’s. In 1944-45, male life expectancy at birth in Japan had been driven down essentially to Neolithic levels (under 25 years). Yet barely three decades later — in the late 1970s — Japan was estimated to enjoy virtually the highest male life expectancy in the world.

Can Russia hope for an analogous revitalization of health trends in the decades immediately ahead? From today’s vantage point, such an outcome would seem unlikely. Remember: The Russian crisis has erupted in a country in a formal state of peace.²⁶ In origin, duration, and character, Russia’s mortality crisis is fundamentally different from those others. And in every respect, Russia’s distinctions portend both greater difficulties in re-attaining previous health conditions and a more limited scope for exacting health gains after that status quo ante is finally reached. Paradoxically, even if Russia’s health recovery were to begin immediately — or were discovered to be already underway — the particulars of the country’s health crisis suggest that Russia’s international health ranking might nevertheless continue to decline for another several decades.

Devastating as the Spanish Civil War, World War II, and the Korean War all were, moreover, the demographic toll that each of those catastrophes imposed appears to have had surprisingly limited impact on the health of the crises’ survivors. Recent estimates by demographers, for example, suggest that World War II and its repercussions cost Western German women born in 1920, who were exposed directly to the destruction and privation of that terrible defeat, an average of only about six months of life expectancy.²⁷

No similar presumption can obtain for Russia. To the contrary: Given the prolonged period of health stagnation and decay before the recent Russian health crisis, and the indications that Russia’s pattern of excess deaths may be partly or even largely related to accumulated lifestyle-related risks, there is every reason to expect the burden of this crisis to continue to weigh heavily upon the Russian people even after its most acute phase has passed.

Two specific features of Russia’s current patterns of death and disease argue especially strongly against the likelihood of a speedy health turnaround.

The first has to do with the country’s current cause-of-death structure — the particular types of fatal illnesses, in other words, that are killing people in modern Russia. For Russia’s deadly ailments, by and large, are afflictions that tend inherently to be more resistant than others to immediate medical interventions, and less amenable than others to significant short-run control.

The point can be illuminated by contrasting cause-of-death patterns in contemporary Russia and post-war Japan (see Figure 1). In 1995, Russia’s overall age-standardized death rate was just about the same as Japan’s had been in the early 1950s. The composition of the two countries’ death rates, however, was dramatically different.

In postwar Japan, infectious and communicable disease was a vastly greater threat to public health than it is in Russia today. Death rates from respiratory illnesses (among them, pneumonia and influenza) were over two-thirds higher than in contemporary Russia, and mortality from tuberculosis (a major killer in Japan during those years) was fully seven times higher. Fortunately for the Japanese, those were diseases that could be rapidly and inexpensively suppressed by newly invented medicines and fairly basic public hygiene measures. In the face of these sustained interventions, declines in death rates were immediate and dramatic. In just the 10 years between the early 1950s and the early 1960s, for example, Japan’s TB death rate fell by 63 percent.

In Russia today, the principal causes of death — CVD and injury/poisoning — together account for two-thirds of the nation’s mortality. Death rates from CVD are nearly twice as high for modern Russians as they were for postwar Japanese; death rates for injury and poisoning, over three times higher. And unfortunately for Russia, these are not the sorts of deaths that can be easily prevented through inexpensive prophylactic health policies.

In theory, an injury prevention strategy could bring quick benefits. In practice, such a strategy would be daunting to enact in Russia today. It would have to induce tremendous behavioral changes on the part of the Russian people — most important, a radical drop in the prevalence of heavy drinking. Given Russia’s seemingly unique passion for vodka, eliciting sustained declines in alcohol consumption would not be easy. Nor would it be inexpensive. In addition to the direct costs of an anti-alcohol campaign, there could be major revenue implications for the state, for traditionally the Russian budget has been almost as dependent upon liquor as have the Russian people.²⁸

Unlike sudden injuries, CVD typically is the culmination of a lifetime of insults visited upon the cardiovascular system. With heart disease, in a real sense, today’s "bills" cover "debts" accumulated over long periods in the past. For this reason, trends in deaths from heart disease in any country can never turn on a dime. Even with sensible, well-funded medical policies and wholesale popular embrace of a more "heart-healthy" lifestyle — none of which conditions obtain in today’s Russia — the control and reduction of CVD death rates tends to be a relatively gradual affair. And, of course, it is now known that heredity plays a significant role in cardiovascular risk. Some researchers speculate that such hereditary risk factors may be disproportionately concentrated in particular ethnic populations.²⁹ If there should happen to be a hereditary predisposition to CVD for some non-trivial fraction of the Russian population, reductions in cardiovascular mortality would presumably prove that much more difficult to achieve.

A second, related, reason we should not expect speedy improvement in Russian health conditions is that Russia’s health trends today embody a large measure of what might be termed "negative momentum." In Spain, Western Germany, Japan, and South Korea, local health conditions had been progressively improving for decades before their respective cataclysmic upheavals; when the conflicts that triggered their mortality crises came to a close, the survivors and their descendants continued upon already-established paths of national health advance. In Russia, by contrast, health conditions have been stagnating — in fact, worsening — for over three decades.

To appreciate just how much "negative momentum" lies within contemporary Russian health trends, one might compare death rates for Russia proper in 1994 and, say, 1964. For men 15 years of age and older, death rates were higher in 1994 than they had been 30 years earlier — for most age groups, in fact, far higher. For men in their early 30s, mortality levels were twice as high for 1994 as for 1964; for men in their early 50s, they were almost two and a half times as high. The situation was only somewhat better for women. For them, death rates were worse than they had been three decades earlier for all groups 25 and older; for women in their 30s, 40s, and 50s, death rates typically had jumped by about half from 1964 to 1994.

These health setbacks mean that, at any given age, Russian adults are dying at a tempo that had been observed back in the 1960s only among distinctly older age groups. In 1994, the trend reached its nadir, with the absolute death rate for Russian men in their late 20s, for example, matching the death rate for men in their early 40s in 1964. While mortality rates have improved somewhat since the annus horribilus of 1994, Russian men, according to the latest data available, are nevertheless today dying at a pace reported by counterparts fully 10 years their elder back in the 1960s; for a number of female age groups, the differential remains at five years or more.

If death rates provide an accurate reflection of general health conditions for a country like Russia, it would seem that the Russian population as a whole has been growing progressively frailer in recent times — that irrespective of chronological age, today’s men and women alike are in a real sense more "elderly" than were their counterparts in their parents’ generation.

Under such circumstances, simply re-attaining within the next 20 years the health levels Russia "enjoyed" in the 1960s will be no mean feat; indeed, it will require far-reaching changes in both lifestyle and environment for the country as a whole. The 50-year-olds in Russia 20 years hence are the 30-year-olds of Russia today — and by many indications, these particular 30-year-olds are strikingly less healthy than their predecessors a few decades earlier. The same may be said of most of the current Russian cohorts — male and female alike — that will compose the majority of the Russian population, and the great majority of the Russian labor force, 20 years from now. Modest as the goal may sound, getting back to the status quo ante is an ambitious health goal for Russia today — one that, quite possibly, may not be accomplished for years.

In its latest round of world demographic projections, the United Nations World Population Division proposes an overall life expectancy of just over 70 for Russia for the years 2010-15 — just over 65 for men; just over 75 for women.³⁰ These life expectancy projections are a bit more optimistic than those of the Russian State Statistical Committee (Goskomstat)³¹ — whose estimates, in turn, may prove to be overly optimistic for reasons already mentioned. But even taken at face value, their implications are arresting, as Figure 2 demonstrates.

If the U.N. projections prove correct, for example, male life expectancy in Russia in 2010-15 will be barely higher than it was back in the early 1960s — that is to say, half a century earlier. Moreover, during Russia’s prolonged bout of stagnation, health conditions in most of the rest of the world have been gradually improving — and are projected to continue to improve in the future. Thus Russia’s international health standing is envisioned as declining for decades to come — even after the country’s health recovery has commenced.

In the early 1990s — after the onset of Russia’s current, acute mortality crisis — life expectancy for the country as a whole is estimated to have been almost five years higher than in the collectivity the U.N. terms the "less developed regions" (low-income Asia, Africa, and Latin America). Twenty years from now, by these projections, overall life expectancy in Russia would be only about two years higher. Life expectancy for Russian men would be ever so slightly lower than the overall male average for those regions.

In starker terms: In the Western hemisphere, to go by these projections, only Bolivia, Guatemala, and Haiti would have a lower male life expectancy than Russia’s own 20 years hence. Russia’s overall life expectancy would be lower than those of such Asian countries as China, Indonesia, Iran, and Vietnam. Male life expectancy would be lower in Russia than in India or Pakistan — and would be just about the same in Russia and Bangladesh.

Projections of this sort, of course, must be treated with caution. In the event, the ones just cited may overestimate Third World health progress: A terrible epidemic, war, or other disaster may depress life expectancy far below the future levels anticipated. But that caveat holds equally for projections of health progress within the Russian Federation. Though they can hardly be presumed to foretell the future, these projections emphasize just how easy it will be in the years ahead for Russian health conditions to slip further down into the ranks of the Third World — and how extraordinarily hard it will be to forestall such an eventuality.

If Russia’s health prognosis is indeed as gloomy as it seems, mortality and disease will pose major obstacles to economic development in Russia for decades to come.

In our era, the wealth of nations lies in their human resources. Land, commodities like oil, and even physical property have all been making a steadily diminishing contribution to economic output over the course of the modern age. A debilitated, unhealthy Russia is utterly unlikely to be capable of maintaining a highly productive economic system. Rather, Russia’s continuing relative decline in international health rankings is likely to be accompanied by a continuing relative decline in her international economic standing. Given Russia’s prospective health problems, its economy 20 years hence may look even smaller by comparison with others than it does today.

Internationally, the correspondence between health and productivity is a strong one, as may be seen in Figure 3. No matter whose statistics one chooses or what time period one examines, countries with higher levels of life expectancy tend to have higher levels of per capita output — and the ones with lower output tend also to have poorer levels of health.

The relationship between health and economic productivity is of course vastly more complicated than can be depicted in a simplified graphic. For one thing, health improvements are often themselves consequences of productivity improvement: Higher incomes permit populations to purchase better medical care, and to adopt lifestyles that reduce the threats of ill health and death.³² Conversely, improvements in health may have productivity-enhancing properties that come into play only over the long run³³ — properties that a point-in-time snapshot like Figure 3 is incapable of representing.

Nevertheless, the fact remains that, at any given time, a country’s level of life expectancy turns out to be quite a good predictor of its level of income. There are, of course, certain countries for which such predictions consistently veer off the mark, but even in those cases, the deviations are readily explicable.

The United States, for example, "overperforms" economically — its income level is always higher than would be predicted solely on the basis of its health attainment. That differential may be understood in terms of the added productivity made possible by our technological pre-eminence, our corporate/managerial advantages, and our cadre of highly trained specialists. Conversely, China is an "underperformer" economically — there, per capita output is always lower than the country’s life expectancy per se would predict. But given China’s technological backwardness and the still problematic nature of its "institutional infrastructure" (markets, laws, and the like), it is hardly surprising that human resources should be less productive in China than they might be elsewhere.

For the Russian Federation today, life expectancy happens to be a rather good predictor of productivity. Russia’s per capita GNP, in other words, is just about what one would guess from its level of life expectancy; by some comparisons, in fact, Russia’s output levels look slightly better than one would predict on the basis of health alone. That should be sobering news for Moscow, for it suggests that the country’s current economic weakness is not so much an aberration attendant to its ongoing "transition process" as it is a fact connected closely with the country’s extraordinarily high levels of mortality and illness. Unless Russia can hope to emerge as a U.S.-style "overperformer," its future economic and health progress will be closely linked.

For all the reasons we have already seen, health progress in Russia over the next several decades may well be painfully slow. Just what would this portend for the Russian economy?

One way of thinking about the question would be to compute illustrative GNPs for Russia and other countries on the basis of today’s international relationships between health and productivity, but using the numbers for life expectancy and population size that are projected for, say, two decades from now. Obviously, this will be a highly imperfect approach, but it may nonetheless prove useful in gleaning an impression of what lies ahead.

Although current U.N. demographic projections envision a total Russian population smaller 20 years from now than it is today, they also anticipate life expectancy to be somewhat better. Using crude, health-based "predictors," such a future Russia could be assigned a real GNP of a little over a trillion present U.S. dollars. Taken at face value, that total would imply consequential economic progress for Russia in the years ahead — a respectable pace of GNP growth averaging, say, 2.5 percent per year.

But the world is a moving target and much of the world may be moving more rapidly than Russia in the decades ahead. Certainly health-based "predictors" of economic performance would suggest as much. The same methods that depict a future Russia with a trillion-dollar economy 20 years from now, for example, can be used to conjure up a Turkish economy of equal or even greater size. Similar calculations portray a Russia virtually encircled in Asia by larger economies: Not just Korea, Japan, China, and India, as today, but also Pakistan and Iran — all could have economies at least as large as Russia’s own.

This illustrative approach, indeed, suggests that Russia’s international economic ranking could drop steadily over the coming 20 years, notwithstanding an envisioned measure of national health recovery and economic progress. At the moment, Russia’s economy is probably the world’s thirteenth or fourteenth in terms of overall size.³⁴ Crude, health-based calculations imply that it might possibly be as low as, say, twentieth two decades from now.

What would it mean to be the world’s twentieth largest economy 20 years from now? We might get some sense of the geopolitical ramifications by considering the world’s twentieth largest economy today. The World Bank provides PPP adjusted estimates of national output for 1997; though these should not be taken as precise, they offer at the least a sense of scale.

Consider Thailand or Australia. Neither of them would have been the world’s twentieth largest economy in 1997 — they were both almost certainly too big for that. Instead, visualize something in the vicinity of Argentina or South Africa: perhaps Holland.

With the power of the Dutch economy, or the South African economy, or the Argentine economy at its disposal, a radical or revisionist state could today cause tremendous difficulties for its neighbors, its region, and arguably even the entire international community. It could be a nuisance, a headache, or (if left unchecked) a predatory menace. But no matter what its international disposition, no matter how shrewd and ruthless its statesmen, a country with an economy the size of Argentina’s today could not hope to lay claim to Great Power status. The gap between that ambition and the resources necessary to realize it would simply be too great.

What holds for Argentina today may obtain for the Russian Federation tomorrow. A less peaceable, more militant Russian state than the one we know today could easily be a source of tensions and a cause of troubles that the international community currently does not have to contend with, and naturally would prefer not to. But if the Russian Federation’s relative economic standing continues to slip in the decades ahead, genuine Great Power status will drift ever further from the grasp of Moscow, irrespective of the priorities, ideology, or skill of its leadership. Russia’s potential for mobilizing national power is severely impaired today by the sickness of its people — and sickness looks to be an even more crippling constraint on Russian power over the generation to come.

An unhealthy Great Power?

It is, of course, possible to argue that Russia’s current trends in sickness and death will not necessarily impede the country’s comeback on the world stage. At least two such objections deserve consideration.

The first would hold that the economic costs of Russia’s health crisis are not nearly as grave as has been suggested here. Consider a possible counterargument by analogy. Some recent econometric research on the repercussions of the international AIDS epidemic, for example, has concluded that this pestilence, gruesome as its human consequences may be, has had only a negligible impact on economic growth and output — even in AIDS-ravaged areas of sub-Saharan Africa.³⁵ Using similar reasoning and a similar econometric framework, one new study estimates that the total costs of Russia’s mortality crisis are surprisingly low: only 0.3 percentage points a year knocked off the country’s economic growth rate.³⁶ That would be a drag on economic growth, to be sure, but only a relatively minor one: by implication, Russia’s burden of disease might not be nearly so onerous as to prevent the county’s ascendance as a major global economic power — and thus, a major political power — in the decades immediately ahead.

Without gainsaying the sophisticated modeling techniques being marshaled here, one can make two points about this type of objection. First, it is quite possible that estimates of a negligible economic cost for the sub-Saharan AIDS epidemic are actually quite wrong, drawing as those models did on much more preliminary information about a scourge that now is radically depressing life expectancies in countries across the entire sub-Sahara.³⁷ Second, the debilitating illnesses and afflictions pressing down life expectancy in the Russian Federation today would appear to be distributed much more broadly over the populace than would be an AIDS epidemic of equal lethality; if so, the economic impact of the Russian-style health retrogression could be commensurately greater.

A second kind of objection asserts that, however weakened, the Russian populace remains a force to be reckoned with in world affairs due to its formidable potential on the field of battle. Edward N. Luttwak offered a variant of this argument almost 15 years ago, when he warned readers against "Delusions of Soviet Weakness":

Yet this objection, too, now appears overtaken by certain events. Operation Desert Storm may have offered us a glimpse of the next face of war: the hi-tech, information-intensive arrangements that currently travel under the banner of the "revolution in military affairs." While this nascent "revolution" may not invest the armies that embrace it with invincibility, it looks nonetheless to confer upon them tremendous advantages over their "pre-revolutionary" opponents. That being the case, what are its implications for Russian military might?

A debilitated Russian populace is unlikely to support a "revolution in military affairs" worthy of the name. In a sick country, amassing the requisite corps of soldier/specialists to conduct high-technology warfare may be a challenge in itself. (Brave and regimented drunkards may have succeeded in marching on Paris and Berlin in the past, but they would fare rather less creditably today in, say, high-precision aerial combat.) More important, though, a debilitated Russian populace will be hard-pressed to finance the far-reaching expenditures and investments that a meaningful "revolution in military affairs" would demand.

If Russia cannot support a full-fledged "revolution in military affairs" in the next decades, it may still be able to field a large conventional force — a force that would perhaps enjoy overwhelming capabilities by comparison with a number of neighboring states. But such an armed force would have little capacity for projecting military power far beyond its borders or against Great Power adversaries³⁹ — no matter how courageous or casualty-tolerant the Russians happened to be.

Too sick to matter?

A decade ago — at the end of the Soviet era — the Russian Federation contained the world’s fifth largest population. By 2020, according to U.N. projections, Russia’s population will be no larger than ninth. In the late 1980s, Russia’s life expectancy, though lower than Europe’s, Japan’s, or America’s, was nonetheless higher than Asia’s or Latin America’s; 20 years from now, according to U.N. projections, Russia’s life expectancy would be lower than those of 125 of the 188 countries and territories assayed — and as we have seen, even this may turn out to be an optimistic assessment.

In the Soviet era, Russia was the sick man of Europe. Today, it is also the sick man of Asia. This illness does not look to be quick in passing. If the humanitarian implications of Russia’s health crisis are pressing, the strategic implications also appear to be inescapable.

Russia’s well-wishers — like the Russian people themselves — should hope for a speedy establishment of civil society, a sturdy rule of law, and sound, steady economic policies for the Russian Federation. They should also pray for enlightened public health measures to tackle the country’s terrible health situation (a program, incidentally, to which not one of Russia’s many political parties at this time is yet committed).

Russia’s imagined antagonists, for their part, should not base their fears and apprehensions on the specter of a rapidly reviving "Great Power" Russia. As orderlies at medical institutions around the world can attest, even a weakened patient must be treated with care if he is seized by delirium. But it looks as if Russia is going to be in bed for a long, long time.

--Nicholas Eberstadt is a visiting scholar at the American Enterprise Institute and a researcher at the Harvard Center for Population and Development Studies.