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Epidemiologic Transition:Russian examplesAbdel Omran. The
Epidemiologic Transition: A Theory of the epidemiology of
population change. Milbank Quarterly.
1971;49:509-538http://www.who.int/docstore/bulletin/pdf/2001/issue2/vol.79no.2.159-170.pdfFaina
Linkov, PhD, University of Pittsburgh
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Questions to be discussed at the end of the lecture
Can Omrans theory be applied to changing mortality patterns in
Russia?Epidemiologic transition in Russia: did it take
place?Reversal of transition in Russia. How does it relate to
Omrans theory?
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Epidemiologic transition: DefinitionThe epidemiologic transition
is that process by which the pattern of mortality and disease is
transformed from one of high mortality among infants and children
and episodic famine and epidemic affecting all age groups to one of
degenerative and man-made diseases (such as those attributed to
smoking) affecting principally the elderly.
Encyclopedia Britanica
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Stages of Epidemiological TransitionAge of Pestilence and
FamineAge of Receding PandemicsAge of Degenerative and Man-made
diseases
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Age of Pestilence and FamineCharacterized by high mortality
rates, wide swings in the mortality rate, little population growth
and very low life expectancy
Traditional society, chronic shortage of food, poor sanitary
conditions, high MCH morbidity and mortality, environmental
problems, young population
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Peter I, the first emperor of Russia
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Age of Receding PandemicsEpidemics become less frequent,
infectious diseases in general become less frequent, a slow rise in
degenerative diseases begin to appear, improved life expectancy,
organized health services, increased proportion of older people
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Alexander III, the last Russian Emperor to die from natural
causes
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Age of Degenerative and Man-made diseases
Chronic diseases, cheap calories, morbidity overshadows
mortality, rise in living standards, dramatic decline in fertility,
comprehensive healthcare
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Mickhail Gorbachev, the first and the last President of the
USSR
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Infant Mortality Rate in Russia: 1940-1993
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Theory criticisms
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Applications of Omrans Theory to Russia: Difficulties in
Applying the General RulesIncreased morbidity associated with WWI
and WWII, famines, and political repressionsReverse transition in
1990sExcess mortality for Russian males
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Russias transition in 1990s
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Net Migration and Natural Increase in Russia, 19802001
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Russia: decreasing population
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The health care principles upon which the Soviet health care
system was to be based (Nikolai Semashko): government
responsibility for health universal access to free services a
preventive approach to social diseases quality professional care a
close relation between science and medical practice continuity of
care between health promotion, treatment and rehabilitation.
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Next steps following the establishment of the Semashko model in
1918
The health care system was under the centralized control of the
state, which financed services by general government revenues as
part of national social and economic development plans. All health
care personnel became employees of the centralized state, which
paid salaries and provided supplies to all medical institutions.The
main policy orientation throughout this period was to increase
numbers of hospital beds and medical personnel*.
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Next steps following the establishment of the Semashko model in
1918 (cont.)
Russia made massive strides in arresting the spread of
infectious diseases. Drastic epidemic control measures were
implemented, particularly in the cases of tuberculosis, typhoid
fever, typhus, malaria and cholera. These involved community
prevention approaches, routine check-ups, improvements in urban
sanitation and hygiene, quarantines, etc.
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The period until 1991
Life expectancy (both sexes)
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The period until 1991
Life expectancy in 1965
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A campaign against alcoholBy the 1980s, the gap between Russia
and Western countries in life expectancy at birth came to about 10
years for men and 6 years for women, mostly due to high death rates
among those of working age (6). In the mid-1980s, the government
made an attempt to address this problem (9). It was by then
generally understood that potentially avoidable human losses were
mostly attributable to excess adult age mortality from particular
causes such as injuries, accidental poisoning, suicide, homicide,
sudden cardiac death, hypertension and other conditions closely
related to alcohol abuse and its consequences.
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Life expectancy related to Campaign
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But.Russia failed to maintain this record, however: by 1987 the
USSR was no longer able to enforce the anti-alcohol campaign and
death rates rapidly resumed their upward trend from 1988 onwards.
The anti-alcohol campaign was largely prohibitive and did not
affect the attitude of the majority of Russias population towards
alcohol.
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The period after 1991
The health status of the Russian population declined
precipitously following the collapse of the Soviet Union in late
1991. By all accounts, in the last decade Russia has been
experiencing a shock unprecedented in peacetime to its health and
demographic profiles.
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Life expectancy in Russia, male
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Life expectancy in Russia, female
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The leading causes of death in the Russia
FederationCardiovascular diseases with rates that are the highest
in the European Region
External causes of injury and poisoning
Cancer
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Causes of the mortality crisis
Major social and economic shock and income stratification in a
population already vulnerable because of:Poor diet, high levels of
smoking, and weak systems of social support, in which alcohol and,
increasingly, intravenous drugs, are easily available.Health care
system is poorly equipped to respond to challenges.
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Questions to be discussed at the end of the lecture
Can Omrans theory be applied to changing mortality patterns in
Russia?Epidemiologic transition in Russia: did it take
place?Reversal of transition in Russia. How does it relate to
Omrans theory?
Omran has writen several classic papers on the epidemiologic
transition. This lecture will be dedicated to the process of
epidemiologic transition in Russia.
http://www.who.int/docstore/bulletin/pdf/2001/issue2/vol.79no.2.159-170.pdf
Virtually all industrialized countries followed the pattern of
epidemiologic transition described by Omran. During various periods
of its history, Russia also followed this pattern, however in this
lecture we will learn that Russias pattern of morbidity and
mortality does not fit Omrans theory perfectly. We will discuss
these questions at the end of the lecture. There is no right or
wrong answer to these questions. The content of this lecture is
relevant to the territory of Russian Federation, as well as the
countries of the Former Soviet Union, which became separate
independent countries around 1991.Epidemiologic transition was
first described by Abdel Omran in early 1970s. The majority of the
points he made in his classic paper are true today. These are the
three major stages of epidemiologic transition coined by
OmranDuring the age of pestalence the population on a reoccuring
basis is being decimated by epidemics of infectious diseases. The
mortality rates drive the system. Life expectancy is low, fertility
is high, but the high fertility rates are off set by very high
mortality rates.Peter I, famous Russian tsar of the 18th centurey,
had 10 legitimate children. Only 1 of them lived past the age of
30. 7 children died in infancy. Thus, despite being one of the
richest people of his time, the morbidity and mortality patterns of
his family followed the classical route of the age of pestilence
and famine. In this era, the epidemics of TB, plague, malaria, etc.
begin to subside. The death rate goes down with little change to
the fertility rates, thus population growth occurs. During this
time one sees the beginning of non-communicable diseases.Alexander
III was a Russian monarch of the late 19th century, who lived
during the timeframe corresponding to the age of receding
pandemics. Only 1 of his 6 children died in infancy. This is the
age we are living in todayMickhail Gorbachev, Soviet/Russian leader
of the late 20th century has just 1 child, who is currently in her
50s and still alive. This demonstrates a very interesting concept
outlined by Omran: fertility rates go down with the age of
degenerative disease and children survive much longer. One of the
major points of Omrans theory is that infant mortality is the basic
driving force for increases and decreases of life expectancy. A
radical reduction of the infant mortality rate (IMR) occurred in
Russia in the late 1940s and the 1950s. Between 1940 and 1956, the
IMR in Russia decreased by approximately 4 times, from 200 per
1,000 to 49 per 1,000.[18] In the next decade, the IMR was cut in
half to 25.5 per 1,000 in 1965 (Figure 4.5). As a result, the
increase in life expectancy at birth was very large between 1938-39
and 1965--24.3 years for males and 27.1 for females (Table 4.3).
Decreasing mortality at ages under 5 contributed approximately
equal fractions of the improvement for males and females (16.5 and
16.8 years, respectively). The influence of mortality decline at
adult ages on overall life expectancy improvements was much smaller
and unequal by sex: 7.8 years for males and 10.3 years for females.
Hence, during two postwar decades, Russian women gained
significantly more than Russian men due to the more favorable
mortality trends at adult ages. Despite economical crises that took
place in Russia over the past 15 years, infant mortality remains
relatively low, however male life expectancy is very short.
2 major challenges/criticisms of the theory-epidemiologic
transition may not be unidirectional (reversal of
transition)-consideration for variation among groupsAfter the
breakdown of Soviet Union in 1991, Russia underwent series of
economic crisis. Life expectancy in the 1990s, especially for
males, decreased significantly. This shows decrease in Russian
population starting in the 1990s, which still continues today,
despite increases in migration. This is another illustration of
decreasing populationHow come life expectancy in Russia during the
1960s was similar to that in the US and other developed world? The
answer is simple: prevention and public health. Figure 4.2 shows
for each age group the proportion of mortality due to four
principal diagnostic categories of causes of death: 1) infectious
diseases (tuberculosis, diarrheal diseases, all other food-born or
air-born infections, influenza, rheumatism, pneumonia and other
acute respiratory diseases, septicemia, inflammatory diseases,
venereal diseases, etc.); 2) degenerative diseases (cardiovascular
diseases, cancers, chronic respiratory, digestive, geneto-urinary,
nervous diseases); 3) external causes (accidents and violence); and
4) other and unspecified causes. The top figure presents
information for Russian males in 1938-1939 while the lower panel
presents the same information for U.S. males in 1940. OURCES: Real
Per Capita Income and Daily Protein Intake provided by the
Laboratory for Prognosis of Population Wages and Consumption,
Institute for Economic Forecasting, Moscow; Physicians and Hospital
Beds Per 10,000 Population from "Sources of Statistical Data,"
given in this paper; Real Alchohol Consumption, by Shkolnikov,
Nemtsov, 1995, and evaluated by A. Nemtsov.Figure 4.14--Real Per
Capita Income, Daily Protein Intake, Number of Physicians and
Hospital Beds per 10,000, and Real Alcohol Consumption, Each
Compared to the Basic Level of 1970: Russia, 1970-1994
As such, a large part of the striking rise in mortality in the
1990s can be ascribed to the effects of a number of serious shifts
in Russian society. All of them are closely interrelated. It is
possible, however, to extract the two principal factors among them.
These are: 1) lower living standards; and 2) social
disorganization. We cannot discuss the links between these two
here. However, we can say that the negative changes in living
conditions themselves are not as bad as to lead to the massive
deterioration in public health evident in the shifts in mortality
by age and cause of death in 1992-93. In many countries, where
living standards are much worse than in Russia--even in some
developing countries--male life expectancy is significantly higher.
We can suppose that some kind of complex interaction effect, coming
from both principal factors, is responsible for the deteriorating
health situation. In that case, the negative influence of the first
component (real living conditions) is reinforced by the second
group of factors (socio-psychological conditions) and vice
versa.