Washington Profile: Russian health and demographic issues are now an often cited in the press, especially in the West. But Russia is not the only country to be undergoing a demographic decline, as many countries in Europe are also facing problems of their own, and despite problems in healthcare, Russia continues to experience rapid economic growth. Is it possible that the alarmism is not always justified?
Nicholas Eberstadt: Certainly, you can't discount this possibility. I am sure there are particular accounts that one could find that are alarmist and unwarranted. But the situation with Russia's health and demographics is truly worrisome. It's worrisome to outsiders from a purely humanitarian standpoint, and one would think it would be worrisome to Russian citizens and decision-makers, not only for humanitarian reasons, but also for basic economic and even strategic reasons. A couple of basic facts frame the comparison: Russia's combined life expectancy of men and women today is lower than it was 40 years ago. Russia is virtually the only industrialized society during peacetime in which such a thing has ever taken place, and death rates for men and women of working ages are vastly higher, and for certain age groups, over twice as high as they were 40 years ago. That in it of itself, I would say, is tremendously troubling and worrisome, especially when one considers that life expectancy has been gradually improving and death rates have gradually been declining in most of the rest of Europe, and in the developed regions as a whole. You do point to a very important paradox: the paradox of stagnating or deteriorating health statistics for a country whose per capita income level has dramatically increased over the past decade. That is a paradox to be sure, because usually specialists say that wealth makes for health. But there are two things at play here that may account for this strange exception: one is the nature of the Russian health problem, which is deeply embedded in what we might call the demographic momentum of Russian society. Which is to say that in the past, people could come up with inventions, medicines, antibiotics, and different sorts of medical, so to speak, silver bullets that would eliminate communicable infectious disease to improve health dramatically with a little bit of improvement in income. Russia's mortality and health woes are very much embedded in not infections but in chronic disease, heart disease, stroke, and other things, which are the accumulation of insults over the course of a lifetime. Today's young Russians look to be less healthy in the mirror of mortality than were their parents. That's very hard to turn around; it takes a long time to turn it around. The other part of the paradox of rising incomes with stagnating or deteriorating health may have to do to some degree with what Cliff Gaddy has described as Russia's virtual economy, and the enclave nature of modern, contemporary Russian economic growth being so heavily concentrated in a few sectors like oil and gas and other resource export sectors that have less impact on the living standards of the general population. You do point to a very important paradox, because usually one doesn't see rising income and stagnating health in any modern society. In fact in many modern societies one sees improving health even when income goes down, during recessions or other parts of the business cycle. The Russian problem has to be explained as a sort of exception to these other more general rules.
Washington Profile: The collapse of socialized medicine and economic shocks after the end of the Soviet Union are often blamed for the health and demographic crisis in Russia. Are there also other factors involved?
Nicholas Eberstadt: Certainly, the increase in death rates coincided with shock therapy, and there was another spike after the financial crisis of 1998, a spike, by the way, from which Russian mortality has only recovered very slightly, despite the economic boom. The origins of the current Russian health crisis or health disaster, whatever one wishes to call it, go back well into the Brezhnev era and relate to the end of the Khrushchev era. In the early to mid 1960s, Soviet Russia was the site of some very strange new trends, which is to say at that period of time, death rates for men in their middle ages started to rise, and they continued to rise and this phenomenon of rising death rates for middle age men spread to younger men, and then to older men, and then spread to middle age women, and then to younger women, and then to older women. So that by the end of the communist era, almost all of Russia's working age adults were part of a vulnerable group in which death rates have been rising, in some cases rising for decades. This all started and evolved rather far during the communist era, so the health crisis that we see today started under Soviet communism, it just hasn't ended with the end of communism.
Washington Profile: What explains, then, the rise in death rates in the 1960's?
Nicholas Eberstadt: It's still poorly explained and poorly understood. One guess that people have at first is that this was a sort of echo effect from the Second World War. The men who were in their 60s had been combatants in WWII and they had severe privations and health stresses, and were unusually brittle and vulnerable because of the upheaval that they had been through. And that sounded perfectly plausible, but this phenomenon of rising death rates of men in their forties continue to present day, and men in their 40s today were born in the 1950s, ten years after WWII, so you can't really blame the Second World War on what's going on now. Some of the particulars we have somewhat of a handle on. Vodka is obviously critical in this health catastrophe. The extreme binge drinking which has and continues to characterize Russian life is connected with the extreme heart disease and with the hugely high injury rates that adults in Russia experience today. Patterns of smoking and lack of exercise and poor diet also have their contributions, but part of this is a big mystery, because there is something that you might want to call an "x factor". Some years ago the World Health Organization began a study that it called monica, monitoring cardiovascular health in Europe. The surveys in Russia showed that there were much higher health risks: hypertension, smoking, cholesterol and so forth, than in western Europe, that's not necessarily a surprise. The surprise was that the death rates from heart disease where about twice as high as the risk factors would have suggested in it of themselves. Not only are the risk factors that we can observe more worrisome in Russia then in western Europe, but the death rates from those risk factors are even higher than we would have predicted. So there is a sort of additional x factor, you might say, an additional Russia factor involved here and its not clear that we've got any comprehensive explanations for this yet.
Washington Profile: The Russian healthcare system is often blamed for many of the health ills that we see today. Could the lack of proper healthcare help explain the high death rates from cardiovascular disease?
Nicholas Eberstadt: That's certainly would be one part of it. One of the surprising things about the health crisis in Russia today is that Russia as an economy devotes a non trivial share of GDP to health spending. As I recall the estimates for health and medical spending in Russia today are over six percent of GDP. Now that's very low compared with the United States of course, but the United States is a complete outlier on healthcare spending in relation to economic output. Six percent of GDP wouldn't be that different from Japan, which has got the healthiest, longest living population in the world today. If the healthcare system is implicit in this catastrophe, and I think there is an argument that the system is a big problem in Russia, the problem is not too little spending, its too little returns, too little results from all of the spending that Russians are doing on health.
Washington Profile: The Russian authorities have recently unveiled a plan to solve the demographic crisis by 2025 and expect that the country's population will grow by this time to reach 145 million due to better living standards and migration. Social programs, higher expenditures on healthcare, public education campaigns, incentives for young families, etc., are included in the plan. What are your thoughts on this plan? Is it realistic?
Nicholas Eberstadt: I don't think it's realistic, and there are a couple of reasons why I don't. The main reason I don't think it's realistic is that the country's demographic decline is, one might say, structural, at this point. Last year was a relatively good year for Russian demographics from the Kremlin's viewpoint, because the excess of deaths over births was "only" a little less than 700,000. That's a huge difference. For every 100 babies being born in Russia today there are about 150 people dying.That's an enormous structural gap. The plan that's been unveiled is supposed to reverse this situation. I think even if the policies are somewhat more successful then I suspect they will turn out to be, its going to be very difficult to lower death rates dramatically in Russia over the next ten years or so and its going to be very difficult to encourage a sustained increase in birth rates. These are two very different sets of phenomena. Because the rising younger generation in Russia has already been through so many health risks, even with pretty substantial health intervention, and even with much more comprehensive health programs then we have seen so far, reducing Russia's total deaths while the population is aging is going to be a tough job. Right now, excess mortality, which is to say the death rates above what we would have expected, say, during the Gorbachev era, which wasn't exactly a time of health paradise, excess mortality against that benchmark is running at half a million excess deaths a year. Now it might well be possible with sustained health interventions to prevent 100 thousand or 200 thousand of those deaths every year, but it would take a whole lot more to get back to the status quo. So there is a big problem with excess mortality in it of itself. The other side of the equation is the fertility level, and Russian fertility is very low these days, although it has crept up over the past five or six years. But it is still down 30-40 percent below the replacement level. Is it feasible to think that Russian fertility will rise to replacement level over the next decade or so? Well if Russian fertility does rise up to replacement level, if it does rise by 50 percent from its current levels, this would be because of change in desired fertility on the part of parents in the Russian Federation. So far I don't think we've seen any big signs of a big demand for more children. Rather, what we seem to be observing is that Russia is becoming part of the rest of Europe with respect to ideas about ideal family size. In the rest of Europe, fertility levels are very far below the replacement level. There are a few exceptions like France's, which are close to replacement levels, but for the most part, European norms on fertility are one or at most two children as the ideal family size. What drives births in modern, relatively affluent societies, more than any other factor, are parental desires about how many children to have. Unless there is a transformation of Russian attitudes about children, its going to be hard for any kind of program of birth incentives or birth schemes to convince Russian parents to have more children then they see as the ideal.
Washington Profile: Russia is not the only country to attempt to increase birthrates through government policy and incentives. How effective have these kinds of policies been in other countries, for example, in western Europe?
Nicholas Eberstadt: Birth incentive plans are almost always ineffective. The typical history of birth incentive plans in western Europe and elsewhere has been to elicit a small blip in birth rates followed by a big slump. The reason for the blip is that some parents that are kind of on the fence about having a second or a third child have their timing affected by the introduction of these incentives. But one has the slump after that because all that happens is a timing phenomenon. There usually isn't much of an encouragement through these incentives for people who were just planning to have two children to end up with three, four, or five, and you can see why there wouldn't be, because if one were to have a serious pronatalist economic plan, you'd be getting into some very big money. There would have to be vastly larger outlays than for social security, health care, or any other existing programs. Because you'd basically be hiring women to be baby ranchers. That, I think, explains part of their limited success in the historical record. It turns out, by the way, to be very difficult to talk up the birth rate. Talk from the bully pulpit in the government doesn't usually convince people to have children out of patriotism.
Washington Profile: To turn to the issue of migration, the Russian government plans to keep a cap on a foreign labor force influx--between 160,000 and 300,000 people a year, according to the new plan. How is this likely to impact on the demographic situation?
Nicholas Eberstadt: Russia has a bit of the same problem that other European countries have, with the prospect of population decline and the question of changing ethnic composition. A lot of the prospective migrants to Russia are not of Russian ethnicity, and as you know, the government has increasingly indicated a nationalist or a nativist, whatever you want to call it, objection to immigration to the Russian federation. There still are a number of millions of Russians in the near abroad, but the flow of Russian ethnic migration to the Russian Federation has declined almost to a trickle over the past decade, and barring some sort of awful political upheaval, I don't know how realistic it would be to think that these ethnic Russians in the near abroad might want to pack up and head back to the Russian Federation. So Russia is facing the same kind of issues as Europe, and the question is whether it is possible to turn newcomers into loyal and productive citizens. And some places have a better track record of this than others.
Washington Profile: What can you say about the demographic patterns of the other former Soviet countries?
Nicholas Eberstadt: The so-called European republics of the FSU went through the same sorts of shocks that the Russian Federation has been experiencing. A drop in birth rates and a spike in death rates with the end of communism. Russia's shocks have been more extreme and more prolonged, then say, the shocks in the Baltic countries, where there was a drop off in fertility, and is still low today, but mortality trends are heading in the right direction in the Baltic republics. Ukraine is quite similar to the Russian federation with the drop in fertility and the rise in death rates, but not quite as extreme. Moldova I can't tell you about. Belarus I think is like Ukraine, similar to RF patterns but not quite as pronounced. In the Central Asian republics, there has been a rise in death rates, but this has apparently been due more to increases in infant mortality and child mortality, not quite so much to increases in death rates among the working ages, and the shock in birth rates hasn't been as extreme. Birth rates by and large are at replacement or above replacement in the Central Asian republics. In the Caucasus, fertility is very low in Armenia and Georgia, I think at Russian levels or even at below Russian levels, but I believe the mortality situation has stabilized and health trends seem to be pointing in generally the right direction.
Washington Profile: So it seems that Russia has had the most pronounced demographic shocks. . . .
Nicholas Eberstadt: Russia has been the most extreme. Russia has had the most severe, prolonged drop in life expectancy. I guess I myself am not so concerned with birth trends as about death trends. I think there is no obvious self evident ideal family size, its not obvious whether we would want birth rates to go up or go down at any given time. I think it's quite obvious that we want death rates to be going down, not up, and when they are going up, that's the wrong direction. The implications of changes in birthrates are ambiguous over the near and medium term. We can't say the same thing about mortality, and mortality trends have pretty much been going in the wrong direction in Russia for forty years.
Washington Profile: Is there an example in history of a country that bounced back from a similar decline in population and life expectancy?
Nicholas Eberstadt: Usually the shocks that we see in Russia and these severe spikes in death rates and drops in birth rates, and drop in life expectancy and maybe even drop in population, usually these are brought about by war, or by famines or by terrible epidemics and pestilences. In most cases, those are relatively brief bouts. A couple of years at the most, after which time normally reasserts itself. What's so striking and troubling about the Russian demographic evolution is that this deterioration in public health has been unfolding over the course of four and maybe now more decades. The only analogy that I can make, and this is one that people in Russia hate, is to sub-Saharan Africa with the AIDS catastrophe. If I am talking to people in Russia about demographics I will sometimes get the lecture, "Mr. Eberstadt, Russia is not Africa." True, Russia is not Africa, but there is a very unhappy similarity. The only two parts of the modern world that have suffered long term declines in life expectancy during peacetime have been Russia and, to a lesser degree, a few other parts of the post-Soviet space, and sub-Saharan Africa.
Washington Profile: What can and should be done to reverse the demographic situation in Russia?
Nicholas Eberstadt: You mentioned earlier the paradox of rising incomes and continuing bad health. Another paradox in modern Russia, or until recently, was the emergence of competitive and relatively open politics with many political parties and an almost complete lack of public mobilization for dealing with the health emergency that is underway. I find this a bit of a mystery myself. I don't understand it. There are even ecological parties in Russia that are worried about the death of the trees--but not about the death of the Russians. It's a mystery to me. Since Putin's administration has had power, roughly 4 million premature, excess deaths have taken place in the Russian Federation. That's more than two World War I's worth of casualties for Russia. I would think that public concern as well as public policy would be an imperative here. If there were public concern, public outrage about this situation, there are a number of things that could be done in the short run, including the implementation of trauma units in cities to staunch the death flow from accident injuries; could be some education about cardiovascular disease and heart disease and the other main killers. But a lot of these would take time. Turning around the bad Russian health trajectory is a bit like turning around a super tanker. It would take a long time, and with gaining momentum over time, results will be seen more in the future than in the first several years. But if Russia is going to join the rest of Europe in terms of its demographics, if Russia is going to eliminate the terrible chasm between survival schedules in its territory and in western Europe, it's not at all too soon to begin making this a top priority.
Washington Profile: What is the alternative? If there is no public outcry and if business continues as usual, to what extent could demographics have an impact on economic and social development in Russia over the next 15-20 years?
Nicholas Eberstadt: Russia's current survival schedule is about the same as India's. Life expectancy in Russia and in India are (inaudible) quite close to one another. The Putin government, of course, has the idea of long term economic growth to reach Portugal levels, Western European levels, but you can't have Irish levels of productivity on Indian levels of health. In the modern world, health and wealth are very closely connected. This fact is being disguised in the Russian case to some degree by the oil and energy boom, the bubble that is favorably affecting public finances and GDP numbers right now. But in the long run, for a modern economy, wealth lies in human beings, not in the ground. If the human capital of Russia is becoming increasingly debilitated, and if human numbers are steadily decreasing, Russia's economic power cannot be increasing. Russia risks prolonged relative economic decline, in a world where many of its neighbors are growing very rapidly, becoming greater powers. Of course I am thinking of China, but I am also thinking of India. For the Russian population to be shrinking steadily through severe excess mortality, to be stagnating or declining in terms of their health capabilities in a world of more or less steadily improving health standards, I think this would look pretty grim and pretty dangerous.
Nicholas Eberstadt is the Henry Wendt Scholar in Political Economy at AEI.