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. Last Updated: 07/27/2016

State of the Nation

As social and economic chaos take their toll on an already shaky country, Russia's diagnosis for the 21st century is grim: According to demographic estimates, the population is expected to dwindle by nearly 20 percent in the next 50 years. The reasons for the drop are none the less devastating for their simplicity: widespread alcoholism, smoking and crippling poverty. Solutions exist, but whether Russia is prepared to take on the challenge of fighting bad health seems unlikely. Michael Wines of The New York Times reports.

PITKYARANTA, Northern Russia Ч When the chest pains first gripped him that February day in 1998, Anatoly Iverianov was driving a tractor through one of the birch-and-pine forests that carpet Russia's border with Finland, dragging fresh-cut logs to a wood lot.

"I had a glass of vodka," he said. "I thought that would help."

It didn't. Iverianov was having a heart attack. Within six months he suffered another. Two years later, he is disabled, impoverished, embittered and sick Ч so sick he has been in the local hospital three times since August.

Standing in his crumbling hillside apartment in a Brezhnev-era block overlooking the paper factory, Iverianov added up the negatives: his disability pension is a pittance; he is bored and useless at home; hospitalization gives him no respite from illness.

"I've been drinking and smoking a lot," he said defiantly. "And I'm not alone."

Quite the opposite: Two years after two heart attacks, 45-year-old Anatoly Iverianov is a Russian Everyman.

In a country whose most overworked word is krizis, or crisis, here is a genuine one: Russian life expectancy has fallen in six of the last 10 years.

It fell every month last year alone, to an average of 65.9 years for both men and women Ч about 10 years less than in the United States and on a par with levels in Guatemala. Moreover, government statistics through last August point to a further drop in 2000.

It is a sore-thumb symptom of a precipitous decline in Russia's public health, a spiral not seen in a developed nation since the Great Depression, if then. Life expectancy is not just a medical issue, but a barometer of a society's health. In a sense, it is a lagging indicator of poverty, stress, cohesion and stability Ч and of a government's ability or willingness to take care of its own.

Since 1990, according to the most recent figures, the death rate has risen almost one-third, to the highest of any major nation, and the birth rate has dropped almost 40 percent, making it among the very lowest. Mortality from circulatory diseases has jumped by a fifth; from suicides, a third; from alcohol-related causes, almost 60 percent; from infectious and parasitic diseases, nearly 100 percent.

Not all the toll was registered in deaths. The rate of newly disabled people rose by half.

When Russia's death rate surpassed its plunging birth rate in the mid-'90s, demographers called it the Russian cross and suggested that it had profound implications.

By a United Nations estimate, Russia's population of 145.6 million could shrink to 121 million by 2050. In a report early this year, the Central Intelligence Agency forecast that by 2002, 1 in 70 Russians will carry HIV, the virus that causes AIDS Ч almost twice the U.S. rate. Tuberculosis, once nearly under control, is epidemic, and the CIA says shortages of money and medicine "are creating the context for a large increase in infectious diseases."

Infections are only one factor in Russia's premature deaths. The leading killers are cardiovascular disease and violence, and the victims are not the elderly so much as young and middle-aged men. They are the working backbone that in theory should be available to help rebuild this nation. But the average citizen downs a world-record 16.6 liters of alcohol a year. Reflecting that, accidents and violence have passed cancer as the leading cause of death after heart disease, something unthinkable for a modern nation.

Russian leaders sound increasingly apocalyptic. President Vladimir Putin has warned of an emerging "senile nation," too old and feeble to compete globally.

And the intelligence agencies in the United States believe that the deteriorating public health picture in Russia, and in the hospitals and clinics struggling to deal with it, could lead to political upheaval at worst and relief emergencies at best.

Such gloom is not unrelieved. After plunging in the early 1990s, life spans rose steadily from 1995 to 1998 before sliding again. Drinking has declined from mid-1990s highs. And in cities, there is growing Ч and crucial Ч awareness that good health is no longer the state's problem, but an individual duty.

Nor is the problem irreversible. Soviet health improved greatly, if briefly, after Mikhail Gorbachev cracked down on alcohol abuse in the late 1980s. Russia's current health minister, Yury Shevchenko, a cardiologist, favors reshaping medicine to emphasize prevention as well as treatment Ч and appears to have Kremlin backing.

Thomas Graham, a scholar at the Carnegie Endowment for International Peace in Washington, says the decade's trends are markers not just of bad health but social crisis.

"In a word," he said, "it means that we have a Russia that's in decline. The long-term tasks facing Russia now are quite daunting. And Russia, at this point, just doesn't have the resources to deal with that."

Poverty has hastened the decline. Russia's elaborate system of state-run health care is even more desperately underfinanced now than in Soviet times. Hospitals are critically short of money, drugs and even syringes. The Soviet concept of free and universal medical care, however desultory in the past, now exists in name only. Paying for care, on or under the table, is the norm.

But money is only one problem.

The greater problem, far more difficult to gauge, is the collapse of the Soviet framework, which essentially propped up society: the guaranteed pay envelope, the free housing and child care, the cheap vodka, the numbing relief of having no responsibility for the future because the state carried it all, the sense of being part of a great empire.

Especially outside the big cities, that crumpled framework has left behind a wreck of despair, deep insecurity, poverty and even shame. And the ravages of the Russian loss are evident in the self-destructive quality of the mortality data: wholly preventable accidents, heart attacks, homicides and suicides whose rates, always high by Western standards, abruptly vaulted off the charts with the arrival of freedom.

"There was a psychological shock," said Vladimir Shkolnikov, a Russian demographer at the Max Planck Institute in Rostock, Germany, and a leading expert on his country's mortality crisis. "It's the pace of reform. It's labor force turnover, the magnitude of change in the labor market. It's lifestyle and alcohol because alcohol consumption is a very important force in the large jump in mortality."

Vodka and Death

Robust health has never been this land's defining trait. Soviet medical care was rationed by party rank and loyalty. As befit a system that saw people as cogs, the masses got enough to get them to the farm or factory Ч and little more. The Communist solution to high infant mortality was to subsidize births. Vodka and cigarettes, red meat and butter were state-promoted balms for a cruel life.

And when such policies began reaping a harvest of rising death and illness in the 1970s and 1980s, the Kremlin's response was to stamp the damning statistics secret. It is clear now that Russian life expectancy peaked at 68.8 years in 1965 and, but for a brief aberration in the 1980s, had fallen about nine months by the time the Soviet Union collapsed in 1991.

The Soviet government bears much blame for that. Western nations spent $1 in $8 dollars on health in the 1980s. The Soviet Union spent barely $1 in $30 of a far smaller income Ч and walled itself off from breakthrough drugs and devices that Western investments reaped.

Not that Iverianov sees it this way. Asked when his life took its turn for the worse, he did not hesitate. "The moment the Union ended," he said.

From Iverianov's four-story stucco apartment block in the center of Pitkyaranta, the capital of a verdant, lake-flecked swatch of northeast Russia, it is barely an hour to the Finnish border.

But that is the wrong yardstick. The true distance from Pitkyaranta to Finland is measured in years, not hours.

In Pitkyaranta, a newborn boy can expect to live just past age 57 1/2, about as long as a boy in Yemen or Nepal. An hour north, a Finnish boy can expect to live nearly 15 years beyond that, almost as long as an American. A Pitkyaranta girl can look forward to living 72 years Ч as long as a girl in Peru. A Finnish girl should make it past 79, roughly as long as an American.

"You won't find any other land border in the world where there's such a sharp difference," said Pekka Puska, a doctor and expert on Russia at Finland's National Public Health Institute.

Much of Pitkyaranta's district could be mistaken for Finland: lakeside dachas besieged by snow-covered potato vines; hillside boulders discarded by retreating glaciers.

But it is a surface likeness. Pitkyaranta and the Missouri-size province that surrounds it, Karelia, are among the unhealthiest places to live in western Russia. The Russian cross is on full display here: twice as many people died in Pitkyaranta last year as were born, almost precisely the reverse of the situation 20 years ago.

To see why, talk to Galina Pritchiyev, 55, dark-haired, stout and stoic, who lives in Ryaimyalya, a bankrupt collective-farm village of unpainted cabins and untethered cattle about 40 kilometers south of Pitkyaranta.

Pritchiyev has hypertension. So does her husband, a retired tractor driver who had a heart attack in 1992 at 53. So do half the men and women in Pitkyaranta district, which includes her village.

That makes sense. High blood pressure is caused by a fatty diet, obesity, excess alcohol and lack of exercise, all in abundance here. The Pritchiyevs get pensions totaling about $50 a month Ч enough for milk, butter, bread and oil from the market, and little else. A few calves provide beef; a garden produces potatoes and tomatoes.

Exercise for its own sake is unheard of, and with jobs scarce, she said, few even benefit from farm labor. The young people have all left; nobody will work for the 500 rubles (about $18) that a dairymaid or other unskilled worker makes in a month.

"So a lot of people have started to drink," Pritchiyev said. "They drink samogon, spirits, whatever," she explained, using a word for moonshine. "They drink from boredom. There's no work. And there is very little hope."

The Pitkyaranta hospital physician who works with alcoholics, Dr. Mikhail Lipovetsky, echoes that. "The samogon made here causes very serious damage to the liver and heart," he said, but added that drinking it was "one of the few ways families without any money can entertain themselves."

The consequences are evident at the local morgue. Compared with numbers from 1990, the rolls of last year's dead make telling reading.

In 1990, 277 people died in Pitkyaranta district. Last year, 422 died. In 1990, cardiovascular disease claimed 147 lives. Last year, it claimed 220.

In 1990, there were 38 alcohol-related deaths, from homicides and suicides to accidents and poisonings. Last year, there were 90 Ч overwhelmingly among men under 60.

Not least, seven of Pitkyaranta district's 26,800 souls died last year of acute alcohol poisoning Ч one more than the previous year's total fatal alcohol poisonings in Illinois, population 12.1 million.

"There's no simple answer as to why male life expectancy is so short in Russia," said Dr. Mikhail Uhanov, 56, the hospital's chief physician. "But you could probably say drinking is in first place. In every courtyard, you can buy a bottle of vodka made of who knows what, even here in this little town.

"Sometimes people realize how harmful it is to their health. And they don't value their health enough to care."

Officially, vodka is not a problem for Pitkyaranta district. The number of registered alcoholics Ч those who seek treatment from Dr. Lipovetsky Ч totals 164. Privately, however, officials say the number is closer to 4,000.

In the 1980s, doctors seldom saw more than two or three cases of alcoholic psychosis a year. This summer, during Pitkyaranta's two-week-long White Nights Festival, there were 14.

Vladimir was one of them. During White Nights, he passed out drunk on the floor of the town's huge lakeside paper mill and woke up in the hospital. He has been back three times since then, each time to dry out from two-week binges on 80-cent liter bottles of samogon.

"I wouldn't say it's that hard to quit," he said recently, with the rheumy-eyed conviction of a man who has quit many times.

What is more interesting, however, is why a 45-year-old man with a wife and two children binges at all. One answer is that his life crumbled along with the communist experiment.

In 1990, Vladimir had been at the paper mill 20 years and was making 300 rubles a month, then about $180. His wife held a high-ranking job at the local food depot. In Soviet society most essentials were free, so their life was comfortable.

The Soviet Union vanished in 1991. So did the old rules: Vladimir's wife argued with her bosses and soon found herself jobless, an impossibility in Soviet times, when the unemployed either accepted new work or were exiled.

"She wasn't able to find anything for a year," Vladimir said, "and then she tried to start a private store. That worked for two years or so, and then that went bankrupt."

It was about then, in 1995, that alcoholic psychosis first sent Vladimir to the hospital. Things got worse. Money problems shuttered the paper mill, and for perhaps a year there was no pay. The mill reopened, but in 1998, Russia's economy crashed, and Vladimir's salary, 1,000 inflated rubles, was suddenly worth $35.

His wife found work that year as a sales clerk. Vladimir, by then a hospital regular, was moved off the papermaking line and handed a broom.

One child is away at school now. The rest of the family lives in a two-room apartment in a brick-and-wood tenement, on a diet of macaroni, potatoes and cucumbers, the occasional herring and "only a little bit of meat."

"They don't pay me anything like pay," he said. "It's like kopeks. And the prices in the stores Ч my pay would go into a kilo of sausage."

Would that it did. A typical binge can eat up a third of Vladimir's monthly wages.

It is an old story, said Dr. Uhanov, the chief physician. "There are many men who lost their jobs, or if they kept their jobs, they were not paid as much. Their alcohol consumption increased despite the fact that they didn't have enough money. It's typical of Russia."

Ask Vladimir why he drinks, and the answer comes slowly.

"I can't explain it straightaway," he said. "I have a home. But I have nothing to do."

Ask Dr. Lipovetsky, and he answers readily: "Social reasons. That, and a lack of belief in the future. A lot of people drink from a loss of belief.

"It's the same way across most of Russia. You don't need a lot of statistics to show that. It's obvious."

Neighbors Decades Apart

Two hours north of Pitkyaranta in the pristine Finnish town of Joensuu, Vesa Tuominen has a markedly different idea of how to spend his time. The thermometer has yet to hit 7 degrees Celsius, and a cold drizzle soaks the bike paths that weave through town. Tuominen, oblivious to the rain, is stretching after a brisk 25-minute jog.

He is not finished. Shortly, he will strip from his sweats to a swimsuit for a dip in one of Joensuu's frigid lakes, indulging in a predilection he shares with about 900 others in the local Ice Bears Club.

Of course, not all of them are like Tuominen, a retired schoolteacher, 65. Some are considerably older.

"We have some swimmers who are 80," he said.

Joensuu, population 51,000, is the capital of North Karelia, the Finnish district directly opposite Pitkyaranta. It seems everything Pitkyaranta is not. Crowds of cyclists ignore rain and even plow through snow; a lit cigarette draws stares; the usual drink is beer, not vodka. The average man in Joensuu can expect to outlive his Pitkyaranta neighbor by 15 years.

Yet three decades ago, the life span difference was measured not in years but months.

Joensuu was then the center of an impoverished region dependent on timber for survival. In both towns, people drank heavily, ate poorly and smoked ceaselessly. And both towns recorded the highest rates of cardiovascular disease on earth.

In the 1950s, a Finnish researcher noticed that lumberjacks in North Karelia suffered frequent heart attacks despite jobs that kept them exceptionally fit. A 1970 study found that exercise was not the only key factor in cardiovascular health. Diet and smoking made it onto the radar screens.

Finland's response was the North Karelia Project, a five-year effort to cut heart deaths by changing people's habits. It was a scorched-earth campaign against cigarettes and butter, a combination of modern medicine and state-of-the-art propaganda.

Local legislators passed one of the world's first bans on smoking in public places. To accentuate the positive, no-smoking areas were renamed smoke-free zones. Shopkeepers and trade groups joined to spread the message, then novel, that heart disease was preventable.

Dairy farmers were converted to growing the sweet berries that flourish in Finland's 20-hour summer days, simultaneously reducing artery-clogging milk fat and adding heart-friendly vitamin C to diets.

The results were so remarkable that the program was adopted nationally. The latest survey, in 1997, showed North Karelians had cut death from heart failure among working-age residents by some 70 percent in just 25 years and slashed lung cancer deaths by 70 percent.

From 1974 to last year, life expectancy in Joensuu rose almost eight years for men and almost six for women. And little North Karelia now has nearly 300 berry farms, compared with only a few 30 years ago.

The program is now so ingrained that it is a point of local pride, its director, Vesa Korpelainen, said during a recent chat in his downtown Joensuu office.

And that is part of its secret. "We've done this work boots-in-the-mud," he said. "We've gone all around North Karelia. People come to us when we have an activity in a grocery store or some other place and say, 'I'm also participating in the North Karelia Project.'"

Until this region fell under Soviet control after World War II, Pitkyaranta was largely Finnish. Its name is Finnish. While most Finns fled north when the Red Army moved in, Finnish blood still flows here.

It is tempting to believe that what worked in North Karelia will work in Pitkyaranta. And in 1992, Finnish researchers came to Pitkyaranta with precisely that in mind.

Dr. Uhanov is the point man for Finnish research here, the leader of perhaps 20 hard-core volunteers trying to re-create Joensuu's success.

They have plastered the walls of the hospital, the open-air market and other public places with posters and begged for television time so they could condemn butter and praise fruit.

They have held health fairs, delivered lectures and staged quit-smoking contests, awarding Finland vacations to the lucky few who can stay off tobacco for a month.

And they have scored modest successes. The last detailed survey, in 1997, showed that smoking fell about 10 percent among younger men. It also leaped almost 50 percent among young women, a rise nevertheless lower than in Russia at large.

Residents used less butter and more cooking oils Ч largely because times are harder, and margarine and oil are cheaper than butter. More were eating fruit daily, though still barely 10 percent, and women were eating more fresh vegetables.

"The men say salads are not a man's food," said Dr. Svetlana Pokusayeva, a leader of the Pitkyaranta effort. "But nevertheless, there are changes. It's a combination of economic factors and our propaganda."

The most important change, says Dr. Tiina Laatikainen, a researcher on the Pitkyaranta project at the Finnish Public Health Institute, is that residents' knowledge about their health has increased remarkably.

That said, eight years of evangelizing have not reaped a quick conversion as in Joensuu. That speaks to the depth and tenacity of Russia's health problems, Dr. Laatikainen said Ч and to its economic ones, too.

"The most difficult things have been the social and economic pressures," she said. "People are not willing to change their lifestyles when they have to struggle to survive a normal life."

Chain of Misery

No one could expect Pitkyaranta to match Joensuu's early success. The Finns had merely to raise life expectancy. The Russians must stop it from plummeting.

"The big message is that there isn't a single cause," Martin McKee, a leading scholar on Russian public health at the London School of Hygiene and Tropical Medicine, said in a recent interview. "It's a chain of causation, with alcohol and stress playing major roles. We need to understand, why do people drink? And why are the consequences so grave? And a decade, 15 years after it all started, we're still floundering around with far too little information."

In many nations, the response to such shocks would be addiction treatment and psychiatric help. Russia has few such cushions to offer.

Psychiatry is still emerging from the Soviet dark ages, when a diagnosis of mental illness was a political weapon. That remains true in parts of Russia, according to an October report by Moscow Helsinki Group, a human rights watchdog.

Mental hospitals, even more grossly underfinanced than the rest of the health system, are often true warehouses: St. Petersburg Psychiatric Hospital No. 3, for example, is 130 years old and houses 2,000 patients, twice its capacity. Alcoholics Anonymous, long banned from the Soviet Union, established programs in some Russian cities in the 1990s, and its 12-step treatment method is emulated by some churches and charities. But only a tiny fraction of alcoholics get intensive treatment. The majority are left, with their families, to fend for themselves.

The director general of the World Health Organization, Gro Harlem Brundtland, said in an interview that there was no reason for pessimism about Russia's situation, despite alarming rises in disease and an admittedly inefficient medical system.

She said that political leaders understood the scope of their nation's crisis and the urgent need to address it, and that a mending economy would provide money for health programs and improve living conditions.

And she said there were quick fixes to some problems: ending 24-hour vodka sales and curbing cigarette advertising, for example.

Of course, alcoholism and disease are not confined to Russia. Poor health habits place American life spans squarely in the middle range of developed nations. For all its leading-edge technology, the U.S. health care system is no model of efficiency for Russians to emulate.

But building a modern health system takes years and billions of dollars that Russia does not have. And as for weaning the country from ingrained habits, when Gorbachev imposed a series of restrictions on alcohol, he was nearly toppled from power. Any such undertaking would pose a formidable challenge for leaders today.

Mending Russia's shattered health will take all that and something more difficult: surgery on millions of dark Russian souls like that of Iverianov, the 45-year-old heart patient and former woodsman. Iverianov is a caricature of what ails the country. He treats chest pain with vodka. He smokes Ч not much, he contends, though "just sitting around, I can smoke a whole pack, especially after a good drink." His diet is "whatever you got Ч no delicacies, of course," which translates into bread, potatoes and the occasional chicken.

Household life is hard. Iverianov receives a $35-a-month disability pension. His wife gets about $18 a month for cleaning a local school. That must feed and clothe the two of them and two sons, 23 and 7.

It is not enough. "I've got three specialties from school, and already I can't get a job in any of them," said Viktor, the elder son, already an angry, arm-waving clone of his father. "In the last two years, we've moved three times to smaller places to save money."

This is what independence gave the Iverianovs: the ability to sell their home in order to survive. But with two rooms and a kitchen for the four of them, they have little left now that they can sell.

To more than a few experts, Russia's problem is not just whether a rising economy will lift the boat. It is whether a society that has demolished a 1,000-year compact Ч a loaf of bread and a bed in exchange for the loss of all individuality Ч now regards its masses as people, not expendable parts in some vast machine.

In that respect, the experts say, a decade of falling life spans, so far unaddressed, is not encouraging.

"In a sense, Russia has a life expectancy which we've managed to earn," said Sergei Ermakov, a principal demographer at the Research Public Health Institute in Moscow. "Russia has never spared resources. There has always been lots of wood, lots of water, lots of iron ore, lots of land and lots of people. And the attitude taken by the Russian leadership toward the people wasn't any different."

Iverianov would not argue with that. "In general, this isn't working," he said. "Basically, the country itself has fallen apart and into bankruptcy. And now I'm waiting for them to turn the lights off here."

Iverianov's story does not have a happy ending.

Just before 3 p.m. on Nov. 21, he was brought once more to Central Clinical Hospital by ambulance, this time displaying a weak pulse and almost no blood pressure. Doctors suspected a heart attack. Three hours later he died.

An autopsy concluded that he had been killed by fluid in the lungs and heart failure due to chronic alcoholism.

Iverianov would have turned 46 last month.