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LIL88746_GJONCA 18/04/05 13:32 Page 665

ESPACE, POPULATIONS, SOCIETES, 2004-3 pp. 665-679

Arjan GJONÇA Department of Social Policy London School of Economics and Political Science Houghton Street London WC2A 2AE Royaume-Uni [email protected]

The Crossroads of : Afirst look at regional adult mortality differences in the

INTRODUCTION An awareness of the past is an essential almost half a millennium the was a component to any understanding of the pre- zone of border conflict between the Ottoman sent. This is true for all populations, but and Hapsburg empires, both of whom none more so than the Balkans. Most sought to consolidate their control by delib- aspects of the , and current erately encouraging settlement by groups pattern of ethnic and cultural diversity in the they favoured and discouraging others. Balkans, though complex, are, fortunately, In contrast with the distribution of different already very well documented [, 1973; ethnic and cultural groups, which reflects Poulton, 1991; Bookman, 1994; Carter and the long and turbulent history of the region, Norris, 1996]. While a simple definition of the national borders of the Balkans mostly what constitutes the Balkans remains elu- date only from the late-nineteenth and early- sive, and disagreement continues over just twentieth centuries, when a series of inter- how best to categorise the various groups in national conferences, overseen by the great question, there is no doubt that south-eastern powers of the day, partitioned the European Europe is one of the most culturally diverse territories of the collapsing on [Hall and Danta, 1996]. [Palmer, 1993]. The boundaries assigned at With about 20 identifiable ethnic groups, at that time by the major powers owed more to least ten languages (many of which have realpolitik considerations of maintaining a marked regional dialects), three alphabets balance between their various client states and three main religions, the Balkans consti- than creating logical units of cultural identi- tutes a patchwork quilt of traditions and fication. In consequence, national frontiers beliefs. This diversity is undoubtedly influ- bear only a partial relationship to ethnic and enced by the geography and history of the cultural patterns. region. The mountainous terrain of many It is easy to understand that when it comes to areas has encouraged isolationism, while cultural, ethnic and life style differences, it is historical forces led to the arrival and dis- difficult to find a region more diverse than persion of many population groups. For the Balkans. The socio-economic differences LIL88746_GJONCA 18/04/05 13:32 Page 666

666 are also very marked in the region. What is some of these countries after World War II, of particular interest is that those differences but also the relatively stable trends at the are found not just among the nation states, end of the eighties and the beginning of the but also between the numerous regions of a nineties in some of these countries. particular country. Simply remembering the Countries, such as and Yugoslavia former Yugoslavia, which was a state build did not experience mortality increases on ten nationalities, one can understand the among adults in this period similar to other diversity of the Balkans. While analysing the former communist countries. While trends in former Yugoslavia, Kunitz argues and had a less impact of that health transition and mortality trends in this worsening compared to the other East Yugoslavia can only be understood in the European countries. Different scholars have context firstly of moves toward national uni- indicated this phenomena. Thus, Meslé fication of Yugoslavia, and then of the subse- (1991, 1996) points out that countries such quent demise of this aspiration [Kunitz, as Albania and Yugoslavia, which had the 1996, p. 270] Similarly Bookman (1994) has worst life expectancy at birth in 1950 are argued that economic stagnation or decline is among the leaders of Eastern European an essential pre-requisite for traditional cul- countries in 1990. The second important turally-defined differences to emerge. In point considered by Meslé is that compared short, the complex web of cultural, social to the unfavourable trend of mortality in and economic variation can often be hard to most East European countries, apart from disentangle. East Germany, Albania and Yugoslavia In spite of its tremendous diversity, howev- looked much better in 1990. Other authors er, the geographical and political realities of have tried to give some explanations to this the Balkans make it unquestionably a coher- different mortality trend and pattern by ent unit of study. As Sjoberg and Wyzan focusing on particular countries [Watson, (1991) put it, “Despite the great diversity of 1995; and Gjonça et al., 1997]. experiences, one should not lose sight of the It is obvious that there is a profound short- fact that the Balkans are once again an inte- age of, and urgent need for, comparative gral unit whose component states have suf- studies of mortality in the Balkans, which ficient in common to make the concept can not just detail the mortality patterns of meaningful.” these countries, but to also try and find the It is these arguments that make the analysis plausible explanations for these patterns. In in this paper to focus not just on the mortal- particular the national focus of almost all ity differences among the nation states, but studies has tended to obscure the mortality their composing sub-regions, too. differences within ethnically and culturally The mortality trends and patterns of differ- diverse countries of the Balkans. This paper ent Balkan countries have been the focus of tries to avoid this problem, by focusing on different scholars in the last decade. The regional level more than the national states, main reason for this has been not just the and by doing so tries to find the common rapid improvement of life expectancy in determinants of these patterns.

DATADESCRIPTION

The mortality of the populations studied in varied, and not all data are available classi- this paper is generally well documented; fied by region. regular censuses and more or less complete This work is based on aggregate level data death registration data are available for all on mortality of these populations and their Balkan countries from the early-twentieth cause-specific patterns. The sources of these century, or even earlier in the case of data are the publications of national statisti- and Bulgaria. The detail and the quality of cal offices of these countries, as well as inter- the mortality data is of course somewhat national publications. Thus, for Yugoslavia LIL88746_GJONCA 18/04/05 13:32 Page 667

667 most of the data are extracted from the found in the Balkans for this study period. Demographic Statistics (Demografska Part of the problem is the lack of such data Statistika), which was an annual publication for the period this research focuses. of the Federal Statistical Office of However, it is important to say that when Yugoslavia. The data on Bulgaria, Greece those individual level data exist, their com- and Romania are also taken from their annu- patibility between nation states as well as al statistical yearbooks. In order to check on sub-regions is almost impossible. As a con- the accuracy of these data, as well as to fill sequence the analysis of mortality differ- the possible missing data, other international ences in the Balkans in this paper will pri- publications are also used, such as estimates mary be based on the aggregate level data. of Murray et al. in The Health of Adults in Lastly, the analysis in this paper will focus at the Developing World 1992 [Feachem et al., the end of the eighties and beginning of the 1992], or the Demographic Yearbooks of the nineties. This focus is mainly determined by . different reasons. First, most of the Balkan The data on Albania are corrected for com- countries experienced the same social, polit- pleteness of death registration and census ical and economic systems until 1990, as the coverage by the author [Gjonça, 2001]. rest of . Secondly, after 1990 These data have been collected from the Federal Republic of Yugoslavia disintegrat- Albanian national archives. ed, and the Balkans experienced the forma- Other data related to possible determinants tion of new states, such , , of mortality patterns in the Balkans have FRY of etc. But, most of all with also been collected by national and interna- the political and economic changes that hap- tional publications. One important point to pened to most of the Balkan countries after make here is that the individual level data 1990, the system of data collecting changed that can explain the casual mechanism for and consequently the information collected this mortality patterns are very difficult to be also changed.

LONG-TERM TRENDS OF MORTALITY IN THE BALKANS, 1950-2000

In the last 50 years mortality of all Balkan years, while for females the gap was about countries with the exception of Greece have 12 years. This sex differential of life been converging. After World War II, there expectancy at birth is mainly due to the life was a large difference between life expectancy at birth for females in Albania, expectancy at birth of the Balkan countries. which was lower than the males. Gjonça Thus, if Greece is left out, the gap of life (2001) argues that this difference was due to expectancy at birth for males was about 7 the traditional values of Albanian society,

Figure 1a. Life expectancy at birth for males in the Balkans, 1950-1997 LIL88746_GJONCA 18/04/05 13:32 Page 668

668 where female infants and children were dis- and for females by about 23 years. advantaged compared to males. Improvement of mortality in Romania have The mortality of these countries starts con- been slow compared to other Balkans, verging after 1970, different from what’s hap- while in Bulgaria mortality has even wors- pening at the same time in Europe. In 1990 the ened since seventies, in particular for males. gap between the highest and the lowest life It is important to mention here that in 1960, expectancy at birth, again if Greece is left out, Bulgaria achieved a very high life expectan- is for males about 2.8 years, and for females cy at birth for both sexes, similar to that of about 2.3 years. The most substantial improve- Greece, and some more prosper countries of ment of mortality during this period occurred Europe, such as France and Great Britain for Yugoslavia and Albania. Life expectancy at for males, and and for females birth for Yugoslavia improved for males by [Meslé, 1991, pp. 600-602). This experi- 14.6 years, and for females by 17.6 years. ence was also found to other East European While for Albania for males by about 16 years, countries.

Figure 1b. Life expectancy at birth for females in the Balkans, 1950-1997

SOURCES: Statistical Yearbooks of each country, and UN Demographic Yearbooks. NOTE: Data on Albania are corrected for the completeness of death registration. The experience of Greece is different from tality improved gradually. The last two that of the other Balkans. After World War decades, in particular, show an increasing II, life expectancy at birth in Greece was gap of life expectancy at birth between much higher compared to the other Greece and the other Balkan countries, in Balkans. During the following years mor- particular Romania and Bulgaria. This

Figure 2. Infant mortality rate of the Balkan countries, both sexes, 1950-1997. LIL88746_GJONCA 18/04/05 13:32 Page 669

669 increased gap comes mainly as a result of a have a very high infant mortality rate at about slow down or even worsening of mortality 41.6 and 26.9 deaths per thousand live births, in these countries. Thus, in 1990 the differ- respectively. While Greece and Bulgaria have ence in life expectancy at birth between relatively low values of infant mortality rate Greece and Bulgaria is about 6.4 years for at 9.7 and 14.8 deaths per thousands, respec- males, and 4.8 years for females, while in tively. The high infant mortality rate is not a 1960 the mortality in Bulgaria was better phenomena of the nineties in the Balkans, but for both sexes. it has been high since World War II compared When different components of overall mor- to other Europeans. Thus, in 1950 for all tality are considered, a different picture of Balkans, except of Greece, infant mortality mortality differences in the Balkans is rate was over 100 deaths per thousands. noticed. Thus, when infant mortality rate is Yugoslavia had the highest infant mortality considered, as shown in Figure 2, it is clear rate at 139.8, and Albania following up at a that in opposite to life expectancy at birth, value of 134 deaths per thousand live births. infant mortality rate instead of converging Similar to the difference of life expectancy at has still been very diverse even in the 1990. birth, the difference between Greece and Thus, Albania and Romania, despite the other Balkans is also evident at infant mortal- improvements during this period, still in 1990 ity trends.

Figure 3. Life expectancy at age 15 in the Balkans, 1950-1997

Another interesting point to make regarding a divergence through time. Countries that infant mortality rate in the Balkans is that have most of the improvements in life despite the high life expectancy at birth expectancy at age 15 are Yugoslavia and achieved by most of these countries in the Albania, with respectively 6.6 years for nineties, infant mortality rate remains still Yugoslavia and 6.9 years for Albania from high, and this includes Greece, too. 1950 to 1990. Figure 3 shows the changes of mortality It is surprising to see a controversial pattern over age 15, through life expectancy at age such as the Albanian one, where infant mor- 15 during the period 1950-1990. It is inter- tality rate is among the highest in Europe, esting to note that quite a large amount of while mortality for ages over 15 years is variance of mortality in the Balkans might among the lowest in Europe. Previous be due to the differences of mortality at research has found that this controversial ages over 15 years. Thus, in 1990, life pattern is due to the importance of diet and expectancy at 15 varies from 57.3 years in life style factors for this country [Gjonça Romania to 60.6 years in Albania and 63.0 and Bobak, 1997]. years in Greece. Another very distinctive The changes of mortality among adults in feature of these ages is that instead of con- the Balkans will be the focus of the next ses- vergence of mortality among these Balkan sions of this paper, where a detailed analysis countries, what one can see from Figure 3 is by age and region will be introduced. LIL88746_GJONCA 18/04/05 13:32 Page 670

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ADULT MORTALITY PATTERNS IN THE BALKANS AND SUB-REGIONAL DIFFERENCES

In attempting to analyse patterns of adult The second dimension of difference in mortality in Europe, scholars to date have European adult mortality is that between focused on two major divisions in Europe. Western and Eastern Europe [Bobak and The first is the division between Northern Marmot, 1995, 1996; Meslé, 1991, 1996]. and (or the Mediterranean), The collapse of communism in Eastern where the mortality rates of adults in the lat- Europe has been accompanied by an ter group are much lower than in the North increase in the death rates among adults, European countries. These differences are and especially among males, since the late not just found between nation states, but eighties. Different authors attribute this also within particular countries. Thus, dis- worsening of mortality to a range of fac- tinctive differences are found in Italy tors, including the effect of increased stress between the South and the North, when due to economic, political and social uncer- mortality is much lower in the tainty, a rise in alcohol consumption and Mediterranean South to the more continen- smoking. tal North. This north-south gradient of mor- The analysis of adult mortality in the Balkan tality differences is found also in other countries is also broken in sub-national level Mediterranean countries, such as France, in this session. Figure 4 shows the adult and recently in Albania [Gjonça mortality differences by region for all and Bobak, 1997, Gjonça, 2001]. Most of Balkan countries, including Bulgaria and these differences are attributed to the effects Romania, for which the regional detailed of the and life style. information is lacking.

Figure 4. Regional Differences in adult mortality (45q15) in the Balkans 671 Figure 4, where adult mortality differences the Mediterranean), ; and one in are put in one scale, shows clearly that the the south-east Balkans, . This selec- north-east south-west gradient of mortality tion of regions was done to see if there is in the Balkans is evident. Thus the areas any change of mortality pattern relative to with the lowest adult mortality are south- the location in the Balkans. west regions of Greece, such as , It is known that Greece has among of the Peloponnese, Central Greece and . lowest mortalities in Europe, in particular its Then, the south-west Albania, Greek regions adult mortality. In 1990, Greece had a life of Thessaly, Macedonia and Athens do expectancy for males of 74.6 years and for slightly worse, but better than the rest of the females 79.7 years. Looking at the previous Balkans. The regions that follow are north- decades, mortality in Albania and east Albania, Greek Thrace, FYR of Yugoslavia was much higher than Greece. Macedonia, and . Central Thus, in 1951 Greece had an life expectancy Balkans follow this group, Bulgaria and at birth of 63.5 years for males and 66.7 for , and the worst adult mortality is females, while Albania and Yugoslavia had a found in the extreme north-east - in life expectancy at birth of respectively 51.9 Romania, and in the extreme north-west - in and 55.0 years for males, and 51.3 and 58.7 Croatia and Slovenia. for females. This difference in the level of Just looking at this map it is clear that mor- overall mortality makes the comparison of tality differences in the Balkans are very mortality patterns difficult. However, in much related with the geographical position order to facilitate comparison of mortality of its regions. However, some further analy- this approach is followed. sis that look at more details are presented First, for the same level of life expectancy at below. birth (life expectancy at birth in 1989 The comparison of the values of probability Albania is taken), the nqx values of selected of dying between ages 15-60 as indicator of Greek and Yugoslav regions were interpolat- adult mortality might sometimes hide the ed for both sexes. Then, the differences variation of mortality in this large age- between the patterns are calculated as ratios group. In order to see the differences in the of the probabilities of dying values (nqx val- patterns of mortality in the Balkan regions a ues) between each region and Albania. The different approach is followed here. Albania standard deviations of all ages and ages 15- is chosen as the country whose mortality 60 are calculated to see the variation of each pattern will be the base of comparison. pattern (Greek and Yugoslav region) from The regions selected are those bordering the Albanian pattern. The values of standard Albania in the north-east, Kosova and FYR deviations are given in Table 1. In other Macedonia, in the south-east, Greek Epirus words, the values of Table 1 show the and Greek Macedonia, as well as three more standard deviation of the ratios between the regions; one in the very north of the mortality rates (nqx values) of these regions Balkans, Croatia; one in the very south (in and Albania. Higher the value of standard

Table 1. Variation from Albanian mortality pattern of some selected regions in the Balkans

Note: 1.The level of life expectancy at birth on which these calculations are based is for males 67.92 years and females 73.84 years (life expectancy at birth of Albania in 1989). 2. The standard deviations are shown in per hundred. LIL88746_GJONCA 18/04/05 13:32 Page 672

672 deviation, larger the differences between the among adults, is more similar to that of the age-mortality patterns of these regions and bordering Greek region of Epirus, and the Albania. southern region of Peloponnese, than with Table 1 shows a higher variation for females the north-eastern bordering regions of FYR than for males compared with Albanian pat- of Macedonia, Greek Macedonia, and tern (except for Croatia). This means that Kosova. Croatia in the very north of Balkans Albanian mortality pattern for females is and Greek Thrace in the very east are even much more different than the male pattern more dissimilar. when compared with these regions. The When the regional differences were consid- other distinctive point of this table is that ered at the beginning of this session, adult Albanian pattern is similar (the SD is lower) mortality was compared for both sexes to the Greek regions, but not to those of combined. Table 2 shows the values of Yugoslavia. For example, the comparison of probability of dying between ages 15-60 for males for all ages shows that the lowest vari- these regions and Albania for males and ation from the Albanian pattern is in the females separately. The comparison now Greek regions of Epirus, Macedonia, and includes all the former Yugoslav republics, Peloponnese. A similar result holds for all Greek regions, as well as Romania and females, but in this case the variation is low- Bulgaria. Albania is sub-divided into two est between the Albanian pattern and Greek main mortality patterns found at the begin- Epirus and Peloponnese. It is also clear that ning of this session, north-east and south- the more the comparison moves towards the west regions. north Balkans, the more the variation is By looking at the values of the probability of increased, implying that the patterns are dying between ages 15-60 in Table 2, it is more distinct from each other. Thus, the clear that for both sexes, Albania has slight- variation for Croatia is the highest for both ly higher adult mortality than Greece and its sexes, but especially for males - three or regions, but much lower than Yugoslavia four times higher than the Greek regions of and other north-east Balkan countries of Epirus and Peloponnese. The regions locat- Romania and Bulgaria. The worst adult ed in the east of the Balkans, FYR of mortality in 1990 is found in the north east Macedonia, Greek Macedonia, and Thrace of the Balkans, in Slovenia, Croatia, also show more differences from Albania, Romania, Bulgaria, Serbia and Bosnia- though to a lesser extend than Croatia. . Moving further in the south, These differences within the patterns are adult mortality improves even within even more clear-cut, when ages 15 to 60 are Yugoslavia. Thus, the southern regions have considered. The most similar models to a better adult mortality than the northern Albania again are those of Greek Epirus and regions. Kosova has better mortality than Greek Peloponnese. Further one moves in the northern regions, but not compared with north or east, the higher the variation from FYR of Macedonia and Albania in its South, the Albanian pattern. Thus, for males, com- and Montenegro in its west. This “north-east parison with the Greek regions shows that in rule” is true even for Albania. The north-east Greek Macedonia, and further east, Thrace, of Albania has a more similar adult mortali- the standard deviation is higher than in ty with its north regions of Montenegro, southern regions of Greece. This is also true than its eastern neighbour FYR of the further one moves north. Thus, the vari- Macedonia. While south-west Albania has a ation among FYR of Macedonia and better mortality compared with any region to Albania is higher than the Greek regions, its north-east, but it has slightly higher adult but is lower than Kosova, and even lower mortality than the southern Greek regions of when than Croatia. For females, once more Epirus Peloponnese or Crete. This is partic- Albania has a similar pattern to Greek ularly true for male adult mortality. Epirus and Peloponnese, and a rather differ- Concluding this session on adult mortality ent one from Croatia, FYR of Macedonia comparison in the Balkans, one can easily and Greek Macedonia. say that a south-west north-east gradient of What this analysis shows is that the mortality is present in this region. This was Albanian mortality pattern, particularly shown by the regional analysis of individual LIL88746_GJONCA 18/04/05 13:32 Page 673

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Table 2. Adult mortality measured by probability of dying between ages 15-60 of Albania and other regions in the Balkans

Note: The division of Albania into north-east and south-west is based on the division shown in figure 4.

nation states, as well as by the analysis of causes of death are not considered. The fol- the whole Balkan as one entity. One cannot lowing session concentrates at only one of discuss the possible reasons behind this very the main causes of death for all of those distinctive adult mortality pattern, if the countries - the cardiovascular diseases.

REGIONAL DIFFERENCES ON CARDIOVASCULAR MORTALITY IN THE BALKANS

It is not by chance that the focus of this ses- While for Yugoslavia these values were 6.2 sion is the analysis of the cardiovascular for cardiovascular diseases, and 4.6 for neo- mortality differences. All the Balkan coun- plasms. tries in general have low mortality and in Different from the data on mortality in gen- such a case, the main cause of death eral, the data on causes of death differ on the becomes the cardiovascular diseases. Thus, level of details of their availability. Thus, for previous research [Murray et al., 1992, pp. Yugoslavia the level of the cause specific 302-350]. shows clearly that for countries data is on 5 years age groups, allowing the such as Greece, Bulgaria, Yugoslavia and calculations of multiple decrement life tables Romania, the main cause of death in mid- for all regions of this country. While for eighties were the cardiovascular diseases Albania these data were available for larger (especially for men). Thus, the probability age intervals allowing us to calculate only of dying between ages 15-60 value for males the standardised mortality rates (SMRs), for cardiovascular diseases in Bulgaria was instead of net probability of dying. While for 7.8 per hundred, while the next major killers the other three countries this information was were the neoplasms, with a values of 4.6. missing by age, making it impossible to LIL88746_GJONCA 18/04/05 13:32 Page 674

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Figure 5. Regional differences in adult mortality from cardiovascular diseases (measured by SMRs), Albania 1989.

build comparable indicators. Nevertheless, It is important to mention here that cardio- these data allow us to see if the mortality dif- vascular diseases in 1989 Albania counted ferences from cardiovascular diseases follow for about 38% of all deaths. From Figure 5 it that of all causes for adult ages by region in is clear that both sexes show the same pattern each of these three countries. Figure 5 shows of differences in cardiovascular mortality for the regional differences in mortality from adults. Thus, the worst mortality from car- cardiovascular diseases in Albania for males diovascular diseases is in the north-east area and females separated. Ages considered here of the country. For both sexes the seacoast are the same as in the all cause mortality - district of Shkodra in the north has a low rate 15-60 years. from cardiovascular mortality. It is interest-

Figure 6. Regional differences in cardiovascular mortality for former Yugoslavia, 1988. q (measured by 45 15) LIL88746_GJONCA 18/04/05 13:32 Page 675

675 ing to note that the seacoast districts, starting tality for adults. If the cardiovascular mor- from the north, with Lezha and Kruja, to the tality for these two regions will be analysed south, with Vlora and Saranda have the low- by sex, than the reason is clear because for est cardiovascular mortality rates in the females both of them have very low cardio- country for both sexes. The cardiovascular vascular rates, respectively of 2.1 and 2.7%. mortality map show similar differences as While if the male cardiovascular rates are adult mortality map for Albania. The only considered, the map of cardiovascular mor- difference here is that the most urban cities tality differences will not change much from such as , Durres, and the industrial city the all cause mortality. Serbia and Bosnia- of Elbasan are among the cities with the Hezegoviana in centre of Yugoslav republic highest cardiovascular mortality in the coun- have similar cardiovascular mortality with try. Thus, Figure 5 shows the same south- each other and Croatia, but still lower than west north-east gradient in mortality as the the rest of the country, including Slovenia. all cause mortality in Albania. Overall for the former Yugoslav republic it Figure 6 shows the cardiovascular mortality can be said that the differences in cardiovas- differences in the former Yugoslavia in cular mortality are relatively showing the 1988, measured by the net probability of differences in all cause mortality for ages 15 dying. Looking at the map, the values show to 60 years. The only difference comes from relatively similar differences with all cause Slovenia which has a very low cardiovascu- mortality. Again the regions with low car- lar mortality for females. diovascular mortality are Montenegro with a Concluding this section on cardiovascular net probability of dying of 3.1 %, followed mortality differences, despite the fact that by Macedonia and Kosova with probability only two countries were considered, it can of dying between ages 15-60 respectively of be said that the north-east south-west gradi- 4.4 and 4.6 %. The only difference here is ent of mortality does still persist. The maps that Slovenia and Croatia have a relatively of mortality from cardiovascular diseases to low cardiovascular rate than one would a large degree reflect also the all cause mor- expect from their high rate of all cause mor- tality differences for the adult ages.

CARDIOVASCULAR DISEASES AND DIETARYPATTERNS IN THE BALKANS

When data were discussed at the beginning infant mortality rate. Kosova and FYR of of this paper, it was stated that the individual Macedonia had the highest rate of infant data to discuss the casual mechanism are mortality in 1990, but at the same time they missing, not just for the Balkans as a whole, are the most undeveloped regions of but also for individual countries. Moreover, Yugoslavia. The old age are also most sus- if one wants to look at determinants of mor- ceptible to the ill effects of economic tality pattern found in regional level, these decline and environmental hazards. And it is data are non-existent. In such circumstances argued that that was the case in former any effort to try and find a casual mecha- Yugoslavia [Kunitz, 1996]. But, it is impos- nism for deciding on the influence of differ- sible to find any correlation between the ent factors to mortality pattern, is limited. level of adult mortality in former Yugoslav That is why the discussion of this session is regions and their level of developments. based on existing evidence on both individ- Thus, Kosova and FYR of Macedonia, ual and aggregate level data for this area. which as explained were the most undevel- Different authors have tried to find a corre- oped regions of Yugoslavia have among the lation between socio-economic develop- lowest levels of adult mortality, as well as ment of these countries and their levels of cardiovascular mortality in the former mortality. Thus, in the former Yugoslavia Yugoslavia. one can possibly relate the level of develop- Also, Matsaganis [Matsaganis, 1992] found ment of different regions with the level of out that there was no relationship between the LIL88746_GJONCA 18/04/05 13:32 Page 676

676 social and economic development of Greek Yugoslavia, there were about four cohorts. regions and their level of overall mortality. Two of them in Croatia - one in Dalmatia Thus, the two extreme regions, Athens as the and the other in Slavonia, and the other two wealthiest, and Thrace as the poorest in the in Serbia - one in Velika Krsna, and the other country have similar mortality. The analysis in Zrenjanin. We will be reviewing the evi- in this work of adult mortality found also out dence coming from this 20 years follow up that these two regions have the worst levels study of these six cohorts located in the of adult mortality in Greece, historically. Balkans [Keys et al., 1980, 1986]. The case of Albania is similar. It has been This study which involved 16 male cohorts proven that there is no relation between the (mainly rural - 11 of them) included popula- regional differences of overall mortality in tions of north Europe, , Japan, general and adult mortality in particular with and predominantly the Mediterranean popu- the level of education in Albania (education lations. The cohorts were males, aged 40-59 is taken as an indicator of development). No at the entry study, that were followed for 20 relation was also found between the level of years (some cohorts 25 years). The size of urbanisation and industrialisation and the the cohorts varied from 500 to 1000 men, mortality differences [Gjonça, 2001]. with exception of the American cohort) In such circumstances, where the socio-eco- [Vershuren et al., 1995]. The aim of the nomic differences cannot be accounted for study was to find out if the death rate and the regional differences in an area, one has to incidence of coronary heart diseases were turn to the possible life-style factors. It is related to any risk factors, and to what been established for a long time that the low extent do these populations differ from each mortality in the Mediterranean countries has other, based on these risk factors. Our par- been attributed to the positive effects of the ticular interest to this research is because the Mediterranean diet. High intakes of populations chosen in the Balkans are repre- monounsaturated fats and low intakes of sat- sentatives of the North and South Balkans, urated fats and high consumption of fresh the West and East Balkans, as well as the fruits and vegetables and of wine have been Mediterranean and Inland Balkans. Thus, most often proposed to account for the dif- the two Croatian cohorts (Dalmatia in - ferences between the northern and southern coast and Slavonia in inland Croatia) were European mortality. chosen because the diet of one group It is ironic that one of the first evidence sup- (Dalmatians) is based on oil and the porting the positive effects of Mediterranean other on lard [Keys et al., 1980, p. 72]. The diet and life style has come from a study two cohorts in Serbia are part of the central which involved some of the Mediterranean Balkans, and the Greek islands of Crete and populations of the Balkans. The “Seven Corfu are located in the south and north of Country” study which involved 16 cohorts Greece. It has to be mentioned that the eval- from different populations and countries uation of evidence from this study was fol- involved six cohorts from the Balkan popu- lowed up to 20 years after the first entry, but lations. Thus, in Greece two cohorts of men because two of the cohorts “dropped out” aged 40-59 were enrolled in the study. One (the Croatian ones) we are considering the cohort was from the island of Crete and the results of the 15 years evaluation [Menotti et other from the island of Corfu. In former al., 1989, pp. 175-179).

Table 3. Fifteen-year death rates, violence excluded, per 10000 “healthy” men aged 40-59 years at entry, for all causes, coronary heart diseases (CHD)..: Seven Country Study

Source: Keys et al., 1986, p.905, Table 1. LIL88746_GJONCA 18/04/05 13:32 Page 677

677 The authors found marked differences in the Apart from other factors, the authors looked 15 years death rates and coronary heart dis- at the relation between the coronary heart eases rates for the cohorts under the study. rates and the calorific intakes in diet from The results for only six cohorts are extract- total fats, unsaturated and saturated fats. ed and shown in Table 3. Death rates are low Some of the results are given in Table 4. The in Corfu and Crete, but most notably the study showed high correlation between the death rates from coronary heart diseases. average percentage of dietary energy from Another interesting evidence here is that the saturated fatty acids and the incidence and death rate for all causes and for coronary death rate from CHD. Thus, the correlation heart diseases in Dalmatia is much lower coefficients were r=0.80 for incidence of than in Slavonia. CHD and r=0.84 for the death from CHD.

Table 4. Mean percentage of calories in the diet from total fats, saturated fats, monounsaturated and poly- unsaturated fats in 10000 “health” men aged 40-59 years at entry: Seven Country Study

Source: Keys et al., 1986, p.907, Table 2.

Among other findings, one of the most effects of Mediterranean diet in explaining important was the major differences found the regional differences between those among the cohorts in the percentage of cohorts. monounsaturated fatty acids in the diet, This evidence is also supported by the case which reflects the use of olive oil. The olive of Albania. First, it has been argued in a pre- oil used in the diet of Italy, Greece, and vious work [Gjonça, Wilson and Dalmatia (Croatia) is around 80% oleic acid. Falkingham, 1997] that the low mortality in What has been attributed to monounsaturat- Albania could be attributed to the tradition- ed fatty acids in the diet of these cohorts al forms of the Mediterranean diets existing could well be considered as simply due to in the country. But, in a later work, Gjonça the oleic acid. From the above cohorts, three and Bobak argued that even the regional dif- are Mediterranean populations and they are ferences in Albania can be explained by dif- similar to each other in that olive oil pro- ferent regional dietary patterns of the coun- vides from 15-30 % of total energy, with try [Gjonça and Bobak, 1997]. Thus, the wine an important part of their meals. In north east having a more continental dietary contrast, the other cohorts of Yugoslavia the pattern, where animal fats were widely used main energy comes from milk and meat fats, has a worse mortality, than the south-west and the alcoholic beverages used are beer Albania, where a Mediterranean dietary pat- and distilled liquors, often not taken with tern, based on a large use of olive oil and meals [Keys et al., 1986, p. 912]. fruits and vegetables is predominant. Figure Most important finding of this study for us is 7 shows the comparison of regional mortal- that in the two cases; first, the CHD mortal- ity differences compared to the regional dif- ity differences between Crete in the south ferences in the production and consumption Greece and Corfu in North are explained by of . It is important to mention here that the use of olive oil in the two cohorts; and Albania a country with 3.2 million people secondly, so are the differences between cultivates 5.8 million olive trees [INSTAT, Dalmatia in the West Croatia and Slavonia 1992], which are mainly used by only 2/3 of in East Croatia. Thus, most of the research the country’s population, located in the coming from this study support the positive south-west. LIL88746_GJONCA 18/04/05 13:32 Page 678

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Figure 7. Geographical distribution of olive production and regional adult mortality in Albania

CONCLUSIONS AND AN AGENDA FOR FUTURE RESEARCH

It was stated earlier in this paper that the regional differences. There is ample evidence research reported here is only a first tenta- of a North-East to South-West gradient of tive step towards a thorough comparative mortality across the Balkans. The role of diet epidemiology of the Balkans. In order to in shaping these differences is still conjectur- make further progress we need more consis- al, but seems to us highly plausible. One rea- tent and detailed aggregate information as son to argue this is the fact that both impover- well as a greater body of individual level ished Albania and relatively wealthy Greece data. This information becomes even more are part of the low mortality South-West zone, difficult in the 1990s and at present due to while Slovenia, the richest area of the the conflicts gripping the whole region. Communist Balkans, experiences high adult However, in this paper I have been able to mortality. Clearly the main causes of the sketch out the beginnings of a comparative regional patterns must transcend conventional analysis and to advance a hypothesis to form definitions of the level of development. In this the basis of future research: that diet does regard, the lessons from the Balkans may be indeed play a major role in determining of much wider relevance than might at first be regional mortality patterns. I have based this imagined. conclusion on the following results: Finally, I believe that the present work helps When considering trends over time, diet may set an agenda for future research. I hope to be an important consideration in understand- overcome the data deficiencies that prevent us ing why some South-East European countries, reaching a definitive conclusion here. Better such as Albania and Yugoslavia did not expe- aggregate information, especially on cause- rience worsening mortality during the 1970s specific mortality, and more individual-level and 1980s seen in many other Communist information on diet and health, will enable us countries of Eastern Europe. However, this to reach firmer conclusions. Even this limited remains highly speculative. analysis, however, has clearly shown the I am much more certain of the cross-sectional value of a comparative perspective. LIL88746_GJONCA 18/04/05 13:32 Page 679

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