Chapter 9 Morbidity and Mortality in the Transition Countries of Europe

______________________________________________________________________________________________ 153 CHAPTER 9 MORBIDITY AND MORTALITY IN THE TRANSITION COUNTRIES OF EUROPE Ellen Nolte, Martin McKee and Anna Gilmore crises, and a number of CIS countries, including Russia Background and Ukraine, saw an actual decline in their Human After the fall of the Berlin Wall in November 1989, Development Index in the 1990s, reflecting economic Europe’s political, economic and cultural borders shifted stagnation and the inability to protect incomes and once again in the 20th century, with the break-up of the alleviate human poverty. However, despite economic former communist bloc adding 22 new countries to the growth, the more successful countries of Central and map of Europe. An immensely diverse region, Europe Eastern Europe, like those in Western Europe, saw an comprises some of the richest countries in the world increase in income inequalities, albeit of varying degrees alongside regions that have undergone dramatic political, (Cornia et al., 2003), with an impact on levels of poverty. social and economic changes during the last decade, a Thus, Poland experienced an increase in GDP per capita number of which having ended the 1990s with incomes of 2.4 per cent per year between 1987/1988 and close to those of the least developed countries. The 1993/1995, which was, however, accompanied by a 14 economic disparities show a distinct geographical pattern, per cent rise in levels of poverty (UNDP, 2003). It has with national income per capita falling almost been estimated that poverty, defined by a poverty line of exponentially along the west-east axis. Thus, in $2 per day, has almost trebled during the 1990s, to close Luxembourg in 2001, GDP per capita was, at $53,780 to 100 million people or 25 per cent of the population in (PPP1), about 50 times that in Tajikistan ($1,170) and at Central and Eastern Europe and the CIS (UNDP, 2003). least 20 times that in the countries of the Caucasus This diversity in social and economic patterns region, Moldova, Uzbekistan or Kyrgyzstan (UNDP, across the European region is mirrored, to a considerable 2003). extent, in patterns of health that date back to the late The political and economic transition in the former 1960s, with a remarkably clear-cut division along pre- communist countries of Central and Eastern Europe has 1990 political borders (Meslé, 2004; McKee and been difficult for all countries affected, but, at the risk of Zatonski, 2003). Thus, during the last 30 years the health oversimplification, can be described as a ‘tale of two indicators of the peoples of Central and Eastern Europe regions’ – Central and Eastern Europe on the one hand and the former Soviet Union (FSU) have undergone and the successor states of the former Soviet Union changes that have been very different from the health which are now members of the Commonwealth of trends seen in their western neighbours. As a Independent States (CIS)2 on the other. Several countries consequence, the 1990s have seen a dramatically in Central and Eastern Europe have made remarkable increased gap in health status between countries in the progress since the mid-1990s, with ten countries, European region (WHO Regional Office for Europe, including the Baltic states, having joined the European 2002). This gap is reflected in, among other health Union in 2004. In contrast, the countries emerging from indicators, life expectancy at birth. Figure 1 shows trends the Soviet Union have been experiencing deep economic in life expectancy since 1980 in different European countries that have, for simplicity, been grouped into countries of the pre-enlarged European Union (EU 15), 3 1 PPP (Purchasing Power Parity): a rate of exchange that accounts Central and Eastern Europe (CEE; 12 countries ), the 4 for price differences between countries, allowing international FSU and Central Asia (CAR ). It shows that while life comparison of real output and incomes. At the PPP $ rate as used here, expectancy steadily increased in Western Europe, it only PPP $1 has the same purchasing power in the domestic economy as has $1 in the United States. 2 CIS refers to the 12 successor countries of the Soviet Union that 3 Albania, Bosnia and Herzegovina, Bulgaria, Croatia, Czech now form the Commonwealth of Independent States and does not Republic, Hungary, Poland, Romania, Slovakia, Slovenia, FYR of therefore include the three Baltic states of Estonia, Latvia and Lithuania Macedonia, Serbia and Montenegro. that were also part of the former Soviet Union (FSU); reference will be made to both. 4 Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan, Uzbekistan. 154 ______________________________________________________________________ The new demographic regime FIGURE 1 Trends in life expectancy at birth in Europe, 1980-2000 80 85 men women 75 EU EU 80 70 CEE CEE 75 65 CAR FSU 70 CAR 60 FSU Life expectancy at birth (years) birth at expectancy Life Life expectancy at birth (years) birth at expectancy Life 55 65 1980 1985 1990 1995 2000 1980 1985 1990 1995 2000 Ye ar Ye ar Source: WHO Health for all database 2002. slowly improved in the countries of Central and Eastern Among women, life expectancy at birth has also Europe, following years of stagnation throughout the been lowest in Portugal, although alternating with Ireland 1980s. The successor countries of the Soviet Union, in and, in the 1990s also Denmark, and highest in France. contrast, saw a series of unexpected fluctuations in which In 2001, figures ranged between 79.2 years in Ireland and life expectancy improved substantially in 1985 before 82.9 in France (WHO, 2002). However, figure 2 also falling back after 1987, accelerating downwards until suggests that there is a general trend towards convergence 1994, followed by brief but considerable improvement in terms of life expectancy at birth within the EU 15. until 1998 and then falling back again, the changes in the 1990s broadly mirroring the economic crises In contrast, there is a wide variation between the experienced. countries in transition. After a period of stagnating or even improving mortality, especially during the 1980s, However, these general trends conceal a mortality many countries in Central and Eastern Europe pattern that differs between countries, especially experienced a mortality crisis in the early 1990s after the regarding the diverse republics of the FSU. Within the fall of communism (figure 3). In some countries, this European Union, whilst steadily improving in all member worsening of mortality was short-lived and was followed states over recent decades, there is still considerable by improvements in health, which were rapid in some variation in life expectancy at birth, e.g. for men, Portugal countries, such as East Germany, Poland and the Czech has continuously been at the bottom of the table with life Republic, but delayed in others, such as Hungary. In expectancy of 72.7 in 2002, and Sweden has been at the contrast, there was a continuing steady deterioration for top with 77.7 years in 2001 (WHO, 2002) (figure 2). FIGURE 2 Trends in life expectancy at birth in the member states of the European Union, 1980-2000 80 85 men Sw eden women France EU 75 EU 80 70 Portugal Portugal 75 65 70 60 Life expectancy at birth (years) Life expectancy at birth (years) 55 65 1980 1985 1990 1995 2000 1980 1985 1990 1995 2000 Year Year Source: WHO Health for all database 2002. Morbidity and mortality in the transition countries ______________________________________________________ 155 FIGURE 3 Trends in life expectancy at birth in selected countries of Central and South-Eastern Europe and the former Soviet Union, 1980-2000 Central Europe South-East Europe 85 85 women women E-Germany ) Slovakia ) 80 Slovenia 80 Albania Poland Czech Rep. Croatia Macedonia Bulgaria 75 75 Serb/Monten. E-Germany Hungary Slovenia Czech Rep. Romania Albania Macedonia 70 70 Serb/Monten. Bulgaria Hungary Romania 65 65 Croatia Poland Life expectancy (years at birth 60 Life expectancy (years at birth 60 men men 55 55 1980 1985 1990 1995 2000 1980 1985 1990 1995 2000 Baltic states 85 85 North West CIS women women ) 80 ) 80 Lithuania Ukraine Estonia Belarus 75 75 Latvia Russia Moldova 70 Lithuania 70 Belarus Estonia Ukraine 65 65 Moldova Life expectancy (years at birth 60 Life expectancy (years at birth 60 men Latvia men Russia 55 55 1980 1985 1990 1995 2000 1980 1985 1990 1995 2000 Caucasus Central Asia 85 85 women women ) 80 Georgia ) 80 Armenia Kazakhstan 75 Azerbaijan 75 Kyrgyzstan Tajikistan Uzbekistan Georgia 70 70 Armenia Turkmenistan Azerbaijan 65 65 Uzbekistan Kyrgyzstan Life expectancy (years at birth 60 Life expectancy (years at birth 60 Turkmenistan men Kazakhstan men Tajikistan 55 55 1980 1985 1990 1995 2000 1980 1985 1990 1995 2000 Source: WHO Health for all database 2002. men in Bulgaria and Romania and no improvement for as acting as a control, showing what may have happened women until the late 1990s. In the FSU countries the in its neighbours had the Soviet Union not ceased to path followed by each country was initially much more exist. consistent, with a rapid fall in life expectancy until 1994. As will be seen later, figures shown for the This was followed by a recovery which, in some Caucasus, the Central Asian republics and some countries countries such as Russia and Ukraine, then peaked in in South-Eastern Europe have to be interpreted with 1998. caution. However, most of the countries in that region, One of the few exceptions to this pattern was that were part of the Soviet Union, broadly followed the Belarus, which after 1994 continued on a downward path, pattern seen in the European FSU countries, with albeit without the sudden declines experienced elsewhere. improvements in some countries since the mid-1990s Belarus also differs from its neighbours in retaining a (men in the Caucasus) but relative stagnation in others model of government that is little changed from the (Central Asia).

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