LETTERS TO THE EDITOR
different groups: the Western European countries and the
Eastern European countries. The two groups have been closed
for decades, i.e. there was neither any real communication
between them nor any flow of patients. The interventions
included many factors influencing health status like—among
others—lifestyle, health culture, behaviour and habits of the
population, health care infrastructure and manpower, health
expenditures, regulatory framework, environmental factors,
social deprivation, etc. The outcome of the trial can be
measured by both economic and epidemiological indicators.
Owing to the limited availability of data from the Eastern
European countries, the effect of interventions and the
outcome of the ‘trial’ could have been assessed mainly
only after the social changes of 1990. The gap in life expectancy
between the countries of Central and Eastern Europe and the
countries of Western Europe was closing up during the 1950s
and early 1960s. In the Eastern European countries mortality
rates had increased or were virtually unchanged since the
mid-1960s, especially in middle-aged and elderly men. However from the mid-1960s the health status in the former
socialist countries stagnated or deteriorated, whereas in the
Western countries it improved steadily.3 By 1990 it became
clear that on a long term, the Eastern European countries
underwent a significant decrease in life expectancy4 and an
increase in mortality while the Eastern European economies
also experienced a collapse compared with the Western ones.5
Around 1990 we realized that although the political changes
destroyed the physical iron curtain made of steel and stone it
has remained alive in epidemiological terms (Figure 1).
The epidemiological and economic indicators showed a
further decline after the social and political changes in 1990
on a short term. In Eastern Europe cardiovascular mortality
rates reached a maximum in the period 1990–94.6 By 1990
there was a 4 year gap in life expectancy, which, by 1997, in
men, had widened to 6 years. The decrease in gross domestic
product (GDP) was 3% in the Czech Republic, 13% in
Hungary, 42% in Lithuania and Russia, and 60% in Ukraine.
Mortality changes after 1989 in Eastern Europe were correlated
with changes in GDP and changes in income inequalities.5
797
The papers by Tapia Granados1 and Brenner2 reveal the
importance of within country changes in mortality and economy
based on the example of the United States, but we would like
to emphasize this relationship between the countries of Eastern
and Western Europe.7 The political status and economic
background of the two parts of Europe between 1945 and
1990 with the existence of the iron curtain had a significant
effect on the health status of the population, which should be
investigated more in detail.8
Conflict of interest: None.
References
1
2
3
4
5
6
7
8
Tapia Granados JA. Increasing mortality during the expansions of the
US economy, 1900–1996. Int J Epidemiol 2005;34:1194–202.
Brenner MH. Economic growth is the basis of mortality rate decline in
the 20th century—experience of the United States 1901–2000. Int J
Epidemiol 2005;34:1214–21.
Forster DP, Jozan
1990;335:458–60.
P.
Health
in
Eastern
Europe.
Lancet
Chenet L, McKee M, Fulop N et al. Changing life expectancy in
central Europe: is there a single reason? J Public Health Med
1996;18:329–36.
Marmot M, Bobak M. International comparators and poverty and
health in Europe. BMJ 2000;321:1124–28.
Kesteloot H, Sans S, Kromhout D. Dynamics of cardiovascular and
all-cause mortality in Western and Eastern Europe between 1970 and
2000. Eur Heart J 2006;27:107–13.
Marmot M. Epidemiology of socioeconomic status and health: are
determinants within countries the same as between countries? Ann N
Y Acad Sci 1999;896:16–29.
Boncz I, Klazinga N, Rutten F. East–west life expectancy and health
expenditure gap in Europe: a case study from behind the iron curtain.
Presented at the Public Health Association of Australia 32nd Annual
Conference, Australia, Canberra, November 26–29, 2000.
doi:10.1093/ije/dyl075
Advance Access publication 25 April 2006
Centrally planned economies, economic slumps, and health conditions
From JOSÉ A TAPIA GRANADOS
I am not sure why Boncz and Sebestyén,1 while ignoring
contributors providing specific comments on Eastern Europe to
the IJE debate on mortality and economic growth,2,3 refer in
their letter to other contributions4,5 in which nothing is said
about the issue. Whatever Boncz and Sebestyén’s reasons for
this, they discuss colourfully the division of Europe in Yalta
(1945) into an American and a Russian sphere of influence,
Institute of Labor and Industrial Relations and School of Social Work,
University of Michigan, Ann Arbor, MI, USA.
E-mail: [email protected]
describing it as ‘the largest medical trial in history,’ in which
the two groups of patients—countries—separated by ‘the iron
curtain,’ were assigned to two different treatments, ‘capitalism’
and ‘socialism.’ Clever or gaudy, the metaphor seems to be
stretched and I am doubtful to what extent it may be useful as
a heuristic device. Indeed, a large portion of one ‘treatment
group,’ the USSR, had been ‘treated’ from 1917. Then, after
1945, countries like China, Cuba, Vietnam, Ethiopia, etc. were
included in a similar ‘treatment’ group, though this happened
in other continents and not behind the European ‘iron curtain.’
Insofar as ‘the iron curtain’ refers to the lack of civil liberties,
798
INTERNATIONAL JOURNAL OF EPIDEMIOLOGY
Figure 1 Life expectancy at birth in 10 countries in Eastern–Central Europe, some formerly part of the USSR. Data from the HFA database (WHO
European Regional Office)
though that is basically the case in China today, ‘the curtain’ is
now rarely—if ever—mentioned by freedom-loving politicians
à la Kissinger and investors happily doing business in that
country.
It is presently in fashion, and Boncz and Sebestyén go with it,
to use the term ‘formerly socialist regimes’ to refer to the USSR
and other countries that during former decades had authoritarian regimes organized under what the World Bank then
called ‘centrally planned economies’. Since these countries had
regimes that claimed themselves as socialist, nothing wrong
seems to be implied by the use of this term. However, this use
tends to blur things rather than clarify them. A number of
countries defined themselves as socialist in the 20th century—
for instance, Nazi Germany, India, and Sri Lanka—in spite of
having regimes that were organized both politically and
economically along lines quite different from the Soviet
block regimes. In these, Leninist parties exerted authoritarian
control of state power and, through it, managed a strongly
centralized economy. In spite of the process of privatization of
state-owned assets in the 1990s in Eastern Europe, China, and
other economies formerly under centralized planning, there are
substantial political continuities in many of them. For instance,
Yeltsin and Putin were both high ranking officers in the
‘socialist years’ of the USSR and the same can be said about
many other politicians and new tycoons in Eastern Europe, not
to mention China. This emphasizes the permanence of power
configurations and ruling elites, even with changing economic
structures and policies.
Though this is not my field, I think there is substantial
evidence to accept Boncz and Sebestyén’s view that ‘the gap in
life expectancy between the countries of Central and Eastern
Europe and the countries of Western Europe was closing up
during the 1950s and early 1960s’, but from the mid-1960s
health conditions in Eastern Europe stagnated or worsened,
whereas in Western Europe they improved steadily. Unmentioned by Boncz and Sebestyén, however, are other major
instances related to the health experience in authoritarian
regimes with centrally planned economies. For instance, the
famine and the demographic crisis during the forced collectivization of agriculture and the peak political repression in
Russia in the 1930s, and the disastrous consequences—in terms
of drop in agricultural production and consequent famine—of
the so-called Great Leap Forward in China in the late 1950s,
which has been charged with somewhere between 14 and
26 million deaths.6 While the magnitude of these demographic
disasters is under active discussion among social scientists, it
has been a view generally accepted since the 1980s that China,
along with the Indian state of Kerala, Sri Lanka, and Costa
LETTERS TO THE EDITOR
Rica, were outstanding examples of significant health progress
in the decades after the Second World War.6–8 Obviously, these
matters are troubled with major ideological undercurrents, and
any particular sample of publications on these issues9–11usually
contains both high-quality scholarship and not-so-good
political propaganda.
In the 1990s the USSR disintegrated, most Central and
Eastern European countries went from the Russian sphere of
influence into the American one, and all the resulting countries
went through a transition whose major aspects were the
conquest of civil liberties and an accelerated process of
privatization, often implying severe cuts in social services.
The social and health consequences of these changes are still
under discussion, but the amount of destitution, disease, and
death, that the transition brought with it in the 1990s has been
documented.12–14 Eastern Europe and Africa are the two major
demographic disasters in the late 20th century. Fortunately, in
terms of heath indicators, in recent years conditions seem to be
improving in many countries in Central and Eastern Europe,
but they are stagnant or worsening in Russia and other
countries formerly part of the USSR (Figure 1). In China,
where the lack of civil liberties coexists now with increasingly
unregulated and open markets, the huge acceleration of
economic growth since the 1980s has been associated with a
strong deterioration of health care15 and a significant stagnation in the reduction of mortality rates since the 1980s.13
To ascertain why life expectancy stagnated or worsened
in the Soviet bloc countries in the 1970s and 1980s, why it
dropped significantly during the social disruption and
poverty-ridden transition of the early-mid 1990s, why it
continued falling later in some countries but not in others,
and why the socioeconomic crisis during the 1980s and 1990s,
for instance, in Latin America, did not reverse the long-term
trends in rising life expectancy—all these are in my view major
issues to be investigated by social scientists.
799
References
1
2
3
4
5
6
7
8
9
Boncz I, Sebestyén A. Economy and mortality in Eastern and Western
Europe between 1945 and 1990: the largest medical trial of history. Int
J Epidemiol 2006;35:796–97.
McKee M, Suhrcke M. Commentary—Health and economic transition. Int J Epidemiol 2005;34:1203–06.
Tapia Granados JA. Response—Economic growth, business fluctuations and health progress. Int J Epidemiol 2005;34:1226–33.
Brenner MH. Commentary—Economic growth is the basis of
mortality rate decline in the 20th century: Experience of the United
States 1901–2000. Int J Epidemiol 2005;34:1214–21.
Tapia Granados JA. Increasing mortality during the expansions of the
US economy, 1900–1996. Int J Epidemiol 2005;34:1194–202.
Riley JC. Rising Life Expectancy: A Global History. New York: Cambridge
University Press, 2001.
Sen A. Public action and the quality of life in developing countries.
Oxf Bull Econ Stat 1981;43:289–319.
Sen A. The economics of life and death. Sci Am 1993;268:40–47.
Eberstadt N. The Tyranny of Numbers—Mismeasurement and Misrule.
Washington, DC: American Enterprise Institute, 1995.
10
11
12
13
14
15
Navarro V. Has socialism failed? An analysis of health indicators
under socialism. Int J Health Serv 1992;22:583–601.
McGuire JW, Frankel LB. Mortality decline in Cuba, 1900–1959:
Patterns, comparisons, and causes. Lat Am Res Rev 2005;40:83–116.
Cornia GA, Paniccià R (eds). The Mortality Crisis in Transitional
Economies. New York: Oxford University Press, 2000.
United Nations Development Program. Human development trends
2005. Available at: http://hdr.undp.org/docs/statistics/data/flash/
2005/2005.html (Accessed February 20, 2006).
Stillman S. Health and nutrition in Eastern Europe and the former
Soviet Union during the decade of transition: a review of the
literature. Econ Hum Biol 2006;4:104–46.
French HW. Wealth grows, but health care withers in china. New York
Times 14 January 2006:A1.
doi:10.1093/ije/dyl076
Advance Access publication 27 April 2006
Bias in studies of influenza vaccine effectiveness: the authors reply to Hak et al.
From LISA A JACKSON,1,2* MICHAEL L JACKSON1,2 and NOEL S WEISS2
In our study of elderly members of a large health care plan, we
found that seniors who had received influenza vaccine had a
lower risk of death in periods before the start of the influenza
season, during the influenza season, and in the summer than
seniors who had not been vaccinated.1 The greatest reduction
in risk was before the onset of the flu season—during that
period the death rate among the vaccinated was 60% lower
than among the unvaccinated. Influenza causes an estimated
5% of deaths in seniors during the influenza season,2,3 and so
makes at most a negligible contribution to deaths outside the
1
2
Center for Health Studies, Group Health Cooperative, Seattle, WA, USA.
Department of Epidemiology, University of Washington, Seattle, WA, USA.
* Corresponding author. E-mail: [email protected]
influenza season. The association we observed must therefore
be spurious, probably due to confounding. The important
question is, what is the source of the confounding?
Hak et al.4 have hit close to the crux of this issue when they
suggest that we ‘should have excluded persons likely to die
during the pre-influenza season’ from our study population.
We agree that there is a healthy vaccinee bias due to factors,
such as severe illness and frailty, which are associated with an
increased risk of short-term mortality and a decreased likelihood of vaccination. This bias influences the estimates
obtained in analyses of both influenza and non-influenza
time periods. To reduce the influence of bias we must be able to
accurately identify the confounding factors. Our results suggest
that covariates defined by diagnosis codes do not allow us to