deaths from alcohol and violence in moscow: socio-economic determinants

19
European Journal of Population 14: 19–37, 1998. © 1998 Kluwer Academic Publishers. Printed in the Netherlands. 19 Deaths from Alcohol and Violence in Moscow: Socio-economic Determinants LAURENT CHENET 1* , DAVID LEON 1 , MARTIN MCKEE 1 and SERGUEI VASSIN 2 1 European Centre on Health of Societies in Transition, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK; 2 Centre for Demography and Human Ecology, Russian Academy of Sciences, 32 Krasikova, 117418 Moscow, Russian Federation ( * author for correspondence) Received 22 January 1998; accepted in final form 9 February 1998 Chenet, L., Leon, D., McKee, M. and Vassin, S., 1998, Deaths from Alcohol and Violence in Moscow: Socio-economic Determinants, European Journal of Population / Revue Européenne de Démographie 14: 19–37. Abstract. Objective: To examine the association between accidental, violent and alcohol related adult mortality in the Russian capital and socio-economic status characteristics such as educational status, occupational group and marital status. Data and methods: individual death records for Moscow City for the years 1994 and 1995, for 86121 deaths between the ages of 20–59. Proportional mortality analysis was used to compare trends for alcohol related deaths and accidental and violent deaths (representing 5 and 28% of all deaths in this age group), with multiple controls consisting of deaths from cancer at various sites. Results: The probability of death from alcohol related diseases increased as education level de- creased, with those men failing to complete secondary education over two and a half times as likely to die from these causes than men with higher education. Blue collar workers were also much more likely to die from these causes than white collar workers. Marriage had a marked protective effect for both men and women. Conclusion: Despite 75 years of official egalitarian ideology, there are marked socio-economic differ- entials in mortality in Russia. For the causes of death analysed, socio-economic mortality differentials were greater for women than for men. Chenet, L., Leon, D., McKee, M. et Vassin, S., 1998, Mortalité liée à l’alcoolisme et à la violence à Moscou: déterminants socio-économiques, European Journal of Population / Revue Européenne de Démographie 14: 19–37. Résumé. L’objectif de cet article est d’examiner l’association entre mortalité liée à l’alcool, aux accidents et à la violence dans la capitale russe, et les caractéristiques socio-économiques, telles que l’éducation, la profession et l’état matrimonial. Les données utilisées sont les enregistrements de décès individuels à Moscou, pour 1994 et 1995 (86122 décès entre 20 et 59 ans). La méthode d’analyse de données de mortalité proportionnelle est utilisée pour comparer les tendances de mor- talité liée, d’une part à une consommation excessive d’alcool, d’autre part aux accidents et à la violence (respectivement 5% et 28% de l’ensemble des décès), avec des contrôles multiples (décès par cancer à differents sites). Les résultats montrent que la probabilité de décès directement lié a

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Page 1: Deaths from Alcohol and Violence in Moscow: Socio-economic Determinants

European Journal of Population14: 19–37, 1998.© 1998Kluwer Academic Publishers. Printed in the Netherlands.

19

Deaths from Alcohol and Violence in Moscow:

Socio-economic Determinants

LAURENT CHENET1∗, DAVID LEON1, MARTIN MCKEE1

and SERGUEI VASSIN21European Centre on Health of Societies in Transition, London School of Hygiene and TropicalMedicine, Keppel Street, London WC1E 7HT, UK;2Centre for Demography and Human Ecology,Russian Academy of Sciences, 32 Krasikova, 117418 Moscow, Russian Federation (∗author forcorrespondence)

Received 22 January 1998; accepted in final form 9 February 1998

Chenet, L., Leon, D., McKee, M. and Vassin, S., 1998, Deaths from Alcohol and Violence in Moscow:Socio-economic Determinants, European Journal of Population / Revue Européenne de Démographie14: 19–37.

Abstract. Objective: To examine the association between accidental, violent and alcohol relatedadult mortality in the Russian capital and socio-economic status characteristics such as educationalstatus, occupational group and marital status.Data and methods: individual death records for Moscow City for the years 1994 and 1995, for 86121deaths between the ages of 20–59. Proportional mortality analysis was used to compare trends foralcohol related deaths and accidental and violent deaths (representing 5 and 28% of all deaths in thisage group), with multiple controls consisting of deaths from cancer at various sites.Results: The probability of death from alcohol related diseases increased as education level de-creased, with those men failing to complete secondary education over two and a half times as likelyto die from these causes than men with higher education. Blue collar workers were also much morelikely to die from these causes than white collar workers. Marriage had a marked protective effectfor both men and women.Conclusion: Despite 75 years of official egalitarian ideology, there are marked socio-economic differ-entials in mortality in Russia. For the causes of death analysed, socio-economic mortality differentialswere greater for women than for men.

Chenet, L., Leon, D., McKee, M. et Vassin, S., 1998, Mortalité liée à l’alcoolisme et à la violence àMoscou: déterminants socio-économiques, European Journal of Population / Revue Européenne deDémographie14: 19–37.

Résumé. L’objectif de cet article est d’examiner l’association entre mortalité liée à l’alcool, auxaccidents et à la violence dans la capitale russe, et les caractéristiques socio-économiques, tellesque l’éducation, la profession et l’état matrimonial. Les données utilisées sont les enregistrementsde décès individuels à Moscou, pour 1994 et 1995 (86122 décès entre 20 et 59 ans). La méthoded’analyse de données de mortalité proportionnelle est utilisée pour comparer les tendances de mor-talité liée, d’une part à une consommation excessive d’alcool, d’autre part aux accidents et à laviolence (respectivement 5% et 28% de l’ensemble des décès), avec des contrôles multiples (décèspar cancer à differents sites). Les résultats montrent que la probabilité de décès directement lié a

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20 LAURENT CHENET ET AL.

l’alcool croît, alors que le niveau d’éducation decroît; les hommes n’ayant pas achevé leur éducationsecondaire ont un risque plus de deux fois et demie plus élevé de mourir pour cette cause que ceuxqui sont plus éduqués. Les ouvriers ont aussi un risque plus élevé de mourir pour cette cause que lesemployés. Le marriage a un effet protecteur tant pour les hommes que pour les femmes.

En dépit de 75 d’idéologie officielle egalitaire, il y a de très fortes differences socio-économiquesdans la mortalité en Russie. Pour les causes étudiées ici, ces différences sont plus fortes pour lesfemmes que pour les hommes.

Key words: alcohol, homicide, Russia, socio-economic factors

Introduction

Until the second half of the 20th century, life expectancy at birth in Russia laggedwell behind Western European levels. However, after World War II progress wasso rapid that in 20 years, life expectancy at birth in Russia nearly caught up withthat of Western Europe. Since the mid 1960s however, there has been no furtherconvergence of Russian mortality towards Western levels. The earlier success ofthe fight against infectious agents was followed by a failure to curtail rising cardio-vascular and cancer mortality rates. Moreover deaths from accidents and violenceas well as from alcohol related mortality remained much higher than in WesternEurope. During the 1980s, Gorbachev’s anti-alcohol campaign had an importantimpact: in 1987 male life expectancy had reached 65 years and female 74, butthis advance was short-lived. Since then, Russians have suffered an unprecedentedmortality crisis that has reduced male life expectancy to 57 years in 1995 andfemale to 71 years. Accidental and violent deaths as well as alcohol-related mor-tality have played a major role in the recent increase, with young adults of workingages being most affected (Meslé, Shkolnikov et al., 1994; Meslé, Shkolnikov etal., 1995). Moreover, not only did mortality rates from alcohol-related diseasesincrease seven-fold for adult in their forties between 1988 and 1994 (and accidentsand violence mortality rates five-fold), but there is also evidence that alcohol playeda major role in the increase in cardiovascular mortality (Leon, Chenet et al., 1997).

The analyses presented in this paper were undertaken to identify socio-demographic determinants of mortality that might provide a better understandingof the Russian mortality crisis and help focus policy initiatives. We obtained in-dividual mortality records for two years, 1994 and 1995, during which mortalitypeaked (there is evidence of a decrease in 1996), for Moscow, the capital city.It is recognised that Moscow is not fully representative of Russia as London orCopenhagen are not typical of the United Kingdom or Denmark (Charlton, 1996;Juel and Sjøl, 1995). In particular while mortality rates from accidents and violencewere previously lower in the capital than in the rest of the country, the situation isnow the opposite. The fall in male life expectancy in Moscow was greater than inRussia as a whole. One possible explanation for this is the faster, greater pace ofsocio-economic changes in the capital. For example, the abolition of price controlsand removal of restrictions on private commercial activities in 1992 led to rapid

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DEATHS FROM ALCOHOL AND VIOLENCE IN MOSCOW 21

changes in the nature of life in Moscow compared to the more isolated, remote, orless developed areas where changes occurred at a slower pace. However, focusingon the capital partially avoids the issue of heterogeneity of the Russian population.Moreover, Moscow contributes an appreciable proportion of the total population(6%), and lessons from the situation in Moscow are likely to have particular reso-nance in government and amongst policy makers (who live and work in the capitalcity).

Data and methods

Deaths occurring in the city are registered at one of the 30 borough (rayon) officesresponsible for the register of vital status (ZAGS). Since 1993, the Moscow Sta-tistical Committee (Morgorstat) has established a centralised computerised systemto recover details recorded on the death certificate. The present analysis in basedon these data files for 1994 and 1995, covering just over 300,000 deaths. Of these,86,121 deaths aged 20–59 years that occurred in Moscow from January 1st, 1994to December 31st, 1995 were analysed.

For each death, the record includes among others the following variables: na-tionality, date of birth, marital status, occupational group, education, date of death,place of death, cause of death. The family member or next of kin who registers thedeath provides information on the maximal educational level attained and the oc-cupation of the deceased. Education is coded into 6 categories (higher, incompletehigher, secondary special, secondary, secondary incomplete or primary education)as described in Table 1a. Given the small numbers in the incomplete higher educa-tion category, this category has been merged with higher education. Occupationis coded into non manual, manual, unemployed (not dependent) or dependent.Unemployed (not dependent) refers to concerns people who are not participatingin paid activities but nevertheless receive an income (from the state for example):students and pensioners would be included in this category. On the other hand,the not employed dependent concerns people who are entirely dependent on theirrelatives and have no income whatsoever. The relationship between educationallevel and occupational status is described in Table 1b. Marital status (married, nevermarried, widowed, divorced) is taken from the deceased’s identification documentsthat have to be brought when a death is registered.

Cause of death is recorded using a unique system of disease classification basedon ICD-9 but containing only 175 categories. Correspondence between the SovietClassification and ICD-9 for causes of interest to this study are given in Table 2.

PROPORTIONAL MORTALITY AND THE CASE CONTROL FRAMEWORK

In the absence of data on the denominator we may approach the analysis withinthe framework of a case-control study. This is an extension of the conventionalproportional mortality method used in epidemiology (Breslow and Day, 1987) and

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Table 1a. Russian educational classification

Educational category Years of education Comments

Primary or less up to 8 years education this category would include people with learning or physical dis-abilities

Incomplete secondary 8–10 years

Secondary 10–11 years

Secondary special 11–13 years includes additional training in specific vocational skills for quali-fied non-manual and manual professions (corresponding occupations:technicians in mechanics, machinery etc., engine drivers, cooks nurses,etc . . .

Higher incomplete 13–15 years Includes those who spent at least three years at universities, institutesor higher military schools

Higher education 15–17 years

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23Table 1b. Moscow City deaths 1994 and 1995

Male deaths, age 20–59

Alcohol-related deaths Accidents and violence

Occupational group Occupational group

Educational level Non- Unemployed Unemployed Educational level Non- Unemployed Unemployed

manual Manual not dependent dependent manual Manual not dependent dependent

higher 197 52 84 79 higher 1894 462 540 465

secondary special 53 200 72 128 secondary special 462 1660 318 663

secondary 38 644 205 455 secondary 292 4258 938 2528

incomplete secondary 3 254 109 238 incomplete secondary 20 1325 399 874

primary and less 0 18 11 24 primary and less 1 82 94 60

Female deaths, age 20–59

Alcohol-related deaths Accidents and violence

Occupational group Occupational group

Educational level Non- Unemployed Unemployed Educational level Non- Unemployed Unemployed

manual Manual not dependent dependent manual Manual not dependent dependent

higher 19 7 25 14 higher 346 59 231 121

secondary special 25 30 42 36 secondary special 185 285 214 243

secondary 6 89 96 159 secondary 90 521 360 660

incomplete secondary 4 28 52 67 incomplete secondary 10 149 157 143

primary and less 0 6 13 2 primary and less 0 10 45 7

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24 LAURENT CHENET ET AL.

Table 2. Classification of causes of death

Cause of death Soviet Classification ICD-9 codes

Alcohol-related diseases

Alcohol psychoses 73 291

Alcohol dependence syndrome 75 303

Alcoholic liver cirrhosis 123 571.0–571.3

Diseases of the pancreas 126 577

Accidental poisoning by alcohol 163 860

Accidents and violence 160–162; 164–175 800–858; 861–999

(excluding accidental alcohol poisoning)

All neoplasms 45–67 140–239

has been regularly used in the British decennial analyses of mortality by occupationand social class where the validity or comparability of the corresponding denomi-nator data from the census is questionable (Registar General, 1978). In this report,we are interested in the association between education, occupation, and maritalstatus and mortality from alcohol related diseases and from accidents and violence.The deaths constitute two case series. The control group could be selected as allother causes of death. However, we have chosen to use cancer as the controls,as rates from this cause have not shown the major fluctuations observed in therecent period for many other causes. As certain cancer deaths are related to socio-demographic differences which may distort specific case control comparisons, ourapproach to this has been to look at the sensitivity of our estimates to the use ofdifferent sub-groups of cancer as controls (McDowall, 1983).

CASES AND CONTROLS

As the major increase in mortality in the recent period was among people ofworking age, the analyses have been restricted to deaths between the ages of20–59 years. Two case series were analysed: (i) alcohol related diseases (alco-hol psychoses, alcohol dependence syndrome, alcoholic liver cirrhosis, diseases ofthe pancreas and accidental alcohol poisoning) and (ii) all accidents and violence(excluding alcohol poisoning). These two broad categories represent respectively 5and 28% of all deaths in this age group. The importance of alcohol related mortalityand accidents and violence as a marker of recent fluctuations in mortality makes itimportant that the factors associated with them are better understood.

The control series are (i) all neoplasms; (ii) all neoplasms minus lung cancer;(iii) all neoplasms minus stomach cancer; (iv) all neoplasms minus lung, stomachand cancer of the upper aero-digestive tract; (v) all neoplasms minus cancer of the

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DEATHS FROM ALCOHOL AND VIOLENCE IN MOSCOW 25

breast (women only). The cancers that are excluded have been chosen as those that,on the basis of experience elsewhere, are most likely to be associated with factorssuch as education and marital status, or alcohol in the case of cancer of the upperaero-digestive tract.

Data were analysed with the STATA statistical package (STATA, 1997) usinglogistic regression for men and women separately. Age at death was includedas a categorical variable in 5-year age bands in every model in order to removeany potential confounding effect. Education, occupation and marital status wereincluded as 5, 4, and 4-level categorical variables respectively. The minority ofdeaths with missing values for these three explanatory variables were excludedfrom analysis.

Results

Although, to our knowledge there have been no systematic attempts to assess thequality of these data, detailed examination of completeness and coherence of infor-mation for each variable, and daily, weekly and monthly variation in the numbersof deaths, have not identified any major inconsistency.

The ratio of male to female deaths was 2.8:1 (63,502 deaths to men and 22,619deaths to women). Education, occupation and marital status were specified for 95.4,89, and 95.6% of all deaths respectively.

The probability of death from alcohol-related diseases increased as educationallevel decreased, with those men failing to complete secondary education over twoand a half times as likely to die from these causes (Table 3). The correspondingfigure for women was an over eight fold increase. The exception to this trend wasthat the odds ratio was lower in those with only primary education who were lesslikely to die from these causes than those with secondary education. It has beensuggested that this category includes a highly selected group of the populationcharacterised by physical disability or learning disorders. The overall pattern wasindependent of the control group, although the magnitude of the effect did vary,in particular if all cancers of the lung, stomach and upper aero-digestive tract areexcluded, the odds ratios increase, as would be expected.

Turning to deaths from accidents and violence, analysis by educational levelshowed a very similar pattern with increasing probability of death amongst thosewith lower levels of education. Once again those with only primary education havea lower probability of death than those with secondary education.

Trends by occupational group show the same pattern as in Western countries:male blue collar workers have a risk of dying from alcohol-related diseases thatis twice as high as for white collar workers (Table 4). Amongst women the corre-sponding figure is a three fold increase. Two categories deserve further attention:not working but not dependent and not working and dependent. The former in-cludes students and pensioners and shows a lower risk of dying than peopleengaged in any professional activity while the latter, consisting of people dependent

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26 LAURENT CHENET ET AL.

Table 3. Moscow City Deaths, 1994 and 1995 – Proportional mortality analysis – Educationlevel

Alcohol-related causes, age 20–59

Odds ratios

95%confidence interval Educational status (number of ‘case’ deaths)

men

Control cause Higher Secondary Secondary Secondary Primary

Education Special (incomplete) or less

(443) (520) (1542) (693) (61)

all cancer 1 1.58 2.15 2.60 2.04

1.35 1.85 1.89 2.45 2.24 3.02 1.48 2.81

all cancer but lung 1 1.72 2.37 2.96 2.38

1.46 2.02 2.08 2.71 2.53 3.46 1.70 3.33

all cancer but stomach 1 1.64 2.15 2.58 1.96

1.39 1.93 1.88 2.46 2.20 3.01 1.42 2.72

all cancer but lung, stomach1 2.18 3.08 4.35 3.20

and UADT∗ 1.83 2.60 2.67 3.56 3.65 5.18 2.20 4.66

women

Control cause Higher Secondary Secondary Secondary Primary

Education Special (incomplete) or less

(71) (150) (396) (162) (23)

all cancer 1 2.73 5.43 8.66 5.87

2.03 3.65 4.18 7.07 6.41 11.70 3.52 9.78

all cancer but lung 1 2.72 5.43 8.80 6.10

2.03 3.65 4.17 7.07 6.51 11.90 3.65 10.18

all cancer but stomach 1 2.76 5.54 8.79 6.13

2.06 3.71 4.25 7.21 6.49 11.89 3.66 10.26

all cancer but lung, stomach,1 2.74 5.50 9.08 6.49

and UADT∗ 2.04 3.68 4.22 7.17 6.70 12.32 3.86 10.92

all cancer but lung, stomach,1 2.61 5.13 8.54 5.24

UADT∗, and breast 1.93 3.53 3.92 6.73 6.24 11.70 3.08 8.93

∗ UADT – upper aerodigestive tract.

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DEATHS FROM ALCOHOL AND VIOLENCE IN MOSCOW 27

Table 3. Continued

Accidents and Violence, age 20–59

Odds ratios

95%confidence interval Educational status (number of ‘case’ deaths)

men

Control cause Higher Secondary Secondary Secondary Primary

Education Special (incomplete) or less

(3597) (3379) (8892) (2872) (253)

all cancer 1 1.17 1.38 1.41 1.22

1.06 1.29 1.27 1.49 1.28 1.55 0.99 1.51

all cancer but lung 1 1.28 1.53 1.62 1.45

1.15 1.42 1.40 1.67 1.46 1.80 1.14 1.81

all cancer but stomach 1 1.22 1.37 1.40 1.18

1.10 1.35 1.26 1.49 1.26 1.55 0.95 1.46

all cancer but lung, stomach,1 1.62 1.99 2.38 1.92

and UADT 1.43 1.83 1.80 2.20 2.09 2.71 1.45 2.54

women

Control cause Higher Secondary Secondary Secondary Primary

Education Special (incomplete) or less

(789) (985) (1796) (502) (66)

all cancer 1 1.51 2.08 2.57 1.87

1.33 .172 1.85 2.33 2.19 3.01 1.36 2.57

all cancer but lung 1 1.51 2.07 2.60 1.93

1.33 1.71 1.84 2.33 2.22 3.06 1.40 2.67

all cancer but stomach 1 1.53 2.11 2.61 1.95

1.36 1.75 1.88 2.37 2.22 3.07 1.41 2.71

all cancer but lung, stomach,1 1.52 2.09 2.69 2.07

and UADT 1.32 1.73 1.86 2.36 2.28 3.18 1.48 2.89

all cancer but lung, stomach,1 1.44 1.96 2.52 1.68

UADT and breast 1.25 1.66 1.72 2.23 2.10 3.02 1.18 2.39

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28 LAURENT CHENET ET AL.

Table 4. Moscow City Deaths, 1994 and 1995 – Proportional mortality analysis – Occupa-tional group

Alcohol-related causes, age 20–59

Odds ratios

95%confidence interval occupational group (number of ‘case’ deaths)

men

Control cause non-manual manual not working, not working,

not dependent dependent

(293) (1190) (484) (928)

all cancer 1 2.22 0.55 4.75

1.89 2.60 0.47 0.66 3.97 5.66

all cancer but lung 1 2.42 0.58 5.25

2.05 2.84 0.49 0.69 4.36 6.32

all cancer but stomach 1 2.30 0.54 4.56

1.95 2.71 0.45 0.64 3.80 5.49

all cancer but lung, stomach, 1 3.14 0.76 6.15

and UADT 2.63 3.74 0.64 0.92 5.01 7.53

women

Control cause non-manual manual not working, not working,

not dependent dependent

(54) (160) (228) (278)

all cancer 1 3.97 0.88 9.01

2.86 5.52 0.63 1.21 6.57 12.36

all cancer but lung 1 3.99 0.86 8.77

2.87 5.55 0.62 1.19 6.38 12.03

all cancer but stomach 1 4.06 0.86 8.96

2.92 5.66 0.62 1.19 6.52 12.33

all cancer but lung, stomach, 1 4.09 0.84 8.82

and UADT 2.94 5.71 0.61 1.17 6.40 12.15

all cancer but lung, stomach, 1 3.98 0.93 9.27

UADT and breast 2.83 5.60 0.67 1.30 6.65 12.91

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DEATHS FROM ALCOHOL AND VIOLENCE IN MOSCOW 29

Table 4. Continued

Accidents and Violence, age 20–59

Odds ratios

95%confidence interval occupational group (number of ‘case’ deaths)

men

Control cause non-manual manual not working, not working,

not dependent dependent

(2681) (7805) (2299) (4615)

all cancer 1 1.58 0.34 2.40

1.43 1.74 0.31 0.37 2.12 2.72

all cancer but lung 1 1.72 0.36 2.67

1.55 1.91 0.32 0.40 2.33 3.05

all cancer but stomach 1 1.62 0.33 2.30

1.46 1.80 0.30 0.37 2.02 2.62

all cancer but lung, stomach, 1 2.22 0.47 3.12

and UADT 1.96 2.50 0.41 0.52 2.67 3.66

women

Control cause non-manual manual not working, not working,

not dependent dependent

(634) (1025) (1013) (1178)

all cancer 1 2.07 0.42 2.81

1.77 2.41 0.37 0.49 2.40 3.29

all cancer but lung 1 2.08 0.41 2.74

1.78 2.42 0.36 0.48 2.34 3.22

all cancer but stomach 1 2.11 0.42 2.80

1.80 2.47 0.36 0.48 2.37 3.29

all cancer but lung, stomach, 1 2.13 0.40 2.75

and UADT 1.81 2.50 0.35 0.47 2.33 3.25

all cancer but lung, stomach, 1 2.09 0.45 2.89

UADT and breast 1.76 2.50 0.38 0.53 2.40 3.48

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30 LAURENT CHENET ET AL.

Table 5. Moscow City Deaths, 1994 and 1995 – Proportional mortality analysis – Maritalstatus

Alcohol-related causes, age 20–59

Odds ratios

95%confidence interval Martial status (number of ‘case’ deaths)

men

Control cause married single widowed divorced

(1705) (521) (115) (929)

all cancer 1 2.09 2.19 2.95

1.79 2.43 1.72 2.79 2.63 3.31

all cancer but lung 1 2.14 2.26 3.05

1.82 2.05 1.75 2.92 2.70 3.45

all cancer but stomach 1 2.06 2.16 2.90

1.76 2.41 1.70 2.77 2.57 3.27

all cancer but lung, stomach, 1 2.41 2.64 3.37

and UADT 2.00 2.89 1.95 3.56 2.92 3.89

women

Control cause married single widowed divorced

(375) (82) (124) (219)

all cancer 1 1.55 2.46 1.98

1.19 2.03 1.96 3.11 1.64 2.38

all cancer but lung 1 1.54 2.48 1.96

1.17 2.01 1.96 3.12 1.63 2.36

all cancer but stomach 1 1.54 2.54 1.99

1.17 2.02 2.01 3.20 1.65 2.39

all cancer but lung, stomach, 1 1.52 2.58 1.97

and UADT 1.16 1.99 2.04 3.27 1.63 2.37

all cancer but lung, stomach, 1 1.55 2.51 1.95

UADT and breast 1.17 2.06 1.96 3.20 1.60 2.37

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DEATHS FROM ALCOHOL AND VIOLENCE IN MOSCOW 31

Table 5. Continued

Accidents and Violence, age 20–59

Odds ratios

95%confidence interval Martial status (number of ‘case’ deaths)

men

Control cause married single widowed divorced

(10706) (3821) (442) (4041)

all cancer 1 1.52 1.62 2.29

1.34 1.72 1.35 1.95 2.08 2.52

all cancer but lung 1 1.52 1.62 2.29

1.35 1.72 1.35 1.95 2.08 2.52

all cancer but stomach 1 1.47 1.56 2.19

1.30 1.66 1.31 1.86 2.00 2.42

all cancer but lung, stomach, 1 1.66 1.91 2.51

and UADT 1.43 1.92 1.50 2.43 2.23 2.83

women

Control cause married single widowed divorced

(2108) (631) (426) (987)

all cancer 1 1.41 1.77 1.69

1.21 1.65 1.54 2.05 1.52 1.89

all cancer but lung 1 1.39 1.78 1.68

1.19 1.63 1.54 2.06 1.51 1.88

all cancer but stomach 1 1.40 1.82 1.70

1.20 1.64 1.56 2.11 1.52 1.91

all cancer but lung, stomach, 1 1.38 1.85 1.69

and UADT 1.18 1.62 1.59 2.15 1.50 1.89

all cancer but lung, stomach, 1 1.42 1.79 1.69

UADT and breast 1.19 1.69 1.52 2.11 1.49 1.92

on the income of a relative appear to be particularly vulnerable. Once again thesame pattern is apparent for accidents and violence, but generally with much lessof an increase in odds ratio.

Compared to being married, being single (as in never married), widowed, ordivorced are all associated with increased probability of death from alcohol-related

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32 LAURENT CHENET ET AL.

Table 6. Moscow City Deaths, 1994 and 1995 – Proportional mortality analysis

Accidents and Violence, age 20–59

odds ratio (no. of deaths)

95%confidence interval Educational status (number of ‘case’ deaths)

Higher Secondary Secondary Secondary Primary

education special (incomplete) or less

men

traffic accidents 1 (634) 1.19(459) 1.14(967) 1.26(239) 0.78(20)

160–162 0.99 1.43 0.98 1.33 1.02 1.56 0.45 1.36

other accidents 1 (662) 1.81(647) 2.20(1642) 2.85(637) 2.08(63)

166–172 1.54 2.13 1.93 2.51 2.41 3.36 1.45 3.02

violent deaths 1 (2248) 1.68(2211) 2.18(6122) 2.57(1944) 2.06(164)

173–175 1.47 1.91 1.96 2.42 2.24 2.95 1.53 2.79

women

traffic accidents 1 (167) 1.23(173) 1.22(229) 1.19(46) 0.40(3)

160–162 0.97 1.57 0.97 1.52 0.83 1.72 0.12 1.33

other accidents 1 (115) 1.69(151) 2.39(279) 3.02(81) 2.50(14)

166–172 1.30 2.20 1.89 3.01 2.21 4.13 1.37 4.57

violent deaths 1 (494) 1.59(645) 2.36(1258) 3.23(367) 2.63(49)

173–175 1.37 1.85 2.05 2.70 2.67 3.90 1.81 3.84

causes and accidents and violence (Table 5). This protective effect of marriageis seen for men and women. However, never to have been married seems morehazardous for men than for women. On the other hand widowhood seems to beassociated with a greater increased risk for women than for men while particularlyhigh odd ratios are observed for divorced men.

Again, the increases in odds ratios are much higher for alcohol-related diseasesthan for accidents and violence.

In order to understand why the odds ratio are consistently lower for accidentsand violence than for alcohol related deaths, data were further disaggregated into“traffic accidents”, “other accidents” and “violent deaths”, and the logistic regres-sion repeated. As different control groups have had very little influence in theprevious analyses, “malignant neoplasms excluding cancer of the lung, stomach,and upper areo-digestive tract” only was used as a control. The results are given inTable 6, although it should be noted that the numbers involved are rather small sothese estimates of effect lack precision.

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Key features of specific types of accidental deaths are as follow. Accidentaldeaths by falls, fire, drowning, choking, are associated with education in the samemanner as alcohol related diseases, with odds ratios getting nearer those observedfor alcohol related deaths. Accidental deaths due to traffic accidents present anunclear pattern with differences in odds ratios not reaching significance. Whilelooking at motor vehicle accidents only, the odds ratios amongst the less educatedare below 1, although not statistically significant. Violent deaths due to suicide,murder or undetermined as to the intention show a similar pattern to the firstcategory, although the gradient is less steep.

The third subdivision of accidents and violence, the “violent death” categoryincludes deaths due to suicide, murder or “undetermined whether accidentally orpurposely inflicted”. As a group and individually those three categories are in-versely associated with education level. Once again the gradient is steeper for menthan for women. The undetermined category is a particularly interesting one be-cause it is the single biggest cause of death in Moscow in the age group considered(10762 deaths or 12.5% of all deaths, murder is the fourth most common causewith 3425 cases and 4% and suicide is eighth most common with 2126 deaths or2.5%). Besides a higher likelihood of having lower educational status, those in thiscategory are more likely to be male, divorced, manual workers, not Russian andnot to die in hospital (a Chi square test yields p< 0.001 for each variable). 51% ofthem have a “other and unclassified in other items of accidents” under the “type oftrauma” variable, the second highest category for this variable being “intracranialinjury”. Mean age at death is 42 for men and 41 for women. It seems likely thatmany of those people are in fact murder victims, which would mean that murder isprobably the largest single cause of death for Muscovites of working age.

Discussion

POSSIBLE BIAS AND ARTEFACTS

This research is subject to certain caveats. We have not been able, so far, to conductdetailed validation studies, such as comparison of death certificates with hospi-tal case notes. However, a detailed examination of the data has been undertakenand no important discontinuities or other evidence of poor data quality have beenidentified, including analysis of trends by cause of death, and study of daily deathrates.

Although, ideally it would have been desirable to have related deaths to popu-lation denominators disaggregated by the variables of interest, this is only possiblein a very few countries and will be impossible in Russia for the foreseeable future.

The proportional analysis method is not without shortcomings, mainly that onecan not say for certain whether a high odds ratio is the result of a high absolute ratein the cause of interest, or a low absolute rate in the control cause. The choice ofcontrol is therefore crucial. One of the main reasons to choose neoplasms was thattrends in cancer mortality remained remarkably stable during the recent Russian

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34 LAURENT CHENET ET AL.

demographic upheaval (Meslé, Shkolnikov et al., 1995). On the basis of availableevidence it is not possible to choose controls in sufficient numbers that are notlinked to socio-economic status. However, we have tried to minimise this by ex-cluding certain cancer sites. As expected, the odds ratios are greater when cancer ofthe lung or of the upper aero-digestive tract are excluded from the analysis as theseare closely linked with patterns of tobacco and alcohol consumption. Even so, asother cancers are also likely to be more common in lower social classes, our studyis likely to underestimate the impact of socio-economic factors in Russia. How-ever, our results are very consistent, whether we consider education, occupation ormarital status.

SOCIO-ECONOMIC DIFFERENTIALS

This research is important because it confirms the existence of large socio-economic differentials in mortality in Russia. Furthermore, these differences arenot simply between a small elite and the rest of the population but act at all levels.This is consistent with findings from western countries (Davey-Smith, Shipley etal., 1990; Davey-Smith, Neaton et al., 1996). A second important finding is theconfirmation of research from Hungary (Hajdu, McKee et al., 1995) and Poland(Watson, 1995) that shows a protective effect of marriage in Eastern Europe. Thefinding of a greater effect of having never married for men than for women hasbeen documented elsewhere. Once again, it seems that unmarried men have beenespecially vulnerable in a situation of economic transition. The greater effect ofwidowhood on women than men is consistent with what has been observed in otherEastern European countries like Hungary (Hajdu, McKee et al., 1995). Severalfactors are believed to play a role including the economics of marital status: in caseof divorce, men have to pay substantial alimony, and it is possible that in Russia asin many other countries, widows are in a particular precarious situation.

ALCOHOL-RELATED DISEASES VS. ACCIDENTAL DEATHS

The third finding is that the gradient of increasing risk of alcohol related deathsdiffers markedly from that of accidents and violence. The former are much morestrongly related to measures of socio-economic, educational and marital status thanthe latter. A similar difference in the strength of the effect of education on thesetwo groups of causes was also observed by Shkolnikov et al. (unpublished) in theiranalysis of Russian mortality at the time of the 1989 census. This requires furtherexamination.

One explanation would be that high levels of alcohol consumption in somesections of the population result in a generalised increase in deaths from accidentsand violence across all social strata: an example of this would be a drunk driverkilling others who were not drunk. However, a further analysis of the data providesa different explanation.

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When analysed separately traffic accidents generate odds ratios that are sta-tistically not significantly different from 1. If motor vehicle traffic accidents(representing 45% of all traffic accidents) are analysed separately they generateodds ratios below 1 among the less well-educated. Even if alcohol consumptionand traffic accidents are strongly linked, the social stratification of car-ownershipin Russia (with much greater car-ownership by the more wealthy) is probably amuch stronger factor. It is unfortunately impossible to control for car-ownershipwith the data available.

For “other accidents” the pattern of odds ratios is more similar to those observedfor alcohol related diseases even though slightly lower. However, it seems possibleto explain the remaining discrepancy with what is known of the epidemiologyof alcohol related mortality (Skog, 1985; Skog, 1986; Edwards, Anderson et al.,1994). Most alcohol-relateddiseasesoccur amongst heavy drinkers, with a longhistory of alcohol consumption. Even in the case of acute alcohol poisoning (rep-resenting 20% of deaths in this category) which does not require along historyof alcohol drinking, the necessary amount of alcohol is daunting. On the otherhand, accidents can occur amongst occasional drinkers and with a relatively smallamount of alcohol. The difference between the odds ratio can be explained by thosedifferences in risk function. This would imply that heavy alcohol consumption issocially stratified, as opposed to prevalence of alcohol consumptionper sewhichis the norm in Russia.

WOMEN

The social stratification ofheavyalcohol consumption goes some way to explainingthe much stronger association between alcohol-related mortality and education oroccupation observed for women for whom heavy alcohol consumption, especiallyamong those of higher social status, is more likely to be socially frowned upon. As aresult, not as many women die from diseases that are most strongly linked to socio-economic status but those whodo die from those diseases are almost exclusivelydrawn from the lowest socio-economic strata, hence the very high odds ratios.

An alternative explanation would be that social pressure reduces the likelihoodthat doctors will record alcohol-related causes of death on the death certificate,especially for women of a certain social status. However, this is less intuitive foraccidental deaths, and even less for cardiovascular diseases where the same patternis observed (data not shown).

Conclusion

Official egalitarianism has not eliminated the socio-economic differentials in mor-tality: less educated, blue collar workers are most at risk of premature deaths.Although this is widely recognised in the West, it is somewhat less expectedin the Russian context. However, our data cover the years 1994–95, that is two

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36 LAURENT CHENET ET AL.

years after the collapse of the USSR and nearly 10 years after the introductionof perestroika. It is possible that these socio-economic inequalities are new orat least dramatically increased during the shift to a market economy but thesedata do not permit us to differentiate the consequences of present socio-economiccircumstances from those in the past. However, given the growing evidence fromthe West of the importance of exposure to socio-economic factors over a lifetime(Davey-Smith, Hart et al., 1997), it is important that the possibility of long stand-ing inequalities is not ignored, with all the current problems being attributed tocontemporary circumstances. Moreover, the similarities with the West do not stopat educational or occupational status: marital status also has a comparable effecton mortality, suggesting social determinants of health more subtle than presenteconomic circumstances.

Alcohol-related mortality is a public health issue that requires urgent action. Thehigh numbers of young people dying of alcohol-related diseases as well as the veryhigh numbers of accidental deaths (many of which seem likely to be associatedwith alcohol) all point towards alcohol as one, if not the, most important factorbehind the recent Russian mortality crisis.

Even more than accidents, murders seem to contribute substantially to the highmortality amongst young Muscovites. Although this would be impossible to provewithout further legal inquiries into each death, the characteristics of the “undeter-mined as to the intention” all tend towards a very high proportion of homicides.This is also consistent with the fact that whatever the level of consumption ofalcohol in a particular society, many murders are committed in a state of alcoholicintoxication (Skog, 1985; Cherpitel, 1996).

The task of tackling excessive alcohol consumption is not an easy one as thepopulation most concerned (i.e. young males) is the least likely to heed publichealth messages. In the Russian context this is made even more difficult by theclaim that vodka is part of the culture and by vested economic interests. However,the problem has clearly become urgent.

The last but not least of our findings is the much higher impact of socio-economic status on women’s mortality experience. Gender seems to play a rolein Russia that is not entirely consistent with what is observed in the West, withinequalities for alcohol-related and violent deaths being greater for women thanfor men. Further research in this area is urgently needed.

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