Saturday, April 6, 2013

Russia’s Demographics: Stress and Health

Russia’s demographic issues have been a subject of considerable discussion. It has a rapidly declining population characterized by low birthrates as well as low life expectancies. Tony Wood takes a fresh look at Russia and its population in an article titled Russia Vanishes that appeared in the London Review of Books. Low fertility and high emigration rates are relatively easy to explain. But how does one create poor health and premature deaths in a modern society? Wood’s musings on how that might occur prompt another attempted explanation: one based on more modern research into the role stress can play in determining health outcomes.

Wood provides interesting background material. He reminds us that about a century ago Russia was expected to become a modern colossus.

"In 1929 Warren Thompson, one of the founders of demographic transition theory, predicted that ‘the growth of Russia during the next three or four decades will be one of the outstanding events of the modern world,’ and that "Russia may very well rival China and India in numbers by the year 2000’."

What is Russia’s population outlook in the twenty-first century?

"Since 1992, according to data from Rosstat, the state statistical agency, deaths have exceeded births by a cumulative total of 13 million, a figure far exceeding the numbers of immigrants. Russia’s population declined by an estimated 6.4 million between 1991 and 2009, an annual average drop of 337,000."

"Russia is still the ninth most populous country in the world, with 142.9 million inhabitants at the time of the 2010 census. But its demographic contraction is set to continue relentlessly: the UN Population Division envisages a drop to 136 million by 2030, and to 126 million by 2050; by the start of the next century it could be as low as 111 million. This decline – equivalent, by 2100, to more than a fifth of the current population – will push Russia down the global demographic hierarchy: the fourth most populous state in the world in 1950, by 2050 it will have dropped to 18th place, overtaken by Pakistan, Ethiopia and Egypt."

What the early demographers missed was the role that history would play in tormenting the Russian people. An unending sequence of catastrophes descended upon Russia. It began with the First World War, the revolution and civil war that followed, the era of Stalinist repression, and peaked with the slaughter associated with the Nazi invasion.

"This sequence of catastrophes, then, killed somewhere between 50 and 65 million Soviet citizens. The demographic consequences reached backwards as well as forwards in time: mass fatalities effectively cancelled out many of the childbearing efforts of previous generations, while the extermination of so many people obviously had an immediate impact on fertility levels. The Second World War killed 40 per cent of men between the ages of 20 and 49, and 15 per cent of women in the same bracket, removing at a stroke a large part of the child-producing population."

The postwar years have not been particularly easy either, with significant levels of political and economic turmoil. This history leads to easy explanations for why birthrates might fall and emigration might rise. But what is the mechanism that would cause people to die at a younger age?

Wood provides necessary background on the health of the Russian population.

"....from the mid-1960s Russian life expectancy entered a period of decline that lasted until the early 1980s – by a grim historical irony, a time when the country was being ruled by an increasingly gerontocratic Politburo."

"The arrival of Gorbachev coincided with a brief improvement: in 1986-87 Russian life expectancy equalled its Khrushchev-era peak. But then another phase of decline began, which turned into a headlong plunge after the collapse of the USSR: between 1991 and 1994, male life expectancy fell by six years, from 63.4 to 57.4; female life expectancy from 74.2 to 71. There has been some recovery since: in 2009, the figure for men was 62.7 and that for women 74.7. But overall life expectancy, at 68.7, was still below the level achieved in 1961."

"In the 1960s Russians could expect to live 23 years longer than those in the world’s ‘less developed regions’, but by 2010 their advantage was down to 1.9 years. Russian men can now expect to live 2.7 years less, on average, than men in the developing world – with shorter lifespans than men in India, Bangladesh or Ghana."

Attempts to correlate poor Russian health with a deficient healthcare system and poor personal habits have thus far fallen short of the target.

"What explains this terrible state of affairs? Among the factors are the astonishing prevalence of cardiovascular disease in Russia, the country’s notorious drinking culture, problems with child and adult nutrition, lack of healthcare expenditure, and the impact of the shocks of the post-Soviet capitalist transformation. Death rates from cardiovascular disease are four and a half times higher than in Western Europe, at 900 deaths per 100,000 according to figures from 2002. But this isn’t enough to account for the disparities in life expectancy."

"For many experts, having weighed all the factors, the continuing high mortality rates remain an enigma: in Eberstadt’s view, ‘the country is pioneering eerie new modern pathways to poor health’."

Wood suggests that the health of the population might be attributed to the horrible circumstances of World War II.

"In 1985, the German demographer Reiner Dinkel noted that the Second World War, as well as causing enormous and immediate loss of life, may also have had long-term effects on a population’s overall health. With a large proportion of a given country’s conscription-age inhabitants killed or wounded, the population left behind would have a lower average life expectancy. Is it far-fetched to imagine that a Soviet populace shattered by years of war, repression and famine might also suffer disproportionately from health problems, which would then be bequeathed to succeeding generations?"

Wood seems to be suggesting that killing off the healthiest members of the childbearing population in warfare would leave behind a relatively unhealthy segment of the population to reproduce and create the next generation. Genetic deficiencies leading to poor health could then propagated across generations.

Wood makes an interesting point. The death rates were high enough that if only the healthiest were killed a sort of "non-survival of the fittest" would ensue. Given that the deaths were high throughout the population during the war, including among civilians, it is not clear how selective this process might have been.

What might be more suggestive of an explanation resides in this statement: "Is it far-fetched to imagine that a Soviet populace shattered by years of war, repression and famine might also suffer disproportionately from health problems..."

Paul Tough has written about recent research into the effect of childhood trauma on health outcomes as an adult. Trauma in this context does not necessarily relate to physical injury, but rather to any situations in which high or persistent levels of stress are experienced. Years of warfare creates many opportunities to experience stress.

Tough discusses the issue of childhood trauma and its affect on educational prospects of children in his book How Children Succeed.

He provided a more general discussion of health issues in an article in The New Yorker: The Poverty Clinic. This article carried the lede:

"Can a Stressful Childhood Make You a Sick Adult?"

In the 1990s Kaiser Permanente initiated a survey of patients for whom it had a comprehensive health assessment. These people were asked to respond to a questionnaire about adverse childhood experiences (ACE). The type of experiences sought included:

"parental divorce, physical abuse, emotional neglect, and sexual abuse, as well as growing up with family members who suffered from mental illness, alcoholism and drug problems."

They discovered that the respondents, a rather typical middle class assemblage of around 17,000, had experienced many more of these adverse situations than expected. Of greater surprise was the fact that there was a direct and almost linear correlation between the degree of childhood adversity and poor adult health. The researchers constructed a rough "ACE score" for each of the respondents from the number of adverse experiences reported.

"....the higher the ACE score, the worse the outcome, on almost every measure, from addictive behavior to chronic disease. Compared to those who had no history of ACEs, those with ACE scores of 4 or higher were twice as likely to smoke, seven times as likely to be alcoholics, and six times as likely to have had sex before the age of fifteen. They were twice as likely to have been diagnosed with cancer, twice as likely to have heart disease, and four times as likely to suffer from emphysema or chronic bronchitis. Adults with an ACE score of 4 or higher were twelve times as likely to have attempted suicide than those with an ACE score of 0. And men with an ACE score of 6 or higher were forty-six times as likely to have injected drugs than men who had no history of ACEs."

Even when poor health habits as adults were factored out, the correlation persisted.

"The researchers looked at patients with ACE scores of 7 or higher who didn’t smoke, didn’t drink to excess, and weren’t overweight, and found that their risk of ischemic heart disease (the most common cause of death in the United States) was three hundred and sixty percent higher than it was for patients with a score of 0. Somehow the traumatic experiences of their childhoods were having a deleterious effect on their later health, through a pathway that had nothing to do with bad behavior."

Since this study was published the relevant pathway to poor health has been associated with the human body’s response to stress.

"The key pathway is the intricately connected system that our brain deploys in reaction to stressful events. This system activates defenses on many fronts at once, some of which we recognize as we experience them: it produces emotions like fear and anxiety, as well as physical reactions, including increased blood pressure and heart rate, clammy skin, and a dry mouth. Other bodily reactions to stress are less evident: hormones are secreted, neurotransmitters are activated, and inflammatory proteins surge through the bloodstream."

"As a response to short-term threats, the system is beneficial, even essential. But researcher like Bruce McEwen....and Frances Champagne....have shown that repeated, full-scale activation of this stress system, especially in early childhood, can lead to deep physical changes. Michael Meany....and his colleagues have found that early adversity actually alters the chemistry of DNA in the brain, through a process called methylation. Traumatic experiences can cause tiny chemical markers called methyl groups to affix themselves to genes that govern the production of stress-hormone receptors in the brain. This process disables these genes, preventing the brain from properly regulating its response to stress."

"When it comes to adult health, the most important element of the stress response is the immune system, which, during moments of acute anxiety, releases a variety of various proteins and other chemical signals into the bloodstream. In the short term, this process promotes resistance to infection, and prepares the body to repair tissues that might be damaged. After the short-term threat disappears, this inflammation subsides, unless the system gets overloaded, in which case these chemicals can build up, with toxic effects on the heart and other organs."

If one accepts the truth of these results, then one would also expect a generation of extremely unhealthy and dysfunctional adults to emerge from the cohort of Russian children of World War II. The trauma of having dysfunctional parents can then reproduce the poor health and dysfunction in another generation.

The idea that Russia’s population has been broadly affected by such a mechanism is intriguing, but it is pure hypothesis.

Paul Tough used the results of these studies to correlate health and learning problems with the type of traumatic experiences that children encounter in poverty-stricken communities. The notion that poverty and insecurity experienced in childhood can lead to poor adult health outcomes is on much firmer ground.

As poor nations become wealthier they are beginning to suffer from chronic ailments such as diabetes and heart diseases that are usually associated with the poor lifestyle habits of wealthier nations. What if personal habits are not the main causes, and the problem was determined decades ago through childhood experiences that included physical, social, and nutritional insecurity? That is something to ponder over. And that is something to worry about.

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