Abstract

The 19th century in western Europe was a period of massive social change [1]. The opportunities created by the industrial revolution were drawing huge numbers of people into the rapidly expanding cities. Some prospered; the factory owners became rich beyond their dreams and the skilled workers and owners of small businesses developed into a new middle class. Others were less fortunate. A new urban underclass emerged, described eloquently, but in different ways, by commentators such as Charles Dickens [2] and Friedrich Engels [3]. Emile Durkheim coined the term ‘anomie’ to describe the unfolding situation in which existing social and moral norms no longer seemed to apply [4]. Anomie existed on two levels: economic, when traditional institutions, such as organized religion or guilds, were no longer able to fulfil social needs, and domestic, where relationships break down within the family. Durkheim showed how anomie contributed to suicide, a term that he expanded to cover all intentionally self-destructive behaviour [5]. Suicide rates were highest among those most exposed to the consequences of economic transition and those whose domestic situation offered least social support, such as single men. This self-destructive behaviour frequently involved substance abuse, with alcohol playing a prominent role [6]. Although less widely recognized, many also took to opium [7]. It seems possible to extend Durkheim's analysis to many other settings. The writer Frank McCourt, in his semi-autobiographical work Angela's Ashes, describes the role played by alcohol in the process of urbanisation of Ireland in the 1920s [8]. Indigenous peoples in many parts of the world have faced especially harsh transitions at the hands of European settlers. Some have resorted to substance abuse. Ease of production means that this is most often alcohol, as with Native Americans [9] and Inuit [10]. Where alcohol is difficult to obtain, solvents such as glue and petrol provide a substitute while some other substances, such as kava among Pacific islanders and Australian Aborigines, also plays a part [11]. In some parts of Europe where old industries have disappeared but have not been replaced, another marginalized population has turned to heroin [12]. In all these situations, as Durkheim's analysis would suggest, it is those who have experienced the most rapid and uncontrolled transition and who have least social support who have suffered most. Social transitions can thus be found in many parts of the world, affecting different groups in the population to a greater or lesser extent. There is, however, one part of the world where the scale of transition over the past two decades has been on an enormous scale. This is the former Soviet Union. The process that began with the appointment of Mikhail Gorbachev as First Secretary of the Communist Party of the USSR in 1985 progressively discarded the norms and expectations that had existed since the Bolshevik revolution in 1917 [13]. The promotion of glasnost (openness) and perestroika (reconstruction) envisaged a gradual process of change, retaining the primacy of the Communist Party while introducing some elements of a market economy. The pace of change accelerated rapidly in 1991 when a failed coup led to the break-up of one of the world's two superpowers. Soviet republics who owed their boundaries to lines drawn arbitrarily on a map by Stalin were suddenly independent countries. Outside the Baltic States, where the older people could recall a period of post-war independence, few had any idea of how to go about building a nation. Inevitably, in some places this gave rise to violence, as one of the many Soviet nationalities found itself on the wrong side of a disputed frontier [14]. The economic consequences were calamitous. The USSR functioned as a single economic entity. Some republics, in particular those in central Asia, provided the raw materials and energy. Others, especially Russia, Belarus and Ukraine, undertook the final assembly. A tractor might include components from all 15 republics. The trading system based on barter could not withstand the opening of borders as those with something to sell, such as oil, diamonds or precious metals, realized that they could obtain much better prices on the now open world markets. Industrial plants that had suffered from decades of under-investment, safeguarded by large subsidies and low labour costs, could no longer compete with a new generation of manufacturers in Asia. Much of the region experienced a rapid process of deindustrialization on a scale that mirrors that of industrialization in western Europe in the 19th century. What consequences did this have for the populations involved? Nemtsov has described the important role that alcohol has played in the life of Imperial Russia and subsequently the Soviet Union for several centuries [15]. In a planned economy that emphasized heavy industrial production, alcohol was one of the few consumer goods available, giving the population something on which to spend their income and so maintain the circulation of money in the economy. Alcoholism was widespread and largely tolerated, even if officially denied. This changed in 1985, when Gorbachev decided that the loss of productivity due to drunkenness had to be tackled. He introduced a wide-ranging anti-alcohol campaign [16] and, without realizing it, set in train a massive natural experiment that has added greatly to our understanding of the role that alcohol plays in premature mortality, especially among men, in this region. Between 1985 and 1986 male life expectancy at birth increased by a remarkable 2 years [17]. Our subsequent examination of trends in mortality during this period has confirmed that the observed changes were not due to artefact but due to a range of causes that are associated with alcohol, such as injuries, suicide and pneumonia [18]. An initial surprise was the simultaneous reduction in cardiovascular deaths; further research has shown that a significant proportion of cardiac deaths, especially those that are sudden and occur in young men, can be explained by heavy episodic drinking [19]. We have been able to show that these do not represent misclassification of cases of alcohol poisoning [20]. We have also been able to identify the physiological mechanisms that make episodic heavy drinking so dangerous while regular moderate consumption, without episodes of excess, is cardioprotective [21]. The improvement in mortality following the anti-alcohol campaign was short-lived. By the end of the 1980s the authorities in the USSR were no longer able to enforce laws in the way they once could. Alcohol was being produced illegally on a massive scale, to the extent that the sugar used in its production was unobtainable in the shops; there was also indirect evidence of a large increase in consumption of a range of technical spirits. After the USSR broke apart the deterioration in life expectancy accelerated [22], again with the greatest declines among men and, in most countries, a brief improvement after 1994 reversed in the aftermath of the 1998 Russian currency crisis. The causes of death contributing to this continuing decline are largely the same as those that improved following the 1985 anti-alcohol campaign, highlighting the enormous toll of premature male deaths attributable to alcohol in this region. The exceptions are the Baltic States, now members of an enlarged European Union, where the improvement after 1994 has continued [23]. The explanation for this divergence must remain speculative but, consistent with Durkheim's analysis, these three countries have experienced the emergence of an effective civil society based on strong social networks that link the people to their governments [24], a situation that contrasts with that in countries such as Russia where, although horizontal networks exist, there are few vertical linkages between the elite and the ordinary people [25]. The process of post-Soviet transition, like that of industrialization in the 19th century in the West, brought winners and losers. In the former Soviet Union a small group of oligarchs became almost unimaginably rich overnight by taking control of former state assets. As inequalities have widened in this abrupt and socially dislocating process, which groups in post-Soviet society have borne the brunt of the transition and what role have substances such as alcohol and drugs played in this process? We have examined this issue at several levels. In the period when life expectancy was falling rapidly, in the early 1990s, it was clear that not all regions were equally affected. Most obviously, there was a group of regions along the Volga river and in the north Caucasus, characterized by significant Muslim populations, where life expectancy had fallen less than elsewhere. However, the main driver of a reduction in life expectancy was the pace of economic change, as assessed by gains and losses of jobs in large and medium enterprises [26]. When the causes of death in the different regions were compared it was clear that the gap was due almost entirely to those attributable to heavy alcohol consumption, with the excess deaths concentrated among men aged between 20 and 50 years. Where we have been able to analyse the individual characteristics of those dying, we have shown how men with least education and the least social support (in particular the unmarried) have fared worst [27]. The available evidence can be summarized as showing that the rapid fluctuations in mortality in the former Soviet Union were possible because of the scale of the shock coupled with the vulnerability of the population, with the greatest effects seen among those who were most vulnerable and who were exposed to the largest shocks [28]. But what is killing these people? To answer this question we can draw a case–control study in which information on men dying prematurely, obtained from proxy informants, was compared with surviving controls [29]. This highlighted the limitations of asking about how much people drink but revealed a substantially increased risk of premature death among those who had experienced frequent hangovers or whose drinking interfered with their work. An ongoing study is looking in even greater detail at those dying prematurely, triangulating data from proxy informants with those from a range of other sources, including independent evidence of contact with alcohol services and the criminal justice and social security systems, linked to detailed information from autopsies. While alcohol consumption in the countries of the former Soviet Union is on a sufficient scale to make a substantial impact on overall mortality it is not, of course, the only substance that causes concern. The opening of borders in this region has opened up a corridor through which large quantities of heroin are being smuggled into western Europe, primarily from Afghanistan, where the demise of the Taliban has led to a resurgence in poppy cultivation [30]. Inevitably, some of the heroin is siphoned-off en route, displacing traditional use of home-produced extracts of opium poppies [31]. The problems are greatest in some of the places that have been worst affected by the economic decline that resulted from the collapse of the USSR, in particular Ukraine and some central Asian republics. Laurie Garrett has described graphically the emergence of a population of injecting drug users living on the margins of society in Ukraine [32]. As a consequence, rates of infection with HIV are rising faster in this region than in any other part of the world, and while this has not yet impacted on mortality to a significant extent it can be expected to do so in the future. Substance abuse is therefore playing a key role in the health crisis that continues to affect the former Soviet Union, which with sub-Saharan Africa is one of only two major regions of the world where life expectancy continues to decline [33]. Yet recognition of the roles of alcohol and heroin are only the first step; what is needed is to understand why so many people seek solace in substances that will eventually kill them. This takes us back to Durkheim's analysis of the process of industrialization in western Europe. In both examples we can identify the role played by both economic and domestic anomie, with those affected most being those exposed to the most rapid change but with the fewest social and educational resources to help them cope. Of course, the presence of anomie is not the only explanation for the health crisis facing most of the countries in the former Soviet Union. In some countries, especially in the Caucasus, there is now widespread poverty, frequently exacerbated by the occurrence of catastrophic health care expenditure [34]. Others have yet to establish democratic systems and a few, such as Uzbekistan and Turkmenistan, there is widespread denial of human rights. In Turkmenistan this has a direct impact on health, as the increasingly eccentric President Niyazov has recently ordered the closure of all hospitals outside the capital city [35]. Obviously these factors also play a part in varying degrees in other parts of the world. The importance of the concept of anomie is that it provides a potential partial explanation for why some populations find it difficult to escape from their predicament. What does this say about what must happen if life expectancy in the former Soviet Union is not to continue on a downward course? As Diamond has recently shown [36], we cannot simply assume that all will be well in the long term. There are examples of entire populations that have gone beyond the point of no return, a point he illustrates by speculating what was going through the mind of the inhabitant of Easter Island who cut down the last tree on what was once a heavily forested island. Yet many societies do emerge from social transition, often stronger than when the process began. In western Europe the social breakdown that accompanied the industrial revolution gave way to the modern welfare state. The process was long and complex, but a crucial element was the emergence of strong civil society, frequently centred around voluntary organizations, such as the English Friendly Societies, or around local government, which in turn gave rise to functioning institutional structures. It is the lack of these elements that has been identified as one of the greatest barriers to the economic regeneration that is so desperately needed in this region, whether through civil society creating the transparency and accountability to control corruption or institutions to promote the rule of law and support the growth of the small and medium enterprises that are the motor of modern economies [37]. At the same time, stronger civil society and functioning institutions will help to re-establish the social and moral norms that Durkheim identifies as so important. The challenge of creating these institutions should not, however, be underestimated in a society where they have never existed to any significant extent, where membership of organizations separate from the state was often seen as a sign of dissent meriting severe punishment, and where the life of an individual had so little value. Self-destructive behaviour involving substance abuse is not just a consequence of societal breakdown; it is also a cause. This two-way relationship can all too easily give rise to a vicious cycle, in which substance abuse leads to exclusion from the work force and impoverishment, which collectively impairs the scope for economic recovery, which in turn fuels a pervasive feeling of hopelessness [38]. The solution is not easy but experience shows that this downward spiral can be interrupted and even reversed. This will require enlightened policies that give people hope for the future, a challenge in countries where the government has little legitimacy. Those former Soviet countries that have embraced democracy, the three Baltic States, have shown that it is possible to depart from the general trend and achieve sustained improvements in life expectancy [39]. It is possible that Ukraine and Georgia, countries that have undergone a democratic transition more recently, may soon follow them. But many countries in this region are very far from democracy, and cannot wait for political change. There is now considerable evidence about what does and does not work in reducing the hazardous use of alcohol [40,41] and drugs [42] and, as importantly, the harm that they cause those who continue to use them [43]. There is an urgent need to implement more widely those policies that have been shown to be effective, while taking account of local context. While it may be too much to hope that some of the more autocratic rulers will seek to implement such measures, there is some scope for nascent civil society organisations, whether focused on alcohol problems or more generally on community development, do begin to move forward. As this brief review has shown, widespread social upheaval is frequently associated with patterns of substance abuse that impact adversely on health and which, by so doing, can accentuate the adverse social and economic effects of the transition. Policy makers face the challenge of breaking out of this vicious downward spiral, finding ways of changing direction so the their populations can see a light at the end of the tunnel and are protected until they are able to make their own way towards it. This may, however, require a fundamental change in the relationship between the rulers and the ruled.

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