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Epidemiologic transition theory exceptions
Graziella Caselli, France Meslé* and Jacques Vallin**
*Dipartimento di Scienze Demografiche Rome^1 **Institut national d'études démographiques, Paris^2
Introduction
Abdel Omran’s 1971 theory of epidemiological transition is an attempt to account for the extraordinary advances in health care made in industrialized countries since the 18 th century. According to Omran, all societies experience three "ages" in the process of modernization: the "age of pestilence and famine", during which mortality is high and fluctuating, with an average life expectancy under 30 years; the "age of receding pandemics", during with life expectancy rises considerably, from under 30 to over 50 3 ; and the "age of degenerative and man-made diseases", during which the pace of the mortality decrease slackens, while the disappearance of infectious diseases increases the visibility of degenerative diseases, while man-made diseases become more and more frequent. At the time Abdel Omran was developing his theory of epidemiologic transition, the most competent specialists, along with United Nations experts, saw life expectancies as generally converging towards a maximum age, the most advanced countries seeming very close to it. According to the United Nations World Population Prospects, the point of convergence was 75 years (United Nations, 1975).. And as things now stand in the most advanced countries, the increase in life expectancy has slowed down since the 1960s and in some countries has even halted, in particular as concerns men. The "cardiovascular revolution" of the 1970s launched a new period of progress. However, Jay Olshansky and Brian Ault (1986), followed by Richard Rogers and Robert Hackenberg (1987), without criticizing the basic premises of the theory of epidemiologic transition, introduced the idea of a "fourth stage" 4 during which the maximum point of convergence of life expectancies would seem to increase thanks to achievements in the treatment of cardiovascular diseases. Jay Olshansky et al. (1990) set this new maximum at 85 years, the same as that chosen by the United Nations at the end of the 1980s for all countries (United Nations, 1989).
(^1) Via Nomentana 41, 00161, Roma, e-mail : graziella.caselli@uniroma1.it (^2) 133 Bd. Davout, 75980 Paris cedex 20. E-mail: mesle@ined.fr and vallin@ined.fr (^3) See also Caselli (1991) for a description of epidemiologic changes in Europe at the turn of the 20 th (^) century. (^4) Olshansky and Ault: "A fourth stage of the epidemiologic transition". The others refer to a "new" or
"hybristic" stage.
Today, the 85-year threshold is strongly criticized by many authors who believe that such a limit cannot be determined (Barbi et al, 1999; Vaupel, 2001; Carey and Judge, 2001). However, our aim in this article is not to discuss this aspect of the epidemiologic transition, but to study the numerous exceptions observed since the 1960s in the general trend of increasing life expectancy. Not only have many countries (in particular Eastern European countries) lacked the means to experience the "cardiovascular revolution", but a number of others, especially in Africa, have not yet completed the second phase of the epidemiologic transition and are now hard hit by the arrival of new epidemics such as AIDS, or by the reemergence of older diseases. After a brief overview of the first "disruption" of the 1960s, which put an end in the advanced countries of the North to the convergence observed in previous decades, and of the second failure which affected countries of the South, in particular due to the AIDS epidemic, we will see that the fact that Africa has lagged behind the North can be interpreted as a failure to complete the second phase of the epidemiologic transition; in the third part of this article, we will examine the reasons why Eastern Europe has failed to enter the fourth phase.
I. From convergence to divergence
At the time Abdel Omran was developing his theory of epidemiologic transition, events seemed to justify his views. The least-developed countries, in full transition, were gaining control over infectious diseases, and they seemed to be rapidly catching up with the most advanced countries; these, for their part, seemed to have reached a threshold, since the incidence of infectious diseases had been so far reduced that any further reduction could not represent any significant gain in the average life expectancy. What was most feared at the time was that some of these gains in life expectancy might be lost due to the increase in man- made diseases 5 — caused by smoking or car accidents, for instance; these dangers seemed more probable than the prospects of new progress in fields then thought to be governed by the inevitable degeneration of age, such as cancer and cardiovascular diseases. Thus, towards the end of the 1950s, life expectancy in the United States had reached a threshold of about 70, and Russia and Japan were close to reaching that level (see Figure 1).
What Omran's theory could not foresee was that the rise of man-made diseases would be curbed by efficient policies, and especially, that a true revolution was going to take place in the treatment of cardio-vascular diseases. Towards the end of the 1960s, this revolution triggered new advances in life expectancy in countries where it had reached or even exceeded 70 years (Caselli, 1996). However, the countries which reached the latter level were not all able to enter this new phase of the health transition. In the mid-1960s, life expectancy in countries of Eastern Europe and the USSR began on the contrary to stagnate or even decline, due to an increase in mortality from cardiovascular diseases and to the spread of man-made diseases (linked in particular to alcoholism and violence).
The developing countries began their health transition process at a later stage, and by the early 1950s, their average life expectancies were much lower than those of developed
(^5) "Man-made diseases" are diseases linked to the side effects of modernization (alcoholism, smoking, car
accidents, etc.)
to 40 years, while Zimbabwe’s life expectancy has fallen far below its 1950 level (42.9 as compared to 47.7).
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Figure 2. Changes in life expectancy since the 1950s : North-South convergences
(A) and South-South divergences (B)
(Source: United Nations 2001)
These disruptions strongly modify the overall pattern governing life expectancy trends until the 1970s. Figure 3A compares life expectancy gains between 1950-1955 and 1970-75 with the level reached by 1950-55. A glance to the figure clearly shows that at the lower levels (between 30 and 40 years), despite considerable variations, progress is usually rather limited (from 3 to 10 years in 20 years). The countries with a life expectancy of over 40 advanced more rapidly: those whose life expectancy was between 45 and 55 in 1950-55 gained from 9 to 15 years (and even more than 20 years in the case of China, an exceptional achievement). Last, in countries where life expectancy was rather high in the early 1950s, advances were much less spectacular: from 2 to 5 years in cases where life expectancy was over 65 in the early 1950s. Indeed, at first, in countries barely out of the "age of pestilence and famine", where life expectancy was still low, progress was slow, owing to the scope of the task and to the fact that the first advances benefited only a fraction of the population, mostly urban. At a later stage, as the health system reached its full capacity, simple and effective means to curb widespread endemic diseases were implemented throughout the country and life expectancy rapidly grew. However, as we move closer to life expectancy levels reached in developed countries, the pace slows down again, both because there is no longer much to be gained in the field of infectious diseases, and because subsequent progress relies on new findings in other domains (cardiovascular diseases, cancers, man-made diseases). In the past twenty years, however, this now well-known pattern (Vallin, 1968, 1989) has suffered several exceptions (Meslé and Vallin, 1997). Figure 3B is based on the same principle as Figure 3A, and covers the period from 1970-75 to 1995-2000. In this figure, the
picture is much less clear than in the previous one. Many countries still follow the previous pattern (even China), but there are numerous exceptions which concern very specific geopolitical areas. On one hand, many countries of tropical Africa are advancing at a much slower pace than other countries with similar life expectancy levels. Kenya, for example, with a life expectancy of over 50 years in 1970-75, gained less than Sierra Leone, whose life expectancy was only 35 in the early 70s. But above all, the AIDS epidemic triggered a decrease, and in some cases a sharp drop in the life expectancy levels of many African countries (about 10), among which Zambia, Zimbabwe, as mentioned earlier, as well as Botswana, Rwanda, Uganda, Namibia, etc. On the other hand, among the countries with the highest life expectancies in 1970-75, those of Eastern Europe (Central Europe and European republics of the former USSR) embarked on a period of stagnation and even decline, a shared phenomenon which clearly sets these countries apart from other industrialized countries.
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Figure 3. Relationship between initial level and life expectancy gains during two
periods: A) from 1950-55 to 1970-75 ; B) from 1970-75 to 1995-
These developments have radically modified the distribution of the world population in terms of life expectancy. Figure 4 illustrates, at three different points in time (1950-55, 1970- 75 and 1995-2000), the cumulated populations of all the countries of the world, grouped per five-year sections of life expectancy at birth; developed and developing countries are identified separately, according to the UN definition (Figures 4A, B and C). The dominating trend, from one period to the next, is the massive convergence of southern levels towards northern levels. In 1950-55, the life expectancies of most of the developing countries hovered somewhere between 35 and 45 years, far behind most developed countries, which for the most part neared a life expectancy of 65-70. In 1970-75, the wealthy countries still remained a close-knit group, adding another five years to their life expectancy, but the poor countries suddenly broke into separate groups, with a large portion of their populations nearly catching
developing countries. Many other countries (3 rd^ graph, Figure 5) which until the 1980s had been following the same trend stopped in their tracks or even slightly regressed. This is the case of Ghana, Tanzania, Cameroon, Nigeria, Angola, etc. Next are the countries whose life expectancy actually declined over the last two decades, either slightly, like Côte d'Ivoire, the Central African Republic or Burkina Faso, or too recently for purposes of evaluation, such as South Africa, Lesotho or Kenya, Uganda being somewhere in between (Figure 5, 4 th^ graph); in other countries, the decline was very sharp, as in Botswana, Zimbabwe, Namibia and Zambia (5 th^ graph). The 6 th^ graph of Figure 5 illustrates the cases of countries where the increase of life expectancy was hampered in various ways by war or other forms of political violence. In addition to the consequences of the latter situations, Sub-Saharan Africa faces two basic, though different problems. On one hand, it seems that unlike other developing countries, the countries of Sub-Saharan Africa failed to make rapid advances in the field of health once they had reached a certain level of life expectancy. At best, they managed to preserve the slow pace characteristic of the "take-off" phase. Thus, South Africa, which had already exceeded a 45-year life expectancy in the 1950s, did not progress any faster than Guinea or Chad, which had a life expectancy of barely over 30 years in 1950. In addition, in many cases, all progress stopped towards the end of the 1980s. For many of these countries, especially those where life expectancy levels suddenly dropped, the arrival of AIDS is of course to blame (Population Division, 1998; Caraël et Schwartländer, 1998; Awusabo-Asare et al , 1997; IUSSP, 1997). However, this disruption could also be due either to the economic crisis which hit Sub- Saharan Africa in the 1980s (Coussy and Vallin, 1996) or to the reappearance of infectious diseases other than AIDS — a reemergence linked indirectly with economic crisis, but doubtless with other factors as well. (Feachem and Jamison, 1991; Gruénais and Pourtier, 2000).
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Figure 5. Life expectancy at birth: trends since 1950 in all African countries with
a population of over 1.5 million in 2000
(Source: United Nations, 2001)
A) Slower progress than might have been expected
Unfortunately, the only information at our disposal concerning age-specific and cause- specific death probabilities is incomplete. Concerning infant and child mortality, however, which in Sub-Saharan Africa determines for a large part life expectancy at birth, the data provided by various studies and in particular demographic health surveys (DHS-Demographic Health Survey) are a solid basis for analysis. In almost all the African countries where several surveys have been carried out since the 1950s 8 , infant and child mortality declined significantly, at least until the 1980s (Hill, 1989, 1991, 1993; Barbieri and Vallin, 1996, Timaeus, 1998). However, in all these countries, the pace of the decline was relatively slow. Figure 6 compares the findings obtained for several countries where life expectancy grew relatively steadily, at least until the end of the 1980s, with infant-child mortality trends observed in Tunisia, a North African country where life expectancy followed the traditional pattern, in other words gained momentum after a slower "take-off" phase.
(^8) World fertility survey, demographic health surveys, national specific surveys, etc. Overall, about thirty
countries of Sub-Saharan Africa now have at least two precise surveys which can reveal a real trend.
Figure 6. Comparative trends of death probability between 0 and 5 years in two
countries of Sub-Saharan Africa and in Tunisia
(Sources: Waltisperger et al , 2001, for Tunisia; Hill, 1993, for the less recent data; Kourguéni et al , 1993 and Attama et al , 1999 for Niger, Timaeus, 1998, for Ghana)
B) The economic crisis, AIDS and the reemergence of infectious diseases
Above and beyond the generally observed slow decline of infant and child mortality, in recent years many countries of Sub-Saharan Africa have not made any progress at all in this domain; in some cases, the mortality of young children has even increased. This is particularly true in countries most affected by AIDS. A comparison with Tunisia shows a striking contrast: in Zambia, Zimbabwe or Uganda, the declining trend is reversed, whereas in Tunisia, it speeds up (see Figure 7). We also note that in Zambia, the reversal was sudden and lasting, whereas in Uganda, it was less spectacular and soon replaced by a renewed phase of decline. This is probably is due to the fact that the epidemic spread in different ways in each country. In Uganda, the epidemic began earlier, but its progress has slowed down in recent years. It could be that in this context, mother-to-child transmissions were less widespread than in Zambia, where the epidemic broke out more recently but with greater violence. The case of Zimbabwe is the most striking, even though there has been some criticism of survey results. Demographic health surveys usually provide three relatively reliable angles of observation, respectively the periods covering 0-4 years, 5-9 years and 10-14 years preceding the survey. In some cases, however, the data collected for the earlier period is less reliable, not only because of the respondents' memory lapses, but also because the samples do not include women aged over 55 at the time of the survey. Also the mortality of children born to the older women 10 to 14 years before the survey was probably higher than that of children born to younger women. These problems seem to have had a greater impact on the Zimbabwe surveys of 1988-1989 and 1999 than on the others (CSO, 1989). In fact, if we overlook the earlier periods of each survey, the trend observed in Zimbabwe appears very coherent and, of the 3 countries, clearly shows the most sudden reversal: thus, from 1976-80 to 1985-89, infant and child mortality declined almost as fast in Zimbabwe as in Tunisia, an exceptional feat in Sub-Saharan Africa. However, as the country was particularly hard hit by the AIDS epidemic, this caused a sharp increase in infant and child mortality beginning in the early 1990s.
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Figure 7. Comparison of death probability trends between 0 and 5 years in three
countries of Sub-Saharan Africa affected by AIDS and in Tunisia.
(Sources: Waltisperger et al. , 2001, for Tunisia; Gaisie et al , 1993 and CSO, 1997, for Zambia; CSO, 1989,1995 and 2000 for Zimbabwe; Kaijuka et al. , 1989 and Statistics Department, 1996 for Uganda; Hill, 1993 for the earlier data)
In this respect, it is interesting to establish a distinction between infant mortality in the stricter sense of the term and the mortality of children aged 1 to 4 (see table 1). Both the decline and the recent rise are more marked for the second group, which is more vulnerable to infectious diseases than the first. Unlike the other countries of Sub-Saharan Africa, until the 1980s, Zimbabwe was going through a phase of eradication of mortality from infectious diseases, which the advent of AIDS has completely undermined. However, although AIDS affects more children aged 1 to 4 than newborn babies, one must not forget that it is mainly an adult’s disease. Unfortunately, data on adult mortality is even more rare and deficient than child mortality data. The demographic health surveys nevertheless provide some interesting findings thanks to the sibling method (women are asked about the survival of their brothers and sisters). Ian Timaeus (1998) has recently carried out an excellent systematic analysis of the data pertaining to 11 countries for which this type of information was available. In the 6 countries highly affected by AIDS, adult mortality increased sharply, whereas in the 5 others, it decreased. In Zimbabwe, for example, the death probability at 15-60 years nearly tripled for males and more than doubled for females between the 1988-1989 and the 1994 surveys, whereas in Senegal, it declined by 25% for males and 40% for females.
Table 1. Death probability trends in Zimbabwe at age 0 and ages 1 to 4,
according to the last two DHS
(Sources: CSO 1995 and 2000) Period Probability of death (p. 1000) 1q0 4q1 5q DHS 1994 1980-84 59.6 44.4 101. 1985-89 49.6 26.5 75. 1990-94 52.8 25.6 77. DHS 1999 1990-94 53.8 24.4 76. 1995-99 65.0 39.6 102.
The survey findings, however, cover different periods depending on when the surveys were carried out, and as concerns Zimbabwe, a new survey has been made since Ian Timaeus’s study. The 1999 survey shows that the situation has largely deteriorated since the 1994 survey (Figure 8). In order to show the changes in adult age-specific mortality from one
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Figure 9. Recent trends of adult mortality in three countries affected by AIDS:
proportional ratio of age-specific mortality rates provided by the last DHS to
model life tables 10.
(Sources Statistics Department, 1996, for Uganda ; CSO, 1997 for Zambia ; CSO, 2000, for Zimbabwe) The distortion of the mortality curve is of course the consequence of AIDS, which affects mainly sexually active adults. We can see that HIV is transmitted heterosexually in the fact that excess mortality in comparison to model tables affects females at a much younger age than males, especially in Zambia and Zimbabwe, where the epidemic is more recent and more violent than in Uganda. To conclude on the failure of the process of epidemiologic transition due to AIDS, it must be recalled that in some countries the epidemic has broken out only recently and that the consequences will probably be much more extensive than what can be surmised from available surveys. Using models simulating the development of the epidemic, the United Nations has calculated possible consequences on life expectancy in 29 African countries, 3 Asian countries and 2 Latin American countries (Population Division, 2000). On the basis of the estimated prevalence of HIV infections, the authors of the study elaborated a model of HIV incidence and expected trends with a view to calculating the incidence of deaths caused by AIDS. Among these 34 countries, six will be particularly affected by AIDS. All are located in eastern or southern Africa (see Figure 10). Between the highest level of life expectancy ever observed and the estimated or projected lowest point, Zambia should lose 11 years of life expectancy, Namibia nearly 13, Zimbabwe almost 17; South Africa runs the risk of losing more than 18 years, Lesotho over 21 and Botswana over 26. When the results obtained for each country are reinserted into global regional projections, the most strongly affected regions are clearly southern and eastern Africa; but no part of Sub-Saharan Africa has been spared, and in that respect the contrast with North Africa is striking (see Figure 11).
(^10) For each country and each sex, we have chosen the Coale and Demeny model life tables, West model, with the
infant mortality level closest to those observed during the survey: levels 15 (female) and 16 (male) for Uganda and Zambia and levels 19 and 20 for Zimbabwe.
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Figure 10. Past and projected trends for life expectancy at birth in the six
countries most affected by AIDS
(Sources: United Nations 2001) Thus, as regards Africa, the AIDS factor has the strongest deviating impact on the classical pattern of epidemiologic transition. The sudden arrival of this new infectious disease along with its host of opportunistic diseases might even pull many African countries back to life expectancy levels that were prevalent at the very beginning of the second phase of Omran’s transition. It is true that once the epidemic is curbed, their situation should improve much faster than before the epidemic, according to UN projections. However, AIDS is not the only deviating factor. We have already mentioned the impact of wars and other forms of political violence, which unfortunately are quite frequent in Africa — in Mozambique, Ethiopia, Rwanda, Sierra Leone, Liberia, Eritrea, Somalia, Angola, Democratic Republic of Congo, etc. Some data is available concerning these factors, but most often information is lacking, either owing to the nature of the situation itself, or because the countries most affected are also those where government statistics are most deficient. In some cases, like Rwanda for example, genocide has reduced life expectancy as much as AIDS. Once again, Africa seems to have trouble getting rid of a death cause typical of the first and second phases of the epidemiologic transition.
other developed countries has widened since the mid-1960s. On either side, the countries are shown by geographic zone, in order to make the overall opposition between East and West appear more clearly. For males, there is a total opposition on either side of the diagonal between the 1995 and 1965 values. A large cloud of highly correlated points (R = 0.79), parallel to the diagonal and far above it, faces another cloud, also highly correlated (R= 0.72) and located parallel to the diagonal, but this time far beneath, while a third cloud is located right on the diagonal. The first cloud includes countries which made considerable progress from 1965 to 1995, with, as can be seen, life expectancy gains of about 5 years. These are countries of the north, west, and south of Europe or non-European developed countries. The second cloud is that of countries where life expectancy on the contrary declined, also in a very homogenous way, with a loss of about five years. These are the European states of the former USSR. Lastly, the third cloud is made up of countries where life expectancy hardly changed between 1965 and 1995. These are countries of Central Europe. The opposition is less spectacular among females because the gap is smaller between the countries where life expectancy advanced and those in which it declined. This is mainly due to the fact that in the countries where female life expectancy decreased, the decline was not as steep as that of male life expectancy, and in the countries where it grew, the increase was not much greater than that of male life expectancy. However, if we draw a diagonal corresponding to a gain of a little less than two years of life expectancy, we obtain just about the same picture as that of the male situation 11 , with the cloud representing Central Europe, where male life expectancy did not increase, located right on the diagonal. In order to better illustrate the East-West divergence, we will first carry out a demographic analysis of trends in mortality and death causes, and we will next examine whether a multidimensional statistical analysis can help us shed more light on the subject.
A) Reemergence of the East-West divergence
Although none of the Eastern European countries took part in the health improvements made by most industrialized countries since the 1970s, Central Europe and the former USSR experienced this health crisis in different ways (Vallin and Meslé, 2000). Let us add that the Asian states of the former USSR, both in Central Asia and in the Caucasus, were also affected in different ways. In any case, given the lack of reliable data, the latter countries are not included in the present analysis.
1. Specific Eastern Europe trends
There are two differences between Central European countries and the European states of the former USSR. First, since 1965, the situation has deteriorated to a lesser extent in the former than in the latter countries (which explains the result observed in Figure 12). As shown in Figures 13a and 13b, the life expectancy of Central European males stagnated or slightly declined, whereas that of females slightly increased. In the countries of the former Soviet Union, on the contrary, male life expectancy underwent a sharp decline whereas female life expectancy stagnated.
(^11) The coefficients of correlation are just as high (0.83 and 0.84).
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Figure 13b. Annual trend, since 1950, of life expectancy at birth in countries of
Central Europe and the former USSR. Females.
2. Atypical age patterns The decline of life expectancy in Eastern European countries is closely linked to the uncommon distortion of the structure of age-specific mortality. In order to illustrate this phenomenon, we compared age-specific mortality rates in different countries of Central Europe and the former USSR to model tables. We used as a reference the Coale and Demeny model life tables, model West (1983), at life expectancy levels corresponding more or less to the average observed in Eastern Europe towards 1965: level 21 (e 0 = 66.0 years) for males and 22 (e 0 = 75.5 years) for females. In 1965, among females in all the countries and among males in Central Europe, the age-specific mortality structure was not very different from that of the models (see Figure 14). However, in the countries of the former USSR, age-specific male mortality was already atypical, with a significant excess mortality between the ages of 25 and 55. By 1995, this problem had become more acute in the countries where it already existed and had spread to almost all the countries of the former USSR, for both male and female life expectancy. The phenomenon is particularly widespread among males in Russia and Latvia. Conversely, there is practically no sign of it in the Czech Republic. More generally speaking, there is a significant difference between the countries of Central Europe and those of the former USSR, not only in terms of intensity, but also in terms of the ages concerned: in the countries of the former USSR, excess mortality is already quite high between the ages of 20 and 35, whereas in Central Europe, it becomes really apparent only after 35. In reality, as can be seen through the life expectancy changes described in Figures 13a and 13b, the comparison between the situations of 1995 and 1965 covers different historical developments for each region, each having gone through its own specific phases. These must be identified in order to provide a correct interpretation of the present consequences of these more or less long-lasting health crises. 3. The importance of cardiovascular and man-made diseases. The most important difference between East and West concerns mortality due to cardiovascuar disease. To illustrate this fact, we will compare mortality trends due to cardiovascular disease in France, the United Kingdom, Poland and Russia (see Figure 15). In the early 70s, both Western countries were successfully overcoming cardiovascular diseases,
while the Eastern countries, on the contrary, were unable to curb the increase in mortality due to these diseases. The difference is quite significant, regardless of sex. True, towards the mid-60s, in Poland and Russia, the situation of males had deteriorated much more than that of females. But in France and in the United Kingdom, on the contrary, females made rapid progress as early as the early 1950s, much earlier than males, and as a result the sudden progress of the 1970s was less marked for females than for males. Since these two phenomena are complementary, the gap between East and West is just as wide for either sex.
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Figure 14. Ratio of age-specific mortality rates observed in Eastern European
countries to those of the model life tables of Coale and Demeny, model West.
Males: level 21 (e 0 = 66.0 years); females: level 22 (e 0 = 72.5 years)
Mortality due to cardiovascular disease is not the only explanation for the gap between East and West. In Eastern Europe, the increase in the incidence of man-made diseases must also be taken into account. Gorbachev’s 1985 anti-alcohol campaign revealed to what extent Soviet mortality was related to alcohol consumption, since life expectancy suddenly shot up
