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Journal of the American Medical Association: March 11, 1998, ChicagoAuthor(s): Kenneth HillSource: Foreign Policy, No. 111 (Summer, 1998), pp. 157-158Published by: Washingtonpost.Newsweek Interactive, LLCStable URL: http://www.jstor.org/stable/1149392 .

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Global Newsstand

democratic governance. The rapid spread of available information will allow more people to participate in decision making, which, in turn, will lead to the inevitable devolution of power. Consequently, in stark contrast to Kaiser, Gu6henno places little faith in institutional reform, since the process of devolution renders governmental institutions less relevant. Today's "democrats," he argues, should not fret about rework- ing the mechanisms of national sovereignty, but should accept the emergence of global networks and subordinate them to public scrutiny. Democrats must always mistrust the concentration of power-be it national or transnational-and push for its devolution to private citi- zens and nongovernmental organizations. Transparency, however, car- ries a high price. In the future, Gu6henno predicts, as more and more people become involved in the decision-making process, we will see mediocre policies being implemented faster.

-Bernhard Knoll FP

Journal of the American Medical Association March 11, 1998, Chicago

A population's health is affected by myriad factors, from overall wealth to environmental pollution. But identifying the role of any one factor is difficult, not least because controlled experiments on entire popula- tions are impossible. However, a comparison of mortality patterns in Russia and Eastern Europe with those in Western Europe and the Unit- ed States over the last 40 years provides something close to a natural experiment. The results of that experiment, carried in this edition of the Journal of the American Medical Association, demonstrate the pow- erful interrelations between political economy and human survival. They also show why policymakers need to stay abreast of one of the world's preeminent medical journals.

In this edition, demographer Francis Notzon of the U.S. National Center for Health Statistics and collaborators from Russia and else- where compare recent mortality trends in Russia with those in the United States. Life expectancy in Russia remained constant (for females), or declined slowly (for males), from 1965 to 1985, while it rose steadily for both sexes in the United States. In Russia, life expectancy increased from 1985 to 1987, declined gradually for the next three years,

SUMMER 1998 157

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and then fell precipitously until 1994. By then, life expectancy for males had dropped to 58 years and for females to 71 years (compared with 72 and 79 years in the United States). The authors conclude that the mor- tality increases resulted from "rapidly declining social and economic conditions, poor personal health behaviors, and a deteriorating health- care system"-in other words, almost all the possible suspects, exclud- ing environmental contamination.

The accompanying editorial by epidemiologist David Leon of the Lon- don School of Hygiene and Tropical Medicine and demographer Vladimir Shkolnikov of the Center for Demography and Human Ecolo- gy at the Russian Academy of Sciences puts Russia's health crisis in a broader context by including evidence from Eastern Europe. Russia's mor- tality trends have been similar to Eastern Europe's, but with important dif- ferences in timing. The Russian mortality decline in 1985-87 coincided with then-premier Mikhail Gorbachev's anti-alcohol campaign, and the steep increase of the early 1990s was seen only in the countries of the for- mer Soviet Union. In Poland and Czechoslovakia, however, mortality declined sharply in the early 1990s--when it was rising fastest in Russia. Leon and Shkolnikov identify alcohol consumption as the key negative factor in Russia and suggest that increases in consumption were driven by "the stress of economic and political transformation."

What can we conclude? Access to quality health care and changes in per capita income seem to have played minor roles in Russia's mortali- ty trends, since child mortality was little affected and females fared much better than men. Instead, the remarkable similarity of time trends in mortality and alcohol consumption in Russia between 1985 and 1994 leaves little doubt that alcohol played a major role in the Russian mor- tality crisis, and identifies behavior as a major determinant of health. However, alcohol consumption should be seen as a response to changes in the socio-political environment, not as a fundamental cause in its own right. The collapse of a socio-political system destroys social capi- tal, reducing the ability of individuals to operate within the system. The comparative evidence presented in these studies suggests that this loss of control directly affects an individual's access to health care and indi- rectly affects how individuals feel about their lives, both in turn affect- ing a nation's health status and mortality rates.

-Kenneth Hill Director, Population Center

The Johns Hopkins University

158 FOREIGN POLICY

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