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International Journal of Epidemiology 2006;35:796–805
Letters to the Editor
Economy and mortality in Eastern and Western Europe between 1945 and 1990: the
largest medical trial of history
From IMRE BONCZ1* and ANDOR SEBESTYÉN2
A previous issue (December 2005) of the Journal was devoted
to publications analysing the relationship between economic
growth and mortality. The investigations presented in two
papers1,2 came to a contradictory outcome in terms of the
relation between economic growth and mortality in the United
States. We would like to draw the attention of another practical
example on this topic.
Between 1945 and 1990 Europe was divided by the ‘iron
curtain’ into two different parts: the Western European or
capitalist and the Eastern European or socialist countries. The
two groups of countries followed a different development
pattern regarding many factors including—among others—
economy and mortality. This period of 45 years in Europe can
be considered as the largest medical ‘trial’ of history.
‘The study design’ was planned during the Second World
War in the city of Jalta by the political leaders of the Soviet
Union, United Kingdom, and United States of America. The
countries (therefore the patients) were assigned into two
Figure 1 ‘The epidemiological iron curtain’ in Europe: standardized death rates for all causes, all ages per 100 000 population in 1990. Source of
data: WHO Health for All Database
1
2
Department of Health Policy, National
Administration (OEP), Budapest, Hungary.
Health
Insurance
Fund
County Baranya Health Insurance Fund Administration, National Health
Insurance Fund Administration (OEP), Pécs, Hungary.
* Corresponding author. Department of Health Policy, National Health
Insurance Fund Administration (OEP), 1139 Budapest, Váci út 73/A,
Hungary. E-mail: [email protected]
796
LETTERS TO THE EDITOR
different groups: the Western European countries and the
Eastern European countries. The two groups have been closed
for decades, i.e. there was neither any real communication
between them nor any flow of patients. The interventions
included many factors influencing health status like—among
others—lifestyle, health culture, behaviour and habits of the
population, health care infrastructure and manpower, health
expenditures, regulatory framework, environmental factors,
social deprivation, etc. The outcome of the trial can be
measured by both economic and epidemiological indicators.
Owing to the limited availability of data from the Eastern
European countries, the effect of interventions and the
outcome of the ‘trial’ could have been assessed mainly
only after the social changes of 1990. The gap in life expectancy
between the countries of Central and Eastern Europe and the
countries of Western Europe was closing up during the 1950s
and early 1960s. In the Eastern European countries mortality
rates had increased or were virtually unchanged since the
mid-1960s, especially in middle-aged and elderly men. However from the mid-1960s the health status in the former
socialist countries stagnated or deteriorated, whereas in the
Western countries it improved steadily.3 By 1990 it became
clear that on a long term, the Eastern European countries
underwent a significant decrease in life expectancy4 and an
increase in mortality while the Eastern European economies
also experienced a collapse compared with the Western ones.5
Around 1990 we realized that although the political changes
destroyed the physical iron curtain made of steel and stone it
has remained alive in epidemiological terms (Figure 1).
The epidemiological and economic indicators showed a
further decline after the social and political changes in 1990
on a short term. In Eastern Europe cardiovascular mortality
rates reached a maximum in the period 1990–94.6 By 1990
there was a 4 year gap in life expectancy, which, by 1997, in
men, had widened to 6 years. The decrease in gross domestic
product (GDP) was 3% in the Czech Republic, 13% in
Hungary, 42% in Lithuania and Russia, and 60% in Ukraine.
Mortality changes after 1989 in Eastern Europe were correlated
with changes in GDP and changes in income inequalities.5
797
The papers by Tapia Granados1 and Brenner2 reveal the
importance of within country changes in mortality and economy
based on the example of the United States, but we would like
to emphasize this relationship between the countries of Eastern
and Western Europe.7 The political status and economic
background of the two parts of Europe between 1945 and
1990 with the existence of the iron curtain had a significant
effect on the health status of the population, which should be
investigated more in detail.8
Conflict of interest: None.
References
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2
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7
8
Tapia Granados JA. Increasing mortality during the expansions of the
US economy, 1900–1996. Int J Epidemiol 2005;34:1194–202.
Brenner MH. Economic growth is the basis of mortality rate decline in
the 20th century—experience of the United States 1901–2000. Int J
Epidemiol 2005;34:1214–21.
Forster DP, Jozan
1990;335:458–60.
P.
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Lancet
Chenet L, McKee M, Fulop N et al. Changing life expectancy in
central Europe: is there a single reason? J Public Health Med
1996;18:329–36.
Marmot M, Bobak M. International comparators and poverty and
health in Europe. BMJ 2000;321:1124–28.
Kesteloot H, Sans S, Kromhout D. Dynamics of cardiovascular and
all-cause mortality in Western and Eastern Europe between 1970 and
2000. Eur Heart J 2006;27:107–13.
Marmot M. Epidemiology of socioeconomic status and health: are
determinants within countries the same as between countries? Ann N
Y Acad Sci 1999;896:16–29.
Boncz I, Klazinga N, Rutten F. East–west life expectancy and health
expenditure gap in Europe: a case study from behind the iron curtain.
Presented at the Public Health Association of Australia 32nd Annual
Conference, Australia, Canberra, November 26–29, 2000.
doi:10.1093/ije/dyl075
Advance Access publication 25 April 2006
Centrally planned economies, economic slumps, and health conditions
From JOSÉ A TAPIA GRANADOS
I am not sure why Boncz and Sebestyén,1 while ignoring
contributors providing specific comments on Eastern Europe to
the IJE debate on mortality and economic growth,2,3 refer in
their letter to other contributions4,5 in which nothing is said
about the issue. Whatever Boncz and Sebestyén’s reasons for
this, they discuss colourfully the division of Europe in Yalta
(1945) into an American and a Russian sphere of influence,
Institute of Labor and Industrial Relations and School of Social Work,
University of Michigan, Ann Arbor, MI, USA.
E-mail: [email protected]
describing it as ‘the largest medical trial in history,’ in which
the two groups of patients—countries—separated by ‘the iron
curtain,’ were assigned to two different treatments, ‘capitalism’
and ‘socialism.’ Clever or gaudy, the metaphor seems to be
stretched and I am doubtful to what extent it may be useful as
a heuristic device. Indeed, a large portion of one ‘treatment
group,’ the USSR, had been ‘treated’ from 1917. Then, after
1945, countries like China, Cuba, Vietnam, Ethiopia, etc. were
included in a similar ‘treatment’ group, though this happened
in other continents and not behind the European ‘iron curtain.’
Insofar as ‘the iron curtain’ refers to the lack of civil liberties,