Overall, New Deal programs not only helped avert further economic disaster but also were statistically correlated to large and lasting public health improvements. The Great Depression created conditions that public health experts expected would spread infectious diseases, but infections fell steadily—with the biggest declines in the cities and states where New Deal housing programs helped prevent excessive crowding. Across the United States, each $100 per capita of New Deal spending was, on average, linked to declines in pneumonia by about eighteen deaths per 100,000 people—a remarkable improvement at a time when effective drugs to combat the disease were not widely available.
The New Deal also helped improve children’s survival, as construction and rebuilding programs prevented shantytowns from becoming slums where stagnant water and overcrowding often led to diarrhea and childhood respiratory tract infections. Across the United States, each $100 per capita of New Deal spending was on average linked to reductions in infant deaths by eighteen per 1,000 live births.
And the New Deal was associated with reduced suicide rates. As shown in Figure 1.3, the first year of the New Deal (1933) marked the turning point in the rise in suicides. Using extensive statistical models controlling for alternative explanations, we found that each additional $100 per person of New Deal spending was associated with a significant decline in suicides by four per every 100,000 people.
At the time, the American medical community was impressed by the results. Dr. William Welch, president of the American Medical Association, maintained that government investment in public health programs was not only a matter of saving lives and improving people’s quality of life, but also making sound investments that would benefit the economy. “Any undue retrenchment in health,” said Welch, “is bound to be paid for in dollars and cents as well as in the impairment of the people’s health generally. We can demonstrate convincingly that returns in economic and social welfare from expenditures for public health service are far in excess of their costs.”41
Welch was right—the New Deal programs were affordable even during Depression times. By today’s standards, they still offer good value for the money. The social protection programs were as cost-effective, with similar costs per life saved, as common medications.42
Overall, the size of these New Deal relief programs constituted less than 20 percent of the gross domestic product. And they not only reduced deaths but also sped up economic recovery. The New Deal brought an immediate 9 percent rise in average American income, increasing people’s spending and helping to create new jobs. Rather than creating a vicious negative spiral of increasing debt and deficits, as critics of the New Deal had predicted, the stimulus helped the US economy grow out of debt.43
At the time, politicians and the public didn’t have access to data that we have at our disposal. In hindsight, it is possible to see clearly the lasting benefits of the New Deal, both to the economy and to public health.44
Undoubtedly, many of the health effects of the Great Recession will differ from those of the Great Depression. Prohibition is no longer in place, and our investigation into alcohol-related deaths during the Great Recession has found that more Britons and Americans are choosing to abstain from alcohol to save money. But we also found that a small, at-risk group has had the opposite reaction to our current recession: when faced with unemployment, they began drinking heavily. In the UK, where most people are still employed and drinking less overall, those people who lost work during the recession were much more likely to binge drink. Similarly, most Americans are drinking less during the Great Recession, but there is a hidden group of about 770,000 who now drink more dangerously, often landing in emergency rooms. These Americans have experienced a spike in death rates from acute intoxication and alcohol-induced liver failure.45
Political leaders on both sides of the Atlantic now face choices similar to those confronted by Hoover and Roosevelt. Another large, natural experiment is being unleashed on the people of both countries. Under Prime Minister Cameron’s austerity measures in the UK, we see more and more sad stories like that of Brian and Kieran McArdle. The UK economy has yet to recover, as its debt continues to rise. Meanwhile in the US, President Obama is constantly battling with Republican deficit hawks, but has insisted on keeping and strengthening the safety net. And while not quite going so far as a New Deal, the US stimulus has helped lead the country to a slow but real recovery so far.
What the Great Depression shows us is that even the worst economic catastrophe need not cause people’s health to suffer, if politicians take the right steps to protect people’s health. The Great Recession involves a fundamental political choice: whether to apply the lessons of the Great Depression and the New Deal, or to chart an altogether different path that could have dire consequences.
2
THE POST-COMMUNIST MORTALITY CRISIS
Ten million Russian men disappeared in the early 1990s.
The Russian Republic of the Soviet Union had more than 147 million residents. Its population had been growing at the same rate as the United Kingdom in 1990 and 1991, at about 0.3 percent per year. But in 1992, Russia’s population began to vanish. The United Nations had been tracking data on the populations of all nations, and when they noticed this drop, they contacted a team of researchers in Russia.1
The research team set out across the country to investigate. They saw signs that something was amiss when they reached the country’s mono-industrial settlements (mono-gorod)—towns set up by the Soviets to support its military and economy, where everything was planned to the last detail. The mono-towns were so named because they had only one business; the Communist Party had forced each village to specialize. Pitkyaranta, for example, was designed to mill lumber; Norilsk was a giant nickel factory; and several Siberian cities were customized for mining coal. One mining town, Kadykchan, was deep in Siberia’s Magadan region. It had been built by Stalin’s prisoners during World War II to provide coal for the Soviet military. Everything in the town revolved around the mines, and after the war the Soviets thought through all that would be needed for its residents: schools and hospitals next to the factories, housing for the workers and their families, and even holiday resorts a short weekend’s trip away. All of life necessities were in place, designed to support the town’s sole purpose: extracting coal for the Soviet state.
When the research team reached Kadykchan and its neighboring towns, they found what looked like a post-Chernobyl disaster or a ghost town: windows broken, storefronts boarded up. A sculpture of Joseph Stalin’s head that once gazed sternly atop the town hall had crumbled, his jaw eroded into a hollow cavity filled by birds’ nests. Enormous Soviet steel mills had been stripped to pieces, frozen over into large, silenced blocks of ice. Inside the factory, metal tools had caked with rust, and factory floors had overgrown with tomato and potato plants, converted into a garden plot.
At their peak, the Soviet mono-towns had between 10,000 and 100,000 residents, depending on the needs of the industry. Kadykchan once had 11,000 residents. By 1989, at the time of the last Soviet census, the population numbered 6,000. In 2000, when the Russian demographers conducted their visit, there were under 1,000. The population now were mostly women, children, and babushkas (Russian grandmothers), peering curiously through the cracked windows.
Where had all the men gone?2
The answer, it turned out, was hidden in the history of Russia’s turbulent transition from a Soviet Socialist Republic to a Western market economy. The missing men were indicative of a broader collapse that had come with the rapid transition to a capitalist economy. It led to a massive tragedy in its own right—a demographic crisis that still haunts Russia today, and one that was eminently avoidable. The post-communist mortality crisis resulted not from the decision to transition to capitalism, but from specific policy choices about how to manage that transition that turned out to have dire consequences.
In the early 1990s, Russia’s economic system collapsed. Its GDP fell by more than a third, a cata
strophe on a scale not seen in industrialized nations since the Great Depression in the United States. In terms of purchasing power, Russia’s economy in the mid-1990s shrank to the equivalent of the US in 1897. While officially unemployment was zero in the Soviet era, it jumped to 22 percent by 1998. In 1995, government statistics found one-quarter of the population were living in poverty, but independent survey data revealed the poverty rate to be much higher, at more than 40 percent of the population. A decade after the transition to capitalism began, the World Bank estimated that one-quarter of the population were living on less than $2 per day, and people living in the Soviet Union’s former republics reported that they didn’t have enough money to cover their basic nutrition.3
As the Soviet Union began to disintegrate, the fall of one Soviet town’s factory set in motion a domino-like chain reaction. Soviet mono-towns depended on each other for supplies and parts, materials that no other companies in the world manufactured. In time, as one firm went under, it bankrupted its dependent Soviet mono-towns. Virtually overnight, the whole purpose of the Soviet mono-town ceased to be. People were left stranded in remote corners of Siberia, thousands of miles from the large cities of Moscow and St. Petersburg. To survive, they ate potato peelings and foraged in the forests for roots and berries. And there was the boredom, endless boredom. People had nothing to do, nowhere to go, and little hope for a better future.4
It was during that rapid transition that men began to die at an increasing rate. During Russia’s move to the new market economy, men in towns and cities began to disappear—not old or frail men, but young men who would have otherwise been the vital force of the economy. The US Bureau of the Census had forecast that the Soviet Union’s workforce would grow from 149 million in 1985 to 164 million in 1998—projections that were correct until 1990, after which the actual numbers fell to 144 million in 1998.5
Soon after the population data became public in 1999, the UN’s investigative team published their official report, warning that “a human crisis of monumental proportions is emerging in the former Soviet Union, as the transition years have literally been lethal for a great many people.” As shown in Figure 2.1, life expectancy among Russian men dropped from sixty-four to fifty-seven years of age between 1991 and 1994.6
What became known as “the post-communist mortality crisis” turned out to be the worst drop in life expectancy in the past half-century in any country that wasn’t an active war zone or experiencing a famine.7
But the connection between the economic collapse of the mono-towns and the soaring death rates was not immediately clear. We had learned from the Great Depression that even a terrible market crash was no guarantee of a mortality crisis. So if a crashing economy didn’t necessarily equate to a mass rise in deaths, what had caused so many Russian men to die during the economic depression of the 1990s?
We set out to investigate. Our first thought, as we looked into death certificates from this period, was that perhaps these data weren’t real. The Soviet regime was known to have kept its secrets; indeed, the KGB, the Soviet secret service police, could make a man disappear without a trace. Perhaps these men had been killed long ago and their deaths were only now coming to light, after the Russians let independent French and Russian demographers access the data to keep track. Or perhaps the Soviets had inflated their reports of the size of its male population—seeking to intimidate Western countries about their prospects for military recruitment. (This was hardly a far-fetched idea: In 1976, the Communist Party had launched a Commission on the Non-Publication of Data, whose members argued, “We must not reveal the number of boys born. Our enemies could use this information. We must make it a state secret.”)9
FIGURE 2.1 Post-communist Mortality Crisis8
To check whether the rise in death rates was genuine, we pored through troves of death certificates from before the fall of the USSR. We obtained data from the archives of the new government’s demographic organization, Goskomstat. More than 90 percent of all deaths were reviewed and certified by doctors who were able to confirm each death and its cause, a rate higher than in many Western countries.10
An unusual feature of the Russian crisis was that the deaths were concentrated in young, working-age men. Most disease outbreaks disproportionately affect vulnerable people, such as infants and the elderly. The rate of death rose by a disconcerting 90 percent among the subgroup of men aged twenty-five to thirty-nine, in the prime of their lives.
Perhaps there was a terrible outbreak of influenza or other epidemic or widespread famine—or an as yet unknown pollutant from Soviet factories. But the death certificates that we, along with numerous other demographers, reviewed from Russia’s statistical agencies did not support that theory. What the statistics showed was that many of these young men were dying from alcohol poisonings, suicides, homicides, and injuries. Such deaths seemed straightforward: men whose factories had shut down and were out of work were experiencing a high level of mental distress and anxiety, and their response was to turn to alcohol, harming themselves and others.
The young Russian men were also dying of heart attacks. This fact surprised us at first. We might have expected to see men in their fifties and sixties with clogged arteries having a heart attack, but rarely would people in their thirties and forties come to the hospitals with cardiovascular problems. The coroners’ reports showed that the autopsies of the young men’s arteries were clean. There was no plaque buildup. So what had caused the cardiovascular deaths?
To understand Russia’s puzzling mortality patterns, we needed to look at different layers of health problems to understand their root causes. We wanted to move beyond identifying the immediate causes of death and their risk factors such as tobacco, unhealthy diets, and alcohol, to find the “causes of the causes,” the social and economic changes that led people to harm themselves and others.
Since these deaths happened very rapidly, our first suspicion was that Russian men may have “self-medicated” to cope with the stress of the economic downturn—consuming huge amounts of vodka and home-brewed spirits. Russia has long had an epic drinking culture, one encouraged since the eighteenth century by the tsars to keep people from revolting. There’s even a Russian word, zapoi, coined to describe the condition of being so drunk as to be incapacitated for days and even weeks at a time. More than three-quarters of all male industrial workers in Russia today would be considered “at-risk drinkers” by American medical criteria (that is, consuming more than four drinks on a single day).11
Social stress and alcohol go hand in hand; alcohol is a well-known trigger of depression, suicide, and homicide. And alcohol might also explain the rising rate of heart attacks in the young men with clean arteries. Cardiologists knew that in moderation, alcohol can reduce the risk of heart attacks; in large amounts, however, it provokes heart disease.12
Russian politicians had tried to curb their country’s alcohol problems. In 1985, the Soviet Union’s leader, Mikhail Gorbachev, launched an anti-alcohol campaign. It was remarkably effective, immediately increasing overall life expectancy by three years. Not only did alcohol deaths fall, but tuberculosis and heart disease did as well, as alcoholics often experience these two conditions from crowded living conditions and the heart disease impact of heavy alcohol use. But the campaign proved so unpopular that it was abandoned in 1987. It was repealed in part to help raise government revenues from state sales of alcohol. Drinking increased after the program ended so that by 1992, when Russia began its transition to the market, Russian deaths from alcohol were back to their high levels as before 1985.13
Even more troubling, it wasn’t just the amount of alcohol Russian men were drinking during the early 1990s—it was the type. The form of alcohol changed, as men creatively found ways to binge without spending much money (they were, after all, mostly unemployed). Drinkers in Russia, Ukraine, and the Baltic states were drinking alcohols that were commercially manufactured using aftershave, mouthwash, and other products that contained alcohol but were not me
ant for consumption. These sources of alcohol were incredibly cheap and, unlike vodka and spirits, they weren’t taxed. The brews from these alcohols were known as odekolon and were ostensibly sold as perfumes, but everybody knew what their real purpose was: they were labeled by flavor rather than scent, and had flip-top caps so that people could finish them easily in one sitting. These odekolons were particularly lethal: one study showed that drinking non-beverage alcohols increased the risk of death from alcoholic psychosis, liver cirrhosis, and heart disease by a factor of twenty-six over not drinking these substances.14
Vladimir, an odekolon drinker from Pitkyaranta who lost his job when the town’s paper mill went bankrupt, provided an illustrative example of the drinking culture at the time. He was known for passing out drunk on the floor of the town’s abandoned mill after drinking for two weeks straight, often waking up in the hospital. Vladimir binged on cheap odekolons (while in more rural areas people drank home-distilled brews, samogons). People like Vladimir drank more and more during the early 1990s, even as their income dried up. When asked by a New York Times reporter why he continued to drink, Vladimir said, “I can’t explain it straightaway. I have a home. But I have nothing to do.”15
Like millions of other Russian men, Vladimir had no hope for the future, no work, nothing to do, and nowhere to go—and odekolons were the cheapest way out. About one out of every twelve young Russian men was drinking these noxious alcohols. Only about 5 percent of men who were employed drank them, but nearly 25 percent of those who were unemployed did. These data alone couldn’t tell us if the alcohol abuse caused the unemployment or the other way around, but the outcome was devastating either way; the combination of heavy drinking (zapoi) and odekolons was staggering. In Izhevsk, almost half of all deaths of working-age men were found to be attributable to hazardous drinking (when counting binge drinking and the harms from the surrogate alcohols). Across Russia, alcohol was estimated to have accounted for at least two out of every five deaths among Russian working-age men during the 1990s, totaling 4 million deaths across the former Soviet Union.16
The Body Economic Page 4