The current health crisis in Russia is without precedent in modern history. Life expectancy has declined for men and stagnated for women in a persistent pattern since the mid-1960s. The average lifespan of Russian men declined by 5.2 years from 1965 to 2003, while the lifespan of Russian women remained about the same. Obviously something is wrong. In no other industrialized nation in peacetime has longevity been so adversely affected and nowhere else is the gender gap in life expectancy—a difference of 13.2 years—so large. Ironically, despite the Soviet social system’s theoretical goal of a society without class oppression, exploitation, strife, or health inequalities, the health crisis may be grounded in class differences.

Determining whether this is the case requires an examination of the various layers of causal factors underlying the health crisis. The primary cause is known. Cardiovascular diseases and alcohol-related poisoning and accidents are largely responsible for high mortality rates. Russian women are clearly affected because their longevity has not advanced, but the principal victims are men between the ages of 40 and 59, many of whom come from a working-class background. Extensive investigation shows that other causes of death, like infectious diseases, cancer, environmental pollution, and medically avoidable deaths due to ineffective clinical care, are not the major source of the crisis. To identify the ultimate cause, it is necessary to determine what led to the increase in cardiovascular ailments and alcohol-related problems.

The search for secondary-level causes suggests three major candidates: policy, stress, and health lifestyles. We know that Soviet health policy contributed to the failure to address the epidemiological transition from acute to chronic diseases. As Harvard sociologist Mark Field explains, the Soviet health care delivery system lacked the administrative and structural flexibility to adjust to health problems that could not be handled by mass measures that successfully controlled infectious diseases. Post-Soviet policies have yet to improve the situation. Policy, however, did not cause the increase in heart disease and heavy male drinking; rather, it failed to prevent it. This leaves stress and lifestyles as the two leading possibilities.

Under Pressure: Stress and the Soviets

The stress explanation has a logical appeal because of the well-established connection between stress and both heart disease and alcohol use. Some researchers argue that state socialism’s limitations on personal freedom and repressive psychosocial environment constraining innovation, creativity, and life satisfaction promoted widespread feelings of apathy, alienation, and lack of personal control. In the immediate post-Soviet period, these stresses were compounded by high unemployment, the collapse of price controls for food and rent, reduced purchasing power, and new conditions of uncertainty. Virtually all sources agree that the Russian population was subjected to highly stressful social and economic conditions at this time. Women in particular suffered, facing disproportionate job losses and an inability to purchase basic goods when communism collapsed.

Unfortunately, little evidence exists about the effects of stress on health in Russia. Stress research was not sponsored by the Soviet state and has been slow to develop in post-Soviet Russia. In the absence of data, support for the stress explanation for the health crisis remains largely based on speculation. Yet a few studies offer clues concerning the role of stress in the current health situation. These studies show that Russian women are more stressed than men, which undermines assertions that stress has directly affected male longevity. Moreover, stress does not seem to promote greater drinking and smoking among women.

Biological factors like estrogen also protect premenopausal women from heart disease, so stress may simply cause such women to feel miserable rather than shorten their lives. We know, for example, that women in Western societies typically report more stress than men but live longer. However, there is a basic difference between Russia and the West. Life expectancy continues to rise in the West for both men and women, and the gender gap in longevity is much smaller. Given the overall similarity in stress patterns by gender and the dissimilarity in life expectancy between Russia and the West, the answer may lie more fully in an explanation that centers on lifestyle.

Lifestyle Choices

Health lifestyles are collective patterns of health-related behavior based upon choices constrained by individuals’ life chances. “Life chances” is a term introduced by German sociologist Max Weber to signify the chances or probabilities a person has in life to satisfy his or her needs and desires. It is especially indicative of class position.

The higher the social class, the greater the range of lifestyle choices and the higher the probability of realizing them; conversely, being a member of a lower class implies limited choices and lower probabilities for realization. Other social variables reflecting a person’s chances in life include gender, age, race, ethnicity, and living conditions. According to Weber, choices and life chances interact with one another in a dialectical relationship. The four most common health lifestyle choices analyzed by researchers are alcohol use, smoking, diet, and exercise.

Under state socialism, a person’s choices and chances were constrained by a dominant political ideology that officially prioritized the interests of the collective and the state above those of the individual. Consistent with this approach, the central government assumed overall responsibility for health care and perpetuated the belief that health depended on the health care system, not the individual. This situation promoted passivity toward healthy lifestyles and was reinforced by an absence of public health campaigns advocating positive individual health practices. According to Russian sociologist Elena Dmitrieva, “The lack of a self-protective culture in Russia is a result of Soviet times that neglected the individual, its life, and, consequently, its health.” Nor was a sense of personal health responsibility likely to appear in the wake of communism’s collapse because established societal norms for health promotion were missing.

Negative health lifestyles remained the norm, especially for men. Several studies have documented this lifestyle as an entrenched pattern of excessive alcohol consumption and binge drinking, heavy smoking, high-fat diets, and lack of health-promoting exercise. Clinical studies in the United States and elsewhere have found a close association between heart disease and health lifestyles—particularly in relation to such risk factors as smoking, diabetes, high blood pressure, and elevated levels of cholesterol (hyperlipidemia). However, research in northern Russia, Moscow, and St. Petersburg shows that despite high cardiovascular mortality, Russian men and women often exhibit lower levels of cholesterol than do their Western counterparts. These studies suggest that the effects of sustained heavy drinking are more important than cholesterol for premature male cardiovascular mortality. Unsurprisingly, alcohol use has been identified as the single most important variable in the Russian health crisis. Additionally, the cardio-protective features of alcohol seen in the West are not operative in Russian society, probably because of the large volume of episodic consumption and the strong preference for vodka.