Washington Profile: Russian health and demographic issues are now often talked about in the press, especially in the West. But Russia is not the only country to be undergoing a demographic decline, and despite problems in healthcare, Russia continues to experience rapid economic growth. Is the alarmism justified?

Eberstadt: While there may well be particular accounts that one could brand alarmist, the situation with Russia's health and demographics is truly worrisome, for a lot of different reasons. It's worrisome to outsiders from a purely humanitarian standpoint. One would think it would be worrisome to Russian citizens and decision-makers, not just for humanitarian reasons, but also for basic economic and even strategic reasons.

A couple of basic facts frame the comparison: Russia's overall life expectancy­life expectancy for men and women together­is actually about 4 years is lower today than it was 40 earlier. Russia is virtually the only industrialized society during peacetime in which such a thing has ever taken place. Death rates for men and women of working ages are vastly higher than they were four decades earlier­for certain age groups, over twice as high as they were 40 years ago. When one considers that life expectancy has been gradually improving, and death rates have gradually been declining, in most of the rest of Europe, and in the developed regions as a whole, Russia's long-term decline in public health conditions looks even more troubling.

You do point to a very important paradox: deteriorating health levels for a country whose per capita income level has dramatically increased over the past decade. That is a paradox to be sure, because it is widely assumed that wealth makes for health. But there are two factors at play here that may account for this strange Russian exception.

One is the nature of the Russian health problem, which is deeply embedded in what we might call the "demographic momentum" of Russian mortality trends. We hear a lot about the looming threats of epidemic disease in Russia­HIV/AIDS, drug-resistant TB, and so on­and rightly so. Pandemics could cast a terrible pall over Russia's future. But the fact of the matter is that to date, modern Russia's mortality and health woes have been much less a reflection of infections than of non-communicable problems like injury and chronic disease­heart disease, stroke, and so on. Chronic diseases constitute an accumulation of insults over the course of a lifetime. Today's young Russians look to be less healthy in the mirror of mortality than were their parents. That's a very hard situation to turn around; it may take decades­maybe generations­to reverse course under such circumstances.

The other part of the paradox of rising incomes coinciding with stagnating or deteriorating health may have to do to some degree with what Clifford Gaddy of the Brookings Institution has described as Russia's "virtual economy". By this he means the enclave nature of contemporary Russian economic growth being so heavily concentrated in a few sectors like oil and gas and other resource export sectors that have limited impact on the living standards of the general population.

To be sure: usually one doesn't see rising income and stagnating health in any modern society. In fact in many modern societies one sees improving health even when income goes down, during recessions or other parts of the business cycle. The Russian health problem has to be understood as a sort of striking­and tragic­exception to these other more general rules of modern economic and social life.

Washington Profile: The collapse of socialized medicine and the economic shocks after the end of the Soviet Union are often blamed for the health and demographic crisis in Russia. Are there also other factors at play?

Eberstadt: The pos-Soviet increase in Russian death rates coincided with shock therapy, and there was another spike after the financial crisis of 1998 (a spike, by the way, from which Russian mortality has scarcely recovered, despite the subsequent economic boom). But the origins of the current Russian health crisis go back well into the Brezhnev era and relate to the end of the Khrushchev era. In the early to mid 1960s, Soviet Russia began to see some very strange new trends: at that time, death rates for men in their middle ages started to rise. This phenomenon of rising death rates for middle age men spread to younger men, and then to older men, and then spread to middle age women, and then to younger women, and then to older women. So that by the end of the communist era, almost all of Russia's working age adults comprised a vulnerable group in which death rates were worsening, in some cases for decades. The health crisis that we see today started under Soviet communism­it just hasn't ended with the end of communism.

Washington Profile: What explains, then, the rise in death rates in the 1960's?

Eberstadt: It's still poorly understood in a lot of respects.

At first, one guess was that it was a sort of "echo effect" from the Second World War: after all, the middle-aged men from in the 1960s had been combatants in WWII and had undergone severe privations and health stresses­maybe they were unusually brittle and vulnerable because of the upheaval that they had been through? This sounded perfectly plausible, but the phenomenon of rising death rates for men in their forties continues to present day. Men in their 40s today were born in the 1950s and 1960s, decades after WWII, so you can't really blame the Second World War on what's going on now. Some of the particulars we have somewhat of a handle on.

Vodka is obviously critical to this ongoing health catastrophe. The extreme binge drinking which has and continues to characterize Russian life is connected with the extreme heart disease and with the hugely high injury rates that adults in Russia experience today. Patterns of smoking and lack of exercise and poor diet also have their contributions, but part of this is a big mystery, because there is something that you might want to call an "x factor".

Some years ago the World Health Organization began a study that it called MONICA, monitoring cardiovascular health in Europe. The surveys showed that there were much higher health risks in Russia: hypertension, smoking, cholesterol and so forth, than in western Europe. Now, that's not necessarily a surprise. The surprise was that the death rates from heart disease where about twice as high as the risk factors would have suggested in it of themselves. Not only are the risk factors that we can observe more worrisome in Russia then in western Europe, but the death rates from those risk factors are even higher than we would have predicted. So there is a sort of additional "x factor", you might say, an additional Russia factor involved here and it's not clear that we've got any comprehensive explanation for it yet.

Washington Profile: The Russian healthcare system is often blamed for many of the health ills that we see today. Could the lack of proper healthcare help explain the high death rates from cardiovascular disease?

Eberstadt: One of the surprising things about the health crisis in Russia today is that Russia as an economy devotes a non-trivial share of G.P. to health spending. As I recall the estimates for health and medical spending in Russia today are over six percent of G.D.P. (when one combines government and private health spending). Now, that's very low compared with the United States of course, but the United States is a complete outlier on healthcare spending in relation to economic output. Six percent of G.D.P. wouldn't be that different from Japan, which has got the healthiest, longest living population in the world today. If the healthcare system is implicated in this catastrophe, and I think there is an argument to be made that the health care system is a big problem in Russia, the problem is not too little spending, but rather too little returns: too few results from all of the spending that Russians are doing on health.

Washington Profile: The Russian authorities have recently unveiled a plan to solve the demographic crisis by 2025 and expect that the country's population will grow by this time to reach 145 million. Social programs, higher expenditures on healthcare, public education campaigns, incentives for young families, etc., are included in the plan. How realistic is this goal?

Eberstadt: The main reasons I don't think it's realistic is that the country's demographic decline is, one might say, structural, at this point. Last year was a relatively good year for Russian demographics from the Kremlin's viewpoint, because the excess of deaths over births was "only" a little less than 700,000. That's a huge difference. For every 100 babies being born in Russia today there are about 150 people dying. That's a major structural gap.

The plan that's been unveiled is supposed to reverse this situation, and eventually completely fill this gap. But even if the policies prove somewhat more successful then I suspect they will turn out to be, its going to be very difficult to lower death rates dramatically in Russia over the next ten years or so and its going to be very difficult to encourage a sustained increase in birth rates.

Let's deal with death rates first. Because the rising younger generation in Russia has already been exposed to so many health risks, even with pretty substantial health interventions, and even with much more comprehensive health programs then we have seen so far, reducing Russia's total deaths while the population is aging is going to be a tough job. Right now, Russia's "excess mortality" (let's say death rates above what we would have expected, say, during the Gorbachev era, which wasn't exactly a time of health paradise) is running at about half a million excess deaths a year. Now it might well be possible with sustained health interventions to prevent 100 thousand or 200 thousand of those deaths every year, but it would take a whole lot more to get back to Gorbachev-era the status quo ante. So there is a big problem in overcoming excess mortality in it of itself.

The other side of the equation is the fertility level, and Russian fertility is very low these days, although it has crept up over the past five or six years. But it is still down 30%-40% below the replacement level. Is it feasible to think that Russian fertility will reach the replacement level over the next decade or so? Well if Russian fertility does rise up to replacement level, it would have to rise by about 50% from its current levels­and this could only occur with a major change in desired fertility on the part of parents in the Russian Federation. So far I don't think we've seen any big signs of a big demand for more children. Rather, what we seem to be observing is that Russia is becoming part of the rest of Europe with respect to ideas about ideal family size. In the rest of Europe, fertility levels are very far below the replacement level. Apart from a few exceptions like France's, where childbearing patterns are close to replacement levels, European norms on fertility regard one or at most two children as the ideal family size. What drives births in modern, relatively affluent societies, more than any other factor, are parental desires about how many children to bear. Birth incentive schemes have to be seen in this light.

Washington Profile: Russia is not the only country to attempt to increase birth rates through government policy and incentives. How effective have these kinds of policies been in other countries, for example, in western Europe?

Eberstadt: Birth incentive plans are almost always ineffective in the long run. The typical history of birth incentive plans in western Europe and elsewhere has been to elicit a small blip in birth rates followed by a bigger slump. The reason for the blip is that some parents "on the fence" about the timing of a second or a third child take advantage of the introduction of these incentives. And the subsequent slump takes place because the bonuses alter parent's timing of desired births, not desired birth totals. If one were to have a serious pronatalist economic plan, you'd be getting into some very big money. You would have to have vastly larger outlays than are currently accorded to social security, healthcare or any other existing programs. Basically, you'd have to be prepared to be hiring women to work as baby ranchers­and in a modern economy, given the opportunity cost of women's labor, a program like that would be staggeringly expensive. That, I think, explains the limited success of pronatalist efforts in the western historical record. By the way, it also turns out to be very difficult to talk up the birth rate: the bully pulpit and the government usually can't convince people to have extra children out of patriotism or civic duty.

Washington Profile: Russia has become a country with significant immigration flows. How is this likely to impact on its demographic situation?

Russia has the same problem that other European countries have, with the prospect of population decline, and the question of changing ethnic composition. Many of the prospective migrants to Russia are not of Russian ethnicity, and as you know, the government has increasingly indicated a nationalist, or a nativist, objection to immigration to the Russian Federation. There still are a number of millions of Russians in the near abroad, but the flow of Russian ethnic migration to the Russian Federation has declined almost to a trickle over the past decade. Barring some sort of awful political upheaval, I don't know how realistic it would be to think that these ethnic Russians in the near abroad might want to pack up and head back to the Russian Federation. So Russia is facing the same kind of issues as the rest of Europe. Throughout Europe, the key question in this regard is: can the newcomers be turned into loyal and productive citizens? Some places have a better track record of this than others.

Washington Profile: What can you say about the demographic patterns of the other former Soviet countries?

Eberstadt: The so-called European republics of the FSU went through the same sorts of shocks that the Russian Federation has been experiencing: all of them registered a drop in birth rates and a spike in death rates with the end of communism. Russia's shocks have been more extreme and more prolonged, than say, the shocks in the Baltic countries: fertility is still very low in those countries today, but mortality trends are heading in the right direction. Ukraine's trends have been quite similar to the Russian Federation's, with prolonged declines in fertility and the rises in mortality, just not quite as extreme. Belarus is like Ukraine, similar to RF patterns but not quite as pronounced. In the Central Asian republics, there has been a rise in death rates, but this has apparently been due more to increases in infant mortality and child mortality, not quite so much to increases in death rates among the working ages, and the shock in birth rates hasn't been as extreme. Birth rates by and large are at replacement or above replacement in the Central Asian republics. In the Caucasus, fertility is very low in Armenia and Georgia, at Russian levels or even below Russian levels, but I believe the mortality situation has stabilized and health trends seem to be pointing in generally a very positive direction.

Washington Profile: So it seems that Russia has had the most pronounced demographic shocks...

Eberstadt: Russia has been the most extreme. Russia has had the most severe, prolonged drop in life expectancy. I myself am not so troubled by birth trends as by death trends. There is no obvious self evident ideal for family size: it's not even obvious whether we would want birth rates to go up or go down at any given time. But it is quite obvious that we want death rates to be going down, not up­and when they are going up, that's the wrong direction. The implications of changes in birthrates are ambiguous over the near and medium term. We can't say the same thing about mortality, and mortality trends have pretty much been going in the wrong direction in Russia for forty years.

Washington Profile: Is there an example in history of a country that bounced back from a similar decline in population and life expectancy?

Eberstadt: Usually the sorts of demographic shocks that we see in Russia today­these severe spikes in death rates and drops in birth rates, with drops in life expectancy and maybe even drops in population­historically these are typically brought about by war, or by famines or by terrible epidemics and pestilences. In most historical cases, those were relatively brief bouts: after a couple of years at the most, normal trends would reassert themselves. What's so striking and troubling about the Russian demographic condition today is that this deterioration in public health has been unfolding over the course of four and maybe now more decades.

The only analogy that comes to mind, and this is one that people in Russia always hate, is to sub-Saharan Africa with the AIDS catastrophe. If I am talking to people in Russia about demographics I will sometimes get the lecture, "Mr. Eberstadt, Russia is not Africa." True, Russia is not Africa, but there is a very unhappy similarity. The only two parts of the modern world that have suffered long term declines in life expectancy during peacetime have been Russia and, to a lesser degree, a few other parts of the post-Soviet space, and sub-Saharan Africa.

Washington Profile: What can and should be done to reverse the demographic situation in Russia?

Eberstadt: You mentioned earlier the paradox of rising incomes and continuing bad health. Another paradox in modern Russia, or until recently, was the emergence of competitive and relatively open politics with many political parties and an almost complete lack of public mobilization for dealing with the health emergency that is underway.

I find this a bit of a mystery myself. I don't understand it. There are even ecological parties in Russia that are worried about the death of the trees ­ but not about the death of the Russians. It's a mystery to me. Since Putin's administration has had power, roughly 4 million premature, excess deaths have taken place in the Russian Federation. That's more than two World War One's worth of casualties for Russia.

I would think that public concern as well as public policy would be an imperative here. If there were public concern, public outrage about this situation, there are a number of things that could be done in the short run, including the implementation of trauma units in cities to staunch the death flow from accident injuries; could be some education about cardiovascular disease and heart disease and the other main killers. But a lot of these would take time. Turning around the bad Russian health trajectory will be akin to turning around a super tanker. It would take a long time, and with gaining momentum over time, results will be seen more in the future than in the first several years. But if Russia is going to join the rest of Europe in terms of its demographics, if Russia is going to eliminate the terrible chasm between survival schedules in its territory and in western Europe, it's not at all too soon to begin making this a top priority.

Washington Profile: What is the alternative? If there is no public outcry and if business continues as usual, to what extent could demographics have an impact on the economic and social development of Russia in the next 15-20 years?

Eberstadt: Russia's current survival schedule is about the same as India's. Overall life expectancy in Russia and in India are similar today­in fact, India's may now be higher than Russia's. The Putin government promotes the goal of long term Russian growth to reach Portugal's income levels, i.e. western European levels, but you can't generate Irish levels of productivity on Indian levels of health. In the modern world, health and wealth are very closely connected. This fact is being disguised in the Russian case to some degree by the oil and energy boom, the bubble that is favorably affecting public finances and GDP numbers right now.

In the long run, for any modern economy, wealth lies in human beings, not in the ground. If the human capital of Russia is becoming increasingly debilitated, and if human numbers are steadily decreasing, Russia's economic power cannot be steadily increasing. Russia risks prolonged relative economic decline, in a world where many of its neighbors are growing very rapidly: of course I am thinking of China and India, but there are others as well. What would it mean for the Russian population to be shrinking steadily through severe excess mortality in a world of more or less steadily improving health standards? From a Russian standpoint I'd think that would look pretty grim and pretty dangerous.