William C. Cockerham
Health and Social Change in Russia and Eastern Europe.
New York and London: Routledge, 1999, xii + 284 pp. $CDN 34.99 $US 22.99 paper (0415920817) $CDN 113.00, $US 75.00 cloth (0415920809)
Since the early 1970s, the communist countries in East Central Europe have been characterized by rising morbidity and mortality rates, and by stagnating or declining life expectancy. While in the mid-1960s levels of life expectancy in communist East Central Europe equalled or exceeded those in the West, by the time communism collapsed in the late 1980s and in the early 1990s, life expectancy in East Central Europe was four to nine years below that of Western countries. In 1989, as we learn from Table 1.1 in Cockerhams informative and comprehensive study, life expectancy in Bulgaria, former Czechoslovakia, Hungary, Poland and Romania ranged from 65.4 to 68.3 years for men and 72.6 to 75.5 years for women, compared to 71.8 to 75.9 years for men and 78.6 to 81.7 years for women in France, the United States and Japan. Russia exhibited the worst statistics of all: in 1991, life expectancy for men was 63.4 and for women 74.3 years. By 1995, four years after the dissolution of the Soviet Union, Russian life expectancy levels had declined to 58.2 for men and 71.1 for women.
As the author points out, this situation is without precedent in modern history. Nowhere else has health worsened so seriously in peace-time among industrialized nations (p.1). Unravelling the mystery and finding the ultimate origin of the downturn in life expectancy in the region thus became an important undertaking of the author, who is Professor of Sociology, Medicine, and Public Health at the University of Alabama. What particularly intrigued Professor Cockerham was that the what about the situation was relatively obvious, [but] the why was unknown. The typical answer which the author got from local public health experts and physicians was that the causes were due to rising heart disease and other chronic illnesses (p. x). However, he could not find out why this situation was occurring. In fact, the Czech postcommunist Working Group for Reform of the Organization of Health Care offered in its 1990 document an explanation of sorts, but it lacked a specific direction of causality. The adverse morbidity and mortality trends in communist Czechoslovakia were not attributed to any one institution or a specific factor. Instead, the worsening health of the Czech and Slovak populations was explained as the result of the combined effects of environmental pollution, inadequate nutrition, ineffectual functioning of the health care system, lack of individual responsibility for health, and, above all, the totalitarian system of the communist party-state.
Cockerham regards all these factors as only partial explanations that apply to specific individuals rather than whole sociodemographic groups. He argues persuasively and convincingly that the primary explanation for the adverse morbidity and mortality is to be found in policy, societal stress, and health lifestyles - with lifestyles the leading cause ... (p. x). To support this argument, he marshals an impressive array of comparative empirical evidence and theoretical concepts. To highlight the importance of sociodemographic characteristics and social determinants, Cockerham starts his analysis by reminding readers that the rise in mortality was not universal, and that the people most affected were middle-aged males, with those employed in manual occupations appearing to be the most susceptible (p. 13). Realizing that the rise in mortality has been primarily a male working-class urban phenomenon enabled Professor Cockerham to eliminate both environmental pollution and poor medical care as key explanatory variables. If environmental pollution were a primary underlying cause, children, women and the elderly would also be affected. Moreover, while the coal mining region of Northern Bohemia suffers from extensive ecological pollution and the highest mortality rates in the country, rates of cancer are not high relative to the rest of the country (p. 25). In a similar vein, poor medical care does not constitute a primary explanatory variable as health care services in rural areas throughout the region have been generally worse than in urban areas, where morbidity and mortality rates among males were rising more rapidly. Cockerham also rejects the stress hypothesis since he could not find sufficient empirical evidence for a causal link between specific stressors and incidence of specific diseases. This left him with a health lifestyles explanation.
To support this argument, the author provides evidence on the types of disease primarily responsible for higher mortality (e.g. heart disease and cancer), country surveys on health behaviour, comparative research findings on the strong association between cardiovascular disease and lifestyle practices involving diet, exercise, smoking, and heavy drinking, and an insightful theoretical framework. The latter utilizes lifestyles as a key sociological concept explaining human behaviour, and relies on the work of Weber (on social action, life chances and status groups), Giddens (on modernity, and the relationship between agency and structure), and Bourdieu (on social worlds, mind-sets and modes of behaving). The author found Bourdieus concept of habitus especially useful, since he could apply it to health lifestyles grounded in social conditions and general orientation towards living.
All of the individual chapters on Russia, Hungary, Poland, the Czech Republic and Slovakia, Romania, Bulgaria and East Germany are thus built around sociological rather than biomedical themes. Each national chapter typically starts with a brief historical review, followed by mortality and morbidity statistics, and critical examination of explanatory variables of policy, societal stress, and lifestyles. All of the empirical and theoretical arguments are succinctly presented, and are quite easy to follow even by those who know very little about social determinants of health or about the former communist countries in East Central Europe. Health and Social Change in Russia and Eastern Europe therefore meets the needs of various constituencies, and is highly recommended both to specialists and to those lacking familiarity with sociology, public health and/or East Central Europe.