Lawrence King

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An unprecedented mortality crisis struck Eastern Europe during the 1990s, causing around seven million excess deaths. We enter the debate about the causes of this crisis by performing the first quantitative analysis of the association between deindustrialisation and mortality in Eastern Europe. We develop a theoretical framework identifying deindustrialisation as a process of social disintegration rooted in the lived experience of shock therapy. We test this theory relying on a novel multilevel dataset, fitting survival and panel models covering 52 towns and 42,800 people in 1989–95 in Hungary and 514 towns in European Russia in 1991–99. The results show that deindustrialisation was directly associated with male mortality and indirectly mediated by hazardous drinking as a stress-coping strategy. The association is not a spurious result of a legacy of dysfunctional working-class health culture aggravated by low alcohol prices during the early years of the transition. Both countries experienced deindustrialisation, but social and economic policies have offset Hungary’s more immense industrial employment loss. The results are relevant to health crises in other regions, including the deaths of despair plaguing the American Rust Belt. Policies addressing the underlying causes of stress and despair are vital to save lives during painful economic transformations.

Research on intergenerational social mobility and health-related behaviours yields mixed findings. Depending on the direction of mobility and the type of mechanisms involved, we can expect positive or negative association between intergenerational mobility and health-related behaviours. Using data from a retrospective cohort study, conducted in more than 100 towns across Belarus, Hungary and Russia, we fit multilevel mixed-effects Poisson regressions with two measures of health-related behaviours: binge drinking and smoking. The main explanatory variable, intergenerational educational mobility is operationalised in terms of relative intergenerational educational trajectories based on the prevalence of specified qualifications in parental and offspring generations. In each country the associations between intergenerational educational mobility, binge drinking and smoking was examined with incidence rate ratios and predicted probabilities, using multiply imputed dataset for missing data and controlling for important confounders of health-related behaviours. We find that intergenerational mobility in relative educational attainment has varying association with binge drinking and smoking and the strength and direction of these effects depend on the country of analysis, the mode of mobility, the gender of respondents and the type of health-related behaviour. Along with accumulation and Falling from Grace hypotheses of the consequences of intergenerational mobility, our findings suggest that upward educational mobility in certain instances might be linked to improved health-related behaviours.

Eastern Europe underwent one of the most dramatic economic and demographic changes in recent history with skyrocketing mortality rates in some countries during the 1990s. The case of Hungary among the post-socialist transition countries is puzzling for several reasons. Although the Hungarian transition has often been characterized as smooth and successful, a look at the human dimension of the transformation reveals large costs and a slow improvement. Based on the analysis of 29 articles we provide a systematic review of the empirical evidence about the social determinants of mortality in post-socialist Hungary establishing a hierarchy of causes. Socio-economic position, mental health, social capital, alcohol consumption, stress and social integration are the most important explanatory variables that received attention by the researchers. Although economic policies might have played a central role in the rise of mortality there is no empirical research on the political economy of health in Hungary. No critical analysis of post-socialism can be complete without assessing the human costs of economic transformation. Social scientists have much to learn from social epidemiologists who have designed robust methodologies and complex theoretical frameworks to analyse the political economic determinants of health.

To the Editor In their Special Communication, Dr Kesselheim and colleagues¹ challenged an industry claim by finding that “there is little evidence of an association between research and development costs and drug prices,” with drugs instead priced in the United States based on what health systems and society can bear. Several interrelated trends in corporate governance and the financial sector can further explain this phenomenon of high and often escalating prices despite large companies investing only 10% to 20% of their revenue on research and development.

Previous research using routine data identified rapid mass privatisation as an important driver of mortality crisis following the collapse of Communism in Central and Eastern Europe. However, existing studies on the mortality crisis relying on individual level or routine data cannot assess both distal (societal) and proximal (individual) causes of mortality simultaneously. The aim of the PrivMort Project is to overcome these limitations and to investigate the role of societal factors (particularly rapid mass privatisation) and individual-level factors (e.g. alcohol consumption) in the mortality changes in post-communist countries. The PrivMort conducts large-sample surveys in Russia, Belarus and Hungary. The approach is unique in comparing towns that have undergone rapid privatisation of their key industrial enterprises with those that experienced more gradual forms of privatisation, employing a multi-level retrospective cohort design that combines data on the industrial characteristics of the towns, socio-economic descriptions of the communities, settlement-level data, individual socio-economic characteristics, and individuals’ health behaviour. It then incorporates data on mortality of different types of relatives of survey respondents, employing a retrospective demographic approach, which enables linkage of historical patterns of mortality to exposures, based on experiences of family members. By May 2016, 63,073 respondents provided information on themselves and 205,607 relatives, of whom 102,971 had died. The settlement-level dataset contains information on 539 settlements and 12,082 enterprises in these settlements in Russia, 96 settlements and 271 enterprises in Belarus, and 52 settlement and 148 enterprises in Hungary. In addition to reinforcing existing evidence linking smoking, hazardous drinking and unemployment to mortality, the PrivMort dataset will investigate the variation in transition experiences for individual respondents and their families across settlements characterized by differing contextual factors, including industrial characteristics, simultaneously providing information about how excess mortality is distributed across settlements with various privatization strategies.