Warning: Freedom Can Be Dangerous to Your Health

By James O. Jackson/Bonn

THESE PAST FEW YEARS SHOULD have been the best of times for Eastern Europe. Oppressive communist regimes were swept aside, along with the walls, fences, laws and secret-police forces that kept whole populations locked away from the world. Freely elected governments are in office, and the free market is starting to take hold. At long last, East Europeans are looking forward to the kind of material prosperity that the West has known for decades. This should be a time of joy in the East, an era of good health, optimism and babies.

It is not. For many East Europeans the age of freedom is turning into the worst of times since World War II. Eastern Europe is going through a health crisis of dire proportions: demographers and health officials report rates of death and childlessness on a scale normally seen only in wartime. Ailments of both body and mind are near epidemic magnitude. In several countries, including Russia, the population is actually shrinking. "The drop is catastrophic" says Regine Hildebrandt, family minister in the state of Brandenburg government. "It is like war."

In Russia, Bulgaria, Estonia and eastern Germany, deaths are outnumbering births, in some areas 2 to 1. Life expectancy in nearly every part of the East is dropping, especially among men, at a time when even the poorest Third World countries are recording steady increases. In Hungary the average is 65 for men and 74 for women, in contrast to 67.3 and 75 in 1975 and to 73.4 and 81.8 for French men and women today. Death rates in Russia have soared 30% since 1989, with men bearing the brunt, says demographer Murray Feshbach of Georgetown University. By his estimate, life expectancy for Russian men has fallen to 59, about the same as in Pakistan.

"In the past, such abrupt shocks were observed in industrial societies only during wartime," notes Nicholas Eberstadt, a researcher at the American Enterprise Institute in Washington. Writing in the National Interest, a foreign affairs quarterly, he warns that the crisis threatens to undermine the East's struggle to build free and stable societies: "Adjustment to life after communism is proving not just difficult but positively traumatic throughout the entire former Soviet bloc."

The reasons for the crisis are complex. One obvious cause is communism's long and repressive reign. "Health care is no different from any other realm of our life," says Mikhail Prudkin, a Moscow oncologist. "All these problems did not emerge just in these past five or 10 years. They have been piling up for more than 70 years." Industrial pollution, careless handling of radioactive materials, poor safety standards in the workplace have all contributed.

Though communist governments allocated large parts of their budgets to health care, the resources were often used inefficiently. The communist passion for gigantism, for example, built hospitals with enormous capacities; once the system collapsed, so did the subsidies that kept it functioning, turning the facilities into costly white elephants. "In some of these places, they need only half or even a third of the beds they have," says Dr. Timothy Empkie, director for Project Hope in Central and Eastern Europe. "They have to make tough decisions about rationalizing their current facilities before they go on to necessary programs such as antismoking campaigns."

As Empkie suggests, the bad habits of high tobacco, alcohol and fat consumption may be as much to blame as an inefficient system. In Poland, typical of East European countries, about one-third of the 38 million population smoke, and 4 million, overwhelmingly male, drink alcohol on a daily basis. Animal fat, especially pork, is a dietary staple. "The government has never implemented any kind of policy on tobacco and vodka," says Witold A. Zatonski, head of the department of cancer control and epidemiology at Warsaw's Institute of Oncology. "Now in Poland a pack of cigarettes costs less than a loaf of bread."

The same holds true elsewhere. In Hungary, 60% of adult men are smokers, and 15% of the population, mostly men, suffer from alcohol-related ailments. "We really need a government that is strong enough and determined enough to carry out action against smoking," says Lajos Matos, vice president of the Hungarian Society of Cardiology. "But at the moment one has the feeling that ; there are simply too many heavy smokers in parliament."

Though Hungarians are among the wealthiest people in the former Warsaw Pact countries, they suffer some of the highest rates of disease and death. While smoking, stress and drinking are the main reasons, experts acknowledge that a predilection for fatty foods doesn't help: the fat level in the Hungarian diet rose from 30% in 1970 to 38% today; not surprisingly, the death rate from heart disease rose proportionately, from 5.7 to 8.5 per 1,000, at a time when the rate was dropping in virtually all Western countries. Life expectancy for Hungarian men has been falling faster than in any other industrialized country except Russia: in 1970, life expectancy at age 45 was 21.3 more years, compared with 27.4 for U.S. males. Today American 45-year-old males can look forward to 30.7 more years, while Hungarians on average have only 20.4 years left.

The West, meanwhile, is not helping matters. Purveyors of tobacco, alcohol and snack foods have been turning East to make up for shrinking markets at home. PepsiCo is investing $500 million to set up outlets of Burger King, Kentucky Fried Chicken and Taco Bell throughout Poland to serve fast -- and fatty -- food. Tobacco companies are marketing aggressively with campaigns appealing especially to the young: in recent years Philip Morris has put nearly $1 billion into Eastern Europe.

The premise that freedom is linked to health problems is supported by the example of Albania, by far the poorest country in Europe and the one still least penetrated by Western ways. Life expectancy is a respectable 70 for men and 76 for women, higher than anywhere else in Eastern Europe except Georgia and Lithuania. The incidence of cancer and heart disease is relatively low, as are the rates for trauma deaths such as suicide, homicide and auto accidents. The figures, unfortunately, are statistical remnants of a vanished era. Albanians under communism didn't eat much meat, and they can't afford to now either: it makes up only 17% of their diet, less than half the West European average. The unavoidable daily exercise of walking, in a basically carless society, also provides significant health benefits. Inevitably, these bucolic patterns will fade as the modern world closes in.

That is not a full diagnosis of Eastern Europe's ill health, however. The removal of communist fetters also set loose a mass of social problems. In Russia, health authorities are reporting a suicide rate of 45 per 100,000 for 1993 (up from 40 per 100,000 in 1992) and a total of 25,500 murders in 1993, up 53% over 1992. The figures are so shocking that demographers view them with disbelief -- given that the validity of old data bases in Russia is doubtful, and that some cynical health experts are worried that claims of a health crisis could be part of an attempt to squeeze more aid out of Western governments. The fact is that similar trends have been recorded in other formerly communist countries with better statistics and perhaps fewer ulterior motives. "Not one single health statistic has improved since the 1989 revolution," says Dr. Manole Cucu, director of Romania's Institute of Hygiene and Public Health. Poland's Zatonski puts it more bluntly: "The state of health of Poles is disastrous."

The exception to the grim picture should be eastern Germany, which got access to greatly improved medical care when it was absorbed into West Germany in 1990. Not necessarily. Although the overall death rate has dropped slightly, it has risen sharply among those who should be in the prime of life and pink of health, the 35-to-45 age group. For men, the death rate jumped from 3 to 3.8 per 1,000, or 30%. For women of the same age group the increase was 20%, or from 1.3 to 1.6 per 1,000. That suggests an underlying cause that cannot be treated with pills and scalpels. "While it may be too soon to provide a conclusive diagnosis of these national symptoms," says Eberstadt, "they are surely suggestive of extreme -- and as yet unrelieved -- social stress."

That is the conclusion reached by Dr. Hans-Joachim Maaz, a psychiatrist in the eastern German city of Halle who believes that Western-style freedoms and economic systems have come too quickly and with too much outside pressure. "Democratization did not spring up on its own here," he says. "We were told, 'The way you think is wrong. We in the West know better.' Psychologically speaking, that is decapitating. It leads to much discouragement and disappointment." And to depression, suicide, heart attacks and strokes.

The stress of unemployment, which runs as high as 40% in some East European areas, is one cause for rising death rates in the middle years. And even those lucky enough to be employed are often receiving inflation-slashed salaries or have been forced to take jobs far below their level of qualification. "The middle aged are particularly hard hit," says Maaz. "This happens at a time / when their life experience and competence should be most valued. But because that experience comes from the earlier ((communist)) period, it is devalued." The resulting life crisis, he says, manifests itself in everything from vague aches and pains to depression, panic attacks, accidental trauma and, ultimately, suicide. "We often see family violence, child abuse and car accidents," he says. "It's easier to take out your aggression on a neighbor, your spouse or your children. And driving fast or carelessly makes people feel powerful." Those most at risk for early death are, in most countries, the ones least likely to seek or get medical treatment. Says Dr. Erika Saska, an internist at Budapest's St. Emeric's Hospital: "The people for whom prevention would be useful are too busy to leave work and have their blood pressure taken." One of the few who did is Marika Toth, 40 and out of work, who sits smoking in the courtyard of St. Emeric's. She arrived at the hospital by ambulance after collapsing in her cashier's cage at the main Budapest electrical power company. Her blood pressure, she says, had soared to 220/160, "much too high for a woman of my age." It was down to a near normal level after hospitalization -- despite the sneaked courtyard smokes -- "but when I go home to my three children, it's sure to shoot up again. My job prospects are zero, and I don't know how we'll make ends meet."

Toth's situation helps explain another dismaying symptom: while disease and depression are shortening life expectancy at one end, plummeting birthrates are eating away at the other. For reasons both social and psychological, East Europeans are delaying childbirth or even avoiding it altogether. Birthrates in Russia are down 46%, from 17 per 1,000 in 1987 to 9.2 in 1993.

Other countries are reporting falloffs ranging from 20% in Poland to 30% in Bulgaria. By comparison, during World War II, births dropped 25% in Germany and Japan.

By far the most dramatic decline is in eastern Germany where the rate, already relatively low at 12 per 1,000 in 1989, has plummeted to about 6.5 per 1,000. There have been two unusually steep drops: the first in August 1990, a revealing nine months after the fall of the Berlin Wall; the second in the summer of 1991, nine months after German unification. Plainly, people have been too worried about their future to make the long-term investment in hope required to start a family.

Couples waiting to see how things transpire are relying on birth control -- or, more likely, abortion -- to put off the commitment. In many other cases the lack of hope is complete: thousands are opting for sterilization. In the state of Brandenburg, which surrounds Berlin, 6,224 women were sterilized in 1993, vs. 200 in 1989. Other eastern German states report a similar increase in sterilizations, most among those in the 30-to-40 age group. In some areas, as many as 1 in 5 making the permanent choice is under 30.

The paradox of plummeting birthrates at a time when the future should hold great promise is explained by doctors as a psychological reaction to the shrinking job market. The East was never poorer than in the years after 1945, the very period in which the great postwar baby boom occurred. "Then it was a matter of rebuilding amidst the general poverty, with much hope and optimism," says Berlin family researcher Jutta Gysi. "Now, when it comes to young, childless women ((getting sterilized)), the pressure on the job market seems to be so great that they simply don't see any other alternative."

A declining population is not necessarily a bad thing: West Germany's population dwindled throughout the 1970s and '80s, which was a period of unparalleled prosperity. But that decline was a result of smaller families and falling birthrates, not depression and early death. Eastern Europe's illness is as much of the spirit as of the body. Politicians, not doctors, must cure it.

With reporting by James L. Graff/Vienna, Tadeusz Kucharski/Warsaw, Angela Leuker/Budapest and Nomi Morris/Berlin