Troubled transitions : Social variation and long-term trends in health and mortality in Estonia
Abstract: This thesis is about social variation and long-term trends in health and mortality in Estonia. After five decades of Soviet occupation Estonia’s independence was re-established in 1991 on the basis of the historical continuity of its statehood. Estonian independence changed political, economic and social realities; it was accompanied by a sharp decline in living standards. By 1994/1995 the socioeconomic and political situation had started to stabilize. Both transitions, the Sovietization and the return to independence, were particularly hard on the population. Life expectancy had improved little or not at all from the 1960s. At the beginning of the 1990s there was an unprecedented fall. From 1995, life expectancy started to rise again. Cause-specific mortality for 1965–2000 was examined in order to understand both the recent and the earlier long-term health crises in Estonia; educational and ethnic differences in cause-specific mortality were analysed for 1987–1990 and 1999–2000. Self-rated health was examined for 1996/1997. The cause-of-death data come from the national mortality database, and the self-rated health data come from the Estonian Health Interview Survey. Circulatory diseases, neoplasms, and injuries and poisonings account for over 80% of all deaths in Estonia. Circulatory disease mortality started to decline considerably later than in Western countries, is very high by international standards and was sensitive to sudden social changes in the 1980s and 1990s. Cancer mortality rates among men increased, mostly because of lung cancer mortality. Mortality from injuries and poisonings is extremely high, has increasingly been contributing to Estonia’s long-term mortality stagnation and was the major contributor to the decline in life expectancy in the 1990s. Educational and ethnic differences in mortality increased sharply in 1989–2000. In 2000, male graduates aged 25 could expect to live 13.1 years longer than corresponding men with the lowest education; among women the difference was 8.6 years. Estonian men could expect to live 6.1 years longer than Russian men in 2000; among women this difference was 3.5 years. Injuries and poisonings were mainly responsible for the lagging behind of the lower educated and of Russians; in terms of total mortality the ethnic differences were small and not significant in 1989. Generally low living standards (particularly a poor diet), and the increasing gap with Western countries, may have contributed to the long-term mortality stagnation from the mid-1960s. In the 1990s, the increasing differentiation of wealth and opportunity, as well as perceived social exclusion and poor adaptation to the social and economic changes, in particular among the low educated and among ethnic Russians, are important determinants of the growing mortality divide in Estonia. Alcohol consumption, in particular binge drinking, has to be seen as a main cause of increasing mortality among middle aged men from the mid-1960s, most evident in those causes of death that can be directly linked to alcohol. It accounts for a considerable part of circulatory disease mortality as well. Alcohol also contributes to educational and ethnic differences in mortality and their widening over the 1990s. Tobacco smoking, similarly, has contributed to long-term mortality stagnation and the widening of educational, but not ethnic, differences in mortality. Adverse living conditions in childhood may also have contributed to the educational and ethnic differences in mortality and to the long-term mortality development in Estonia. Estonia needs to think hard about policies to remedy this situation.
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