The premature male deaths are primarily due to cardiovascular diseases and, to a lesser extent, alcohol-related accidents and poisonings. The ongoing cumulative effect of these deaths has significantly lowered overall male life expectancy through the years, even though there had been declines in mortality from some cancers, and infectious, respiratory, and digestive ailments (Leon et al. 2007, Mesléet al. 2003). There is strong evidence showing infectious diseases, environmental pollution, and medically avoidable deaths due to poor clinical care make only minor contributions to the rise in male deaths (Hertzman 1995, Shkolnikov et al. 1998, Cockerham 1999, Andreev et al. 2003). Consequently, the increased mortality rests solidly on cardiovascular and alcohol-related afflictions.
Although Soviet medicine had been relatively effective in dealing with communicable diseases, this was not the case with heart disease that requires individualised, long-term, and more expensive treatment regimens. As Field (2000) determined, the Soviet healthcare delivery system was not flexible enough to move effectively beyond the mass measures successful in combating infectious diseases to handling large-scale chronic health problems. Post-Soviet health policies and privatisation trends in healthcare delivery systems have yet to significantly alter the mortality pattern, although there have been efforts for individuals to take greater responsibility for their own health (Rivkin-Fish 2005). Soviet and subsequent health policy was undoubtedly a contributory factor for failing to prevent or reverse the increase in heart disease, but is not the cause of it.
In addition to gender, we know that age and class are highly relevant variables in that the rise in male mortality was most prevalent among middle-age, working-class men in manual occupations with lower levels of education, not older males age 60 and above as would be normally predicted or better-educated men working in tertiary sectors of the economy such as commerce, service, clerical, managerial, and professional positions (Abbott 2002, Andreev et al. 2009, Carlson and Hoffmann 2011). This latter and much smaller group was hardly affected; therefore, any search for social causes needs to focus on the stress and health lifestyles common to male blue-collar workers in mid-life (Carlson and Hoffmann 2011, Cockerham 1999, 2007).
The stress explanation has a logical appeal since stress has a well established connection with cardiovascular afflictions, as well as an important role in the promotion of alcohol use and smoking. It has been suggested that limitations on personal freedom and a repressive psychosocial environment under state socialism constrained innovation and life satisfaction (Bobak et al. 1998, Palosuo 2000, 2003). Stress at the societal level was intensified by the rise in unemployment and poverty, collapse of price controls for food and rent, reduced purchasing power and novel conditions of uncertainty in the immediate post-Soviet period (Shkolnikov et al. 1998). As Leon and Shkolnikov (1998) observed, the collapse of state socialism and the social, political, and economic change that followed created enormous stress for the population, especially workers who were officially favoured by Soviet political philosophy. Unfortunately, there is a lack of evidence documenting a direct relationship between stress and health outcomes in Russia at this time. Stress research was not sponsored by the Soviet state since it was not compatible with the official image of socialism and has been slow to develop during the post-Soviet period.
However, among the few existing relevant studies, males consistently show much lower levels of stress and depression than females (Bobak et al. 1998, Palosuo 2000, 2003, Pikhart et al. 2004, Cockerham et al. 2006b). The finding that Russian men are exceedingly less distressed than their female counterparts tends to undermine assertions that stress is the major cause of the curtailed male life span. We know, of course, that men tend to underreport stress in comparison to women. However, Cockerham et al. (2006a) found that men do acknowledge symptoms of psychological distress in the post-Soviet countries still experiencing the health crisis, just not as much as the women. Thus they are not averse to reporting stress symptoms, but either have less or what they have is mitigated by heavy drinking. Cockerham et al. (2006a) argue that the high level of alcohol consumption is a normative pattern of socialising for many Russian men that blunts stress. Additionally, studies that try to advance the stress explanation by focusing on the transition period when stress was endemic, usually overlook the fact that the health crisis for men began far earlier in the mid-1960s during a more stable period.
Health lifestyles are collective patterns of health-related behaviour based on choices from options available to people according to their life chances (Cockerham 2005). The term ‘life chances’ was introduced by Weber (1978/1922) to represent the chances or probabilities a person has in life to satisfy his or her wants or needs. Although people choose their lifestyle practices, their choices are either empowered or constrained by their chances in life and likely to be consistent with their capability to realise them. A person’s life chances are invariably shaped by the social structures (e.g. class, gender) in their lives that provide the norms for socially acceptable behaviour through socialisation and experience.
There is a critical reaction to the lifestyle explanation for the Russian health crisis that views it as a Western concept so closely linked with liberal economic assumptions about voluntary consumer behaviour that it cannot apply to the Russian context. Another possible criticism is that the lifestyle explanation is dwarfed by the phenomenon it seeks to explain and therefore the utility of the concept for depicting the origins of such a massive health crisis is questionable. Lifestyles, themselves, are collective patterns of ways of living associated not only with individuals, but with large-scale social entities, especially social classes and even nations, that reflect representative cultural practices. Traditions become norms and norms underlie lifestyle choices. A familiarity with current health lifestyle literature thus shows a focus on structural determinants, not voluntary consumer behaviour (Cockerham 2005, 2007). Furthermore, in the absence of any other model accounting for repetitive forms of living expressing group/class-based differences in behaviours, tastes, styles of living, and outlooks, the lifestyle model explains this social phenomenon best. At least this is the case according to Weber (1978/1922), Bourdieu (1984) and Giddens (1991). As Giddens (1991) points out, everyone has a lifestyle.
Under state socialism, life choices and chances were aligned with a dominant political ideology that officially de-emphasised the value of the individual in favour of the state and its goals (Kharkhordin 1999). The state assumed overall responsibility for healthcare and the belief was prevalent that a person’s health depended on the healthcare system, not the individual (Dmitrieva 2005). If people became sick, they expected the government to take care of them at no cost as a benefit of state socialism. There is evidence that this situation promoted a passive orientation toward taking care of one’s health that was reinforced by a lack of public health campaigns advocating healthy lifestyle habits (Cockerham et al. 2002). After the fall of the Soviet Union, the belief that the government is primarily responsible for the individual’s health apparently still prevails among some Russians (Pietilä and Rytkönen 2008).
Negative health lifestyles remained the norm for many people. Several studies have documented this lifestyle as a deep-rooted pattern of excessive alcohol consumption and binge drinking, accompanied by heavy smoking, along with high-fat diets and an absence of health-promoting leisure-time exercise (Cockerham 1997, 1999, 2000, Carlson and Vågerö 1998, Palosuo 2000, 2003, Perlman et al. 2003, Men et al. 2005, Cockerham et al. 2006a, Davidova et al. 2009). The origin of this lifestyle is found in peasant and later working class culture that extended into society as a whole (Cockerham 2007). Prior to the 1917 Russian Revolution, when much of the population lived in rural areas, widespread binge drinking and drunkenness among male peasants took place only on special occasions, usually at weddings, street parties, fairs, and the end of harvests, as well as on days off, such as Sundays and Russian Orthodox Church holidays (Shkolnikov and Nemstov 1997). Vodka with its high alcoholic content was the standard drink. Russian men in pre-Soviet times did not drink alcohol frequently, but when they drank, they tended to drink heavily.
During the Soviet period, however, heavy consumption became common throughout the year in both urban and rural areas, as the influence of the church was repressed and upper class norms eradicated. Many peasants moved into cities to become industrial workers and brought their drinking culture with them. Drinking was not only a form of socialising, but also a means to cope with the drab conditions of factory life and the disappearance of the supportive features of villages. Carlson and Hoffman (2011) investigated changes in the occupational structure of the labour force in the former socialist countries during the hyper-development of heavy industry and the corresponding stagnation/contraction of the service sector. Rises in male mortality were correlated with changes in the occupational structure. They note that the expansion of factory employment and the inability of the social environment to assimilate the influx of new workers led to unhealthy lifestyles and self-destructive behaviour.
Moreover, in the absence of a well-established middle class and its alternative norms of moderate social drinking, the peasant/working-class style of male drinking became the dominant style of consumption (Cockerham 2007). Shkolnikov and Nemtsov (1997) describe the Russian mode of drinking as part of a northern European practice involving rapid group consumption of large doses of vodka. Participants are expected to drink as long as they are able or until the supply of alcohol is gone. Little or no social stigma is attached to male drunkenness because it is not considered abnormal (Segal 1990).
This drinking practice has evolved through socialisation and experience to become an established disposition toward drinking that is customary for a large proportion of the male population, especially those in the working class and with less education (Cockerham 1999, 2000, 2007, Tomkins et al. 2006). It is reproduced over time and in subsequent generations, while proving to be difficult to change. As Palosuo (2003: 40) explains, ‘heavy drinking was habitual in Russia long before the recent upheavals and is not necessarily particularly stress related; on the contrary, drinking has been closely connected with Russian social life, rituals and celebrations’. Former Russian President Boris Yeltsin (2000) put this situation into perspective in his memoirs when he wrote that more than stress is involved in heavy drinking because the traditional Russian lifestyle dictates that it’s impossible not to drink at birthdays, weddings, and with co-workers. It is therefore not surprising that alcohol use continues to have a major role in the male health crisis (Cockerham 2007, Leon et al. 2007, 2009, Davidova et al. 2009, McKee et al. 2001).
Furthermore, it appears that the cardio-protective features of alcohol do not operate the same way in Russian society as in the West, most likely because of the habitual binge drinking style of consumption and strong preference for vodka with its high alcoholic content (Deev et al. 1998). Another difference from the West is seen in Russian studies showing that despite high rates of cardiovascular mortality, both Russian men and women exhibit lower levels of cholesterol than Western populations (Averina et al. 2003). This research suggests that the direct effects of episodic heavy drinking are more important in Russia for premature cardiovascular mortality than high cholesterol levels developing over time and clogging arteries (Leon et al. 2009).
Heavy drinking, as noted, may suppress stress for men. That is, heavy vodka users are not stressed because they drink heavily. Drinking heavily may, in fact, promote feelings of well-being and life satisfaction as seen in a Moscow study in which many male respondents reported that alcohol makes them feel more optimistic about life (Mustonen 1997). Other research finds Russian men reporting alcohol use is beneficial for their health (Abbott et al. 2006). Therefore, as suggested, stress may primarily operate indirectly by promoting negative health lifestyle practices like regular heavy drinking and smoking instead of provoking outright death. Yeltsin (2000: 318), for example, says that he learned ‘fairly early on … that alcohol was the only means to get rid of stress’. This outcome suggests that the normative demands of the Russian male lifestyle are a powerful influence promoting heavy male drinking. It is also important to note that alcohol use may not always be a stress response, but can indicate conformity to cultural norms or hedonistic desires (Horwitz 2002). This may be why Bobak et al. (1999) found alcohol consumption to be spread rather uniformly among males and not necessarily related to material deprivation, economic or political change, or ratings of the economic situation. While economic strain may promote binge drinking (Jukkala et al. 2008), the practice nevertheless appears to be so widespread over the course of the last century that it became normative regardless of Russia’s economy.
Heavy drinkers typically smoke and this is also the case in Russia. As Abbott et al. (2006: 235) put it: drinking and smoking is ‘seen as part of the normal way of life for men − deeply imbedded in taken-for-granted everyday practices’. Even though male smoking is extensive, it has not received the same level of attention from researchers as alcohol. Nevertheless, the existing literature is clear that smoking is considerably more common among males than females (McKee et al. 1998, Davidova et al. 2009, Nazarova 2009). Only a few studies have been carried out on diet and exercise. The Russian diet has changed since the 1960s and contains one of the highest levels of fat in the world. For a time, the proportion of fat in diets showed a steady decrease for adults, but in the last decade it has increased with a rise in the cost of high protein foods causing a shift to cheaper foodstuffs for many people (Nazarova 2009). The few data available on health-promoting leisure-time exercise show it to be minimal for both Russian men and women, as many adults do not engage in any physical exercise at all (Palosuo 2000, 2003, Nazarova 2009).
Overall, negative health lifestyle practices are far more characteristic of men than women and the powerful link between such lifestyles and the major causes of male deaths − heart disease and alcohol-related accidents and poisonings − lends support to the dominant role of lifestyles in the male health crisis. Age and class join gender as important lifestyle variables, since death rates have been highest, as noted, for middle-age, working-class males than any other segment of the population (Cockerham 1999, Tomkins et al. 2006, Andreev et al. 2009). While the lifestyle explanation is not the sole reason for the health crisis which is obviously complex, the evidence for males suggests for nearly half a century it is the primary cause relative to other causes.