Revista Societatii de Medicina Interna
Articolul face parte din revista :
Nr.3 din luna 2011
Autor E. Ginter
Titlu articolBALKAN: NEW DATA ON HEALTH, LIFE EXPECTANCY AND MORTALITY
Cuvinte cheiețări balcanice, starea de sănătate a populației, speranța de viață, mortalitatea infantilă, finanțarea sistemului de sănătate, moștenirea comunistă
Articol
Ginter E.1 , Simko V.2
1Institute of Preventive and Clinical Medicine, Bratislava, Slovakia (emeritus)
2State University of New York, Downstate Medical Center at Brooklyn, USA
Address for correspondence:
RNDr. Emil Ginter DrSc, Racianska 17, 83102 Bratislava
Prof. V. Simko MD, State University New York, Downstate Medical Center at Brooklyn, USA , simko2@verizon.net
A brief review of recent Balkan history provides an important insight for understanding the shifts in population health in the Balkans. Complex events in political and socioeconomic life left behind indelible markers.
Greece was subjected to serious political strife toward the end of World War II. This was resolved by the victory of pro-democratic forces. After 1945 most of the Balkan territory, with the exception of Yugoslavia, fell under the spell and domination of the Soviet Union and was subjected to the dogmatic, all-encompassing communist ideology.
Yugoslavia controlled by Tito had ethnic tensions on a temporary hold and it fell out of the Soviet sphere of influence after 1948, establishing reasonable contacts with democratic EU and the rest of the world. Albania after 1961 fell into strict isolation from all EU including the Soviets and it cherished ties with the Mao’s China. There are deficient data on population health in Albania.
In the late 1980s the post-Soviet vacuum was gradually filled, implementing an open democratic society, privatization and free market economy. In Albania, Bulgaria and Romania these socioeconomic changes were accompanied by a period of social upheaval with political and economic instability, sometimes with adverse consequences. Yugoslavia erupted into episodes of tragic ethnic war.
Since around the 2000, the Balkans adopted a friendly cooperative link with the western EU and with the USA. Greece has been a member of EU since 1981, Slovenia and Cyprus since 2004, Bulgaria and Romania joined the EU in 2007.
Life expectancy and child mortality in Balkan countries
The World Health Organization (WHO) published in 2011 a database titled European Health For All(1) which summarizes the most recent data on European health. It is the main source of statistics included in this review. Balkan countries with reliable statistical resources (e.g. Romania and Greece) reported health data for the period 1970 – 2009. Former Yugoslavia published health statistical data predominantly after 1985. Health reports from Moldova, the region previously separated from Romania and incorporated into the USSR, are even more sparse. Finally, LE in Albania is not included: due to under registration of deaths, LE in this country is spuriously elevated.
Figure nr. 1 depicts trends in male LE since 1970 for most of the Balkan countries. Greece an Slovenia exhibit a vigorous steady improvement in LE and this reflects similar trend observed in EU. Slovenia benefits from a close proximity to central EU. Male LE in Bulgaria and Romania stagnated until the mid 1990s, until the socioeconomic consolidation resulted in improving the LE. Moldova has, comparably low LE that gradually shows a return to values seen before the 1990.
Figure nr. 2 documents LE in Balkan countries from a different perspective, focusing on the period 2008-2009. The male LE particularly reflects the political upheavals of preceeding decades. Greece with established democracy since 1945, reports the longest LE. Territories of former Yugoslavia, Slovenia, Croatia, Montenegro ad Serbia follow Greece in better LE. Communism under Tito did not prove as totally devastating as the Soviet system. Lower LE in Bulgaria and Romania may relate to the oppressive measures of past totalitarian absolutism. Low LE in Moldova, a territory that became integrated with the Soviet Union, is hardly a surprise.
Figure nr. 3, the infant mortality in 2008 (deaths in the first year of life) provides a reverse mirror image of the country LE. Infant mortality is highest in Moldova, high both in Romania and Bulgaria (countries with significant Roma minority)(2). It is somewhat better in former Yugoslavia and lowest in Greece and Slovenia.
Child mortality (deaths before the age of five) (Figure nr. 4) provides more favorable impression. Romania has especially to be commended for an intensive decline in child mortality after 1990.
Premature mortality in Balkan countries.
WHO defines premature mortality as that which occurs within the range of 0 – 64 years of life. This index has an important socioeconomic value: it reflects the sufferring, health disability and health expenses in the most productive age group. All data are expressed as the standardized death rate (SDR). SDR is the age-standardized death rate calculated using the direct method, i.e. it represents what the crude rate would have been if the population had the same age distribution as the standard European population. Since life trends in males are more prominent and respond more sensitively to socioeconomic situations than in females, most of the graphic descriptions focus on men. Trends in females resemble male population in respective regions, albeit being somewhat less pronounced.
CVD still remains the main cause of premature and also general mortality in several Balkan countries. This is despite a very prominent decline of CVD mortality in EU countries that have the privilege of well established social order and effective health care. Figure nr. 5 documents trends of premature male CVD mortality in five Balkan countries. It is of notice that in Romania and Bulgaria the CVD mortality rapidly increased during the communist totality, a sorrowful legacy of the political system’s general failure. This was followed by a decline in CVD mortality that occurred only several years after the fall of communism. The decline in CVD mortality in Romania has been more pronounced than in Bulgaria, yet the mortality in 2010 is still higher than in 1970.
Slovenia did not experience similar rise in CVD mortality after 1970. Presently, the CVD mortality of Slovenian men is even lower than in Greek males. In the past Greece was believed to be an example of low CVD, presumably thanks to the Mediterranean diet(3).
Figure nr. 6 depicts regional differences in premature male mortality from the vantage point of two CVD components: the ischemic heart disease and the cerebrovascular accidents. Two regional extremes are to be noted: Unfavorably high mortality for both disorders in Moldova (possible legacy of the Soviet rule) and the very low mortality in Montenegro, lower than in Greece.
Figure nr. 7 documents another set of premature male mortality: that related to neoplasia. Again, this is quite discouraging for Romania and Bulgaria. In these two countries there has been a progressive increase in male neoplasms, despite the socioeconomic changes brought about by the fall of communism. Romania has the unfortunate distinction to belong to EU countries with a highest oncologic mortality. On the other end of the spectrum, Slovenia distinguished itself by a dramatic decline in oncologic mortality, resembling the trend in some west EU countries. Greece has the lowest oncologic mortality in the Balkans. There have been speculations that this may be the benficial sequel of the Mediterranean diet (4-6). Opposite trends and the existence of oncologic mortality reversal in various parts of EU provide contributing evidence for environmental oncogenic factors that are manageable and urgently require attention.
Figure nr. 8 focusing on the shorter and more recent period 2008/2009, also includes premature cancer mortality in women and the data from additional Balkan countries, Serbia, Croatia, Montenegro and Moldova. It essentially confirms the statistics from the extended period of 1970 – 2010 (Figure nr. 7).
Additional and more detailed data on cancer and related mortality in the Balkans and other EUR countries are available(7). The most fateful oncologic disorder in Balkan countries is cancer of the respiratory tract, larynx, trachea, bronchi and lungs. It would be interesting to associate the oncologic mortality with smoking habits.
Figure nr. 9 compares premature male mortality for CVD and cancer. CVD mortality in Romania, Moldova and Bulgaria has the unfortunate distinction to be about three times higher than in Greece, Slovenia and in most countries of the EU. Interestingly, CVD mortality far exceeds cancer mortality, although cancer is still quite prevalent in Romania and Serbia. Regional differences in cancer mortality are less pronounced than the CVD mortality: SDR for cancer is 101/100 000 in Slovenia and 133/100 000 in Romania.
What about other diseases in the Balkans?
Premature mortality in males related to external causes, injury and poison is still higher than in the EU. However, Balkan females have premature mortality for external causes close to an EU average. Transport accidents in Balkan countries are higher than in the EU, highest in Greece and low in Bulgaria. Suicides are persistently low in Greece. Bulgaria and Romania have suicides close to the EU average. Slovenia had a high rate of self inflicted injuries in the mid 1980s but recently there was a dramatic improvement.
Infection and parasitic diseases were frequent in Romania in the 1970s but there was a dramatic decline even during the following years of communism. However, these disorders in Romania are still most prevalent of all Balkan countries. High proportion of Roma population may be a contributing factor. In Bulgaria and Greece, infection and parasitic disorders were also quite frequent in the 1970s but after an impressive improvement, the present incidence is similar to the EU.
Premature mortality related to respiratory disorders in general and to bronchitis, asthma and emphysema in particular was likewise very high in Romania and Bulgaria in the 1970s. Presently, these disorders are only mildly higher than the average in the EU.
Of great concern is the high mortality for tuberculosis in Romania, seven times higher that the EUR average and exceeded only in the countries of the former Soviet Union.
Premature mortality related to digestive disorders and diseases of the liver has been traditionally low in Greece. Slovenia experienced a strong decline. Unfortunately, an unfavorable trend has been noted in Bulgaria and Romania. Already since 1970 they have had an intermittent rise in digestive mortality. Romanian males have the highest mortality for digestive disorders, exceeded only by the Russian Federation, Ukraine and Hungary. Romanian women surpass in digestive disease mortality even the dire statistics of Hungarian females.
Former high premature mortality for genitourinary disorders in Greece, Romania and Bulgaria substantially declined but it is still higher than the EU average.
Regarding blood dyscrasias, diseases of blood forming organs, mental and nervous system disorders, the premature mortality in the Balkans has much improved and it presently approximates the EU average.
Mortality at older age in the Balkans.
WHO considers population older than 64 a separate health statistic category(1). Figure nr. 10 indicates the trend in LE in women at age 65. Since the 1970s there has been substantial improvement in older women LE in Greece. Remarkably, aging women in Slovenia exceed even Greeks and at the age of 65 they can hope for yet another twenty years of life. For aging Romanian and Bulgarian women, the chance to live has markedly improved after late 1990s and it presently adds a hope for another 16-17 years after the age of 65. The main reason for improved LE in aging women has been a sharp decline in female CVD mortality.
LE in male population after the age of 65 shows similar trends noted in women. Unfortunately, high CVD mortality after age 65 in Bulgarian and Romanian men (Figure nr. 11) keeps them at marked (two-fold) disadvantage when compared to Greeks, Slovenians and the average men in the EU.
Conclusion
Population health in the Balkans in the past fifty years provides a marked example for the influence of political and socioeconomic factors. Most Balkan countries with the exception of Greece and to some extent of Yugoslavia became forcefully separated by the iron curtain from the progress in the free democratic world. Instead of heading for integration with the rest of Europe they were subjected to the eastern ideology of the Soviet Union, with accompanying dire consequences. Despite overwhelming propaganda claims of the communist totality, the facts of life in totality brought about tragic and sobering consequences.
Compared with free EU, the LE in the communist Balkan was stagnant or even declined. An ugly mark on the totalitarian health system was the dramatic rise in CVD mortality at the time when CVD in democratic EU started to decline. The only positive component was a decrease in neonatal mortality and of childhood mortality up to the age of five.
An improvement in general health occurred in the Balkan countries only after the fall of communism, albeit with some delay during the 1990s. The LE began to improve in Romania and Bulgaria, even in Moldova still integrated with Russia.
A troubling dilemma remains: why the delay in the health outcome in the post-communist Balkans, even twenty years after the fall of the iron curtain(8)? This delayed trend becomes even more pronounced when it is reflected on the rapid population health improvement in former post-communist central Europe(9).
Of all Balkan countries, Romania with neighboring Moldova and Bulgaria present with the shortest LE, highest infant mortality, highest premature mortality from CVD, ischemic heart disease and cerebrovascular accidents. Even worse, in these countries premature cancer mortality continues to rise. WHO data presented here are sending a strong signal to the responsible health authorities to deal with a situation, in the context of the EU considered alarming. There is a need to identify the root causes of these unfavorable health profiles.
While the causes of slow improvement in Balkan population health are multifactorial, undoubtedly adversely contributes an unhealthy life style(10, 11): tobacco and alcohol in men, increase in obesity and inconsistent control of blood pressure in women.
The extent of financial support for health care is also decisive. Economic strain and slow recovery of free market mechanisms with uneasy implementation of principles of an open society, have drastically hindered adequate funding for health care. Undoubtedly, there are other variables than a nation’s wealth that determine the outcome of health care. Notwithstanding, in the Balkans there is a very close correlation between the per capita health expenditure (expressed as dollar purchasing power parity, PPP$) and the LE- Figure nr. 12.
The male LE in 2008 was highest in Greece and Slovenia (PPP$ 2900 and 2200, respectively) while the LE was lower in Bulgaria and Romania (PPP$ 910 nad 665, respectively). Moldova with the lowest LE had the PPP$ only 318.
Articol primit în martie 2011, acceptat în iunie 2011
References
1. European Health for All database (HFA-DB). Copenhagen, WHO Regional Office for Europe, [2011] (http://www.euro.who.int/hfadb).
2. Ginter E, Krajcovicova-Kudlackova M, Kacala O et al. Health status of Romanies (Gypsies) in the Slovak Republic and in the neighbouring countries. Bratislava Med J 2001; 102: 479-484.
3. Sofi F, Cesari F, Abbate R et al. Adherence to Mediterranean diet and health status: meta-analysis. BMJ 2008; 337: a1344.
4. Buckland G, Agudo A, Luján L et al. Adherence to a Mediterranean diet and risk of gastric adenocarcinoma within the European Prospective Investigation into Cancer and Nutrition (EPIC) cohort study. Am J Clin Nutr 2010; 91: 381-390.
5. La Vecchia C. Association between Mediterranean dietary patterns and cancer risk. Nutr Rev 2009;67 Suppl 1:S126-129.
6. Pelucchi C, Bosetti C, Rossi M et al. Selected aspects of Mediterranean diet and cancer risk. Nutr Cancer 2009;61(6):756-766.
7. Ginter E, Simko V. Cancer mortality in the European Union (EU). Medicina Interna (Romania) 2010; 7(5): 27-32.
8. Mortality indicators by 67 causes of death, age and sex (HFA-MDB), Copenhagen, WHO Regional Office for Europe, [updated in July 2010].
9. Ginter E, Simko V, Wsolova L. Fall of the iron curtain: male life expectancy in Slovakia, in the Czech republic and in Europe. Cent Eur J Public Health 2009; 17(4): 171-174.
10. Highlights on health in Romania. WHO Regional Office for Europe, Copenhagen, Denmark, 2006.
11. Rehm J, Sulkovska U, Manczuk M et al. Alcohol accounts for a high proportion of premature mortality in central and eastern Europe. Int J Epidemiol 2007; 36: 458-467.
Legends to illustrations:
Figure nr. 1. Trends of life expectancy (LE) in males indicate an impressive improvement in the past forty years for Greece and Slovenia. There has been a modest improvement in LE also in Bulgaria, Romania and Moldova. According to WHO(1).
Figure nr. 2. Presently, the best LE for both males and females is in Greece and Slovenia. Reasonable LE is in Croatia and Montenegro. Lower LE is in Bulgaria, Romania and Serbia, lowest LE in Moldova. According to WHO(1).
Figure nr. 3. Infant motrtality trends in the Balkans resemble the LE illustrated in Figure nr. 2. Infant mortality in this European region improved in the recent past but it remains higher than in the western and central Europe. According to WHO(1).
Figure nr. 4. Data on a rapid decline of mortality in children less than 5 years old are encouraging. According to WHO(1).
Figure nr. 5. Failure of the communist health care system in Bulgaria and Romania is evidenced by a prominent rise in male cardiovascular disease (CVD) mortality. This started to decline only after the fall of the iron curtain, in the mid 1990s. CVD mortality is still higher than in 1970. Slovenia has low CVD mortality, with values lower than Greece. According to WHO(1).
Figure nr. 6. Premature mortality for male ischemic heart disease and cerebrovascular accidents is very high in Moldova and also high in Bulgaria and Romania. Slovenia and Montenegro have more favorable values than Greece. According to WHO(1).
Figure nr. 7 Alarming is the persistent rise in premature cancer mortality since 1970 in Bulgaria and Romania. Downward trend in Slovenia and Greece proves that the fight with cancer is manageable. According to WHO(1).
Figure nr. 8. Premature cancer mortality, prominent in Romania, Serbia and Moldova is obvious also when focusing at a shorter period of 2008/2009. Greece and Montenegro display much more favorable values. According to WHO(1).
Figure nr. 9. CVD mortality remains the main killer in Bulgaria and Moldova (three times the average of Greece, Slovenia or the European Union). CVD mortality in these countries exceeds the mortality for cancer. According to WHO(1).
Figure nr. 10. Women past the age of 65 have the best LE in Greece and Slovenia. Older women in Romania and Bulgaria improved their LE since the mid 1990s. According to WHO(1).
Figure nr. 11. Men at the age of 65 have their hope to live longer threatened more by CVD than by cancer, especially in Moldova, Bulgaria and Romania. There are only minor differences in cancer mortality among the countries. According to WHO(1).
Figure nr. 12. This chart clearly documents the close correlation between national funding for health care and the male life expectancy in the Balkans. According to WHO(1).
Nr.3 din luna 2011
Ginter E.1 , Simko V.2
1Institute of Preventive and Clinical Medicine, Bratislava, Slovakia (emeritus)
2State University of New York, Downstate Medical Center at Brooklyn, USA
Address for correspondence:
RNDr. Emil Ginter DrSc, Racianska 17, 83102 Bratislava
Prof. V. Simko MD, State University New York, Downstate Medical Center at Brooklyn, USA , simko2@verizon.net
A brief review of recent Balkan history provides an important insight for understanding the shifts in population health in the Balkans. Complex events in political and socioeconomic life left behind indelible markers.
Greece was subjected to serious political strife toward the end of World War II. This was resolved by the victory of pro-democratic forces. After 1945 most of the Balkan territory, with the exception of Yugoslavia, fell under the spell and domination of the Soviet Union and was subjected to the dogmatic, all-encompassing communist ideology.
Yugoslavia controlled by Tito had ethnic tensions on a temporary hold and it fell out of the Soviet sphere of influence after 1948, establishing reasonable contacts with democratic EU and the rest of the world. Albania after 1961 fell into strict isolation from all EU including the Soviets and it cherished ties with the Mao’s China. There are deficient data on population health in Albania.
In the late 1980s the post-Soviet vacuum was gradually filled, implementing an open democratic society, privatization and free market economy. In Albania, Bulgaria and Romania these socioeconomic changes were accompanied by a period of social upheaval with political and economic instability, sometimes with adverse consequences. Yugoslavia erupted into episodes of tragic ethnic war.
Since around the 2000, the Balkans adopted a friendly cooperative link with the western EU and with the USA. Greece has been a member of EU since 1981, Slovenia and Cyprus since 2004, Bulgaria and Romania joined the EU in 2007.
Life expectancy and child mortality in Balkan countries
The World Health Organization (WHO) published in 2011 a database titled European Health For All(1) which summarizes the most recent data on European health. It is the main source of statistics included in this review. Balkan countries with reliable statistical resources (e.g. Romania and Greece) reported health data for the period 1970 – 2009. Former Yugoslavia published health statistical data predominantly after 1985. Health reports from Moldova, the region previously separated from Romania and incorporated into the USSR, are even more sparse. Finally, LE in Albania is not included: due to under registration of deaths, LE in this country is spuriously elevated.
Figure nr. 1 depicts trends in male LE since 1970 for most of the Balkan countries. Greece an Slovenia exhibit a vigorous steady improvement in LE and this reflects similar trend observed in EU. Slovenia benefits from a close proximity to central EU. Male LE in Bulgaria and Romania stagnated until the mid 1990s, until the socioeconomic consolidation resulted in improving the LE. Moldova has, comparably low LE that gradually shows a return to values seen before the 1990.
Figure nr. 2 documents LE in Balkan countries from a different perspective, focusing on the period 2008-2009. The male LE particularly reflects the political upheavals of preceeding decades. Greece with established democracy since 1945, reports the longest LE. Territories of former Yugoslavia, Slovenia, Croatia, Montenegro ad Serbia follow Greece in better LE. Communism under Tito did not prove as totally devastating as the Soviet system. Lower LE in Bulgaria and Romania may relate to the oppressive measures of past totalitarian absolutism. Low LE in Moldova, a territory that became integrated with the Soviet Union, is hardly a surprise.
Figure nr. 3, the infant mortality in 2008 (deaths in the first year of life) provides a reverse mirror image of the country LE. Infant mortality is highest in Moldova, high both in Romania and Bulgaria (countries with significant Roma minority)(2). It is somewhat better in former Yugoslavia and lowest in Greece and Slovenia.
Child mortality (deaths before the age of five) (Figure nr. 4) provides more favorable impression. Romania has especially to be commended for an intensive decline in child mortality after 1990.
Premature mortality in Balkan countries.
WHO defines premature mortality as that which occurs within the range of 0 – 64 years of life. This index has an important socioeconomic value: it reflects the sufferring, health disability and health expenses in the most productive age group. All data are expressed as the standardized death rate (SDR). SDR is the age-standardized death rate calculated using the direct method, i.e. it represents what the crude rate would have been if the population had the same age distribution as the standard European population. Since life trends in males are more prominent and respond more sensitively to socioeconomic situations than in females, most of the graphic descriptions focus on men. Trends in females resemble male population in respective regions, albeit being somewhat less pronounced.
CVD still remains the main cause of premature and also general mortality in several Balkan countries. This is despite a very prominent decline of CVD mortality in EU countries that have the privilege of well established social order and effective health care. Figure nr. 5 documents trends of premature male CVD mortality in five Balkan countries. It is of notice that in Romania and Bulgaria the CVD mortality rapidly increased during the communist totality, a sorrowful legacy of the political system’s general failure. This was followed by a decline in CVD mortality that occurred only several years after the fall of communism. The decline in CVD mortality in Romania has been more pronounced than in Bulgaria, yet the mortality in 2010 is still higher than in 1970.
Slovenia did not experience similar rise in CVD mortality after 1970. Presently, the CVD mortality of Slovenian men is even lower than in Greek males. In the past Greece was believed to be an example of low CVD, presumably thanks to the Mediterranean diet(3).
Figure nr. 6 depicts regional differences in premature male mortality from the vantage point of two CVD components: the ischemic heart disease and the cerebrovascular accidents. Two regional extremes are to be noted: Unfavorably high mortality for both disorders in Moldova (possible legacy of the Soviet rule) and the very low mortality in Montenegro, lower than in Greece.
Figure nr. 7 documents another set of premature male mortality: that related to neoplasia. Again, this is quite discouraging for Romania and Bulgaria. In these two countries there has been a progressive increase in male neoplasms, despite the socioeconomic changes brought about by the fall of communism. Romania has the unfortunate distinction to belong to EU countries with a highest oncologic mortality. On the other end of the spectrum, Slovenia distinguished itself by a dramatic decline in oncologic mortality, resembling the trend in some west EU countries. Greece has the lowest oncologic mortality in the Balkans. There have been speculations that this may be the benficial sequel of the Mediterranean diet (4-6). Opposite trends and the existence of oncologic mortality reversal in various parts of EU provide contributing evidence for environmental oncogenic factors that are manageable and urgently require attention.
Figure nr. 8 focusing on the shorter and more recent period 2008/2009, also includes premature cancer mortality in women and the data from additional Balkan countries, Serbia, Croatia, Montenegro and Moldova. It essentially confirms the statistics from the extended period of 1970 – 2010 (Figure nr. 7).
Additional and more detailed data on cancer and related mortality in the Balkans and other EUR countries are available(7). The most fateful oncologic disorder in Balkan countries is cancer of the respiratory tract, larynx, trachea, bronchi and lungs. It would be interesting to associate the oncologic mortality with smoking habits.
Figure nr. 9 compares premature male mortality for CVD and cancer. CVD mortality in Romania, Moldova and Bulgaria has the unfortunate distinction to be about three times higher than in Greece, Slovenia and in most countries of the EU. Interestingly, CVD mortality far exceeds cancer mortality, although cancer is still quite prevalent in Romania and Serbia. Regional differences in cancer mortality are less pronounced than the CVD mortality: SDR for cancer is 101/100 000 in Slovenia and 133/100 000 in Romania.
What about other diseases in the Balkans?
Premature mortality in males related to external causes, injury and poison is still higher than in the EU. However, Balkan females have premature mortality for external causes close to an EU average. Transport accidents in Balkan countries are higher than in the EU, highest in Greece and low in Bulgaria. Suicides are persistently low in Greece. Bulgaria and Romania have suicides close to the EU average. Slovenia had a high rate of self inflicted injuries in the mid 1980s but recently there was a dramatic improvement.
Infection and parasitic diseases were frequent in Romania in the 1970s but there was a dramatic decline even during the following years of communism. However, these disorders in Romania are still most prevalent of all Balkan countries. High proportion of Roma population may be a contributing factor. In Bulgaria and Greece, infection and parasitic disorders were also quite frequent in the 1970s but after an impressive improvement, the present incidence is similar to the EU.
Premature mortality related to respiratory disorders in general and to bronchitis, asthma and emphysema in particular was likewise very high in Romania and Bulgaria in the 1970s. Presently, these disorders are only mildly higher than the average in the EU.
Of great concern is the high mortality for tuberculosis in Romania, seven times higher that the EUR average and exceeded only in the countries of the former Soviet Union.
Premature mortality related to digestive disorders and diseases of the liver has been traditionally low in Greece. Slovenia experienced a strong decline. Unfortunately, an unfavorable trend has been noted in Bulgaria and Romania. Already since 1970 they have had an intermittent rise in digestive mortality. Romanian males have the highest mortality for digestive disorders, exceeded only by the Russian Federation, Ukraine and Hungary. Romanian women surpass in digestive disease mortality even the dire statistics of Hungarian females.
Former high premature mortality for genitourinary disorders in Greece, Romania and Bulgaria substantially declined but it is still higher than the EU average.
Regarding blood dyscrasias, diseases of blood forming organs, mental and nervous system disorders, the premature mortality in the Balkans has much improved and it presently approximates the EU average.
Mortality at older age in the Balkans.
WHO considers population older than 64 a separate health statistic category(1). Figure nr. 10 indicates the trend in LE in women at age 65. Since the 1970s there has been substantial improvement in older women LE in Greece. Remarkably, aging women in Slovenia exceed even Greeks and at the age of 65 they can hope for yet another twenty years of life. For aging Romanian and Bulgarian women, the chance to live has markedly improved after late 1990s and it presently adds a hope for another 16-17 years after the age of 65. The main reason for improved LE in aging women has been a sharp decline in female CVD mortality.
LE in male population after the age of 65 shows similar trends noted in women. Unfortunately, high CVD mortality after age 65 in Bulgarian and Romanian men (Figure nr. 11) keeps them at marked (two-fold) disadvantage when compared to Greeks, Slovenians and the average men in the EU.
Conclusion
Population health in the Balkans in the past fifty years provides a marked example for the influence of political and socioeconomic factors. Most Balkan countries with the exception of Greece and to some extent of Yugoslavia became forcefully separated by the iron curtain from the progress in the free democratic world. Instead of heading for integration with the rest of Europe they were subjected to the eastern ideology of the Soviet Union, with accompanying dire consequences. Despite overwhelming propaganda claims of the communist totality, the facts of life in totality brought about tragic and sobering consequences.
Compared with free EU, the LE in the communist Balkan was stagnant or even declined. An ugly mark on the totalitarian health system was the dramatic rise in CVD mortality at the time when CVD in democratic EU started to decline. The only positive component was a decrease in neonatal mortality and of childhood mortality up to the age of five.
An improvement in general health occurred in the Balkan countries only after the fall of communism, albeit with some delay during the 1990s. The LE began to improve in Romania and Bulgaria, even in Moldova still integrated with Russia.
A troubling dilemma remains: why the delay in the health outcome in the post-communist Balkans, even twenty years after the fall of the iron curtain(8)? This delayed trend becomes even more pronounced when it is reflected on the rapid population health improvement in former post-communist central Europe(9).
Of all Balkan countries, Romania with neighboring Moldova and Bulgaria present with the shortest LE, highest infant mortality, highest premature mortality from CVD, ischemic heart disease and cerebrovascular accidents. Even worse, in these countries premature cancer mortality continues to rise. WHO data presented here are sending a strong signal to the responsible health authorities to deal with a situation, in the context of the EU considered alarming. There is a need to identify the root causes of these unfavorable health profiles.
While the causes of slow improvement in Balkan population health are multifactorial, undoubtedly adversely contributes an unhealthy life style(10, 11): tobacco and alcohol in men, increase in obesity and inconsistent control of blood pressure in women.
The extent of financial support for health care is also decisive. Economic strain and slow recovery of free market mechanisms with uneasy implementation of principles of an open society, have drastically hindered adequate funding for health care. Undoubtedly, there are other variables than a nation’s wealth that determine the outcome of health care. Notwithstanding, in the Balkans there is a very close correlation between the per capita health expenditure (expressed as dollar purchasing power parity, PPP$) and the LE- Figure nr. 12.
The male LE in 2008 was highest in Greece and Slovenia (PPP$ 2900 and 2200, respectively) while the LE was lower in Bulgaria and Romania (PPP$ 910 nad 665, respectively). Moldova with the lowest LE had the PPP$ only 318.
Articol primit în martie 2011, acceptat în iunie 2011
References
1. European Health for All database (HFA-DB). Copenhagen, WHO Regional Office for Europe, [2011] (http://www.euro.who.int/hfadb).
2. Ginter E, Krajcovicova-Kudlackova M, Kacala O et al. Health status of Romanies (Gypsies) in the Slovak Republic and in the neighbouring countries. Bratislava Med J 2001; 102: 479-484.
3. Sofi F, Cesari F, Abbate R et al. Adherence to Mediterranean diet and health status: meta-analysis. BMJ 2008; 337: a1344.
4. Buckland G, Agudo A, Luján L et al. Adherence to a Mediterranean diet and risk of gastric adenocarcinoma within the European Prospective Investigation into Cancer and Nutrition (EPIC) cohort study. Am J Clin Nutr 2010; 91: 381-390.
5. La Vecchia C. Association between Mediterranean dietary patterns and cancer risk. Nutr Rev 2009;67 Suppl 1:S126-129.
6. Pelucchi C, Bosetti C, Rossi M et al. Selected aspects of Mediterranean diet and cancer risk. Nutr Cancer 2009;61(6):756-766.
7. Ginter E, Simko V. Cancer mortality in the European Union (EU). Medicina Interna (Romania) 2010; 7(5): 27-32.
8. Mortality indicators by 67 causes of death, age and sex (HFA-MDB), Copenhagen, WHO Regional Office for Europe, [updated in July 2010].
9. Ginter E, Simko V, Wsolova L. Fall of the iron curtain: male life expectancy in Slovakia, in the Czech republic and in Europe. Cent Eur J Public Health 2009; 17(4): 171-174.
10. Highlights on health in Romania. WHO Regional Office for Europe, Copenhagen, Denmark, 2006.
11. Rehm J, Sulkovska U, Manczuk M et al. Alcohol accounts for a high proportion of premature mortality in central and eastern Europe. Int J Epidemiol 2007; 36: 458-467.
Legends to illustrations:
Figure nr. 1. Trends of life expectancy (LE) in males indicate an impressive improvement in the past forty years for Greece and Slovenia. There has been a modest improvement in LE also in Bulgaria, Romania and Moldova. According to WHO(1).
Figure nr. 2. Presently, the best LE for both males and females is in Greece and Slovenia. Reasonable LE is in Croatia and Montenegro. Lower LE is in Bulgaria, Romania and Serbia, lowest LE in Moldova. According to WHO(1).
Figure nr. 3. Infant motrtality trends in the Balkans resemble the LE illustrated in Figure nr. 2. Infant mortality in this European region improved in the recent past but it remains higher than in the western and central Europe. According to WHO(1).
Figure nr. 4. Data on a rapid decline of mortality in children less than 5 years old are encouraging. According to WHO(1).
Figure nr. 5. Failure of the communist health care system in Bulgaria and Romania is evidenced by a prominent rise in male cardiovascular disease (CVD) mortality. This started to decline only after the fall of the iron curtain, in the mid 1990s. CVD mortality is still higher than in 1970. Slovenia has low CVD mortality, with values lower than Greece. According to WHO(1).
Figure nr. 6. Premature mortality for male ischemic heart disease and cerebrovascular accidents is very high in Moldova and also high in Bulgaria and Romania. Slovenia and Montenegro have more favorable values than Greece. According to WHO(1).
Figure nr. 7 Alarming is the persistent rise in premature cancer mortality since 1970 in Bulgaria and Romania. Downward trend in Slovenia and Greece proves that the fight with cancer is manageable. According to WHO(1).
Figure nr. 8. Premature cancer mortality, prominent in Romania, Serbia and Moldova is obvious also when focusing at a shorter period of 2008/2009. Greece and Montenegro display much more favorable values. According to WHO(1).
Figure nr. 9. CVD mortality remains the main killer in Bulgaria and Moldova (three times the average of Greece, Slovenia or the European Union). CVD mortality in these countries exceeds the mortality for cancer. According to WHO(1).
Figure nr. 10. Women past the age of 65 have the best LE in Greece and Slovenia. Older women in Romania and Bulgaria improved their LE since the mid 1990s. According to WHO(1).
Figure nr. 11. Men at the age of 65 have their hope to live longer threatened more by CVD than by cancer, especially in Moldova, Bulgaria and Romania. There are only minor differences in cancer mortality among the countries. According to WHO(1).
Figure nr. 12. This chart clearly documents the close correlation between national funding for health care and the male life expectancy in the Balkans. According to WHO(1).
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