Health lifestyles and the absence of the Russian middle class

Introduction

The purpose of this paper is to examine the pivotal role of social stratification in the Russian health crisis. This is an important area of inquiry because some sources find negative health lifestyles to be the leading determinant of the crisis and a close connection between class and lifestyles has been observed by social theorists since the 19^th century (Cockerham 2005). Marx (1960), for example, referred to class differences in lifestyles when writing about politics in the 1850s, while Veblen ([1899] 1994) used the lifestyle concept as the basis for his theory of the leisure class in 1899. Weber ([1922: 531–39] 1978: 926–39), however, provided the foundation for contemporary theorising about lifestyles in 1922 in his section on ‘Class, status, party’ in Economy and Society.

Weber (1946, 1978) pointed out that lifestyles not only expressed distinct differences between status groups and their adoption was a necessary feature of upward social mobility, but he also noted that powerful strata were ‘social carriers’ of particular ways of living. These carrier strata were independent causal forces in their own right as they transmitted group and class-specific norms, values, ethics, and ways of life across generations. They were indispensable in the distribution of sociologically significant patterns of behaviour (Kalberg 1994).

Moreover, as in the case of the Protestant ethic and the spread of capitalism, Weber (1958) recognised that certain lifestyles attached to particular groups and strata could expand across class boundaries. These lifestyles had the potential to become normative for the culture of a nation (Bendix 1962). This is an important observation because the origin of positive health lifestyles in contemporary Western society is the middle class, especially the upper-middle class (Bourdieu 1984, d’Houtaud and Field 1984, Featherstone 1987), and it is this strata that is the catalyst for the expansion of such lifestyles into the general population (Herzlich and Pierret 1987). Consequently, the focus of this paper is to investigate the extent to which the middle class similarly serves as a social carrier for the spread of positive health lifestyles in Russia. First will be a brief review of the known causes of the Russian health crisis in order to identify the role of health lifestyles. Next will be an examination of the link between these lifestyles and Russia's class structure.

The Russian health crisis

The Russian health crisis is characterised by premature adult mortality, primarily among 40–59-year-old males (Abbott 2002). Beginning in the mid-1960s, increases in male mortality from cardiovascular diseases and alcohol-related accidents and poisonings could no longer be masked by the decrease in deaths from cancer and infectious, respiratory, digestive, and other diseases (Mesléet al. 2003). Male life expectancy declined from 64.0 years in 1965 to 61.7 years in 1984, but briefly recovered to a modern high of 64.9 years in 1987 that coincided with the third year of Gorbachev's anti-alcohol campaign. It resumed its downward trend in 1988 with the termination of the anti-alcohol measures that consisted of higher prices and lower production. The decrease in male life expectancy accelerated during the fall of the former Soviet Union and the initial post-communist transition, reaching a modern low of 57.6 years in 1994. Following a slight recovery during 1995–98, male longevity turned downward again and stood at 58.9 years in 2005 – some 5.1 years less than in 1965.

Female life expectancy improved gradually from 1965 to 1989 when it reached a high of 74.6 years. At this time, female longevity followed the male trajectory downward over the course of the Soviet collapse and the immediate post-communist period, falling to 71.2 years by 1994. Again, like the males, Russian females showed a brief but slight improvement during 1995–97 when life expectancy recovered to 72.9 years – only to enter a period of decline once again. In 2005 females lived 72.4 years on average compared to 72.2 years in 1965.

The health crisis has obviously affected women in that their overall longevity has essentially stalled or ‘stagnated’ for the last 40 years. But while stagnation characterises the pattern of female life expectancy, the gender gap in years lived between adult men and women has increased because of the accelerated male deaths. In 2005, Russian females outlived their male counterparts an average of 13.5 years; in the United States, in contrast, the gender gap in life expectancy in 2004 was 5.0 years. This disparity in years lived for the Russians is the largest in the world. The gap is more than double that of other industrialised countries and four times greater than it was in the 1960s (Shkolnikov, Field and Andreev 2001). While the health crisis has blunted the capacity of Russian women to extend their life span, it continues to end the lives of men before they reach old age.

Infectious diseases, environmental pollution, and medically avoidable deaths have made only minor contributions to the rise in mortality (Andreev et al. 2003, Cockerham 1999, Shkolnikov et al. 1998a). Instead, the primary level cause of the crisis is premature mortality, as noted, from cardiovascular diseases and alcohol-related accidents and poisonings. In order to uncover the ultimate cause of the crisis, however, it is necessary to drop down to a secondary level to determine what has caused the increase in cardiovascular ailments and alcohol-related problems.

The search for secondary level causes includes consideration of health policy. We know that Soviet health policy was a contributory factor for failing to address the epidemiological transition from acute to chronic diseases. As Field (2000) explains, the Soviet healthcare delivery system lacked the flexibility administratively and structurally to adjust to health problems that could not be handled by the mass measures successful in controlling infectious diseases. Post-communist health policies have yet to significantly improve the situation. Policy, however, did not cause the increase in heart disease; rather, it failed to reverse it (Cockerham 1999). It is therefore necessary to look elsewhere for secondary level causes of the health crisis. There are two principal candidates: stress and health lifestyles.

A measure of the association of distress with health lifestyles

In order to examine whether distress is associated with drinking alcohol and smoking, data from the Russian sample (N = 4,006) of the Living Conditions, Lifestyles and Health (LLH) project are analysed. These data were collected in November 2001 by face-to-face interviews conducted nationwide by the Center for Sociological Studies of Moscow State University. The survey consisted of a representative sample of the adult population age 18 years and over. The sample was selected using multi-stage random sampling with stratification by region and area (urban/rural) (see Pomerleau et al. 2002). Within each primary sampling unit, households were selected using standardised route procedures and within each household the adult with the nearest birthday was selected for the interview.

There was no over- or under-sampling of subgroups, but certain categories of individuals were excluded such as prisoners, military personnel, institutionalised and hospitalised persons, and the homeless. Also excluded were geographically inaccessible regions with few people in the Russian Far North and locales subject to military action like the Chechen and Ingush Republics. The percentage of eligible respondents not contacted after three attempts was 11 per cent and refusals after contact was 16 per cent. The overall response rate was 73 per cent.

Questionnaire items were drawn from pre-existing surveys conducted in post-Soviet countries (Pomerleau et al. 2002). Psychological distress was measured by 12 items arranged in a dichotomous format and coded as no symptom present = 0, symptom present = 1. The symptoms are feeling stressed, unable to concentrate, insomnia, constantly under strain, can't overcome difficulties, losing confidence, shaking/trembling, frightening thoughts, feeling lonely, exhaustion/fatigue, feeling it is impossible to influence things, and feeling life is too complicated. These items were treated as a continuous independent variable and summed for each respondent to create a psychological distress scale. This scale is designed to measure the effects of distress on the health lifestyle practices selected for analysis. Total individual scores range from 0–12. The alpha reliability was .823.

Other independent variables are age, coded in years; married, coded as single, divorced or widowed = 0, married = 1; education, coded as primary or without education = 1, non-finished secondary education = 2, secondary education = 3, secondary vocational education (e.g. medical, technical, pedagogical college) = 4, non-finished higher education = 5, and higher education = 6; disposable income, coded as not enough for nutrition = 1, just enough for food/clothes = 2, enough to buy TV/fridge, but not car/apartment = 3, can purchase expensive goods (car/apartment) = 4; and occupation, coded as agricultural/unskilled worker = 1, skilled worker = 2, office clerk and similar workers without higher education = 3, manager/professional = 4, and top manager/senior official = 5.

Three health lifestyle dependent variables were employed: frequent drinker, habitual vodka drinker, and smoker. These variables were selected because of research identifying the importance of their role in promoting Russian mortality. Each variable is in a dichotomous format. Frequent drinker measures frequency of alcohol consumption (any type of alcohol) and is coded drink three or fewer times a week = 0, 4–6 times a week or daily = 1.

Since the Russian drinking style is often that of heavy episodic vodka drinking that does not necessarily occur frequently (daily or almost daily) another drinking measure – habitual vodka drinker – is employed. A measure of 100 grams (approximately 3.5 ounces or 2.8 shot glasses) or more of vodka consumed per occasion was used to differentiate between casual and dedicated (habitual) vodka drinkers. As surveys of the average amount of alcohol consumed in Russia usually result in underestimation by the respondent (Bobak et al. 1999), habitually drinking more than 100 grams per occasion indicates a serious commitment to vodka consumption. This measure is intended to identify the pattern of vodka drinking in the population, rather than provide an estimate of absolute consumption levels. Habitual vodka drinker measures how much vodka a drinker typically consumes per occasion and is coded as less than 100 grams = 0, 100 grams or over (between 100–300 grams, half a litre, and more than half a litre) per occasion = 1. With some 89.8 per cent of the vodka drinkers consuming over 100 grams of vodka per drinking occasion, the direction of the responses for habitual vodka drinker favour the higher rather than the lower end of consumption levels.

Smoker measures use of cigarettes and is coded nonsmoker = 0, smoker = 1. Self-reported health status is also included as a subjective ranking of a respondent's own health and is coded bad or rather bad = 0, quite good and good = 1. This dependent variable is added to the analysis to determine whether psychological distress affects self-ratings of health.

The data are analysed by logistic regression. The advantage of logistic regression is that it provides the probability of a discrete outcome for each dependent variable. The outcome provided for our analysis is the probability of participation (yes/no) in a particular health lifestyle practice for each case analysed. The statistics presented are the odds ratios, which express the direction and magnitude of the relationship between the independent and dependent variables. The 95 per cent confidence intervals associated with the odds ratios are also reported. The distribution of the variables is shown in Table 1.

The strategy for this analysis is to examine the association of psychological distress with the three health lifestyle practices and self-rated health status separately by gender. Since the literature shows Russian women are more distressed than men and men drink and smoke exceedingly much more than women, measuring the separate effects provides a more precise accounting of how distress affects the health lifestyle practices of both genders. Men and women typically have different lifestyles and may express them in different ways.

Table 2 shows the logistic regression results. The first column in Table 2 depicts the outcomes for males. Males who are younger (OR = .983), unmarried (OR = .604), have less disposable income (OR = .987), and are psychologically distressed (OR = 1.075), are significantly more likely to be frequent drinkers. These differences are all significant at the .05 level. Whereas distressed males are likely to drink more frequently than males who are not distressed, Table 2 shows that distress is not significantly associated with habitual vodka drinking. As will be discussed, psychological distress may not be the optimal variable for explaining habitual vodka drinking among Russian men. Only age and disposable income produce significant differences for male habitual vodka drinking. Younger men are more likely (OR = .963) to drink vodka habitually than older ones and men with less disposable income (OR = .480) do likewise compared to those with more disposable income. These differences are significant at the .01 and .05 levels, respectively.

Table 2 also shows the results for male smoking. Only education (OR = .844) is significant (p < .05) in that men with less education are more likely to be smokers. Finally, for self-rated health status, Table 2 shows that younger men (OR = .971) and men who are not psychologically distressed are significantly more likely to rate their health as good. These differences are both significant at the .001 level.

The only statistically significant variable for female frequent drinking in Table 2 is occupation (OR = .407) in that women in lower status jobs are more likely (p < .01) to drink frequently than women in higher status occupations. None of the independent variables are significant for habitual vodka drinking and only age is significant for smoking (OR = .951). Younger women are more likely (p < .001) to smoke than older women. Younger women (OR = .975) are also more likely to rate their health good. The only dependent variable significantly affected (p < .001) by psychological distress is self-rated health status in that women who are not distressed (OR = .802) are significantly more likely to rate their health good.

Discussion of findings

These data do not support a powerful role for psychological distress in connection with the drinking and smoking practices of the females in this analysis. In Russian society it is appropriate masculine – but not feminine – behaviour to drink alcohol (Segal 1990) and a large gender gap in alcohol consumption exists (Cockerham 1997, 1999, Van Gundy et al. 2005). As Van Gundy and her colleagues (2005) conclude in their comparison of adult drinking in Moscow and Toronto, the interaction of national drinking norms with traditional gender role orientations is a potent influence on alcohol use patterns. Men drink and women typically do not, but for those women who are frequent drinkers, these data show they are likely to have lower-status occupations.

These data also do not show an association of distress with smoking, but they do support other studies that show smoking is increasing among younger women. However, the cause of increased smoking among young women has been credited to the desire to be fashionable and the advertising influence of Western tobacco companies, rather than distress, and is largely restricted to major urban centers (Ogloblin and Brock 2003).

Psychological distress was significant with respect to frequent male drinking, but not habitual vodka drinking or smoking. It may be that once drinking practices are established for a Russian male, habitual drinking suppresses distress. For example, habitual vodka drinkers may not be distressed because they drink habitually. Drinking habitually may, in fact, promote feelings of wellbeing 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). 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’. This may be the major reason that Bobak et al. (1999) found alcohol consumption to be spread rather uniformly among males and not related to material deprivation, economic or political change, or ratings of economic conditions.

Former Russian President Boris Yeltsin (2000: 318) helps place this situation into perspective in his memoirs when he says that he learned ‘fairly early on . . . that alcohol was the only means to get rid of stress’. However, Yeltsin (2000: 318) indicates that more is involved than stress in heavy drinking when he says: ‘The traditional Russian lifestyle dictates that it's impossible not to drink at a birthday; it's impossible not to drink at a friend's wedding; it's impossible not to drink with your co-workers’. This circumstance suggests that the normative demands of the Russian male lifestyle are a powerful influence on heavy male drinking. It is important to note that alcohol use may not always be a stress response, but can indicate conformity to cultural norms or hedonistic motives (Horowitz 2002). Consequently, these data show psychological distress is only a partial tertiary level factor in the health crisis in that it is associated with frequent male drinking, but not the habitual use of vodka. It is therefore necessary to consider normative influences on health lifestyles that have their origin in a particular social class.

Among the indicators of class position in this sample, only low education is significant for smoking. For the drinking variables, only disposable income is a strong predictor. Male respondents with the lowest levels of disposable income are significantly more likely to be frequent drinkers and habitual vodka drinkers in comparison to those with higher disposable incomes. Whereas this result suggests such drinking may be concentrated in the lower class rather than the working class, this is not the case. The regression outcome for male habitual vodka drinking by income shows the direction of the practice weighted toward the lower end of the social scale, but not necessarily lodged at the very bottom.

Class and health lifestyles in Russia

Alcohol use and smoking are important health lifestyle practices having major implications for health and longevity, and invariably reflect differences between social classes (Blaxter 1990, Cockerham 2005). However, there is a paucity of research on the association of class with health lifestyles in Russia. ‘Theoretically,’ as Dmitrieva (2005: 322) points out, ‘Soviet society was described as a classless society, without class oppression, private property, or health inequalities’. Consequently, there was no incentive to study the class-health lifestyle relationship; moreover, sociology was banned as a ‘bourgeois’ science under Stalin, and use of the word ‘sociology’ was illegal (Osipov, Tulchinsky and Kabisha 1995). Both sociology and medical sociology revived somewhat after Stalin's death as supporters of the status quo, but became more independent and expanded in the wake of communism's collapse (Dmitrieva 2005). Research on social stratification in Russia is now emerging and data on health lifestyles – though limited – are available.

The origin of the most pervasive male health lifestyle is found in peasant and working class culture (Cockerham 1999, 2000b). White (1996) finds that prior to the 1917 Russian Revolution, Russians did not consume as much alcohol per capita as the French and Italians, but they favoured vodka with its high alcoholic content over wine and beer, with a predisposition toward periodic bouts of heavy consumption. Tian-Shanskaia (1993), for example, observed widespread binge drinking and drunkenness among agricultural workers in central Russia in the late 1890s, especially at weddings, street parties, and fairs. Russian males typically drank only on their days off, namely Sundays and Russian Orthodox Church holidays (Shkolnikov and Nemstov 1997). When they drank, they drank heavily. During the Soviet period, however, heavy consumption became common throughout the year in both urban and rural areas. Steady levels of moderate drinking were uncommon (White 1996).

Shkolnikov and Nemstov (1997) describe the Russian mode of drinking as part of a northern European lifestyle 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 consumed. Little or no social stigma is attached to drunkenness. Heavy consumption is most typical of Slavs as Russian Jews tend to drink moderately and Muslims not at all (White 1996). Nemtsov (2005) estimates that the consumption of pure alcohol in 2001 reached 15 litres per capita and in some rural areas was as high as 17.3 litres per capita in 2002. These figures are the highest in the world. Given that adult males – who constitute only 25 per cent of the population – drink most of the alcohol, there is an enormous concentration of per capita drinking among Slavic men.

Cockerham (1999, 2000b) finds that the excessive alcohol use stems from the normative demands of this particular lifestyle practice. This practice has evolved through socialisation and experience to become an established disposition toward drinking that is taken for granted by many Russian men. It is reproduced over time and in subsequent generations by its continual activation. Moreover, the subsequent integration of a majority of peasants into an urban working class under communism promoted this drinking style as a habitual working class trait.

Additional evidence on the relationship between class and dispositions toward drinking comes from studies on alcohol use and education. Malyutina et al. (2004) sought to determine whether the social distribution of alcohol consumption changed during the transition to a market economy using data from three surveys conducted between 1985 and 1995 in Novosibirsk. They confirmed previous studies that Russians drink relatively infrequently, but consume a high dose per drinking occasion. They found that men with a university education had the lowest levels of drinking even though alcohol use increased in all educational groups over the decade of their research. The greatest increase was among men with the highest education. Nevertheless, Malyutina et al. found that the lower the education level, the higher the alcohol intake and, conversely, the higher the education level, the lower the intake. The inverse educational gradient in heavy drinking in Novosibirsk was similar to those found earlier in Taganrog (Carlson and Vågerö 1998), St. Petersburg (Plavinski et al. 2003), and nationally (Cockerham 1999, 2000b). Shkolnikov et al. (1998b) likewise suggest that alcohol use varies by education, with the highest consumption at lower educational levels. Given that the educational qualifications of most working class Russians are not high (a secondary education or less), heavy drinkers are over-represented in the working class in Russia's social hierarchy (Cockerham 2000b).

The well-established association between alcohol and cigarettes, along with reports that almost 80 per cent of males in some industrial areas smoke (Hurt 1995), link smoking to the normative structure of male working class lifestyles. Smoking, however, may be pervasive throughout the class hierarchy for males and more research is needed on this topic. When it comes to class distinctions concerning diet and exercise, there is an absence of data. Nevertheless, the existing evidence – especially for drinking – suggests that the working class is the major social carrier of a particularly unhealthy male lifestyle in Russia (Cockerham 2005). Females tend to drink and smoke significantly less than males and they usually have healthier diets; however, like the men, they do not engage in leisure-time exercise (Cockerham 1999). Female drinking and smoking practices are consistent with working class norms that approve of such behaviour for men and not for women. Thus, a tertiary level explanation of the health crisis is the generating of dominant health lifestyle practices by the behavioural dispositions of the working class – what Bourdieu (1984) would call a habitus. The causal relationship between the tertiary (working class dispositions), secondary (health lifestyles), and primary (heart disease and alcohol-related) causes of premature mortality in Russia are depicted in Figure 1.

Where is the middle class?

While the middle class – primarily the upper middle class – has been responsible for the spread of positive health lifestyles in the West (Featherstone 1987), a similar process has not occurred in Russia. Why? The best answer is that a middle class similar to that of the West does not yet exist (Beliaeva 2000, Shankina 2004, Sitnikov 2000). According to Gerber and Hout (2004), fewer Russians were upwardly mobile and more were downwardly mobile in Russia's class structure during the transition toward a market economy. Many people in the former middle strata in Soviet society, namely the intelligentsia and technical specialists (skilled industrial workers, engineers, and scientists), tended to move downward in society. As Gerber and Hout (2004: 696) explain: ‘The new Russian state abandoned both the rhetoric and the actions that the Soviet state had taken to promote opportunity for people with working-class and peasant origins’. When displaced workers in the new economy found jobs again, they were closer to the workers’ social origins than the ones they had before. The desirable jobs were far fewer in number and commanded much higher salaries. They usually went to people whose social origins were those of the former communist elite (the nomenklatura). Members of this stratum used their advantaged positions and connections to secure controlling interests in the privatisation of state property.

Consequently, as Beliaeva (2000) observes, market reforms have conferred benefits and improved the social status of only a narrow segment of people. ‘In these years’, Beliaeva (2000: 43) concludes, ‘it has not yet been possible to establish a full-fledged modern middle class such as constitutes the nucleus of society in the developed countries’. Moreover, the ‘New Russians’ have a negative stereotype in Russian society because of the way in which their affluence was obtained (the theft of state assets or criminal activity) and is now displayed (Balzer 2003). In such circumstances, it is unlikely the upper middle class can serve as role models and promote their style of living in a positive manner.

The absence of independent economic activity and a democratic state providing individuals equal protection under the law, makes it difficult for a Western-style middle class to emerge (Shankina 2004, Sitnikov 2000). Not only is the Russian government becoming less democratic and increasingly authoritarian, but business persons in the new market economy must often accommodate criminal organisations and/or corrupt state bureaucracies (Barkhatova, McMylor and Mellor 2001).

Therefore, as Sitnikov (2000) points out, the economic reforms in Russia have not yet unequivocally and clearly revealed a middle class that will objectively serve as a potent force for change. A review of research by Russian sociologists on the country's transitional social structure suggests that five per cent of the population forms an upper stratum, no more than nine per cent can be considered a middle stratum, and the majority are either working class or lower class with some 40 to 50 per cent of all Russians living near or below the poverty line (Arutiunian 2003, Beliaeva 2000). For many people, an income equivalent to $100 a month is considered fortunate (Balzer 2003). Furthermore, Beliaeva (2000: 46) finds that many in the new middle class have difficulty making ends meet, and claims that some have found themselves in the position of a ‘lumpen proletariat’. This is particularly the situation for intellectuals trying to survive on their own in an economy shaped by market conditions. The emerging middle class not only fails to meet Western standards, but is also losing the position it had attained in the old Soviet Union. Consequently, the social structure of post-Soviet Russia is summarised as a pyramid in which most of the population is squeezed into the bottom, while five per cent are at the top and there seems to be no true middle class at all (Arutiunian 2003).

In the West, a stable and resourceful middle class has served as a powerful social carrier of a positive health lifestyle capable of penetrating the boundaries of other classes. Although significant class differences in the quality of participation persist, the West has not experienced premature mortality and a lowering of life expectancy for either men or women. Mortality from heart disease is at its lowest levels in modern history in the United States, Great Britain, and elsewhere in the West. Until Russia develops a middle class that operates as a social carrier of a positive health lifestyle into the general culture, the health situation may not change for the better. Russia needs a civil society in which a stable, resourceful, and empowered middle class can adopt positive health lifestyles within its own stratum and promote these practices elsewhere in the class structure.