Baltic Health Progress Under Foreign Occupation and Restored Independence

Abstract

When assessing the health progress of the restored Baltic States, we can rely on the 1×1 life tables for the complete restored independence period, published in the Human Mortality Database (HMD 2022). It also contains complete life tables for the Soviet occupation period from 1959, which is the year of the first Soviet census (taken on 5 January 1959) in the Baltic countries since their occupation in 1940. During the Soviet period, they were compiled by the Soviet Central State Office in Moscow and remained classified until Gorbachev’s perestroika era (some selected figures were published only in the 1960s). After the restoration of independence, they have been compiled and are regularly published by national statistical offices.

When assessing the health progress of the restored Baltic States, we can rely on the 1×1 life tables for the complete restored independence period, published in the Human Mortality Database (HMD 2022). It also contains complete life tables for the Soviet occupation period from 1959, which is the year of the first Soviet census (taken on 5 January 1959) in the Baltic countries since their occupation in 1940.¹ During the Soviet period, they were compiled by the Soviet Central State Office in Moscow and remained classified until Gorbachev’s perestroika era (some selected figures were published only in the 1960s). After the restoration of independence, they have been compiled and are regularly published by national statistical offices.

The HMD is the source of life expectancy data on Latvia and Lithuania appearing in Table 11.1 from 1959, and the source for all data on these countries in Table 11.2. It is the sole source of data on the benchmark countries Japan (Table 11.2) and Finland (Tables 11.1 and 11.2). However, data on Estonia for 1950–1989 in Table 11.1 and for 1989–2000 in Table 11.2 are provided according to Katus (2004), who was the best authority on this issue prior to his untimely death. The source on Latvia and Lithuania for the years 1950–1958 is the UN DESA (2021). It provides only 5×5 tables for the 1950–1955 and 1955–1960 periods, so there is some overlap for 1959–1960 between the two sources.

Table 11.1 Life expectancy in the occupied Baltic countries and Finland in 1950–1989

Table 11.2 Life expectancy in the occupied Baltic countries. Finland and Japan in 1989–2040

For the 1938–1950 period, we can rely also on Gapminder (Lindgren 2020) guestimates, which claim that life expectancy for both sexes in 1950 in Estonia (58.5 years) and Latvia (59.5 years) was still below the 1938 level (see Table 10.1). For Estonia, this claim is supported by Katus’ 2004 life tables (see Table 11.1) and data collected by Olaf Mertelsmann (2011: 110), who affirms that life expectancy in 1950 ‘reached 47.6 in towns and 54.9 in the countryside’. However, his figures seem to refer to the mean age at death rather than life expectancy, as no life tables are provided.

The decrease of life expectancy in the 1940s can only be expected because of the war-related disorganisation of the public health system, leading to the spread of infectious diseases and a drop in living standards due to both the war destruction in the cities and the impoverishment of the rural population brought on by Stalinist collectivisation. As a result, in 1950, life expectancy in Estonia (and probably also in Latvia) was markedly below Finland’s level, while in 1938 the life expectancy of males and females was higher in Estonia and Latvia than in Finland (see Table 10.1). However, a brief spurt followed in the 1950s, when life expectancy rose at the rate of around 1 year annually during the decade in all three Baltic countries, with Lithuania making the greatest progress.

During this time, the phase of “receding pandemics” in the epidemiological transition (see Chap. 10) in the Baltic countries reached its end, marked by the replacement of infectious diseases as dominant causes of mortality by man-made and degenerative diseases. The mortality of children, infants and childbearing mothers dropped sharply, mainly due to the greater availability of obstetric services, the introduction of new vaccines against childhood diseases with a high lethality (e.g. polio, diphtheria, measles) and the use of antibiotics. They also helped to reduce mortality from tuberculosis, which had formerly decreased life expectancy at a young and middle age. By 1960, the lag behind Finland was closed and convergence between the Baltic countries had occurred, Lithuania catching up to and even slightly overtaking (until the early 1990s) the other two Baltic countries for the first time in the Baltic region’s history.

Close parity between all four countries endured during the 1960s, when life expectancy remained nearly unchanged for a decade in all four countries. However, since the early 1970s, life expectancy in Finland started to increase again, while in the Soviet-occupied countries, stagnation continued intermittently with a decrease for males. Their life expectancy in the early 1980s was 2 or 3 years shorter than in the 1960s. This was a definite indicator of absolute health regress under late state socialism and its systemic crisis. The Soviet public health system failed to cope with cardiovascular diseases, which became one of the main causes of death from the 1950s, followed by neoplasms. Meanwhile, in the Western countries, a cardiovascular revolution started in the 1960s, including improvements in emergency care, faster emergency response times, defibrillation, thrombolysis, the use of new medicines (statins, beta blockers, angiotensin-converting enzyme inhibitors, anti-platelet agents, etc.) after a heart attack or stroke (Vallin and Meslé 2004). There was also a change in the lifestyles of risk groups, including the consumption of more fruit and vegetables, exercise, and smoking and drinking less.

The underfunded and highly bureaucratised healthcare systems in the late socialist countries remained focused on infectious diseases and were not able to introduce the innovations of the cardiovascular revolution (Healy and McKee 2002). Gorbachev’s anti-alcohol campaign in 1985–1987 did help to bring male life expectancy back down almost to the level of the 1960s. By 1989, Lithuania still preserved leadership among the three Baltic countries, but all three lagged behind Finland by 3–4 (females) or 4–6 (males) years. The gap behind Japan, which had by 1989 established its world leadership in life expectancy increase, was even larger (6–7 years for females and 9–11 years for males).

The first years of capitalist restoration were marked not only by GDP contraction, but also by the decrease of life expectancy, which was largest for males. Both contractions were nearly synchronous, reaching the lowest point in 1993–1994. Indeed, the change of institutional framework in the economy came with significant costs in terms of lost years of human life. At the time of its largest contraction in 1993, Estonia’s output per capita plummeted to the 1963 level (see Tables 9.1 and 9.3). At the time of its largest decrease in 1994 (61.68 years), Estonian male life expectancy plummeted to the level seen in 1955–1956 (see Tables 11.1 and 11.2). There is no output per capita data for Latvia or Lithuania before 1973, but Latvian male life expectancy in the year of its largest decrease in 1994 (58.72 years) was not much above its level in 1938 (56.87). Lithuanian male expectancy at its nadir in 1994 (62.51) was below its level in 1959 (cp. Tables 11.1 and 11.2).

The decrease of female life expectancy was much smaller and therefore it took much less time to recover to the top level under the intermediate system. In all three Baltic countries, this happened before the GDPpc recovery to the 1989 level. However, the return of male life expectancy to the intermediate system level did take more time than economic recovery in all three countries. It was most rapid in Estonia (by 2003–2004), with Latvia following in 2008–2009. In Lithuania, the top intermediate period level (68.30 years in 1964) was superseded only in 2012, when Lithuanian output per capita was 54.3 percent above the 1990 level. This suggests that although economic recovery was a necessary condition for the resumption of life expectancy increase, the hysteresis effect (Scheffer 2009: 18–36) was at work in the relationship between increases of economic output and health improvement: after the drop in life expectancy in the wake of output decrease, the return of life expectancy to its former level was possible only under a much higher GDPpc than was initially needed to reach this level.

The hysteresis effect itself can be explained by the irreversible damage inflicted on the health of the population by the protracted economic recession, especially by protracted unemployment. In Estonia, contraction of output was less than in Latvia and Lithuania, and economic recovery was more sustained. Therefore, the health of the Estonian population suffered less damage than that of the other two Baltic countries (Jasilionis et al. 2011). Importantly, after reaching the nadir in 1994, life expectancy in Estonia consistently increased in 1994–2018. The outcome was the emergence of a new Baltic leader, with life expectancy in Estonia surpassing that in Lithuania and Latvia by 3–4 years by 2018.

In these two countries, during the first decade of the twenty-first century, male life expectancy recovery growth was interrupted by new stagnation (e.g. in Lithuania in 2005–2007, in Latvia in 2004–2006) or even a life expectancy decrease (Stankūnienė and Jasilionis 2011). Puzzlingly, this period coincides with the period of very rapid economic growth (2000–2007). The most credible solution to this puzzle is the wave of emigration to the EU countries in this period, affecting Latvia and Lithuania, but not Estonia (see Chap. 9). Adult males of younger and middle age was the age category most affected by emigration. Most healthy and employable individuals in these age categories departed, and those more exposed to morbidity and inclined to suicide remained in their respective homelands. These effects of self-selection for emigration on life expectancy were similar to the depressing impact of mass emigration on the increase of life expectancy in Lithuania in 1897–1913 and interwar period (see Chap. 10).

Concerning the first restoration years, there were many causes for life expectancy decline. Firstly, the gains of restitution were unevenly distributed. The standard of living among short- and long-term losers from the reforms declined. These included workers of an advanced age, who worked in the large industrial enterprises extinguished by restructurisation of the economy. They suffered both from a loss of income and stress from having to change their job and/or undergo retraining. Secondly, systemic change imposed a great deal of stress both on the winners and losers, related to the change of employer, profession and social status, with the long-term unemployed suffering most. This led to a marked increase in suicide deaths. In 2000, with 50.1 suicides per 100,000 of population, Lithuania was the second (after the Russian Federation with 53.1) worst performing country in the world (World Bank 2021b).² The stress imposed on the population by systemic change also led to the increase of hazard drinking as means of coping with this stress.

Rapid automobilisation of the population was the third cause of mortality increase. Most of the population could only afford mainly used and unsafe cars. They were driven by inexperienced drivers, using an unsuitable street and road network, many of them displaying a lax attitude to safety measures, and exposing themselves as well as others to the hazards of drunk driving. The police had limited resources to control this because it was challenged fighting organised crime, which was another cause of the increase in injuries and violent mortality. Fourthly, the decrease of state revenue during the period of systemic change further worsened the situation of the health care system, which was already heavily underfunded during the late socialist period. Thus, the increased share of deaths due to external causes (accidents, homicides, self-intoxication by alcohol and drugs) became a distinctive feature in mortality statistics during the first decade of restoration.

The number of deaths due to external causes subsided in Estonia and Latvia by 2000, but male mortality from cardiovascular diseases and neoplasms remained at a high level. In Lithuania, the incidence of deaths by external causes returned to the 1989 level only by 2010, while mortality from cardiovascular diseases increased again after an insignificant drop in around 2000. Only by the third decade of restoration did the cardiovascular revolution reach this country. In Estonia, this happened a decade earlier, leading to a noticeable increase in the life expectancy of both sexes already by 2008.

Estonia’s success at pioneering the cardiovascular revolution in the Baltic countries is sometimes explained by the early reorganisation of the received Soviet-style health care system, replacing the hospital-centred model by a primary care system based on family physicians (Aaviksoo and Sikkut 2011: 63). It involved reducing the number of hospitals and hospital beds to redistribute resources for the establishment of family medicine centres, which are reputed to be more efficient. However, such reforms, promoted and lobbied by World Bank experts, were introduced in all three Baltic countries.

A more credible explanation seems to be that Estonia simply had recourse to a cleverer funding scheme under its taxation system, making funding less dependent on the vagaries of party politics, related to the formation of the state budget, or any cuts to these funds because of allegedly more pressing priorities. Namely, in Estonia public health is financed from a special tax, paid by employers and accumulated in a special fund. For this reason, health expenditure on a per capita basis sharply decreased in Lithuania and Latvia during the 2008–2009 crisis, while in Estonia it remained stable (Gudžinskas 2012: 131–146). Due to lower levels and lesser stability in the public financing of health care, patients are asked to pay a larger share out-of-pocket of the service cost in Latvia and especially in Lithuania. This limited access to medical services among low-income individuals, which coincidentally also mostly display the poorest health and need these services the most.

However, this still may provide only a partial explanation for Estonia’s comparative success in raising the biological standard of living within its population. Another important factor is the more rapid change in risky health behaviours, such as not consuming enough fruits and vegetables, not exercising, smoking and binge drinking (Morkevičius et al. 2020).³ Generally, Estonians have a better record on these points than Lithuanians, who in 2018 were the second top drinking nation in Europe (next to the Czechs, 14.5 litres), with 13.2 litres of pure alcohol per capita for the population aged 15 years and older consumed annually. The Latvian record (12.8 litres) is only slightly better, while Estonians (9.2 litres) drank less than Finns (10.8 litres) (World Bank 2021a).

On account of the superposition of so many unfavourable circumstances, Lithuania became one of two token restored capitalism countries that was not completely successful in passing the OIST for early restoration health performance success.⁴ The life expectancy of Lithuanian males decreased both during the late socialist (1973–1989) and early restoration (1989–2008) periods. However, during the longer 1989–2018 period, life expectancy of both sexes in all three Baltic countries increased more than in 1960–2018, so they were completely successful in passing the OIST for the actual health performance success of restoration.

Together with the other post-socialist countries, which did become victims of the export of the Russian Revolution in 1939–1945, the restored independent Baltic countries failed to pass the OOST according to CRHPS by 1989. Based on Katus’ (2004, 2008) and our estimates of life expectancy during the interwar period, decadal life expectancy (population of both sexes) increase rates for 1913–1938 (3.98 years in Estonia, 3.85 in Latvia and 2.80 in Lithuania) are far above those in 1989–2018 (2.76 years in Estonia, 1.58 in Latvia and 1.47 in Lithuania). This has to do with the first period of independence coinciding with the middle period of the “receding pandemics” phase of mortality transition, which is marked by a high life expectancy increase rate. Due to the absolute regress caused by World War II, this transition was over only under the externally imposed socialist system in the 1950s.

Can the restored Baltic States then continue their current success and by the 100th anniversary of the Molotov-Ribbentrop Pact outperform the complete totalitarian era with higher rates of life expectancy increase? This would amount to an increase of life expectancy in 1989–2040 by no less than 11.7 years in Estonia, 10.6 years in Latvia and 19.2 years in Lithuania, and achieving a life expectancy at birth in 2040 of more than 82.0 years in Estonia, 81.03 in Latvia and 90.84 years in Lithuania (for the population of both sexes).

Indeed, for Estonia and Latvia, where the “receding pandemics” phase of mortality transition was near to completion by 1938, these target values are completely realistic, as they are on the level of most advanced capitalist countries by 2018. In the Baltic benchmark country of Finland, life expectancy was 81.63 years (84.31 for females and 78.91 years for males) in this year. As life expectancy in the affluent Western countries will predictably increase during the next two decades, these target values may be even too low to serve as benchmarks for the ultimate assessment of restoration health performance success. For this reason, it is supplemented by the Japanese standard test (decrease of the life expectancy lag behind Japan in 1989 by 1940) and catching up with Finland (see also Chap. 4). The usability of the last criterion is substantiated by the fact that in 1938, two Baltic countries (Estonia and Latvia) did have slightly higher life expectancy values than Finland (see Table 10.1).

As of 2018, only Estonia’s life expectancy increase indicates that this country is on the success track to meet all three target values (see Table 11.2). On account of their longer recovery to reach the intermediate system life expectancy levels, the lag of Latvia and Lithuania behind Finland and Japan increased in 1989–2018. However, I will insist that both countries are able to pass both tests in 2040. The cardiovascular revolution is still just beginning in Latvia and Lithuania, with its huge potential for reducing mortality still not fully appreciated. This is what the lowest positions of these countries in the EU ranking by 2018 according to male life expectancy indicate.

The good news is the decreasing share of adult males and females with raised blood pressure in 2000–2015 in all three Baltic countries, as well as the decrease of mean levels of “bad” (non-HDL) cholesterol for both sexes (NCD-RisC 2021a). The bad news is the increasing body mass index of both males and females in all three Baltic countries and obesity (BMI > 30.0 m/kg²) (NCD-RisC 2021b), with only Lithuanian females being an exception and displaying a decrease from 26.2 m/kg² to 26.1 m/kg² in 2000–2016 and from 26.4 m/kg² to 26.1 m/kg² in 1989–2016 (NCD-RisC 2021c).

Meanwhile, the most advanced Western countries are in the next stage of mortality transition, where life expectancy at birth increases due to the increase in life expectancy at an advanced age (e.g. Barrett et al. 1998; Vallin and Meslé 2004). This increase is related to breakthroughs in cancer therapy and delaying the impact of degenerative diseases. The transfer of these new technologies may increase the effect of the cardiovascular revolution. While the scale of this transfer may be limited by economic factors (new technologies are expensive), there is huge unused potential of life expectancy increase in nudging Baltic males to change their lifestyle habits: to stop smoking, drinking, to exercise more and eat more fruits and vegetables.

Further untapped resources for increasing life expectancy is the decrease of income inequality and improving the funding of health care and supply of public services in general. The Baltic laggard Lithuania has the most untapped reserve of resources for this purpose. Among EU member countries, in 2018, Lithuania still ranked last in its male life expectancy, although its GDP per capita at PPP did approach 75% of the EU mean value, with Lithuania outranking all former communist countries except Czechia and Slovenia and achieving GDP per capita at PPP coequality with Estonia (MPD 2020). While its GDP at PPP nearly doubled in comparison with the 1989 level (cp. Tables 9.1 and 9.3), its male life expectancy only increased by 4.07 years for males and 4.39 years for females (see Table 11.2).

According to contemporary research, income inequality is one of the most formidable obstacles to increasing life expectancy, having not only an indirect, but also a direct impact on mortality (Deaton 2003, 2013; Wilkinson and Pickett 2006, 2015). Meanwhile, in 2018 Lithuania was second and Latvia third (next to Bulgaria) among EU member countries in terms of income inequality. The Gini coefficient value of equivalised disposable income for Lithuania was 36.9, 35.6 for Latvia and 30.6 for Estonia. To put these figures into perspective, the EU-28 value was 30.8, and those for the two member countries with lowest inequality (Slovakia and Slovenia) were 20.9 (Slovakia) and 23.4 (Slovenia) (Eurostat 2021a).

Referring to disposable income, these high Gini coefficient values are certainly related also to Lithuania’s relatively low levels of income redistribution by taxation and government spending, which implies the underdevelopment of the welfare state. As of 2018, Lithuania, in terms of its total government expenditure (34.0 percent of GDP), was the second lowest ranked in the EU, followed only by Ireland (25.3 percent), while the EU-28 mean value was 46.5 percent (Eurostat 2021b). Correspondingly, with total taxes (including compulsory social contributions) making up 30.3 percent of its GDP, it was among EU countries at the lower end of rank order, followed only by Bulgaria (30.0 percent), Romania (26.80 percent) and Ireland (23.2 percent), with the EU-28 mean 40.3 percent (Eurostat 2021c).

The difference between expenditure (34.0 percent of GDP) and taxation revenue (30.3 percent of GDP) is accounted for by Lithuania’s role as a net recipient in contributing to and receiving its share from the EU budget. The role of subsidies from the EU budget was even more important for Latvia, where total government expenditure was 39.3 percent of GDP, but taxation made up only 31.4 percent of its size. Transfers from the EU budget were also important for Estonia, where in 2018 the share of government expenditure was 39.4 percent, and the taxation share in GDP was 33.1 percent. Net transfers from the EU budget allow the Baltic States to fund their public sectors and maintain welfare state institutions with relatively light taxation.

However, as far as they will successfully move towards passing the ultimate test of the economic performance success of restoration, the discrepancy between the impressive economic and rather modest health progress of Lithuania and Latvia will become less and less sustainable. If their annual economic growth rates will remain at the level of the decade after the Great Recession in 2008–2011, by 2040 they will certainly pass the OIST for economic performance success of restoration, as well as pass the Finnish (decreasing the GDPpc gap behind this country to the 1938 level) and American standard tests (see Chap. 9).

As output per capita of the Baltic countries will approach the EU mean level, the Baltic countries will become net donors to fund cohesion programmes for new EU members on its eastern (Belarus, Ukraine, Moldova) and southern (Albania, Bosnia and Herzegovina, Northern Macedonia, Kosovo, probably also Turkey) peripheries. Further human development progress to meet the target values of the ultimate success of restoration will not be possible without fiscal reforms to fund more inclusive social policies. They will surely put the development of the welfare state in the Baltic States on a more solid basis to refute current UN DESA forecasts that by 2040, only Estonia will catch up with Finland or decrease the life expectancy gap behind Japan as of 1989.