The Health Crisis in the USSR

I

If we could judge it solely by advances in health, the twentieth century would be a fabulous success. Few of us who take food and doctors for granted realize or appreciate this. In 1900 life expectancy for the whole of the human race was about thirty years.¹ Today it is twice as long: at least sixty-one years, possibly sixty-three or more.² Since the human lifespan was probably never much less than twenty for any length of time—to drop much below that level is to court eventual extinction³—this means that about three-fourths of the improvement in longevity in the history of our species has occurred in the last eighty years.⁴

Over much of this century the nation in the vanguard of the revolution in health was the Soviet Union. In 1897 Imperial Russia offered its people a life expectancy of perhaps thirty years. In European Russia, from what we can make out, infant mortality (that is, death in the first year) claimed about one child in four,⁵ and in Russia’s Asian hinterlands the toll was probably closer to one in three. Yet by the late 1950s the average Soviet citizen could expect to live 68.7 years: ⁶ longer than his American counterpart, who had begun the century with a seventeen-year lead. By 1960 the Soviet infant mortality rate, higher than any in Europe as late as the Twenties, was lower than that of Italy, Austria, or East Germany, and seemed sure to undercut such nations as Belgium and West Germany any year.

Results like this could not have been achieved without a total transformation of living conditions for the USSR’s sizable Asian and Muslim minority. This indeed has taken place.⁷ By 1960 Moscow could demonstrate that its Central Asians were living fifteen years longer than the Iranians, twenty years longer than the peoples of Pakistan, and nearly twice as long as the Afghanis. In the face of these and other equally impressive material accomplishments, Soviet claims about the superiority of their “socialist” system, its relevance to the poor countries, and the inevitability of its triumph over the capitalist order were not easily refuted.

Things look very different today. The Sixties and the Seventies have proved devastating to Soviet society. To observant travelers and analysts this is apparent in a hundred different ways; none, however, is so dramatic as the turn in health of the Soviet peoples. As Christopher Davis and Murray Feshbach’s startling report argues in convincing detail, health conditions in the USSR have worsened steadily since the mid-1960s, and the deterioration shows no signs of stopping.

Although its findings are sensational, Rising Infant Mortality in the USSR is a very careful piece of work. The credentials of its authors are unimpeachable: Davis is now England’s leading authority on Soviet health care, Feshbach the foremost American expert on Soviet population trends. Their study is based on data not from spy satellites, intelligence agencies, or “think tanks,” but rather from reports released by the Soviets themselves.

As the title suggests, Davis and Feshbach pay closest attention to infant mortality. According to Moscow’s Central Statistical Bureau (TsSU), infant mortality increased by more than a third between 1970 and 1975. Since 1975 TsSU has not reported the USSR’s infant mortality rate, but Feshbach’s estimate, based on the fragmentary evidence of local reports and adjusted for the approximately 14 percent of all infant deaths that authorities do not include in their mortality totals,⁸ is that it could be as high as forty per thousand today. ⁹ Infant mortality rates in both Western Europe and the United States are currently under thirteen per thousand.

Epidemic infant mortality, however, is only part of the picture. Except for teenagers, who are virtually indestructible so long as they do not kill themselves or each other, nearly every age group in the Soviet Union had higher death rates in 1975, the last year in which such figures were published, than in 1960. For men and women over thirty trends were particularly harsh. Death rates jumped almost 20 percent for people in their fifties, and by more than 30 percent for those in their forties. Men fared much worse than women: since 1965 their life expectancy may have declined as much as four years, to something like sixty-two today. Women, however, have not been spared: their life expectancy peaked at around seventy-three in the early 1970s, and may have dropped since then. This means that the average Soviet life span could be under sixty-eight today—lower, in other words, than it was in the late 1950s.

Measured by the health of its people, the Soviet Union is no longer a developed nation. Caloric intake, educational attainment, and the ratio of doctors to people all seem to be higher in the USSR than in Western Europe, and yet in the USSR life expectancy is six years lower, and its infant mortality rate three times as high. There is not a single country in all of Europe, in fact, in which lives are so short, or babies’ death rates so high—not even impoverished, half-civilized Albania.¹⁰ In the realm of health, the Soviet Union’s peers are to be found in Latin America and Asia. If Feshbach’s estimates are right, life expectancy in the USSR is about the same as the average for Costa Rica, Jamaica, Malaysia, Mexico, and Sri Lanka. By the same token, the Soviet infant mortality rate could be replicated in a nation composed in equal parts of Chile, the Dominican Republic, Panama, Taiwan, and Trinidad. These nations, however, are moving up, while the Soviet Union is moving down. If current trends persist, most of Latin America and East Asia will surpass the Soviet Union in a matter of years.

There can be no mistaking it: the Soviet Union is in the grip of a devastating health crisis. We can only understand the full severity of this situation when we remember how difficult it is to push life expectancy down these days. The amenities of modern life—cheap food, clean water, mass education, rapid communication, easy travel, competent doctors, wonder drugs, and the like—make it extremely hard to stay sick or die young. The health-promoting force of these innovations is so powerful that it cannot be overcome even by modern warfare: World War I did not succeed in lowering France’s life expectancy, or World War II Japan’s. The only country in modern times to have suffered a more serious setback in life expectancy was the “Democratic Republic of Kampuchea,” Pol Pot’s Cambodia. Clearly, something in Russia is going very, very wrong.¹¹

What is it that ails the Soviet Union? We cannot be sure. The only people in a position to know are the Soviet authorities, and they have been reluctant to advertise their nation’s health crisis, or to highlight the flaws in their system responsible for it. As a consequence, Westerners are left with a puzzle in which most pieces are missing. Some of the blank spaces can be filled in reasonably well through detective work, and Davis and Feshbach turn out to be very good detectives. However, theirs is primarily a study of infant mortality, and every age group has its own set of vulnerabilities. The declining quality of baby food and nursing formula, the rising (though, by Western standards, hardly scandalous) rate of illegitimacy, and the uterine damage caused by the six to eight abortions the average Soviet woman undergoes during the childbearing years¹²—all of which Davis and Feshbach document—may partly explain the increase in infant mortality, but it will not account for the rising death rates of metalworkers in Kharkov, elderly men in Georgia, or the middle-aged women who work on the USSR’s collective farms.

We are not left wholly in the dark, however. The biggest problems affect everyone. One of these is alcoholism. Americans consider themselves a nation of problem drinkers, and not without reason, but the thirst for alcohol in the Soviet Union is a problem of an entirely different dimension. In the early 1970s, according to a study by Duke University’s V.G. Treml, the Soviet Union’s per capita intake of hard liquor was more than twice as high as America’s or Sweden’s.¹³ Another report by Treml suggests that drinking is even heavier today, thanks in part to the increase in purchasing power Soviet citizens enjoyed during the years of détente. Urban families in the Soviet Union devote nearly the same proportion of their weekly budget to alcohol that American families devote to food,¹⁴ and things have gotten to the point where factory foremen mark their workers sober and fit for duty if they can stand.¹⁵

Mortality breakdowns by cause of death are hard to come by for the Soviet Union, but John Dutton, a researcher now at North Carolina State University, has made a strong case for the complicity of heart disease in pushing up men’s death rates,¹⁶ and this is something alcoholism can exacerbate or even cause. Vodka and samogon (Russian moonshine) seem to take their toll on women and children as well. Davis and Feshbach note that Soviet doctors now rate alcoholism the third most frequent cause of illness for women, and that a report from Lithuania connects excessive drinking on the part of mothers and of mothers-to-be with half or more of the infant deaths in that Republic.¹⁷

Then there is pollution. Again, we think of this as a Western affliction, which indeed it is. The condition, however, seems to take on new meaning in the USSR. Its most obvious manifestation is air pollution. Western visitors have compared the air quality in some Soviet cities unfavorably with Japan’s.¹⁸ Davis and Feshbach show that the nation’s rising incidence of respiratory disease is rather unfavorably linked with what Soviet doctors call “changes in the environment associated with urbanization.” But those forms of pollution which can be seen are probably the least dangerous. Misuse and overuse of pesticides and fertilizers, the careless release of industrial waste and heavy metals into the waters, and radiation emitted from poorly constructed or only partially safeguarded nuclear facilities present far more deadly perils.

A samizdat book cited in Rising Infant Mortality¹⁹ suggests the sort of price the Soviet peoples may be paying for their government’s indifference to these hazards. Purportedly based on suppressed official data, this study by “Boris Komarov” claims that birth defects in the USSR are rising by five to six percent a year, and that the number of “defective” children whose care must be left to the state is increasing by more than 200,000 annually. The work of “Komarov” is as yet uncorroborated, but if pollution is in fact wreaking this sort of havoc on the newborn it must be killing off adults as well.²⁰

Soviet reports often refer to death by “trauma”: this category seems to include suicide, murder, and fatal accidents. Suicide in the USSR may be on the rise, but there is really no way of telling: for official purposes, it does not exist. Conceivably, a spate of suicides could affect a nation’s death rate, but suicide accounts for such a small fraction of all deaths—less than I percent even in Scandinavia—that this is unlikely. The same holds true for murder: a few populations suffering from pathologically high homicide rates do in fact experience a slight shortening of life span, but there is no evidence that any of the Soviet peoples are among these.

Accidents are another story. Heavy machinery and electrical equipment are dangerous under the best of circumstances, and become no safer when produced on shoddy assembly lines and placed in the hands of drunken workers. The Soviet Union may have only a tenth as many motor vehicles as the United States, but it has just as many traffic fatalities.²¹ The carnage in the factory and in the field, under the tractor or the blades of the harvester, is even greater. Davis and Feshbach have estimated else-where that as much as a fifth of the rise in death rates for men in their late thirties may be attributed to the increasing frequency of accidents.²²

Could a progressive decline in the health of an entire nation, affecting people of nearly every ethnic background²³ and nearly every age group, take place without a breakdown in the medical system? In theory, the answer is yes, but given the specifics of the Soviet situation—a monotonous but clearly ample diet, a slow but steady improvement in housing, a well-educated and relatively skilled populace—some sort of failure in medical care would seem almost a foregone conclusion. Davis and Feshbach, always conservative in their appraisals, feel they lack sufficient evidence to prove the Soviet health care system is in decline; the picture they paint, however, hardly inspires confidence.

Influenza, which has been reduced to a nuisance in the rest of the industrial world, is not yet under control in the Soviet Union, and kills tens of thousands of babies each year. The proportion of children dying from “pneumonia,” in fact, is said to be on the increase. Many of the young victims, it seems, start out ridden with rickets, which weakens them to the point where flu can finish them off. Rickets is unknown in the rest of the rich world, and in much of the poor world as well, because it is so easy to cure: it comes from a want of vitamin D, and is remedied by either a change in diet, food fortification, or cheap and convenient vitamin supplements. If Soviet medicine is unable to deal with these simple problems, it is unlikely to be effective against the more serious and considerably more complicated challenges of cancer, renal disorder, or ischemic heart disease.

Why might the quality of medical care in the Soviet Union be declining? There are at least three reasons. First, the Soviet health strategy seems decidedly misguided. When extra funds are to be had, they are spent expanding facilities rather than upgrading them. Medicine is not a prestigious profession in the USSR. It is considered women’s work, which means its practitioners can expect to be underpaid and poorly provided for.²⁴ Like the Red Army of an earlier era, Soviet physicians assault the adversary in huge numbers, but without sufficient ammunition. The USSR has more than twice as many health personnel as the United States, but they must work in hospitals which frequently lack necessary drugs and anesthetics, in which such items as disposable bedding and needles are unknown, and in which even obtaining sterilized instruments can be a demanding ordeal.²⁵ Their morale is probably not improved by the Ministry of Health’s obvious insensitivity to the needs of the infirm. (What other nation can boast a cardiology clinic on the top floor of a five-story walk-up in its capital city?) For these and other reasons, doctor and patient alike do their best to avoid the hospital. According to Davis and Feshbach, obstetricians, gynecologists, and pediatricians now only work twenty-eight hours a week, and the number of patients treated per bed fell 20 percent from 1958 to 1974.

Corruption may also be playing its part. For obvious reasons, figures on the Soviet Union’s “second economy” are unavailable, but it is known to be enormous, and to touch nearly everything.²⁶ Among the goods for sale in the shadow markets are medical services, and patients who want to be sure of quick or competent treatment must be ready to pay their state-provided doctors a handsome “tip.” Similarly, the invalid in search of nominally free but perennially scarce medication must be willing to pay cash and forgo questions. By pulling medical resources out of circulation, the “second economy” works precisely against those people who need help most; the poor and the people scattered in the country. Corruption is said to be on the rise in every part of the USSR’s enormous “socialist” bureaucracy. ²⁷ If this is true it could help to account for a growing health problem on the part of the USSR’s most vulnerable groups.

Finally, there is evidence that the Kremlin has decided to economize on medical care for its people. As medical techniques become more sophisticated, complex, and ambitious, they necessarily become more expensive, since diagnosing and treating disease must remain a human task in an increasingly automated economy. Yet over the past generation the Soviet Union has devoted an ever smaller fraction of its GNP to combating illness. According to one plausible set of estimates, the share was 9.8 percent in 1955, but only 7.5 percent in 1977.²⁸ We may quibble with these specific numbers, but the trend is clear, and the Soviets themselves acknowledge it. According to one official quoted in Rising Infant Mortality, health expenditures as a share of the national budget fell from 6.6 percent around 1965 to 5.2 percent in 1978. The Soviet Union may be the only advanced society to allocate progressively more modest proportions of its output to maintaining the health of its people.²⁹

It is one thing for a nation’s leadership to embark upon a foolhardy policy or to find its plans undercut by the dishonesty of subordinates; it is quite another to pursue a course which will surely mean unnecessary hardship for most of its people. How can we account for what is apparently a high-level decision on the part of a “socialist” government to neglect health care? Inexplicable though this may seem to us, there could be good reasons for it if we take account of Soviet politics. In fact, from the perspective of the Politburo, this cruel choice might seem not only logical, but even reasonable.

From a financial standpoint, the towering problem of the post-Stalin era has been the inefficiency of the economy. A vigorous and dynamic economy is a sine qua non for successful long-term competition with the West. Unfortunately, the Soviet economy has always been an unpredictable machine, and in recent years it has become increasingly temperamental and stubborn. To force it on, its attendants must stoke it with ever greater quantities of capital. The USSR’s rate of economic growth has dropped sharply since the mid-1960s, slipping below that of its OECD rivals in the 1970s, and yet investment has been eating up an ever larger share of total output. From 1965 to 1977 (the last year for which we have detailed estimates) capital requirements for the economy rose from something like one ruble in four to very nearly one in three.³⁰ But investment had to be propped up at all costs; this necessarily meant trimming back elsewhere.

But what was expendable? The United States and its NATO allies were financing their rising investments in social services at the expense of the military,³¹ but for Soviet leaders this course was and remains unthinkable.³² (More than global ambitions are at stake here; a reduction in the role of the military in Soviet society could have very unsettling effects at home.) The masters of the planned economy were left with only one option; they had to reduce the proportion of goods and services for consumers.

In theory, this would be a simple operation: after all, their command over both society and economy is supposed to be total. In reality, it would prove a tricky business. It was no longer possible to force the populace to tighten its belt indefinitely in the name of a distant Socialist utopia. When Stalin died, standards of living by many measures were lower than they had been under Nicholas II.³³ As his successors disassembled his apparatus of terror, they discovered beneath it a phenomenon they associated with bourgeois nations, but understood only poorly: consumer expectations. These could be a powerful force, and had to be taken very seriously, as Nikita Khrushchev’s unhappy career was to attest, for in the final analysis he was expelled from office in disgrace at least partly because he couldn’t fill the larder.³⁴

This lesson was not lost on Brezhnev and Kosygin. If they were put in a position where they had to enforce sacrifices on the consuming public, they would do so quietly and very carefully. Tampering with the diet had become dangerous: peasants, workers, and bureaucrats alike now judged a regime by what it put on their plates. The availability and quality of food would have to be improved, even if it meant buying tens of millions of tons of grain from adversaries.³⁵ Nor would it be feasible to save money by cutting back on the production of such things as brassieres or refrigerators: even a schoolboy would know that nothing in a public economy is so jealously coveted as private property. But who would notice or complain if the government skimped a bit on public, and therefore essentially intangible, services like health care? Denying a sick man an operation, after all, is not nearly so difficult as taking away a healthy man’s shoes.

There is more to keeping people healthy, however, than checkups and digitalis. Medicine’s role in lengthening lives is conspicuous because it is basically curative; of even greater importance are those quiet facets of our daily routine which prevent illness from breaking out in the first place. Decent meals, we all know, are a vital ingredient to a healthy life; less celebrated but perhaps no less essential is the web of personal relationships which can support us against adversity. A mother’s care for her baby, a family’s attention to its elderly or troubled members, and the will to live which such things inculcate, in an often unnoticed way, do for the health of an affluent nation what a ministry of health could never hope to duplicate.

Davis and Feshbach do not pass judgment on the state of mental and social health in the USSR. They are wise not to: their study is careful, fully documented, and grounded in statistics. By contrast, the evaluation of a nation’s mood can only be impressionistic, ambiguous, and highly subjective. Nevertheless, the human element of any social problem is important, and remains impossible to ignore. If we treat the bits of information supplied by Rising Infant Mortality and the accounts of refugees and Western tourists as possibly misleading but important clues which we must put together into a plausible and consistent whole, we will have a better chance of understanding the role of human relations in the health crisis in the USSR.

Let us look at the evidence we have on hand. Death rates for men and women, babies and adults, for city and country, and so far as we can tell, for every ethnic group, are on the rise. Alcoholism, as I have pointed out, is apparently pandemic. (It is so much a part of daily life, in fact, that the state provides drying-out stations in the cities and alcoholic wards for most of the large factories.) Although we cannot tell about murder or suicide, death rates for accidents seem to be unusually high, and increasing.

Rising Infant Mortality points out that Soviet experts have linked the illness of many babies with contaminated infant formula; it seems that even though this problem has been recognized for several years, it has gone uncorrected. The death rate for children in state-run day care centers, Davis and Feshbach note, is twice as high as for those whose families look after them. Despite the evidently appalling conditions that must be endured in these institutions,³⁶ some 40 percent of the Soviet Union’s parents send their children to them. Abortion serves as the nation’s primary form of contraception, and in any given year on the order of ten to sixteen million babies are aborted. The number of live births, by contrast, hovers between four and five million.

Moreover, refugees tell of dying patients denied treatment because their ambulance driver was out shopping,³⁷ or turned up too drunk to get behind the wheel. Visitors who can read Russian often remark on the incessant complaints about absenteeism in the local papers, and the frequency with which party leaders insist that economic targets could be met, even exceeded, if only more workers showed up at their jobs.

What do these things say about alienation and depression, the desire of people to look after their health and to keep others alive? How can we fit these bits of information together to suggest that some virulent strain of anomie is not running rampant or that the Soviet social order is not in the midst of a deadly decay?

II

The spectacle of an industrial nation embarking on a path toward pre-industrial standards of health is deeply disturbing. A mortality crisis of the sort the USSR is now suffering is alien to everything we understand about modern life. In the world as we know it, in fact, the Soviet health crisis should be impossible. How then do we account for it?

Perhaps we might begin by acknowledging what our surprise and confusion with this “inexplicable” turn of events already make amply clear: that those of us in the West are remarkably ignorant about the Soviet Union. We should consider why this is so. Some might blame secretive apparatchiki or restrictive In-tourist itineraries, and of course such things contribute to the problem, but they are not really at its heart. By comparison with other communist regimes—Mao’s China, for example, or contemporary Bulgaria, to say nothing of North Korea or Albania—Brezhnev’s Soviet Union seems almost relaxed in its attitude toward “foreign spies” and “state secrets.” And while our access to Soviet information is deliberately rationed and manipulated, much more is available than is sometimes claimed: as Robert Byrnes has noted, the day has finally come when Sovietologists often have more material at their disposal than they can assimilate.³⁸

We are indeed unfamiliar with the USSR, but this is not so much for a want of information as a lack of understanding. For understanding the Soviet Union, in the words of the French writer Alain Besançon, requires us to “remain mentally in a universe whose coordinates bear no relationship to our own.”

I do not propose to chart out this universe here. The health crisis in the Soviet Union, however, cannot be comprehended without considering several often misunderstood points about Soviet government and Russian society. No serious discussion of the mortality crisis can ignore the Soviet regime’s seeming inability to prevent a deterioration in the nation’s health, and no account of that can be satisfactory if it ignores the contradiction in Soviet political concerns as they are enunciated on the one hand by the rhetoric of Kremlin leaders and on the other by the operational structure of the state.

To oversimplify only slightly, the men in Moscow are forever addressing themselves to questions of the future, while the apparatus under them is fighting against what we in the West would consider problems of the past. In an era of nationalism and decolonization the USSR stands out as an imperial remnant of the nineteenth century (Soviet rhetoric notwithstanding): a “Union” in which Ukrainians, Finns, Kazakhs, Jews, Uzbeks—in all more than a hundred peoples—find themselves thoroughly “guided” by a Russian minority.³⁹ In a century characterized by, and largely reconciled to, secularization and the waning of faith, the Soviet state not only professes a creed which explains the past and affirms the providence of the future, but bows to the cult of personality.⁴⁰ While this seemingly anachronistic tendency can be explained in part by accidents of geography and history, it can also be traced to conditions reflecting realities laid down by the Russian people, who comprise the largest national group within the USSR and whose officers both dominate the government and give Soviet rule its distinctive flavor.

Of all the European peoples, the Russians were the least “Europeanized” before the Revolution. One must wonder whether they do not remain so to this day.⁴¹ Anyone familiar with Russian literature will know that the Russian universe is not easily described. It is complex and contradictory—and no less so for occasionally appearing amorphous. But this should not prevent us from identifying some of the more obvious elements within it. Foreign visitors from the Marquis de Custine to Hedrick Smith have noted that central to the Russian view of the world is a tremendous patriotism and love of the land. This makes itself felt with an intensity unknown in the West, and it is expressed in everything from folk sayings (“One’s own sorrow is dearer than a foreign joy”) to the official name for World War II, which the Soviet Union,alone among all contestants, refers to as “The Great Patriotic War.”

In highlighting the differences between the Russian and the Western point of view, certain incidents seem especially instructive. When asked which of his many punishments at the hands of the Soviet government had been hardest to bear, Alexander Solzhenitsyn unhesitatingly replied “exile.” He had suffered the unspeakable horror and injustice of the Gulag, and endured the better part of two decades of KGB harassment, but to Solzhenitsyn nothing could be worse than to be torn from his people and forced to live apart. While this speaks to a deep and even extraordinary sense of patriotism, it does not speak to this alone.

Implicit in Solzhenitsyn’s response is a special attitude toward authority and suffering which is in keeping with at least one important strand of Russian history. We may remember the words of the people of Novgorod, who in the days before Kievan Rus’ entreated the Vikings to “come and reign and rule over us” because “our land is great and fruitful, but there is no order in it.” We may remember as well that the first two saints canonized by the Russian Orthodox Church, Princes Boris and Gleb, died not as martyrs of faith but as victims of their brother’s plot, accepting their fate without resisting. That the advice of the monk Sylvester, confessor to Ivan the Terrible, was: “Beat your son and he will comfort you in old age.” That it is not at all odd to find folk sayings such as these: “Whom I love I beat”; “Happiness without suffering is incomplete”; “Don’t argue with misfortune, suffer.” And what do we make of this casual observation in the Collection of National Juridical Customs (1990): “If the father leads an inordinate life which brings economic ruin; the children either leave or submit to their fate, but seldom complain against their father”?

Dostoevsky once wrote that the “fundamental spiritual need of the Russian people is…for suffering, perpetual and insatiable, everywhere and in everything.” It might be unwise to dismiss these words. For hundreds of years Western visitors have remarked that in the Russian view of the world suffering is not something to fear, or even to face indifferently, but rather more like a collective reserve of strength, to be added to and drawn on.

Perhaps this attitude can help to explain the current health crisis in the USSR. By this I do not mean, of course, that Russian mothers are indifferent to their children’s illnesses, or that Russian men hope for expiation in a death from alcoholism. If anything, Russian mothers seem closer to their children than mothers in the West. I would suggest instead that deep patriotism and unthinking respect for authority, in combination with a faith in the strength that is to come of suffering, lay foundations for a distinctive and necessarily troubled style of government.

Autocracy and repression were not unique to Russia, but the response to them arguably was. Imperial Russia’s most revered rulers were not enlightened men like Alexander II but instead despots like Ivan the Terrible and Peter the Great, who brought frightful suffering down upon the people, but for a purpose which could be seen and understood. The constraints and opportunities such a situation presents to potential leaders should be evident.

Though hardly inevitable, Joseph Stalin’s system might be said to represent a final logical extension of this particular pattern of governance. The hardships he put his country through could scarcely have been imagined under the czars,⁴² if only because the technology and organizational skill which were to make them possible did not then exist. At the same time, Stalin’s results were incontestable. This is a point those of us in the West often overlook. Stalin inherited a country that was the primary casualty of World War I, and bequeathed to his successors a superpower. It is but a single measure of the success of the “Leader,” and his understanding of the endurance of his nation, that between 1940 and 1953, a period marked by an immensely destructive world war costing perhaps twenty million Soviet lives and a series of purges claiming perhaps not many less, ⁴³ the USSR doubled its production of coal and steel,⁴⁴ tripled its output of cement and industrial goods, and increased its pool of skilled labor by a factor of ten. These rates of growth were geometrically higher than in the less devastated and Terror-free West.

Most surprising, however, was the popular reaction. There was of course revulsion, and there were at least a few large-scale revolts. ⁴⁵ But strange as it sounds, the Stalinist era seems to have been a spiritually satisfying time for a great many of those who survived it. ⁴⁶ Even today, after a full generation of so-called “de-Stalinization,” this man, who saw to the death of at least twenty million and perhaps as many as fifty million of his own subjects,⁴⁷ whose crimes against humanity are matched in this century only by Hitler’s is admired and even worshiped by a stratum of discontents (evidently vastly larger in number than the dissidents⁴⁸ ) who feel that life lost much of its meaning when the state feel into the hands of mere economic knitters.⁴⁹

The seeds of today’s mortality crisis, I would argue, lie in Stalinism. It is not that Stalin’s own rule was a failure; in many ways it can be seen as an achievement of brilliance. Despite the continuing purges, the politically inflicted famines, and World War II, for example, Stalin managed to raise life expectancy in the Soviet Union from about forty-four when he assumed total power to about sixty-two when he died. The problem is that Stalinism has brought on an extensive failure of government in a system where the government encompassed not only political administration but the economy and society itself. To put it simply, Stalin’s was an impossible act to follow. For Stalinism is a self-immunizing process, but not a self-correcting system. Thus, it is at once inconceivable for his successors to continue on the tyrant’s path and impossible to stray far from it.

This was not yet clear in the 1950s. Stalin’s death was followed by a period of intense elation.⁵⁰ For a time it seemed possible that Socialist Utopia might be within striking distance. It was said that a new era had dawned, that the ascetic dedication of the Revolution would be married to the contentments of consumerism to bring forth a New Soviet Man. By the early 1960s it had become clear that this would not be possible.⁵¹ Stalin’s world was dead, and with it had died both the Red Terror⁵² and the possibility of absolute faith in the nation’s leadership. The self-sacrificing obedience these engendered would not last long. A new world of consumerism, however, could not be born. Only “liberalization” could breathe the sort of life into the Soviet economy which consumerism would require of it.

But meaningful liberalization would threaten the political apparatus directing society, and hence the Party itself. This was unacceptable. Thus the peoples of the Soviet Union found themselves caught between two worlds. They had been stranded without faith, and at the same time deprived of an option for the “good life.” Given the shape of things, moreover, there were no prospects for a future any better. At this point the USSR experienced a quiet but monumental change: in the words of John Bushnell, the New Soviet Man turned pessimist.⁵³ Almost immediately thereafter things began to fray. If the problem was distinctively Russian in its construction, its results were to affect all, without regard to language or ethnicity.

Preoccupied as we Americans were by our own troubles in the Sixties and the Seventies, it is perhaps understandable that we did not immediately recognize that the Soviet Union was grappling with problems far more profound than our own. During the Eighties, it may become increasingly clear that we are witnessing the wearing down of a system.⁵⁴ The pace of the planned economy, whose performance is unencumbered by business cycles, has slowed to a creep over the past fifteen years. Despite a constant infusion of new technology and a steady upgrading of the education of the workforce, there have been no improvements in overall productivity in the USSR for more than five years; in agriculture and other important sectors of the economy, the efficiency of expenditure has been dropping for most of the past decade.

The simplest routines of management seem to have become arduous struggles, to be won only on occasion. In 1965, for example, only 1.7 percent of the state’s construction and assembly projects were abandoned before completion. By 1975, according to official figures, the proportion was over 40 percent. Discipline and morale are on the wane. Since the early 1950s per capita sales of alcohol have risen by a factor of five; thanks to samogon, which is brewed and sold illegally, total consumption may have increased even more rapidly. Corruption and marketeering, acts of “economic sabotage” punishable by death under Stalin, account for as much as 20 percent of Soviet turnover today. The state is finding it increasingly difficult to keep track of people in its controlled society. In 1962 the difference between the Soviet adult population and the number politically “registered” was 3.4 million; by 1975 it was nearly ten million—one in sixteen. And then, not unrelated to any of these things, there was the rise in death rates for nearly every group in society.

By some measures—electrical output per capita, the availability of meat⁵⁵ and clothing, average waiting time for new apartments—the standard of living is noticeably better today than in the early 1960s. But prospects for the future are incontestably worse. For the first time since Operation Barbarossa, Soviet leaders must think seriously about combating anarchy. Today’s anarchy, of course, is far less threatening, but it is also less easily confronted. Crack divisions and Russian patriotism will not keep alienation and dissatisfaction from the gates of Moscow. To hold its country together today, the Politburo must rely on the cohesive power of its most effective instruments of government and those institutions which enjoy the deepest and most widespread support.⁵⁶ What would these be? At the risk of being arbitrary, I would suggest that four seem to stand out above all others: the army, the secret police, the restrictive and highly sophisticated system of political privilege, and the black market.⁵⁷ There are risks in leaning on any of these pillars in the current crisis. Feeding elitism or unleashing the black market, for example, could increase morale or efficiency temporarily, but could only intensify the long-term problems the Communist Party of the Soviet Union must eventually face. In the current struggle, the CPSU must rely heavily on inertia, but if the past fifteen years are any measure, inertia will not serve them at all.

The Soviet health crisis presents the Politburo with serious problems. The increase in death and disease probably cannot be stemmed at any acceptable cost. Cutting the liquor monopoly’s output might force sobriety upon the Slavs, but this would be financially disastrous—taxes on alcohol could pay the state’s full health and education bill⁵⁸—and could do more than any samizdat tract to awaken the masses. The health budget could be increased, but only at the expense of military preparedness or economic growth. The rise in death rates, then, will probably continue. But consider what this means. An increase in mortality and morbidity necessarily is a burden on the economy and a drain on resources. It is not at all clear that the country can afford this. The Soviet economy is currently stalling; according to some analysts, it may even have entered negative growth.⁵⁹

Inefficiency is in large part to blame for this slowdown; the debilitation of the workforce, and the demoralization which underlies it, do not bode well for the cadres charged with achieving a turnaround. The impending labor shortage, assured by the fact that there are fewer fifteen-year-olds than twenty-five-year-olds in the USSR today,⁶⁰ can only be worsened by a deterioration in the health of the population, and despite its attempts at modernization the Soviet economy is still highly labor-intensive. If the economy begins to shrink, Moscow must decide which will feel the loss: the factory, the army, or the consumer.

This is not a situation which can be muddled through. If investment is cut back, the economy will presumably be even feebler in the future. A cutback in military expenditures might not only imperil the chances of successful long-term competition with the United States, with whom the Red Army has finally achieved parity,⁶¹ but possibly security within the Soviet sphere of influence. A continuing peacetime cutback in goods and services for the consumer could intensify the health crisis, and even contribute to an erosion of the legitimacy of the Soviet government. As a backdrop to all of this, there is the continuing shift in the composition of the Soviet population. In 1950, there were five Russians for every Muslim; by the end of the century, the ratio will be down to two-to-one.⁶² Thus not only the power of the Soviet economy, but the effectiveness of the state in mobilizing it, are likely to be called into question by the health crisis and related difficulties in the upcoming years.

One cannot help wondering how these problems will affect US relations with Moscow. Predictions are inappropriate; we understand too little about the USSR, and unexpected events might in any case prove decisive. Still, we must bear in mind that improving the ability of the state apparatus to project itself abroad and improving people’s lives are two quite different things. In Bismarck’s day the fortunes of a nation rested largely on the skill and eloquence of its emissaries, the competence and reliability of its informants, the judgment of its leaders, and the strength of its armies. Bismarck, of course, lived in a world which did not yet know of development aid, the doctrine of universal human rights, or the United Nations, but the laws governing international success may not be entirely different in his age and ours.

Soviet diplomats, trade representatives, and propagandists may or may not be more skillful than their counterparts in the West.⁶³ There is little doubt however that they are better financed. To give but one example: in 1978, the year of Moscow’s neutron bomb scare, the Soviet Union spent $2 billion around the globe denouncing American militarism.⁶⁴ For a variety of reasons, Soviet intelligence-gathering agencies are generally regarded as more sophisticated and better financed than those of the West.⁶⁵ Despite their insularity and evident paranoia, it can also be argued that (at least at the highest echelons) Soviet leaders tend to be more experienced, shrewd, and, in important ways, more reasonable than the men in Washington with whom they must deal.

Fortunately for us all, the differences in military strength between East and West remain untested, but impartial analysts tell us the match is fairly even. Still, we must remember two things. First, Soviet military and diplomatic doctrine is, by some accounts, geared to a greater degree than Western doctrine to the application of force in day-to-day situations;⁶⁶ second, neither the United States nor the Soviet Union is spending more than a fraction of the money on weapons that it could afford in a time of crisis.⁶⁷ A case could be made that Russian leaders, remembering 1905 and 1919, fear that conflict abroad will bring with it great risk of instability, and even overthrow, at home. But if we take all this into account, we should see that it is at least also possible for Soviet power in the world to increase even as the domestic base upon which it is built deteriorates.

It should not be necessary to explain that short-term strength, in tandem with a prospect of long-term weakness, is not a prescription for international stability—especially when the government in question is both immensely powerful and demonstrates expansionist tendencies. Those who would discount the effects of the Soviet health crisis on international politics, or would see within that crisis only incentives for an inward turn in Moscow’s attention, should also consider whether this unhappy situation might have profound consequences for the rest of the world as well.