The Health Crisis in the USSR: An Exchange

To the Editors:

This note is a response to Nick Eberstadt, “The Health Crisis in the USSR” which appeared in The New York Review of Books, February 19, 1981. All quotes unless otherwise noted are from Eberstadt’s article. Contrary to Eberstadt’s sensationalist claims, neither Soviet medical care nor Soviet socialism is falling apart. While there is a real problem with infant mortality, Eberstadt grossly exaggerates and misinterprets its significance. The problem is a negative (and temporary) result of the rapid progress made in raising living standards and freeing women from their traditional roles.

Life Expectancy

Life expectancy in the USSR in 1975 was 70.4 years (up from 68.4 years in 1960 and 70.0 in 1970).^* Life expectancy in the US in 1975 was eight months longer than in the Soviet Union. Contrary to Eberstadt, life expectancy in the USSR is not the lowest in Europe, nor is it comparable to those of the less developed capitalist countries in Latin America. In 1975, Soviet life expectancy was higher than that of Finland, Portugal, Yugoslavia, Romania, Poland, Hungary, Czechoslovakia, and “half-civilized” Albania. The USSR was further considerably ahead of the major Latin American countries such as Mexico (64.7), Chile (62.6), Brazil (61.4), and Argentina (68.2). It should be noted that the Soviet overall life expectancy is only slightly lower than that of the major advanced capitalist countries such as the United Kingdom (72.4), Japan (72.9), and West Germany (71.3). In 1900, the average newborn Russian could expect to live for about thirty years (seventeen years less than a newborn in the US born at the same time) (Eberstadt, p. 23). In a little more than a single generation, the Soviet system was able to take a population which had been living in medieval conditions and bring it up to roughly Western European standards of nutrition and health care.

It should be noted that the life expectancy for non-whites in the USA in 1975 was 67.9 years. If the Soviet figures of eight months below the overall US average indicates a “mortality crisis alien to everything we understand about modern life” what does a differential of 6.4 years (between white and black life expectancy in the US in 1975) indicate? That it is nothing inherent in the Soviet form of socialism that is causing the slower increase in Soviet life expectancy between 1960 and 1975 of 2.0 years, compared to 3.1 for the USA, is demonstrated when comparing the two Germanies. In 1960, East Germany (traditionally the poorer rural region) had a life expectancy of 68.3 years (1.3 years less than West Germany), but by 1975, it had a life expectancy of 72.6 years (an improvement of 4.3 years) compared to the West German life expectancy of 71.3 (now a 1.3 year advantage for the East Germans). The East German life expectancy is in fact higher than that of Austria, Belgium, Italy, Switzerland, the United Kingdom, Canada, and Australia. If the US advantage over the USSR is sufficient to indicate a “deeply disturbing health crisis” and to imply “virulent anomie” and “rampant social decay,” what then can be inferred about West German, Canadian, Australian, or Swiss society, whose differential life expectancy compared to East Germany is of the same order?

Most of the stagnation in overall life expectancy in the USSR over the 1970s is due to increased infant mortality. While infant mortality rose by 36 percent from its all-time low in 1970–71 to 1975–76 (the last period data are available) the death rate for children aged one to four declined by 5 percent. There was no change at all in the death rates of those aged five to forty or those over sixty-nine. The only age group besides infants to experience a significant increase in its death rate over the 1970s was the forty to fifty-nine group (where alcoholism, which has become a more serious problem with increasing purchasing power, takes its toll) (see Davis and Feshbach, Table 1). The decrease in infant mortality in the 1970s runs against the strong long-term trend. In 1961–65, the rate averaged 30.3 per 1,000, in 1966–70 25.8 and 1971–75 26.3 per 1,000 (Davis and Feshbach, Table 2).

The increase in infant mortality has not occurred in all Republics of the USSR, in fact it has largely been concentrated in Central Asia. The five-year moving average for the Russian Republic (where half of Soviets live) was 23.3 per 1,000 in 1970 and 23.0 per 1,000 in 1975. The (estimated) infant mortality rate for Central Asia on the other hand rose from 34 per 1,000 in 1970 to 46 per 1,000 in 1975. Infant mortality in Central Asia before the revolution approximated 330 per 1,000 (Eberstadt, p. 23). In 1960, the rate for Italy was 44 per 1,000, while that for Austria was 38 and West Germany 34 per 1,000. Sixty years of Soviet power reduced the infant mortality rate in Central Asia to approximately 1/8 of its former magnitude, bringing it to Western European levels of about 25 years ago. It should be noted that infant mortality in Soviet Central Asia is qualitatively lower than that of comparable countries across the Southern Soviet border which share ethnic groups with the USSR. The infant mortality rate for Turkey in 1970 was 153 per 1,000; for Afghanistan in 1975, 269 per 1,000; and for Iran in 1975, 120 per 1,000.

While the qualitative improvement in diet and health care made available to Soviet Asians has enabled them to reduce their infant mortality to one-third/one-fourth that of the related peoples across the border, the rates for the Western Republics of the USSR are comparable with those of most Western European countries. The three-year moving average for 1970 for Estonia was 17.4, for Lithuania 18.3, for the Ukraine 17.3, for Belorussia 18.0. In 1973, these were respectively 16.4, 17.0, 18.3, 17.4, and 16.7—in three cases a decrease and in only one an increase. These figures compare favorably with the 1975 rates of 21 per 1,000 for Austria, 20 per 1,000 for West Germany, 21 per 1,000 for Italy, and 16 per 1,000 for the United Kingdom and the USA (24 for non-whites). Given the fact that these latter countries are considerably more wealthy and urbanized than the Western part of the Soviet Union, the Soviet attainment of equivalent infant mortality rates in its Western Republics is a significant achievement and certainly represents a major success of the Soviet health care system, rather than a “reversion to preindustrial standards.”

Urbanization and the Changing

Role of Women

The Soviet Union, especially its poorest and most rural regions, is rapidly urbanizing, e.g., in the 1959–1970 period, the rate of increase in urban population for Moldavia was 90.7 percent, Tadzhikistan 80.3 percent, Uzbekistan 68.5 percent, Kirghizistan 67.2 percent.

In the Soviet Union virtually all women now work outside the home. In 1970, the labor force participation rate of Soviet women aged sixteen to fifty-four was 89.1 percent. Women in urban areas often live at some distance from their place of employment and are often separated from their children, who are usually in child care centers for much of the day. A Soviet study of perinatal mortality rates in Latvia in the 1962–67 period found that the death rate was 15.0 per 1,000 for women who were not working, 13.7 for collective farmers, and 19.4 for wage workers (Davis and Feshbach, p. 12). This suggests that those women who are either full-time housewives or collective farmers are better able to look after their children’s health than those that work in the modern sector. Thus we would expect infant mortality to increase the most rapidly where urbanization and the labor force participation of women in the non-farm economy increased the most rapidly.

Medical Care

Eberstadt asserts “health conditions in the USSR have worsened steadily since the mid-1960s.” The much more careful authors on which he bases his article, however, argue, “During the 1970s, obstetrical, gynecological, and pediatric services have improved and inequalities in their distribution have lessened. The quality of Soviet medicine in general has probably not deteriorated” (Davis and Feshbach, p. 24). Contrary to Eberstadt’s claim the USSR has increased the share of its national product spent on health (while at the same time decreasing the share it allocated to the military). In 1969, the USSR spent 2.3 percent of its GNP on health and 13.6 percent on the military. In 1978, it spent 2.4 percent on health and 12.2 percent on the military. In this period, while the Soviet population grew by 8 percent, absolute resources allocated to health care rose by 59 percent (US Arms Control and Disarmament Agency; World Military Expenditures and Arms Transfers: 1969–1978, 1979, Table 1).

Although quality medical care for infants is readily available throughout the Soviet Union (including the rural parts of Central Asia) there remains a problem with getting many parents (especially those of rural and Islamic backgrounds) to fully utilize that care.

A Soviet study found that in 61 percent of the cases which resulted in death from pneumonia, the parents did not seek medical help until after the second day of illness, and in 19 percent of the cases the infants were hospitalized too late (Davis and Feshbach, p. 20). Another Soviet study of infant pnoumonia found that 22 percent of parents first tried to treat the disease themselves without consulting a doctor, and in 12 percent of the cases the child was sent to a day care center in spite of showing the first symptoms of the disease (cited in Davis and Feshbach, p. 19). It should be noted that the Soviets have intensified public education about proper child care (e.g., a Russian language edition of Dr. Spock’s child care manual has been published) (Davis and Feshbach, p. 20).

Changes in Child Care Patterns

The rapid decline of the extended family and of the availability of grandma to look after the children, concomitants of rapid urbanization, industrialization and rising living standards, combined with the almost universal labor force participation of women, has meant an especially rapid expansion of day care facilities which look after a rapidly growing proportion of children after the two months paid leave period which new mothers are allowed. In 1970, 50 percent of urban and 30 percent of rural children were in day care centers (Davis and Feshbach, p. 20). Between 1970 and 1977, the number of children in such centers increased by 37 percent. The rapid socialization of child care, while liberating for women, has had a negative effect on infant health. A Soviet study found that the frequency of illness among children in day care centers was almost twice as high as that for children not in such centers and that the difference was due mostly to the higher incidence of infectious diseases, especially influenza, among children in day care centers (Davis and Feshbach, p. 20).

Breast-feeding has also rapidly declined while the use of infant formula has radically increased. A Soviet study found that “the death rate from all causes among formula-fed infants is 3 to 5 times that of breast-fed infants and the death rate from gastro-intestinal illnesses is 10 to 12 times higher.” Another study of a traditionally Islamic area concluded: “The early weaning of the infant has a major influence on the level of infant mortality. It is well known that infants on formula or mixed feeding are especially susceptible to the risk of gastro-intestinal illness, and the death rate of such infants is many times higher than that of breast-fed babies” (cited in Davis and Feshbach, p. 18). Formula feeding in the USSR probably most effects disease either because more traditional parents tend not to sterilize properly, or because children do not get a properly balanced diet.

Influenza Outbreaks

A number of Soviet studies have found that the principal cause of infant deaths in the 1970s was pneumonia. Influenza sets the stage for pneumonia. The USSR experienced virulent epidemics of influenza in each of the years 1971-1976. During this period a number of antigenic shifts in the influenza virus occurred; consequently the Soviet population repeatedly lost its natural immunity. These influenza epidemics have affected infant mortality, both through the infants’ themselves contracting the disease, thus making them more susceptible to fatal infections, and because pregnant women infected with influenza have a higher probability of giving birth prematurely (premature infants, of course, have higher rates of mortality).

Rapid urbanization, the decline in the extended family, the massive and increased use of day care facilities, and the rapid decline in breast-feeding (all associated with susceptibility to influenza), combined with the fact that virulent epidemics of influenza occurred in each of the years from 1971 to 1976, would seem to be strong evidence that it was the combination of these factors that was responsible for the rising infant mortality rates of many republics in this period.

The role of influenza, pneumonia, and other infectious and contagious diseases in the rising and stagnant infant mortality rates is revealed by the fact that the death rate for children aged one to four declined at the same time as the infant mortality rate rose. It would appear that: (1) weaker infants succumbed to these diseases before age one, thus producing a hardier stock of one- to four-year-olds, (2) immunities were developed before the age of one, and (3) the factor of premature birth (induced by mothers with influenza) spent itself by age one.

Conclusion

Eberstadt’s description of the USSR as “embarking on a path toward preindustrial standards of health,” and experiencing “a mortality crisis alien to modern life,” caused by a “virulent strain of anomie running rampant” and the “deadly decay” of Soviet society, all facilitated by the “fundamental spiritual need of the Russian people for suffering, perpetual and insatiable, everywhere and in everything,” would appear to be something of an overstatement.

Studies of the considerable difference in infant mortality experienced by infants in day care centers versus those taken care of by parents or other relatives, as well as the even more significant differences between those on formula and those who are breast-fed, make it clear that the primary source of the rising infant mortality rates in some republics and the stagnation in others is mediated through these factors. The infant mortality problem in Soviet society is apparently a negative consequence of the rapid progress made in industrializing, raising living standards, employing women in industry, and socializing child care. Progress which in many cases has been made more rapidly than public health education (concerning proper medical treatment and formula feeding) and the development of fully adequate child care facilities have been able to keep up.

It is clear that improvement in public health education, and improvement in the quality of child care facilities (including better screening of potentially sick infants), can rather easily resolve the problem (as has been the case in East Germany), and the long-term trend of decreasing Soviet infant mortality resumed.

Careless polemics such as that of Eberstadt only help recreate the hysterical anti-Soviet/ anti-Communist atmosphere characteristic of the Cold War of the 1950s. Such an atmosphere will almost certainly once again be used to support US military intervention in the less developed countries to suppress popular insurgencies (generally branded as “Communist”) against rightist military dictatorships whose major merit is the protection they offer to the economic interests of the mega-corporations in the US. Such anti-Soviet hysteria is also used to lend support to the scuttling of arms limitation talks and the rapid all-around military build-up of the US (with the ever increasing danger of nuclear war this entails). Whatever else might be wrong with the Soviet Union, they do not kill babies (nor are they responsible for either national liberation movements or the insane remilitarization of the US).

Albert Szymanski

Department of Sociology

University of Oregon

Nick Eberstadt replies:

Mr. Szymanski is to be commended for his skepticism. As he clearly realizes, inept or irresponsible resesarchers can obscure the truth through manipulation of statistics. Mr. Szymanski has obviously done a great deal of homework, and his proposed account of the Soviet Union’s recent health problems is internally consistent.

But even skeptics can get in trouble if they are unfamiliar with the proper methods of choosing and interpreting social statistics. If Mr. Szymanski will bear with me, I will attempt to outline the shortcomings of his critique.

Let us start by trying to get our facts straight. A wide variety of estimates is available for such things as GNP capita, income, distribution of output, and hidden sectoral subsidies for the economics behind the “Iron Curtain.” In part, this is because communist nations restrict the westward flow of information. But even those data which are provided not infrequently turn out to be defective. There are a number of reasons for this, one of which is the desire to shape data to political convenience. Setting such figures straight can be difficult, and results are often none the better for the passions which the study of communism can arouse. As a consequence, the Western literature of the Soviet Union is replete with a dangerously large number of inadequate, or even self-serving, estimates.

Mr. Szymanski has unfortunately stumbled across a few of these. Those Arms Control and Disarmament Agency figures on the Soviet economy, for example, should not be taken seriously. This is not the place to recap the recent debates on Soviet economic development or political strategy, but reputable analysts across a wide range of inclinations—from “doves” like Arthur Macy Cox to “hawks” like William T. Lee—would contend that the fraction of the economy devoted to military expenditure has not shrunk over the past decade.

For this to happen, the pace of economic growth would have to be more rapid than the rate of increase in military expenditure. As best we can tell, defense allocations in the USSR have been rising by 4 or 5 percent annually since 1968, while economic slowdown reduced the growth of the Soviet GNP to something like 3 or 3.5 percent a year for the 1970s. As for health care allocations, Soviet officials themselves say that these have decreased as a proportion of the government budget over the period in question: one need look no further than the Davis-Feshbach pamphlet to confirm this. The notion that health care outlays would have increased by nearly three-fifths from 1969 to 1978—this during a time when capital requirements nearly doubled, and the Red Army added to its ranks more than half a million men, while the economy as a whole expanded by twofifths or less—can only be described as fanciful.

The figures Mr. Szymanski has chosen to represent current Soviet life expectancy are equally distant from reality. He relies upon the 1979 World Bank World Atlas of the Child, an unoffending and often useful source, but one with definite limitations nonetheless. It is a handbook, after all, which purports to measure life expectancy in Brazil, Chile, and Mexico down to the last tenth of a year—practically to the month. For such precision to be meaningful, these figures would be more accurate than the government reports upon which they were based.

By the same token, the atlas’s estimate for Soviet life expectancy circa 1975 is apparently taken from the World Health Organization, and that organization’s figure is derived not from data, but rather from an extrapolation predicated on the assumption that life expectancy always increases over time in industrial societies. The Davis-Feshbach study is important precisely because it challenges that assumption.

Mr. Szymanski may reject my judgments and distrust the calculations of Christopher Davis and Murray Feshbach, but Mr. Alexander Smirnov cannot be suspected of exaggerating Soviet difficulties. He is a leading demographer at Gosplan, the USSR’s state planning committee. On June 4, 1981, the Christian Science Monitor reported Smirnov as saying not only that Soviet life expectancy has indeed been falling, but also that Soviet infant mortality rates are 13 percent higher today than twenty years ago. By simple arithmetic this would mean at least forty-two, and possibly as much as forty-five per thousand infants die, a rise of well over 50 percent since 1970. Even at forty-two, the Soviet infant mortality rate would be Europe’s highest. It would also be higher than those of the following countries: the Bahamas, Barbados, Bermuda, Chile, Costa Rica, Cuba, Guyana, Jamaica, Panama, Trinidad and Tobago, Uruguay, Venezuela, and Argentina. The list could easily be continued. Moreover, if Mr. Feshbach’s estimates are correct—and to date all revelations from the USSR have confirmed his conclusions—the USSR’s life expectancy is lower than that of any nation in Europe—including little Albania. Mr. Szymanski might be interested to learn that a boy born in Calcutta can now expect to live longer than a boy born in the USSR.

As for comparisons of East and West Germany, the World Atlas of the Child is once again an inappropriate reference. It was not intended for exacting, up-to-date cross-use. We would do better to check back with official sources, such as the Federal Republic’s Bevölkerung 1978 (published in July 1980) and the DDR’s Statistisches Jahrbuch 1980. Those two compendiums unambiguously show that West Germany’s life expectancy is higher. For men, the difference is about three months; for women, it is over a year. Over the course of the 1970s West Germany has in fact outperformed East Germany in the race to a healthier life: the men of the Bundesrepublik have “gained” nearly a year, and women about half a year, on their Prussian counterparts. Comparisons of infant mortality rates are complicated by differences in definition and by the fact that about a quarter of the babies born in West Germany are the children of Gästarbeiter from Turkey, Yugoslavia, and other high-mortality regions. Even so, the most recent statistics indicate that the fraction of babies dying in West Germany is lower than the rate for East Germany.

To be sure, East Germany’s health prospects did improve more rapidly back in the 1960s than did the Federal Republic’s, and credit should be given where it is due. A number of things, however, may have made East Germany’s experience in the 1960s unique. The DDR is now beset by growing manpower shortages, economic dilemmas, and military obligations of a different nature from those across the border. It remains to be seen whether the East Germans will be able to keep pace in the realm of health in the future.

In general, Europe’s communist nations have not performed as well as its capitalist states in providing health for their people. Mr. Szymanski would have seen this if he had source material that went beyond 1975, the last date of entry for the World Bank atlas. There is, of course, a diversity of performance on both sides of the Iron Curtain, but taken in aggregate, life expectancy is not only lower in the Warsaw Pact countries than in NATO, but it is also rising more slowly.

Now, let us move on to questions of interpretation. Mr. Szymanski contends that rising infant mortality in the USSR is a byproduct of “modernization,” an accidental side effect of the progress Soviet governance has brought to the peoples of the USSR. More specifically, he suggests that rising death rates can be attributed to rapid urbanization and the liberation of women.

Urbanization is indeed proceeding apace in the USSR, but this is nothing new. Urbanization has been underway for nearly a century, yet infant mortality, so far as we can tell, did not begin to rise until the 1970s. Urbanization, moreover, is now a worldwide phenomenon—yet since World War II none of the nations of Latin America, Asia, or Africa has been beset by long-term rises in its children’s death rates. And Mr. Szymanski seems to have forgotten one of the more consistent findings of twentieth-century sociology: that infant mortality is almost always lower in cities than in the countryside. One would expect that in the Soviet Union, as elsewhere, rapid urbanization should push infant mortality down, not up.

There are similar drawbacks with Mr.Szymanski’s hypothesis about the status of Soviet women. To begin with, I confess that I find his assertion that women have found the Soviet experience “liberating” to be dubious. I suspect that many of the USSR’s mothers, who must typically work long hours at menial jobs, wait several hours in line daily for family shopping, and raise children without recourse to such traditional figures as the babushka, would share my skepticism. In all fairness, however, I suppose that “liberation,” to paraphrase Molotov, is a matter of taste.

Other contentions are less subject to debate. From Jamaica to Johannesburg increases in the fractions of women working outside the home has had no adverse effect on infant mortality rates. In fact, infant mortality has fallen dramatically in the poor nations over the past twenty years. Female “participation” in the Soviet labor force rose rapidly with the first Five Year Plan in 1928, and has been rising since then—but infant mortality did not begin to rise until about 1970. The proportion of working-age women serving in Eastern European labor forces, moreover, is not very different from that of the Soviets, yet so far as one can tell infant mortality in those nations is still falling.

Bottle formula does indeed seem to be partly responsible for the upsurge in Soviet infant mortality, but I am not convinced by Mr. Szymanski’s exposition. The Soviet Union is not the only country in the world to use infant formula. In much of Latin America, for example, infant formula is widely used. It has some well-recognized dangers—prepared improperly, it can be a positive threat to a child’s health—yet no rise has been registered in Latin American infant mortality rates. In Chile, powdered milk is an important supplement to the diet of most youngsters, yet the death rates for Chile’s children have dropped substantially over the past decade. If infant formula in the Soviet Union is recognizably murderous, then Soviet infant formula is unique. (Of course, Davis and Feshbach imply that this may well be the case.)

Influenza, to take another one of Mr. Szymanski’s points, also seems to have contributed to the Soviet health problem. But why? The USSR was not the only nation in the world to battle flu in the 1970s. Here in the United States we dealt with at least three severe rounds. Yet from 1970 to 1979, according to the Center for Disease Control, the total number of babies to die from influenza in America was something like 2,000. In the Soviet Union, on the other hand, the total seems to have been something like 200,000. Were Asian strains really a hundred times more lethal in Alma-Ata than in Atlanta?

Mr. Szymanski argues that the rise in death rates was basically limited to the Central Asian republics: which is to say, the Soviet Union’s Muslims. Were he to go back to the Davis-Feshbach pamphlet, he would see that this is not so. Infant mortality was rising in cities in nearly every region of the USSR between 1970 and 1974, after which time such information began to be suppressed.

Simple arithmetic demonstrates just how difficult it would be for the Soviet Union’s Muslims to be the sole force behind the USSR’s dramatic increase in infant mortality. Soviet officials now seem to be admitting that infant mortality has risen by well over 50 percent in the last ten years. Approximately one Soviet baby in three is Muslim. Even though Muslims suffer substantially higher infant mortality than their non-Muslim compatriots, nothing short of an explosion of death rates on their part alone could drag the national average to anything near forty-five per thousand. If all other Soviet babies enjoyed “European” levels of health (typified, say, by infant mortality rates of 15 per thousand or less), Muslim infant mortality rates would have to have risen to something like one hundred per thousand—which is to say that the health levels of Soviet Central Asia’s children would have to have fallen below those of the children of South Africa’s blacks. This seems unlikely. More plausible would be the suggestion that the mortality burden is shared among many of the different ethnic and linguistic groups of the USSR.

All of Mr. Szymanski’s partial explanations, however, ignore a central problem. Mortality rates have not risen for children alone. If Mr. Szymanski were to check with the Davis-Feshbach pamphlet, he would see that they were rising for every age group over thirty. Another announcement by Mr.Smirnov, this one in the London Times (June 12, 1981), indicates that death rates for all children under five have risen dramatically over the past decade. Murray Feshbach recently estimated that the life expectancy for Soviet men has fallen by as much as four years since 1965. This is not a matter of infant mortality so much as of a disturbing resurgence of death in middle age. Forty-five-year-old men presumably do not die of sour bottle formula or maternal neglect. An explanation that would satisfactorily account for rising death rates among almost all age groups, among people separated by vast distances, and (in all likelihood) among many different nationalities would have to be all-encompassing—perhaps, as I suggested in my piece, as all-encompassing as the Soviet system itself.

Mr. Szymanski would strengthen his arguments if he were to familiarize himself with a few important conceptual distinctions. One of these is the difference between “health” and “medicine.” Medicine is only one of man’s many weapons against death and sickness: others include diet, education, sanitation, and communications. Health conditions can deteriorate against a background of improving medical care: think, for example, of the early days of Bangladesh. Immediately after independence the new nation had many more highly trained doctors applying their skills within its borders than the previous entity of East Pakistan had ever enjoyed. But the infusion of medical talent was a response to natural disaster, war, and the famine and disease that these caused. Consequently, in spite of the doctors, mortality was higher by a disconcerting margin in 1971 than it had been in, say, 1968. Health will always deteriorate if a medical system cannot keep pace with new challenges. The number of “doctors” in the USSR has risen over the past decade, but so has mortality. This may be ironic, but it is not inexplicable.

Another useful distinction is that between a rate and a level. Right now, the difference in life expectancy between residents of the Soviet Union and the United States is, by coincidence, about the same as between black and white Americans. This does not mean that the two situations are equivalent. The black-white gap speaks to many of our nation’s most serious problems: violence (handguns alone take a year off the black American man’s life), the deterioration of the family, unequal access to medical care. What should not be forgotten, however, is that the black-white gap was more than fifteen years at the turn of the century, and more than ten years at the start of the New Deal. Black progress has been slower and more erratic than it could, or should, have been. But, at least in the realm of health, the black-white gap is being closed. By contrast, Soviet life expectancy seems to have been higher than ours in the late 1950s: since then ours has risen by more than five years, while theirs may actually have fallen. The black-white and the Soviet-American life chance gaps speak to entirely different sets of circumstances and prospects for the future. They are trends going in different directions.

As for my explanation of the roots of the Soviet health predicament, Mr. Szymanski should reread the second half of my article. I repeatedly stated that in my view the current health crisis in the USSR is not a result of some penchant for personal suffering on the part of masochistic Russian mothers and children. What I tried to explain was that a punishing and brutal system of governance had arisen on Russian soil, that it reached its logical extension under Stalin, and that the post-Stalin era was characterized by a failure of government in a system where government is meant to subsume economy, society, and even human spirit. The essence of the post-Stalinist dilemma seems to me this: that it is at once impossible for Stalin’s successors to continue in the dictator’s ways, and inconceivable to stray far from his path. Until this dilemma is resolved, I would not expect quick solutions for any of the great Soviet problems, including health. The Soviet Union’s difficulties are unique.

To bring a long letter to an end, I would like to address Mr. Szymanski’s puzzling accusations about my motives in writing this article. I would have thought my sympathy for the Russian people, and the other peoples of the Soviet Union, was evident. As I tried to point out, they have undergone hardships of the body and soul which those of us in the West can only imperfectly understand. As for the use to which my article will be put, I very much doubt that this essay has done anything to revive the “cold war,” or to raise the chance of thermonuclear holocaust. I have always thought that the attempt to analyze social problems, and the open debate attendant on such efforts, promoted understanding, and thereby reduced unnecessary tensions.