A career in public health: an Eastern European perspective
As I read Rod Griffiths' fascinating account of a career in public health, I was immediately struck by the parallels with my own. Like him, I had been pursuing a clinical career before moving to public health. In my case the conversion came when, in my outpatient clinic in Belfast in the 1980s, I was confronted with patients living in the community whose diet was so inadequate that they developed beriberi and scurvy, while in one of my wards 80% of the patients had some complication of alcoholism. It was not clear how the research I was undertaking on peptide biochemistry was going to be of immediate help to them.
My career, too, has been shaped by events elsewhere. In 1989 I was appointed as a senior lecturer at the London School of Hygiene and Tropical Medicine, tasked with developing a programme of research in Europe that would complement the school's traditional work in low income countries. In the interval between being interviewed and taking up my post, the ‘Europe’ in which it was possible to work suddenly became a great deal bigger, as one country after another in eastern Europe dismantled its border controls and rejected its communist rulers. Within two years, the USSR itself had ceased to exist. Even before the political changes, it was becoming apparent that the Soviet bloc was facing a health crisis. The first evidence to reach the west was in a 1980 paper by Christopher Davis and Murray Feshbach in a US Census Bureau report.1 They had realised that infant mortality was actually rising in the USSR. This attracted little attention outside a select group of demographers; it was a year later that Nick Eberstadt brought it to a wider public in a wide ranging and remarkably prescient review in the New York Review of Books, where he painted a picture of a very sick society.2 Perhaps the CIA would have benefited from reading it, given recent revelations about their abysmal lack of understanding of what was really happening in the USSR at the time.3
It was, however, in the former Soviet satellite countries that I first established collaborations. They were countries I knew reasonably well, having travelled through many of them, initially on Interail as a teenager but subsequently in a little more comfort. Throughout the 1980s, life expectancy had stagnated, leaving the area increasingly far behind their western neighbours. An immediate problem was to identify partners to work with. Few people had any real understanding of modern public health and undergraduate teaching focused on basics in hygiene, often taught by departments whose responsibilities included Marxism-Leninism.4 There were, however, a few exceptions, especially in Hungary, where the model of ‘goulash communism’ had allowed academic exchanges with the west. I was fortunate to develop a remarkable collaboration with a Hungarian colleague, tragically cut short when he was killed by a speeding driver. This was only one of many reminders of the sum of human misery behind the statistics we studied.
With funding initially from the European Union and later the World Bank, we were able to build a modern school of public health in Debrecen, in eastern Hungary.5 It has thrived and now stands as an example to the entire region. Research collaborations followed. We began to understand the complexity of the high mortality during the late communist period. Working age men had fared worse, although those who were married had enjoyed some protection.6 Tobacco and, especially, alcohol were clearly important, but so was a failing healthcare system.7
It was clearly more difficult to work in the former Yugoslavia, by then in the midst of a series of civil wars. Paradoxically, we already had well-established links, having run a summer school in Dubrovnik with Croatian colleagues during the 1980s. Amid the unfolding tragedies, it was an inspiration to work with colleagues from Bosnia, Croatia and Serbia who were doing so much to build bridges that others were, in some cases literally, destroying. I will never forget one month in 1994 when, shortly after visiting Auschwitz while at a meeting in Krakow, I flew into Sarajevo, my UN pass allowing me to cross the front lines separating the airport from the besieged city. Even though the horrors of Srebrenica had yet to occur, it seemed that we had made little progress in over half a century.
Initially, we had avoided involvement in Russia. Mindful of Churchill's observation that it was ‘a riddle wrapped in a mystery inside an enigma’, we had placed it in the ‘too difficult’ tray. Eventually, David Nabarro, then Chief Medical Advisor at the Department for International Development, persuaded us that we could no longer ignore the unfolding crisis. More importantly, he gave us the necessary money to undertake the research. Once again, we were fortunate in developing productive collaborations, in this case with Russian demographers. The pattern of mortality we were confronted with was unprecedented. In 1985, a steady decline in life expectancy was suddenly reversed, although only temporarily. By the time the USSR broke up, it was declining rapidly. The brief improvement had coincided with a wide-ranging, but short-lasting, anti-alcohol campaign, initiated by Mikhail Gorbachev.8 But could this explain these remarkable fluctuations in mortality? We have since been able to demonstrate, beyond any doubt, the extremely important contribution of hazardous drinking to the high level of mortality in Russia and its neighbours,9 to a considerable extent due to the widespread consumption of cheap but potent surrogate spirits such as aftershaves and cleaning liquids.10 Although their consumption was recorded even in Imperial Russia, the creation of a market economy enabled a massive increase in production and distribution. There can be little doubt that this is a major factor in the continuing downward trend in Russian life expectancy.
I have also been fortunate to have had a career that has been fascinating and fun, although also with times of great sadness. Looking back, what has been achieved? A great deal. 1 May 2004 was a time to celebrate, as eight former communist countries completed their journey to EU membership. The health of their citizens has improved more than we could ever have anticipated, but there is still a long way to go before they finally close the gap with their western neighbours.11 The range of food on sale in Tesco's stores in eastern Hungary and in London is little different, a far cry from the days when a request for a salad in a Hungarian restaurant was greeted with incredulity by a waiter who reminded me, ‘It's winter’. Yet elsewhere, the situation is much less optimistic. Some countries, such as Belarus and Turkmenistan,12 have simply replaced one form of dictatorship with another. Some of the smaller countries, such as Moldova and Armenia, have yet to recover fully from the economic collapse that followed independence. In Russia, a few have become super-rich but many more have been left behind. It is now apparent that the poor health of its population is a barrier to future economic development.13 Yet, even here, there are some signs of hope as the Russian government has, at last, started to clamp down on the manufacturers of surrogate alcohols. Like Rod Griffiths, I have little doubt that the next 25 years will be at least as interesting as the last.
- © 2009 Royal College of Physicians
Reference
- ↵Davis C, Feshbach M. Rising infant mortality in the USSR in the 1970s. Washington DC: United States Bureau of the Census, 1980.doi:10.1093/ije/dyl235
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- ↵Weiner T. Legacy of ashes: the history of the CIA. New York: Doubleday, 2007.
- ↵McKee M, Bojan F, Normand C, on behalf of the TEMPUS consortium for a new public health in Hungary. A new programme for public health training in Hungary. Eur J Publ Health 1993; 3:58–63.
- ↵McKee M. A decade of experience in eastern Europe. In: Foege W, Black R, Daulaire N, Leadership and management for improving global health. New York: Joosey Bass/John Wiley & Sons, 2005:167–86.
- ↵Hajdu P, McKee M, Bojan F. Changes in premature mortality differentials by marital status in Hungary and in England and Wales. Eur J Publ Health 1995; 5:259–64.doi:10.1093/eurpub/5.4.259
- ↵Chenet L, McKee M, Fulop N et al. Changing life expectancy in central Europe: is there a single reason? J Publ Health Med 1996; 18:329–36.doi:10.1093/oxfordjournals.pubmed.a024514
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- ↵McKee M, MacLehose L, Nolte E. Health policy and European Union enlargement. Buckingham: Open University Press, 2004.
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- ↵Marquez P, Suhrcke M, McKee M, Rocco L. Adult Health in Russia – More than Just a Health Problem? Health Affairs 2007; 26:1040–51.
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