ISSN 1019-JJ16, Huald of!ht Rim/an ACtJ«my o/ScifflUS. 1016, Vol. 86, No. 6, pp. 471-480.

0 Pkinda Publishing lid. 2016.

Original Rmsian Tut C S.A. Boiuov, [. V. Somorodskaya, 2016. published in l'atniJ.: Rossi/skol Akatftmil Nawlc, 1016, Vol 86, No. /2. pp. 1099-/097.

From the Researcher's Notebook======

Determinants of Mortality
S. A. Boitsov1 and I. V. Samorodskaya2*
National Research Centerfor Preventive Medicine, Ministry of Healthcare, Moscow, Russia
e-mail: 1profboytsov@gmail.com; 2samor2000@yandex.ru
Received December 4, 2015

Abstract-Domestic and international studies on the effect of socioeconomic and environmental factors,
genetic and behavioral features, and the health care system on mortality are analyzed. The necessity to dis-
tinguish between the notionsfactor.s affecting mortality rates andfactor.s affecting mortality (longevity) is speci-
fied. Mortality rates are significantly affected by demographic processes (birth rate, mortality, migration),
while mortality depends on a complex of factors, the significance of each of which is still undetermined and,
in the opinion of the authors, varies substantially in various populations depending on combinations of these
factors.

Keywords: mortality, mortality rates, longevity, socioeconomic factors, environment, genetic factors, behav-
ioral factors, health care system.
DOI: 10.1134/S 1019331616060010

According to the preliminary data of the Russian ening diseases and premature death ofa concrete indi-
Federal State Statistics Service (Rosstat), in the first vidual is favored by behavioral risk factors (smoking,
half of 2015, an increase in mortality was recorded in alcohol abuse, low or, on the contrary, extremely high
Russia compared to the previous years, in which there physical activity, unhealthy diet), constitutional-bio-
was a clear tendency toward a decrease in the mortality logical peculiarities (high cholesterol and arterial pres-
rates of the population both as a whole and individu- sure, congenital and genetic anomalies of develop-
ally by all age subgroups. The causes of the change in ment, "apple-shaped" obesity, depression), and living
the dynamics of the rates have been discussed many in unfriendly conditions (a bad environment, poverty,
times by the Russian government, the mass media, social stress).
and various scientific forums. The diversity of the The mortality rate in a population, calculated as
opinions proposed makes it important to analyze the the number of deaths per IO00 individuals, largely
results of studies assessing the effect of various factors depends on demographic processes-the birth rate,
on mortality. the age structure of the population, mortality within
First of all, it is noteworthy that the degree of sig- individual age-sex subgroups, and migration pro-
nificance ofthese factors depends on the longevity and cesses. For example, with the mortality level in age-
premature death risk of an individual or those of a stratified subgroups being equal, mortality is overall
population group or society as a whole. The risk of higher in the population with a higher share of elderly
death of an individual depends on the presence of a people. However, if an increase in the share of elderly
serious dccompensated congenital or acquired dis- people is accompanied by a decrease in mortality in
ease, the opportunity to obtain timely quality medical each age group, the value of general population mor-
aid, the curability of the case (the availability of tech- tality rates decreases. Hence, in Germany, according
nologies that make it possible to cure the disease or to World Bank data, under the increase in the share of
lengthen the patient's life against the backdrop of the people older than 65 years from 14.9% in 1990 to
disease), age (the most significant factor because 20.6% in 2010 and the simultaneous increase in aver-
immortality-providing drugs have not been developed age longevity from 75 to 80 years, crude mortality rate
thus far), and presence in extreme conditions (natural decreased from 11.6 to I0.5 per IO00 people. In Russia,
disasters, war, extreme sports and leisure, and so on). the share of people older than 65 years increased in the
The development of chronic disabling and life-threat- same period from 10.3 to 12.8%; the mortality rate,
from I1.2 to 14.2; and longevity decreased from 69.3 to
• Sergei Anatol'evich Boilsov, Dr. Sci. (Med.), is Director of the 69.0 years (also according to World Bank data).
National Research Center for Preventive Medicine (N RCPM).
Irina Vladimirovna Samorodskaya, Dr. Sci. (Med.), is Head of The impact of individual demographic processes is
the Laboratory or Demographic Aspects of Public Health at the to an extent neutralized in standardized mortality
same center. rates, which account for the age structure of the pop-

473
 ,.I
I
I 474 BOITSOV, SAMORODSKAYA
I ulation and can be at variance with actual data, pri-
marily because of differences in the demographic
structure of the populations under comparison. With-
out standardizing the coefficients, the comparison of
mortality rates can be incorrect and even meaningless.
At the same time, the values of standardized rates
depend on the choice of the "population standard''
and standardization method [l, 2).
According to studies, mortality in a population
sampling (or the life expectancy indicator, which is
more correct for such assessments) depends on a large
complex of factors, which we divide, very condition-
ally, into several subgroups in this article. The authors
of many works refer to WHO data, according to which
hea1th status is determined 50% by lifestyle; environ-
menta1 and hereditary factors contribute 20% each;
and the remaining 10% is the quality of hea1th care.
Note that we failed to find the source of these cita-
tions, as well as references to a mathematical model
that would account for all currently known mortality-
affecting factors.
Socioeconomic factors. Numerous studies repeat-
edly mentioned the presence of a close interrelation
between the socioeconomic development of the state,
the level of incomes, social protection, and the health
status of the population. There are convincing proofs
today that the mortality gradient (expressed differ-
ences in mortality rates between the rich and the poor)
manifests itself between both rich and poor countries
and within a country, between groups of the popula-
tion singled out depending on their socioeconomic
status. In addition, as WHO documents emphasize,
mortality in socially unprotected population layers
with low incomes is much higher in poor countries
than in rich ones, and the mortality gradient value
between well-to-do and impoverished population
groups, for example, in Europe is significantly lower
compared to the countries of the Middle East and
North Africa (3, 4).
The interrelations between economic indicators
and mortality are by no means linear; nevertheless,
Rosstat data about mortality in Russia show that,
during the economic reforms, which brought mass-
sca1e impoverishment and acute stratification of the
population by living standards, the mortality rates
increased significantly (5, 6). To assess the situation in
Russia, it is also noteworthy that the negative effect of
the poverty of individual population strata and the
growing inequa1ity of incomes can reduce the positive
effect of GDP per capita growth. For example, in
Latin American countries, the growth of GDP against
the increasing inequality of incomes led to a very
insignificant increase in longevity and a decrease in
infant mortality [7].
The systems approach-based expert analysis of
publications dedicated to the problem of mortality
shows that factual data cannot fully explain today the
differences in hea1th status between various socioeco-
HERALD OF THE RUSSIAN ACADEMY OF SCIENCES
nomic strata of society. The effect of socioeconomic
factors is indirect, affecting individual population
groups through other factors [8). For example, a
higher mortality in men who belong to socially and
economically disadvantaged population groups is
observable against the background of a greater inci-
dence of smoking, alcohol abuse, and hard physical
work among them [9].
A number of publications demonstrated a close
interrelation between mortality, economic factors,
and factors of social stress. The latter include poor
housing; no fixed abode; a sense of job insecurity;
harmful, dangerous, or constant stress- and depriva-
tion-related work; discrimination; a lack of career
prospects; the necessity to make great efforts to pro-
vide for a family and bring up children under difficult
conditions; alienation from the life of society; and
inadequate pension provision [3, 4). In the United
States, the relative risk of death from a11 causes among
people with a low level of social support is 1.34 and
leads to an additional 150 000 deaths a year [ 10). At the
same time, social support and socia1 integration play a
protective role. For example, a survey of 32 624 men
revealed that the highest risk of death from a cardio-
vascular pathology (1.90) is observable in people with
the lowest level ofsocial support [ ll]. Note that social
support is defined as care by family members, friends,
and acquaintances; emotional, bidirectional, and
active interpersonal exchange of information; the
presence of well-developed social ties; participation in
group events (family gatherings, group games, partici-
pation in religious life, etc.); and material support for
community members.
The effects of periods of economic turbulence on
the health status and mortality rates have been studied
actively of late. The series of economic crises in the
United States and European countries led to a
national budget deficit, a significant economic slow-
down, and a high level of unemployment; in the aggre-
gate, all this prompted an increase in the number of
homeless people, growth of alcoholism and inhalant
abuse, an increase in the frequency of cases of domes-
tic violence and suicides, and limited access to medical
care [12). Overall, however, critica1 processes in the
economy have an insignificant effect on longevity in
industrially developed countries. Their consequences
become more serious if a decline in economic indica-
tors combines with profound social and political
changes [ 13).
One of the largest international studies, which
included people who lived in the United States and
11 European countries, showed significant differences
in longevity and the level of mortality between poorly
educated .and well-educated individuals 114). In the
United States, the relative risk of death among people
of 25-64 years of age in the first category exceeds that
in the second one by 1.8 times; for people older than
65 years, this excess is 1.3 times [15). However, just as
Vol. 86 No. 6 2016
 DETERMINANTS OF MORTALITY
with other socioeconomic factors, the level of educa-
tion affects health and mortality rates indirectly,
through membership in a socioeconomic group and
the lifestyle typical of this group. People with a low
level of education have low incomes and often no
medical insurance or permanent job, and they are ill-
informed of risk factors, symptoms of diseases, oppor-
tunities to receive medical care, etc. 116, 17).
The environment. Studying the impact of water,
soil, and air pollution on human health is a complex
task that requires analyzing a very large scope of fac-
tual data and scientific works that consider the effects
of pollutants on the organism. According to the results
of meta-analysis of 30 studies dedicated lo identifying
the dependence of mortality and health status on cli-
matic changes (warming), the latter are accompanied
by changes in the adaptive mechanisms and social
conditions of life (dwelling designs, cooling systems,
etc.) 118). Since it is very difficult to integrate the
entire complex of changes in statistical models, accu-
rate and differentiated evaluation of the effect of envi-
ronmental changes on health and the development of
recommendations on overcoming negative conse-
quences turns out to be rather problematic.
According to data of the Institute for Health Met-
rics and Evaluation (IHME), the environmental fac-
tors that exert the most significant influence on the
level of mortality are currently air pollution, profes-
sional factors (working with asbestos, arsenic, beryl-
lium, cadmium, trichloroethylene, lead, radon, and so
on), and the presence and supply of clean potable
water. The share of deaths associated with unfriendly
environmental factors is 14.9% of the total number of
deaths, according to IHME calculations. A number of
studies point to a complex effect of weather/air pollu-
tion on mortality [19-21].1
Most of the studies testify to a significant growth of
mortality in periods of extreme heat or cold (heat and
cold waves) in a number of the planet's regions. The
notions of hear and cold are defined proceeding from
the mean daily temperatures not only for each climatic
zone but also for individual cities, especially megalop-
olises. In Russia's northern regions, according to the
data provided by B.A. Revich and D.A. Shaposhnikov,
cold waves have a stronger effect on the level of mor-
tality than heat waves, and long cold waves yield a
more grievous effect than short cold waves, although
long heat waves, on the contrary, cause less significant
changes in mortality compared to short ones L20J .
The influence of climatic and weather factors
becomes stronger under the presence of unfavorable
economic conditions. The US Center for Disease
Control and Prevention notes that the risk of addi-
tional weather-related deaths (including those caused
by heat and cold waves, floods , and hurricanes) is two
1 vorable conditions of life can stimulate aging before
For more detailed information, s.:c http://vizhub.h~allhdata.org/
gbd-compan:jhealmap.
HERALD OF THE RUSSIAN ACADEMY OF SCIENCES
475
to seven times higher in low-income regions than in
high-income ones [22]. Note that a growth of mortal-
ity in a population is recorded in most cac;cs, although
the concrete cause of the deaths is neither hypother-
mia nor heat illness but other pathological states, for
example, a flare-up of a chronic disease. This identifi-
cation of causes of death is related, on the one hand, to
critical flare-ups of chronic diseases against an
unfriendly weather background and, on the other, to
the lack of reliable criteria to register extreme weather
conditions as causes of death (21 ).
Genetic factors. The role of genetic factors in the
development of a number of diseases leading to a sig-
nificant decrease in longevity (hemophilia, hereditary
hypcrlipidemia, sickle-cell disease, etc.) has been
proved by now. However, the spread of such diseases
in a population is quite low, and there are no strong
data to show that they affect mortality rates in the
country or region. In addition, despite the fact that
scientists across the world constantly describe and
study geographical regions or individual ethnic groups
with a high share of people over 90 years of age 123,
24J, there are no weighty arguments that would show a
dependence between an increase in human longevity
and various genetic features. According to the data of
another meta-analysis, the lack of reliable proofs that
genetic factors affect longevity is, among other things,
due to the fact that, against the backdrop of significant
variability, many genes provide very weak effects at the
individual level. The results of the analysis of five stud-
ies on the long-lived from the United States, Europe,
and Japan only confirmed the hypothesis that the
influence of genetics on longevity increases late in life
but does not make mortality vary depending on the
country and region (25].
The phenomenon of premature aging has not been
proved either. There are only scientific hypotheses and
results that indirectly indicate that it may exist. Sup-
posedly, this phenomenon may rest on a complex of
unfavorable socioeconomic circumstances, particu-
larly those that manifest themselves at the early stage
of human life, in childhood. The results of a 20-year-
long study of aging processes in 954 participants, the
Dunedin Study birth cohort, have been presented
recently. By the end of the study, the participants of
the same chronological age (38 years) differed signifi-
cantly in their biological ages, which was assessed
using a procedure developed for this study. Already by
the middle of life, some of the reporting panel had
aged more quickly than their contemporaries, had
worse physical health indicators, demonstrated a
decrease in cognitive functions and signs of brain
aging, and looked older. Scientists allowed the possi-
bility of the influence of the "social gradient in health"
(in children born into poor families compared to their
cohort born into rich families, the phenomenon of
accelerated aging develops) and concluded that unfa-
the development of chronic diseases [26 J.
Vol. 86 No. 6 2016
7
476 BOITSOV. SAMORODSKAYA
Unhealthy lifestyle and other behavioral risk factors.
The most vulnerable groups in terms of the risk of
developing life-threatening conditions and premat ure
death include persons of no fixed abode and job,
orphaned children, migrants, persons with behavioral
risk factors (alcoholism, substance dependence, and
extreme leisure and tourism that is life-threatening to
oneselfand others), and people with biological behav-
ioral peculiarities that increase the risk of developing
chronic noninfectious diseases and premature death.
Most behavioral risk factors correlate with low
incomes, a low level of education, and the absence of
a fixed abode and job. The higher the specific share of
people of risk groups in society, the worse the social
health and the higher the probability of premature
death. Since it is impossible lo assess precisely the
contribution ofeach risk factor (or even a group offac-
tors), many current ideas based on expert opinions and
theoretical conclusions, are perhaps mere myths. For
example, the latest global study DALY2 has shown that
there exist 67 factors that favor premature death
and/or loss of health (27]. They include hypertension·
t?bacco smoking; low vegetable and fruit consump~
t1on; alcohol abuse; a high body mass index; high con-
t~nts of glucose and cholesterol; low physical activity;
h1g~ salt consumption; environmental air pollution
owmg to the use of solid fuel; low consumption of
foods containing whole grains, nuts, dietary fiber, and
s~afoods with a high content of omega-3 fatty acids;
h.'gh meat consumption; drug taking; the professional
nsk of traumas and backache; undernourishment in
childhood; improper breastfeeding; iron deficiency;
and sexual violence. The study specifies that the anal-
y~is ~ed data collected in the course of sample inter-
views ma number of countries. However, to assess the
contribution of risk factors, not a 95% confidence
interval but a 95% uncertainty interval was used. Jn
other words, in essence, the report, usingjudgements,
measured parameters relative to which the notion true
~alue has no co~ceptual meaning. The uncertainty
mterval only specifies a value range corresponding to
the spread of assessments that, in the opinion of
expert_s, can be obtained from the results of a poll by
other independent specialists.
At the same ~ime, according to other data, although
an unhealt~y lifestyle and risk factors substantially
affect the nsk of death of an individual, they exert a
relative!!' insignificant effect on the longevity of the
population as a whole [28). An individual who smokes
is overweight, and leads a sedentary life can los~
seven-to-eight or more years of life. However, if about
a quarter of the population smokes and each smoker
qu~ts thi~ b~d habit, the overall longevity of the popu-
lation will mcrease by 1.5 years. If overweight and
1 (by 9 times for m 7n and by 13 times for women ) (33).
- DA~Y (disability ~dj11:5ted life year) is a generalizing indicator of
pubhc hc:allh, which includes the years of life lost as a result of
premature death an~ the ye~rs of life lived with a disability
(mental and/or physical anguish determined by a disease).
HERALD OF THE RUSSfAN ACADEMY OF SCrENC ES
obese people return to a normal weight, their life
expectancy, according to estimates, increases by
approximately 1.5 years. Taking into conside ration
that more than half of Brits and Americans are over-
weight and every fifth resident of these countri es is
obese, their return to a normal weight could ensure an
increase of about 0.5 years in the total longevity of the
population l28J.
A negative effect of alcohol use on the mortali ty
level is registered in all countries. Simultaneously,
many Russian and foreign specialists have drawn
attention to the inadequate consideration of alcoho l-
related mortality: since there are no clear criteria of
differential diagnostics, a significant numbe r of deaths
against the background of alcoholic visceropathies are
included in the structu re of mortality from diseases of
internal organs of the body (29-31 ). In additio n,
deaths caused by alcohol abuse are associated with
something shameful; this is why only a few cases (for
example, persons of no fixed adobe or unidentified
bo~ies) are assigned to the alcohol poisoning column ,
while the rest of deaths from alcohol poisoning are
masked by other causes, including cardiovascular dis-
eases. Hence, official statistics of alcohol-related
deaths can be significantly understated, and not only
in Russia but also in a numbe r of other countri es. For
example, in Germa ny, understatement ofthe spread of
alcohol abuse is observed, as is an understated numbe r
ofsick leaves and death certificates that specify alcohol
abuse and its consequences as the cause. This is
explained by the unwillingness of doctors to stigmatize
the patients (patients with this diagnosis are consid -
ered as "dangerous," guilty of their diseases disre-
garding recommendations, and "unworthy" df better
treatment); therefo re, in making a diagnos is doctors
often limit themselves to "obvious" cases [3d.
A numbe r ofstudies show that the value ofalcoh ol-
related mortality depend s on the quantit y of alcoho l
consumed and the emergence of somatic and psychic
compli cations . Accord ing to the data of the meta-
analysis that general izes the results of nine cohort
studies, includi ng 62 950 particip ants [321, under a
low level o_f long al~ohol consum ption ($30 g of pure
alcohol dally), the nsk of death for men is the same as
~mong nondrinkers. However, if the daily consum p-
uon o~ alcohol reaches >30-59 g, the relative risk of
death mcreases, amounting to l.19, and for those who
take ~6? g a day, 1.52. Anothe r meta-analysis, which
generahzcs the results of80 observational studies (with
~ total numbe r of 85~ 722 individuals surveyed), iden-
tified that, for men with an alcohol-associated somatic
and/or mental patholo gy, the relative risk of death
was 3.3~ and that for women was 4.57 (compa red to
tho~e w1tho~t such disorde rs). The risk of death is
not1cc~bly higher among people of $40 years of age
Note that, accordm g to information from the website
of the Inte~n ational Center for Alcoho l Policie s
(http://www.1cap.org/Policylssucs/DrinkingGuidelines/
Vol. 86 No. 6 2016
 7
I
I DETERMINANTS OF MORTALITY
V StandardDrinks/tab id/ 126/Default.aspx), differ1:nt
studies define the notion of 1 drink differently, which
is used to calculate the amount of alcohol consumed;
quantitatively, it can mean from 6 to 28 g of alcohol.
Naturally, this considerably hinders the comparison of
results.
The WHO report "Equity, social determinants,
and public health programmes" [34) , the authors of
which analyzed a number of international studies,
notes no direct relation between mortality and alcohol
use. The adverse effect of alcohol depends not only on
the quality and quantity consumed but also on the
social environment in which it is consumed and the
degree of the marginalization of its consumers (3, 4,
33). Some studies show that the most negative effect is
caused by the combination of alcohol use and addi-
tional "interfering" factors, such as economic and
political crises; a low socioeconomic status; dietary
and behavioral habits; the availability (geographic and
financial) and quality of medical aid; and the presence
of barriers in obtaining it, determined by alcoholic
stigmatization. On the contrary, high socioeconomic
and family statuses have an expressed protective effect.
Factors associated with health care delivery. Despite
t~e equal spread of risk factors in Europe at the indi-
vidual level, longevity, especially among men, in
Western European countries is much higher than in
Eastern Europe. Scientists attribute this fact to the
better organized and more effective public health sys-
tem ~nd successful health care policy (measures on
smoking and road accident control, etc.), characteris-
tic of Western European states (35).
. It :°eeds no proof that survival in life-threatening
situations almost fully depends on the organization of
medical aid, the development of medical technolo-
gies, and the qualification of the medical staff. At the
same time, it is very difficult to evaluate the influence
of a health care system on mortality rates. According
to the WHO report on the state of health care systems
across the world (3), the contribution of medicine to
~ortality rates is difficult to predict: the programs
mtroduced to combat diseases and reduce mortality
are often inefficient. The programs compete with one
another for scarce resources, while the structural
probl~ms of health care systems (funding, labor remu-
neration, and human resources) remain practically
unsolved, and people who have the misfortune to be
outside of all the current program priorities are left
without care.
· The ~uge number of publications in medical jour-
na~ test~es to a ~ecr~ase in mortality in groups of
patients with defimte diseases as a result of the intro-
ductiol:'1 of new medical technologies. However, at the
same time, some of them lead to the phenomenon of
so-called dcl~yed m?rtality. For example, although
newborns with senous congenital abnormalities
hereditary diseases, and birth traumas arc saved due t~
HERALD OF THE RUSSIAN ACADEMY OF SCIENCES
477
the newest treatment methods, their longevity turns
out to be shorter than that of healthy newborns.
Another negative effect of advanced technological
possibilities in medicine is what experts call the para-
dox of the introduction of new medical technologies.
For example, it is shown that this factor (among oth-
ers) determines the differences in mortality and lon-
gevity in Britain and the United States (not in favor of
the latter): in the United States, up to 7.5 mln surgeries
are insufficiently substantiated, although any surgery
can lead to complications and death [28].
Medical errors also make a certain contribution:
according to the results of the Washington Medical
Science Jnstitute, in the late 20th century, from 44 000
to 98 000 deaths annually could have been explained
by malpractice; according to recent assessments, the
number of preventable deaths associated with medical
intervention-caused injuries in US hospitals has
reached 200 000-400 000. Similar interrelations are
indirectly indicated by the results of the review of
seven studies conducted in the United States, Spain,
and Israel and dedicated to the influence of doctors'
strikes on the mortality level [36). All the studies noted
that mortality during strikes either remained the same
or decreased but never increased. The paradoxical
data in the article [36) are explained by the fact that,
first, hospitals often concentrate and strengthen emer-
gency medical services during strikes and, second, no
highlighted strike continued long enough to assess the
consequences of a long-term limitation on access to
medical aid. The third point is that there are no elec-
tive surgeries during strikes, including those assigned
unreasonably.
Therefore, the tight web of positive and negative
effects in organizing and delivering medical aid hin-
ders assessment of the influence of medical factors
and the identification of the contribution of individual
medical interventions and technologies to public
health and mortality. In addition we should bear in
mind that the results of the sa:Ue measures taken
within a health care system will be different in different
popul~t!on groups and depending on the system of
org~ruzmg and funding medical aid, the readiness of
p~ticnts or persons with a risk of the development of a
d1se~se for cooperatio~, and the degree of observing
~cd1cal ~cc?mmendatlons. The studies did not idcn-
t~y convmcmg population data that could help assess
directly the ~ontribution of medical aid to increasing
total longevity. The data that underlie the existing
assessments are not complete, which makes the assess-
ments themselves approximate. Nevertheless, we can
assu~e that me~icine is of much more help in pre-
venting a worsening in the quality oflife determined by
the develo~ment of chronic diseases (pain and dis-
comfo~ r~lief and the mitigation of disabling somatic
comph~at1ons and psychotraumas) than in decreasing
mortality.
Vol. 86 No. 6 2016
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I 478 BOTTSOV, SAMORODSKAYA
The problem of assessing the contribution of individ-
ual mortality-affecting factors and groups of factors.
The majority of studies on the ac;..•;essment of factors
affecting the dynamics of mortality rate in a popula-
tion are theoretical and analytical; ecological studies
are noteworthy. The latter are based on identification
of correlation ties and give no grounds to state the
presence of a cause-and-effect dependence. Some
Russian specialists attribute the higher mortality rntes
in Russia compared to developed European countries,
the United States, Canada, and Japan to difficult-to-
formalize (and, consequently, statistically unprovable)
indicators such as insufficiently modernized social,
political, and economic institutions; enduring archa-
isms in mass consciousness and behavior; and the
presence of serious crisis processes in society. There
are studies that assess combined, expert opinion-
based indicators, for example, the Global Peace
Index. This index, which was proposed by sociologists
and economists of the Institute for Economics and
Peace jointly with the University of Sydney, accounts
for both internal factors, for example, the level of vio-
lence and crime in a country, and external ones, such
as the position of the country in the system ofintema-
tional relations, military expenditures, and other
parameters. ln 2015, the results of analysis on the
association between life expectancy and the Global
Peace Index were published [37). The study included
data on longevity in 158 countries from 2007 through
2012. The scientists discovered that the Global Peace
Index has a statistically significant negative associa-
tion with longevity, which remains after taking into
account the education index and the gross national
income. According to the regressive model, 61% of
differences in longevity between countries can be
explained by the above three factors, which, in the
opinion of the authors, shows the necessity to make as
many efforts as possible to resolve conflicts peacefully
and to widen contacts and interactions between states.
Despite numerous studies on the complex assess-
ment of factors affecting mortality rates, it is very dif-
ficult to prove the contribution of each of them at the
population level using statistical methods. The result
(mortality rates) depends on the balance and interac-
tion of all the above-considered factors, which often
have opposing effects on longevity. For example, the
spread of risk factors elucidated in the Russian study
"Essay" (a low consumption of vegetables and fruits
by 4396 of the participants and an excessive consump-
tion of alcohol by6.4%) is almost 2.5 times lower than
in a similar study conducted in Germany, the German
Health Interview and Examination Survey for Adults
(a high level of alcohol consumption being registered
in 17.996 of the respondents and a low level of the con-
sumption of vegetables, in 90%). However, overall
mortality and, in particular, cardiovascular mortality
in Germany is, according to WHO data (http://
www.euro.who.int/ru/data-and-evidence/database),
195 deaths per 100 000 individuals compared to
HERALD OF THE RUSSIAN ACADEMY OF SClENCES
512 deaths recorded for our country. Therefore,
accounting for the possibility that several different cri-
teria and age differences could have been be used in
the samplings, we may conclude that the spread of risk
factors in Germany is neutralized, most likely, by the
higher level of economic development, including the
quality of medical care, compared to that in Russia.
At the same time, many scholars emphasize that
differences in the availability of preventive measures
and medical aid for patients from different socioeco-
nomic layers of society are growing even in economi-
cally well-to-do countries, leading to a significant dif-
ferentiation in health status and the level of mortality.
According to experts, the measures taken within a
health care system are effective only in combination
with socioeconomic changes in society. The journal
Circulation has recently presented a shared opinion of
specialists, who supported the following conclusion
[38, p. 888):
Despite declines in CVD mortality over the past
several decades, it remains the leading cause of death
in the United States, and many disadvantaged groups
are disproportionately burdened with poor cardiovas-
cular health. lo this statement, we provided an over-
view of the substantial body of work documenting the
influence of social factors on the incidence, treat-
ment, and outcomes of CVD. We argued that,
although we have traditionally considered CVD the
consequence of certain behavioral, biological, psycho-
logical, and genetic risk factors, we must now broaden
the focus to incorporate a third arm of risk, the social
determinants of health. Failure to demonstrate aware-
ness of this third dynamic will result in a growing bur-
den of CVD, especially in those with the least means
to engage in the health care system.
The same is said in an article by US oncologists:
"Because of costs, about 10 to 20% of patients with
cancer do not take the prescribed treatment or com-
promise it. It is documented that the greater the out-
of-pocket cost for oral cancer therapies, the lower the
compliance" [39, p. 997).
The overwhelming majority of studies assess a lim-
ited number of factors. The reason is that, in conduct-
ing statistical analysis and constructing statistical
models with the assessment of the role of each factor,
one can take into account only a limited number of
them. In addition, the degree of the factors' influence
relates only to the sampling under study and can be
substantially different in another sampling. The fact
that long-standing studies are necessary to assess the
influence of individual (for example, behavioral) fac-
tors on mortality/longevity indicators is also a prob-
lem. However, this is also fraught with difficulties
because the negative effects of other factors unac-
counted for (economic crises, environmental pollu-
tion, etc.) can be observed over a prolonged period,
and it will be difficult in assessing the results to differ-
Vol. 86 No. 6 2016
 DETERMINANTS OF MORTALJTY 479

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