The Health Crisis in the

USSR: An Exchange

Albert Szymanski, reply by Nick Eberstadt

NOVEMBER 5, 1981 ISSUE
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 Eberstadts article. Contrary to Eberstadts 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 197071 to 197576 (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
196165, the rate averaged 30.3 per 1,000, in 196670 25.8 and 197175 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 16.7in
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 nonwhites). 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 19591970 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 196267 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 childrens 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 mid1960s. 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
Eberstadts 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: 19691978, 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. Spocks 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
Eberstadts 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 antiSoviet 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 Unions 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
inclinationsfrom doves like Arthur Macy Cox to hawks like William T. Lee
would contend that the fraction of the economy devoted to military expenditure
has notshrunk 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 1978this 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 lesscan 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 yearpractically 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 atlass estimate for Soviet life expectancy circa 1975 is
apparently taken from the World Health Organization, and that organizations 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 DavisFeshbach 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 USSRs
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 Europes 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. Feshbachs estimates are
correctand to date all revelations from the USSR have confirmed his conclusions
the USSRs life expectancy is lower than that of any nation in Europeincluding 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
RepublicsBevlkerung 1978 (published in July 1980) and the DDRs Statistisches
Jahrbuch 1980. Those two compendiums unambiguously show that West Germanys
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
ofGstarbeiter 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 Germanys health prospects did improve more rapidly back in the
1960s than did the Federal Republics, and credit should be given where it is due. A
number of things, however, may have made East Germanys 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, Europes 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 phenomenonyet since World War II none of the nations of Latin America,
Asia, or Africa has been beset by long-term rises in its childrens death rates. And Mr.
Szymanski seems to have forgotten one of the more consistent findings of twentiethcentury 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.Szymanskis 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 USSRs
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 thenbut 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. Szymanskis 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
dangersprepared improperly, it can be a positive threat to a childs healthyet 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 Chiles
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. Szymanskis 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 Unions 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 Unions
Muslims to be the sole force behind the USSRs 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 thousandwhich is to say that the health levels of Soviet Central
Asias children would have to have fallen below those of the children of South Africas
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. Szymanskis 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-yearold 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-encompassingperhaps, 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 mans 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
nations most serious problems: violence (handguns alone take a year off the black
American mans 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 Stalins successors to continue in the
dictators 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 Unions difficulties are unique.
To bring a long letter to an end, I would like to address Mr. Szymanskis 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.