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To understand the widespread use of alcohol in Russia it is necessary to reflect on the nature of the country. The early inhabitants of the territory that is now Russia survived in a cold and hostile climate, with little agricultural potential. Most people lived in abject poverty, on meagre rations, and their only source of alcohol was weak beer and small amounts of mead (a honey-based drink). In the 16th century the system of serfdom was introduced, leading to a worsening of conditions for the rural poor who became virtual slaves. With barely enough resources to survive, alcohol became unattainable for most. In contrast, those living in the newly established towns were able to obtain alcohol from korchmas, facilities that served food and low-alcohol drinks. The consumption of vodka began in the 15th or 16th centuries. However, until the mid-18th century, Russian vodka was never stronger than 20° (Pokhlebkin 1991). In 1474 an edict of Prince Ivan III introduced a tax on vodka, creating a new source of revenue and one that the state had a strong interest to sustain. Ivan IV (the Terrible) closed down the korchmas and introduced the czarist kabak (lush house). These premises no longer sold food (Zhirov & Petrova 1998); as a consequence, the kabaks became liquor dens. The many historical descriptions of Russian drunkenness refer to events in the kabaks. Heavy drinking remained an urban phenomenon, as the kabaks were found almost exclusively in towns (Zhirov & Petrova 1998). This is illustrated by the writings of Kil'burger, a Swede who visited Russia in 1674 and who, while describing graphically the scale and effects of drinking in Russia, noted that '. . . kabaks, however, are not many either in Moscow or the rest of the country. Between Novgorod and Moscow, over a distance of more than 500 versts (approximately 500 km) I encountered a mere 9 or 10. There are many villages, in fact, . . . in which not even a drop of beer is to be found' (Kurts 1915). The urban–rural divide was accentuated by the high price of vodka; in the 17th century a pail of vodka (12.3 l) was up to twice as expensive as a cow (Kurukin 1998). Consequently the impact of heavy drinking was highly concentrated within a small section of the population; as late as 1897, the urban population in Russia was a mere 14.5%. The second and most important stage in the growth of drinking in Russia began in 1716, when Peter I (the Great), prompted by the drain on his treasury as a consequence of foreign wars, temporarily removed all restrictions on distillation. The number of kabaks increased rapidly and by 1885 they numbered up to 80 000 (Pryzhov 1914), equivalent to about one per 1400 inhabitants. This was associated with a growth in public revenues from alcohol sales, which increased by nearly 30% at the end of the 18th century under Catherine II, and by 38% under Alexander II (Zhirov & Petrova 1998). The third stage followed the abolition of serfdom in 1861. In 1863 the price of vodka fell substantially as the number of distilleries increased. For the first time, vodka became affordable for the rural poor. By then, Russia had developed a reasonably good system of statistics on alcohol consumption. A near doubling of alcohol consumption in Russia was recorded in 1864 (reaching 6.2 l per capita), the highest figure recorded in czarist Russia (Ostroumov 1914). Actual consumption was somewhat higher due to the illicit production and sale of liquor, although this was subject to serious criminal sanctions. However, in the following year consumption declined to 4.1 l, beginning a sustained decline that continued into the 1890s, when it reached 2.6 l. This was due in part to the closure of kabaks (on 1 January, 1886) and their replacement by traktire, where food was sold with alcohol. However, it also reflected a steady increase of excise duties, which rose 2.5-fold in the course of 30 years. In the early 1890s, however, the downward trend was arrested by the growth of industrialization, when the rural population migrated to towns to work in the new factories (with consumption reaching 3.3 l in 1913). This was, however, well below levels in western Europe at the beginning of the 20th century, with an annual consumption of over 20 l in France, 15 l in Italy and 10 l in Spain and Great Britain. A succession of events in the first half of the 20th century kept alcohol consumption under a degree of control. Russia experienced two world wars, a civil war and the Stalinist terrors of the 1930s. In addition, there were 'semi-dry' laws of 1914 and 1918 which, at different times, banned the production and sale of alcoholic drinks stronger than 12° to 20° (Zaigraev 1992). It was not until the early 1950s that there was a precipitous growth of alcohol consumption in Russia, reaching 4.5 l in 1960, 8.2 l in 1970 and 10.5 l in 1980 (figures for total registered alcohol sales, including wine and beer; official data from Goskomstst of the Russian Federation). However, once again these are the official figures; by the end of the 1970s home distilling of samogon is estimated to have added another 3–4 l (Treml 1997; Nemtsov 2000). At this time the nature of consumption began to change, both in quantity but also in quality; from time immemorial heavy drinking in Russia was concentrated during holidays, whereas it was now common on work days, often during working hours and at the place of work, and spread to young people and women, among whom it had previously been subject to social disapproval. In 1985 Mikhail Gorbachev launched a wide-ranging anti-alcohol campaign. Prior to this, actual per capita consumption was estimated at 14.2 l (Nemtsov 2000). The campaign was associated with a decline in sales of alcohol from state outlets which fell by 63%, although the decline in actual consumption was less, an estimated 25% (to 10.5 l in 1986)(Nemtsov 2000), due to a massive growth in what had previously been a moderate level of home distilling (a quarter of all consumption). As a result of the anti-alcohol campaign, life expectancy among males increased by 3 years within a 3-year period (from 62 in 1984 to 65 in 1987). However, the positive effect of the campaign was short-lived; by 1991–92 alcohol consumption and life expectancy returned to their initial level. In the years since 1985, alcohol consumption and life expectancy have fluctuated in parallel, with a rise in consumption until 1994, a decline until 1998, and another increase from 1999 until the present. These fluctuations have been the subject of extensive research that confirms the central role played by alcohol; while other factors, such as smoking, nutrition and weaknesses in health care contribute to the high background mortality in Russia, they do not explain these fluctuations. By 2001, consumption had climbed to 15.0 l while male life expectancy fell to 59 years (Nemtsov 2003). Unlike the situation in the past, consumption in rural areas was even higher, at 17.3 l in 2002) (Zaigraev 2004a). A major factor is the low price of alcohol, much of which is counterfeit and not subject to taxation. The alarming health consequences of alcohol in Russia are due not only to the level but also to the nature of consumption, with consumption of very strong drinks (up to 80–90% of alcohol), binge drinking (McKee & Britton 1998) and drinking on an empty stomach. As a result, it has been estimated that more than 30% of deaths in Russia can be attributed, directly or indirectly, to alcohol (Nemtsov 2001). This contrasts starkly with figures for European Union countries (plus Norway) where the corresponding figure is only 4% (a re-computation of Ramstedt's 2002 data): male life expectancy in those countries is between 74 and 77 years. However, the staggeringly high level of alcohol-attributable losses in Russia derive not only from the level and nature of alcohol consumption but also the widespread poverty in the population, exacerbated by poor nutrition, poor quality medical care, inadequate emergency services and low skills among health professionals working in alcohol-related areas. In the Soviet Union there was a well-structured system for treating alcohol abuse, in the form of a network of dispensaries (serving the conurbations, with 316 in 1990) and consultation rooms (one paramedic or doctor located in the countryside, with 1943 in 1990). There were 2.7 million alcoholics registered at these state facilities, about 2% of the population (Russia, 1984). However, the true number of people with alcohol dependency was estimated to be about threefold higher. About 5–6% of patients registered (150 000 people) were detained compulsorily by the Ministry of Internal Affairs, under court order, for deviant and semi-criminal forms of alcoholism, typically for periods of 6 months to a year. Post-1991 the Russian Federation has retained the consultation rooms, but many of the dispensaries have been closed (in 1999 only 211 remained), and the number of doctors specializing in treatment of alcohol-related diseases declined from 7100 in 1990 to 4800 in 1999 (Koshkina Korchagina & Shamota 2000). Compulsory treatment of alcoholics has been eliminated. A small private medical care network has emerged. In 1999 there were 169 hospitals providing treatment for alcohol-related disorders, most operating under the auspices of dispensaries, with a further 11 large state facilities. The most common form of treatment is in Russia is directive suggestive psychotherapy, undertaken during a single consultation. This so-called 'coding', based on the work of Dovzhenko, seems at best to have only a placebo effect. It has never been evaluated, but its widespread use is consistent with the beliefs of the Soviet population. Psychopharmacotherapy is provided in hospitals and in dispensaries but family and group psychotherapy are rarely used in Russia. Treatment of alcoholic dependence achieves relatively poor outcomes. One can hardly describe the Russian research base in relation to alcohol as thriving. The main scientific centre is the National Centre of Narcology of the Ministry of Health of the Russian Federation, which addresses only medical and biological issues and has done little to tackle the drastic situation with alcohol in the country. Instead, the main contributions to understanding this situation have come from outside Russia, in particular French researchers Meslé, Hertrich & Vallin, working with the Russian researcher Shkolnikov (Mesléet al. 1996), Finnish researchers Simpura et al. (1997) and a large group of British scientists (McKee & Britton 1998; McKee 1999), again working with Shkolnikov. They have demonstrated the association between the fluctuations of mortality in Russia at the end of the 20th century and changing alcohol consumption (McKee 1999). The British researchers identified the link between drinking and cardiovascular mortality (Chenet et al. 1998; McKee & Britton 1998), which was contrary to the prevailing view that alcohol was had a cardioprotective effect. Recently, Russian authors (Ogurtsov et al. 2001) have shown a substantial difference between the Russian and western European populations in the enzymatic handling of alcohol, with Russians having a high prevalence of a gene for fast activity of alcohol dehydrogenase, allowing individuals to drink large quantities but recover from the resulting intoxication relatively quickly (if they survive). This, they believe, increases the probability of episodic heavy drinking and its immediate consequences. Superficially, the obvious response to the high level of alcohol consumption in Russia and its painful consequences might appear to be to lower the consumption of alcohol. But several factors stand in the way of this solution. The first is the pervasive corruption that underpins illegal alcohol production. The second is the existence of a powerful alcohol lobby which thrives on the income from illegally produced alcoholic beverages. There is also a third element: the weakness and reluctance of the authorities to tackle the country's alcohol problem. Government officials note that 40–50% of the alcohol market is not controlled by the state. President Putin's reply to the suggestion that he should take steps to tackle heavy drinking was: 'Do you think I want to become a second Ligachev?' (Zaigraev 2004b). Ligachev was one of the initiators and promoters of the anti-alcohol campaign of 1985. However, the main difficulty is that the alcohol problem in this large and heavily drinking country evokes almost no reflection in the national consciousness. Millions of personal tragedies attributable to drinking do not coalesce into a public sentiment against alcohol; heavy consumption has become a part of the daily life of a large section of the population. This sustains the official indifference to the alcohol problem; yet if the state could reduce consumption by only 5–10% it could save 100 000–200 000 lives per year (Nemtsov 2003). If the Russian government is really concerned about depopulation of Russia then this is an area where it must act. Martin McKee (European Centre on Health of Societies in Transition, London School of Hygiene and Tropical Medicine) provided invaluable assistance in preparing this manuscript for publication.
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