Ukraine: not only a matter of geopolitics.

Ukraine is once again at a political crossroads. Like many of the world’s troubled nations, its presentday borders refl ect historical events that paid little attention to the national identities of those involved, such as the westward expansion after World War 2 into what had been Polish territory, and Nikita Khrushchev’s unexpected 1954 gift from Russia to Ukraine of Crimea. Just like Russia itself, which at diff erent times has looked to the east or west, the people of Ukraine have struggled to come to terms with two diff erent identities. During the 20th century the geopolitical situation placed Ukraine fi rmly in the east, linked to Russia economically, culturally, and politically, but this century many Ukrainian people have turned their attention to the west. The outcome of this ongoing struggle will have profound eff ects on the health of the Ukrainian population. This is evident when we look at the historical trajectory of Ukraine’s population life expectancy, which has been more dramatic than that of any other European country (fi gure). In the 1930s, Stalin’s forced collectivisation of agriculture led to severe food shortages, and life expectancy in Ukraine fell briefl y to record lows of 7 years in men and 11 years in women. World War 2 and the Stalinist repression of the late 1940s caused further dramatic setbacks. After the collapse of the Soviet Union in 1991, life expectancy in all its newly independent republics fi rst followed a similar fl uctuating course, but while life expectancy in Estonia and the other Baltic republics began to improve in the mid-1990s, Ukrainian and Russian life expectancy did not do so until 2005. The current gap in life expectancy between Ukraine and Sweden, which has one of Europe’s highest life expectancies, is a staggering 14 years in men and 10 years in women. High death rates, together with low birth rates, have caused a true demographic crisis: since the early 1990s, the Ukrainian population has shrunk from 52 to 46 million. High Ukrainian mortality undoubtedly has many causes, but these are ultimately driven by its unfavourable economic and political conditions. Interestingly, within Ukraine there is a clear east–west gradient, with western regions (mostly populated by Ukrainian-speakers) having lower mortality than eastern regions (mostly populated by Russian-speakers), suggesting that the Ukrainian health situation is largely determined by its position on a cultural fault-line between east and west. Specifi c risk factors that have been shown to have a role in the Ukrainian health disadvantage include a high prevalence of smoking, excessive alcohol consumption, lack of access to good quality health care, and low perceived control over the way one’s life turns out. These risk factors are at least partly due to Ukraine’s desperate economic situation. After the collapse of the Soviet Figure: Life expectancy in men and women at birth in Ukraine and selected other countries, 1926–2011 Data are from Meslé and Vallin, the Human Life-table Database, and WHO’s Health for All Database. Data for Estonia are missing between 1939 and 1952, and data for Russia are missing between 1941 and 1945. 0 10 20 30 40 50 60 70 80 90