Health in Russia and the underlying problem of autocracy

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Agreement: I Agree Body: Dear Editor The tragic situation with healthcare in Russia is well highlighted in the BMJ piece by Gerden [1]. As the article states, a contributing factor to this crisis is Russia’s invasion of Ukraine and the associated high military expenditure. But further underlying these problems is Russia being an autocracy led by a personalist autocrat [2]. Such personalist autocrats “tend to be selected for personal characteristics that make them more likely to use military force” [3], along with the evidence that narcissistic leaders are more likely to initiate great power disputes [4]. Autocrats rarely relinquish power voluntarily leading to substantive health impairments in office and associated poor performance (as per the Soviet examples of: Stalin, Brezhnev, Andropov, and Chernenko) [5]. Furthermore, autocracies themselves are poorer at ensuring population health when compared to democracies, including for mortality, life expectancy, and infant health [6] [7]. The Covid-19 pandemic provides a specific example with democracies more likely to have “attitudes that support collective action” [8] and for lower excess mortality, at least in island jurisdictions [9]. Indeed, Russia performed particularly poorly in its Covid-19 response with far higher mortality than the US, which itself was the worst performing high-income country (cumulative age-adjusted excess mortality of 221 vs 91 per 100,000 population for 2020-2021 respectively; data from: [10]). Solutions to the problem of autocracy in Russia must ultimately come from within the country – but the rest of the world can keep nudging Russia towards a return to democracy. This can be via diplomacy and providing incentives for Russia to make democratic steps (eg, with offers to re-establish scientific collaboration and the end to economic and sporting sanctions). It is also critical for countries to provide international assistance to Ukraine to help it end Russia’s invasion and achieve a lasting peace treaty. References 1. Gerden E. Russia’s healthcare crumbles amid Putin’s war with Ukraine. BMJ. 2026;394:e100182. 2. Gill G. Personalist Leadership in Russia: Modes of Personalist Authority-building. Russian Politics. 2025;10(4):465-492. 3. Weeks JL. Strongmen and straw men: Authoritarian regimes and the initiation of international conflict. American Political Science Review. 2012;106(2):326-347. 4. Harden JP. All the world’s a stage: US presidential narcissism and international conflict. International Studies Quarterly. 2021;65(3):825-837. 5. Wilson N, Thomson G, Boyd M. The frequently impaired health of leaders of nuclear weapon states: an analysis of 51 deceased leaders. BMC Res Notes. 2025;18(1):278. 6. McCartney G, Hearty W, Arnot J, Popham F, Cumbers A, McMaster R. Impact of political economy on population health: a systematic review of reviews. Am J Public Health. 2019;109(6):e1-e12. 7. Bollyky TJ, Templin T, Cohen M, Schoder D, Dieleman JL, Wigley S. The relationships between democratic experience, adult health, and cause-specific mortality in 170 countries between 1980 and 2016: an observational analysis. Lancet. 2019;393(10181):1628-1640. 8. Chen C, Frey CB, Presidente G. Disease and democracy: Political regimes and countries responsiveness to COVID-19. Journal of Economic Behavior & Organization. 2023;212:290-299. 9. Boyd M, Baker MG, Wilson N. Democracy, Inequality and Covid-19 Pandemic Outcomes: Age-standardised excess mortality and GDP growth in island and non-island jurisdictions. medRxiv. 2026:2026.2001. 2022.26344652. 10. Boyd M, Baker MG, Kvalsvig A, Wilson N. Impact of Covid-19 control strategies on health and GDP growth outcomes in 193 sovereign jurisdictions. PLoS Glob Public Health. 2025;5(10):e0004554. No competing Interests: Yes The following competing Interests: Electronic Publication Date: Sunday, August 2, 2026 - 22:17 AI use: No, I have not used AI Highwire Comment Subject: Russia’s healthcare crumbles amid Putin’s war with Ukraine Workflow State: Released Full Title: Health in Russia and the underlying problem of autocracy Highwire Comment Response to: Russia’s healthcare crumbles amid Putin’s war with Ukraine Check this box if you would like your letter to appear anonymously:: Last Name: Wilson First name and middle initial: Nick A Email: [email protected] Address: University of Otago Wellington, Mein St, Newtown, Wellington, New Zealand Occupation: Professor Other Authors: Dr Matt Boyd, Adapt Research, New Zealand Affiliation: University of Otago Wellington BMJ: Additional Article Info: Rapid response