This paper examines the pivotal role of social stratification in Russia's health crisis. The primary level causal factor is increased mortality from heart disease and alcohol-related poisonings and accidents. In order to understand the origin of the primary causes, it is necessary to look further for secondary level factors. Whereas policy and stress are important, the leading secondary determinant is negative health lifestyles. The question then arises: What is the source of this lifestyle? This question necessitates a search for tertiary level causes and the absence of a strong middle class in Russia is identified. In Western society, the middle class, especially the upper middle class, is the social carrier of positive health lifestyles across class boundaries. The Russian middle class has not initiated positive health lifestyles countering the predominately negative health lifestyle practices because a middle class similar to that in the West does not exist. Russia needs a civil society in which a similarly stable and empowered middle class can promote positive health lifestyles within its own stratum and elsewhere in the class structure; until this happens, the health situation in that country may not stabilise for the better. © 2007 The AuthorJournal compilation © 2007 Foundation for the Sociology of Health & Illness/Blackwell Publishing Ltd.