The sizeable mortality gap between the German Democratic Republic (East Germany) and the pre-unified Federal Republic of Germany (West Germany) narrowed rapidly after the two states were unified. Despite extensive research, the mechanisms underlying the convergence process are still not fully understood. Significant changes to coding practices and the system of data collection introduced in East Germany shortly after reunification have further complicated the ability of researchers to interpret mortality trends. Our aim is to assess the role of German reunification in the convergence process in light of the evolution of long-term mortality trends by causes of death. Compared to previous studies, we rely on much more detailed mortality data, which we first adjust for notable distortions. We propose an upward correction of cancer mortality, as well as corrections that account for obvious changes in the items selected within the ICD chapter of circulatory diseases. We identify three distinct processes that took place in East Germany around the time of reunification: (1) a sustained reduction in mortality that started before reunification; (2) a temporary increase in mortality in 1990-1991 that was related to the abrupt social transition, as reflected by socially sensitive causes such as accidents, alcohol-related diseases, and acute myocardial infarction; and (3) a reunification-driven process of convergence that was mostly caused by the accelerated decline in mortality from cerebrovascular and chronic heart diseases. Mortality improvements observed in the GDR starting in the 1980s might be interpreted as the first signs of a cardiovascular revolution. Shifts in individual behaviour likely started before reunification, whereas the real progress in medical care occurred later with the implementation of the Western system of health care. We therefore conclude that German reunification per se did not initiate the convergence process, but rather reinforced and accelerated trends that were already apparent.

Institut national d'études démographiques Paris France

Max Planck Institute for Demographic Research Rostock Germany

University of Economics Prague Czech Republic

Zobrazit více v PubMed

Academie für Ärztliche Fortbildung der DDR. (1972). Mitteilungen. Auswertung 1971 der Todesursachenstatistik der DDR. Sonderheft. 1. Februar 1972. Berlin-Lichtenberg.

Anderson RN, Minino AM, et al. Comparability of cause of death between ICD-9 and ICD-10: Preliminary estimates. National Vital Statistics Reports. 2001;49(2):1–32. PubMed

Andreev EM. Method komponent v analize prodoljitelnosty zjizni [The method of components in the analysis of length of life] Vestnik Statistiki. 1982;9:42–47.

Bobak M, Marmot M. East–West mortality divide and its potential explanations: Proposed research agenda. British Medical Journal. 1996;312(7028):421–425. doi: 10.1136/bmj.312.7028.421. PubMed DOI PMC

Bobak M, Skodova Z, Pisa Z, et al. Political changes and trends in cardiovascular risk factors in the Czech Republic, 1985–92. Journal of Epidemiology Community Health. 1997;51:272–277. doi: 10.1136/jech.51.3.272. PubMed DOI PMC

Brückner G. Todesursachen 1990/91 im vereinten Deutschland. Wirtschaft und Statistik. 1993;4:257–278. PubMed

Bubenheim M. Des systèmes d’enregistrement des décès par cause en France et en Allemagne, thèse de doctorat de démographie. Lyon: Université Lumière (Lyon 2); 2000.

Clark DE, Wildner M. Injury mortality in East Germany. American Journal of Public Health. 2000;90(11):1761–1764. doi: 10.2105/AJPH.90.11.1761. PubMed DOI PMC

Colditz GA. Illnesses caused by smoking cigarettes. Cancer Causes and Control Springer. 2000;11(1):93–97. doi: 10.1023/A:1008942707187. PubMed DOI

Diehl K. Mögliche Faktoren für die rasche Reduktion der ostdeutschen ¨-Übersterblichkeit nach der Wiedervereinigung. Warum leben Ostdeutsche seit der Wiedervereinigung länger? Zeitschrift für Bevölkerungswissenschaft. 2008;33(1):89–110. doi: 10.1007/s12523-008-0006-x. DOI

Dinkel, R. H. (1999). East and West German mortality before and after reunification. Unpublished manuscript, University of Rostock.

Eberstadt E. Demographic shocks after communism: Eastern Germany, 1989–93. Population Development Review. 1994;20:137–152. doi: 10.2307/2137633. DOI

Gjonça A, Brockmann H, Maier H. Old-age mortality in Germany prior to and after reunification. Demographic Research. 2000;3(1):1–29.

Grigoriev P, Meslé F, Shkolnikov VM, Andreev EM, Fihel A, Pechholdová M, Vallin J. The recent mortality decline in Russia: beginning of the cardiovascular revolution? Population and Development Review. 2014;40(1):107–129. doi: 10.1111/j.1728-4457.2014.00652.x. DOI

Häussler B, Hempel E, Reschke P. Die Entwicklung von Lebenserwartung und Sterblichkeit in Ostdeutschland nach der Wende (1989–1992) Das Gesundheitswesen. 1995;57:365–372. PubMed

Heinemann L, Barth W, Hoffmeister H. Trend of cardiovascular risk factors in the east German population 1968–1992. Journal of Clinical Epidimiology. 1995;48:787–795. doi: 10.1016/0895-4356(94)00179-T. PubMed DOI

Heinemann L, Barth W, Löwel H. Zur Validität der Herz-Kreislauf-Mortalitäts-Statistik der ehemaligen DDR. Z Gesundheitswissenschaften. 1998;6:108–119. doi: 10.1007/BF02956781. DOI

Heinemann L, Dinkel R, Görtler E. Life Expectancy in Germany: Possible Reasons for the Increasing Gap between East and West Germany. Reviews on Environmental Health. 1996;11(1–2):15–26. PubMed

Hoffmeister H, Wiesner G. Akuter Herzinfarkt-dramatischer Sterblichkeitsanstieg in den neuen Bundesländern? Bundesgesundheitsblatt. 1993;4:130.

Human Mortality Database (HMD). (2016). University of California, Berkeley (USA), and Max Planck Institute for Demographic Research (Germany). Available at: www.mortality.org. Accessed June 22, 2016.

Iglehart JK. Germany’s health care system. New England Journal of Medicine. 1991;324:1750–1756. doi: 10.1056/NEJM199106133242428. PubMed DOI

Jaross W, Assmann G, Bergmann S, et al. Comparison of risk factors for coronary heart disease in Dresden and Münster. European Journal of Epidemiology. 1994;10:307–315. doi: 10.1007/BF01719355. PubMed DOI

Klüsener, S., Grigoriev, P., Scholz, R. D, & Jdanov, D.  Adjusting inter-censal population estimates for Germany 1987-2011: Approaches and impact on demographic indicators (Unpublished manuscript).

Kibele EUB. Regional mortality differences in Germany. Heidelberg: Springer; 2012.

Luy M. Verschiedene Aspekte der Sterblichkeitsentwicklung in Deutschland von 1950–2000. Zeitschrift für Bevölkerungswissenschaft. 2004;29(1):3–62.

Meslé F, Shkolnikov VM, Vallin J. Mortality by cause in the USSR in 1970–1987: The reconstruction of time series. European Journal of Population. 1992;8:281–308. doi: 10.1007/BF01796624. PubMed DOI

Meslé, F., Shkolnikov, V. M, Hertrich V., & Vallin, J. (1996). Recent trends in mortality by causes of death in Russia during 1965–1994. [In French and Russian], Paris-Moscow.

Meslé F, Vallin J. Reconstructing long-term series of causes of death. Historical Methods. 1996;29(2):72–87. doi: 10.1080/01615440.1996.10112731. DOI

Meslé, F., & Vallin, J. (2003). Mortalité et causes de décès en Ukraine au XXe siècle : la crise sanitaire dans les pays de l’ex-URSS, Cahier 152, p. 396 + CD-Rom. Paris: INED

Mielck A. Mortalität und Lebenserwartung: Unterschiede zwischen Ost- und Westdeutschland. Sozialer Fortschritt. 1991;40(9):220–223.

Modelmog D, Rahlenbeck S, Trichopoulos D. Accuracy of death certificates: A population-based, complete-coverage, one-year autopsy study in east Germany. Cancer Causes and Control. 1992;3(6):541–546. doi: 10.1007/BF00052751. PubMed DOI

Müller-Nordhorn J, Rossnagel K, Mey W, Willich SN. Regional variation and time trends in mortality from ischaemic heart disease: East and West Germany 10 years after reunification. Journal of Epidemiology and Community Health. 2004;58:481–485. doi: 10.1136/jech.2003.013367. PubMed DOI PMC

Myrskylä M, Scholz RD. Reversing East–West mortality difference among German women, and the role of smoking. International Journal of Epidemiology. 2013;42(2):549–558. doi: 10.1093/ije/dyt008. PubMed DOI

Nolte E, McKee M. Ten years of German unification. British Medical Journal. 2000;321(7269):1094–1095. doi: 10.1136/bmj.321.7269.1094. PubMed DOI PMC

Nolte E, McKee M. Does healthcare save lives? Avoidable mortality revisited. London: The Nuffield Trust; 2004.

Nolte E, Scholz R, Shkolnikov V, McKee M. The contribution of medical care to changing life expectancy in Germany and Poland. Social Science and Medicine. 2002;55(11):1905–1921. doi: 10.1016/S0277-9536(01)00320-3. PubMed DOI

Nolte E, Shkolnikov VM, McKee M. Changing mortality patterns in East and West Germany and Poland. I: Long term trends (1960–1997) Journal of Epidemiology and Community Health. 2000;54(12):890–898. doi: 10.1136/jech.54.12.890. PubMed DOI PMC

Nolte E, Shkolnikov V, McKee M. Changing mortality patterns in East and West Germany and Poland. II: Short-term trends during transition and in the 1990s. Journal of Epidemiology and Community Health. 2000;54(12):899–906. doi: 10.1136/jech.54.12.899. PubMed DOI PMC

Pechholdová, M. (2008). Reconstruction of continuous series of mortality by cause of death in West Germany for the years 1968–1997. MPIDR working paper; WP 2008-009.

Pechholdová M. Results and observations from the reconstruction of continuous time series of mortality by cause of death: Case of West Germany, 1968–1997. Demographic Research. 2009;21(18):535–568. doi: 10.4054/DemRes.2009.21.18. DOI

Pechholdová M. The impact of ICD10 on cause-specific mortality trends: The case of the Czech Republic compared to West Germany and France. Demografie: revue pro výzkum populačního vývoje. 2011;53(4):360–380.

Perleth M, Mannebach H, Busse R, et al. Cardiac catheterization in Germany. Diffusion and utilization from 1984 to 1996. International Journal of Technology Assessment in Health Care. 1999;15:756–766. PubMed

Ridolfo B, Stevenson C. The quantification of drug-caused mortality and morbidity in Australia, 1998. AIHW (Drug Statistics Series no. 7) Canberra: AIHW; 2001.

Riphahn RT. Die Mortalitätskrise in Ostdeutschland und ihre Reflektion in der Todesursachenstatistik. Zeitschrift für Bevölkerungswissenschaft. 1999;24(3):329–363.

Roemer M. Social policies and Health care systems: Their effects on mortality and morbidity in developed countries. In: Vallin J, Lopez A, editors. Health policy, social policy and mortality prospects. Liège: Ordina Editions; 1985. pp. 541–552.

Rossnagel K, Müller-Nordhorn J, Kulig M, Willich SN. Regional trends in cerebrovascular mortality in Germany after unification (1990–1999) Cerebrovascular Diseases. 2003;16(4):418–422. doi: 10.1159/000072566. PubMed DOI

Schelhase T, Ruebenach S. Die Todesursachenstatistik-Methodik und Ergebnisse 2004. Wirtschaft und Statistik. 2006;6:614–629.

Schelhase T, Weber S. Die Todesursachenstatistik in Deutschland. Probleme und Perspektiven. Bundesgesundheitsblatt–Gesundheitsforschung–Gesundheitsschutz. 2007;50(7):969–976. PubMed

Scholz RD. Lebenserwartung sinkt durch Arbeitslosigkeit um ein Jahr: ostdeutsche Männer sterben früher als westdeutsche. Demografische Forschung aus Erster Hand. 2010;7(3):1–2.

Scholz, R. D., Jdanov, D. A. Kibele, E., Grigoriev, P., & Klüsener, S. (2016). About mortality data for East Germany. Human Mortality Database (http://www.mortality.org/): University of California, Berkeley and Max Planck Institute for Demographic Research.

Thamm M. Blood pressure in Germany: Update review of state and trends. Gesundheitswesen. 1999;61(suppl):90–93. PubMed

Tunstall-Pedoe H, Vanuzzo D, Hobbs M, et al. Estimation of contribution of changes in coronary care to improving survival, event rates, and coronary heart disease mortality across the WHO MONICA Project populations. Lancet. 2000;355:688–700. doi: 10.1016/S0140-6736(99)11181-4. PubMed DOI

Vallin J., & Meslé F., (1988). Les causes de décès en France de 1925 à 1978, Cahier 115, p. 608. Paris: INED, PUF, Travaux et Documents

Vallin J, Meslé F. Convergences and divergences in mortality. A new approach to health transition. Demographic Research Special Collection. 2004;2(2):11–44. doi: 10.4054/DemRes.2004.S2.2. DOI

Vaupel JW, Carey JR, Christensen K. It’s never too late. Science. 2003;301(5640):1679–1680. doi: 10.1126/science.1090529. PubMed DOI PMC

Vogt TC. How many years of life did the fall of the Berlin wall add? A projection of East German life expectancy. Gerontology. 2013;59:276–282. doi: 10.1159/000346355. PubMed DOI

Vogt TC, Kluge FA. Can public spending reduce mortality disparities? Findings from East Germany after reunification. The Journal of the Economics of Aging. 2015;5:7–13.

Vogt TC, Vaupel JW. The importance of regional availability of health care for old age survival: Findings from German reunification. Population Health Metrics. 2015;13(26):1–8. PubMed PMC

Waterhouse JAH, Muir CS, Cornea P, Powell J. Cancer incidence in five continents 1976. Lyon: International Agency for Research on Cancer; 1976. pp. 454–459.

Wiesner G. Zur Gesundheitslage der beiden Bevölkerungen DDR und BRD–ein Ausdruck sozialer Ungleichheit? Bundesgesundheitsblatt. 1992;9:442–447.

Winkler G, Brasche S, Heinrich J. Trends in food intake in adults from the city of Erfurt before and after the German reunification. Annals of Nutrition & Metabolism. 1997;41:283–290. doi: 10.1159/000177956. PubMed DOI

Winston FK, Rineer C, Menon R, Baker SP. The carnage wrought by major economic change: Ecological study of traffic related mortality and the reunification of Germany. British Medical Journal. 1999;318(7199):1647–1649. doi: 10.1136/bmj.318.7199.1647. PubMed DOI PMC

World Health Organization . Global status report on alcohol and health. Geneva, Switzerland: WHO; 2014.

Zatoñski WA, Boyle P. Health transformations in Poland after 1988. Journal of Epidemiology and Biostatistics. 1996;4:183–197.

30 Jahre Deutsche Einheit: Errungenschaften und verbliebene Unterschiede in der Mortalitätsentwicklung nach Alter und Todesursachen

Contrasts in alcohol-related mortality in Czechia and Lithuania: Analysis of time trends and educational differences