Eva Kibele’s (E.U.B.Kibele@rug.nl) guest post is based on her PhD thesis “Regional mortality differences in Germany”, written while she was with the Max Planck Institute for Demographic Research and supervised by James W. Vaupel, Gabriele Doblhammer and Vladimir Shkolnikov. Currently she is a postdoc researcher at the Population Research Center of the University of Groningen, The Netherlands. Her work focuses on the relationship between the living environment and health.

A long and happy life has always been a fundamental human desire, and research into how this can be achieved is booming. A demographic perspective shows that it’s not only people’s characteristics and behavior—like age, sex, income, genetics, lifestyle—that determines health. Where you live also has an important influence. Investigating differences in mortality between regions has been a long-standing demographic research interest, and complements the medical perspective that focuses on individuals.

Regional differences in population health exist almost universally. The atlas on mortality in the European Union (2009) shows mortality differences across the EU regions. Regional mortality patterns generally change only slowly over time.  However, Germany from 1990 is an exception: differences in mortality between East and West underwent tremendous changes after reunification ended the country’s political division. This influenced mortality patterns across regions too.

Life expectancy differences between eastern and western Germany and across districts

Until the mid-1970s, life expectancy levels were similar in East and West. Similar to other countries of Central Europe and the former Soviet Union, where life expectancy stagnated or even declined (especially among men), eastern Germany experienced only slow mortality declines from the mid-1970s until reunification. In 1990 the East-West life expectancy gap was at its peak and life expectancy among men in eastern Germany was 69.2 years, 3.4 years lower than that of western German men. Eastern German women had a life expectancy of 76.3 years – 2.7 years lower than in western Germany (Human Mortality Database). The German divide clearly left its marks on the health of the eastern and western German population.

Figure 1. Life expectancy at birth in the German districts, men. Note: Life expectancy in the districts is divided into 5 classes according to life expectancy quintiles in the districts. Names refer to the German federal states. Source: Kibele (2012)

An East-West divide in life expectancy also appears in all German districts (NUTS-3 regions), as Figure 1 and 2 show. In the mid-1990s, life expectancy in almost all districts in eastern Germany was lower than in the western German districts, for both men and women. But during the 1990s, the East-West mortality division underwent rapid transformation. Many eastern German districts experienced enormous life expectancy gains of more than three years between 1995-1997 and 2004-2006. The East-West life expectancy gap almost closed by the beginning of the 2000s among women, and the gap stabilized at one year for men.

Spatial diversity in life expectancy is not only restricted to East-West differences. Between the most extreme districts, there are differences in life expectancy of more than 3 years among women and more than 5 years among men. High life expectancy in southern Germany contrasts with lower life expectancy levels in northern Germany. Furthermore, especially in western Germany, there are pronounced small-area differences, as seen in Figure 1 and 2.

Along with the great changes in the East-West mortality division, the regional mortality pattern changed between 1995-1997 and 2004-2006, most evidently among women. All districts underwent increases in life expectancy over time, but some underwent a relative deterioration in their ranking.

Figure 2. Life expectancy at birth in the German districts, women. Note: Life expectancy in the districts is divided into 5 classes according to life expectancy quintiles in the districts. Names refer to the German federal states. Source: Kibele (2012)

Strong life expectancy increases of eastern German districts contributed to diminishing regional differences in life expectancy. At the same time, the pattern of regional mortality became more spatially diverse, with more variation within both eastern and western Germany. Within eastern Germany, the improvement in the southern regions was most notable. In western Germany, regions like Saarland and Ruhr (center of North Rhine-Westphalia) lost their position in the low-medium life expectancy class and shifted downwards to the low life expectancy class. Strong life expectancy increases in the eastern German regions hence coexist with high-life expectancy regions in southern Germany and several low-life expectancy regions in western Germany with only small life expectancy gains.

Compositional and contextual factors explain regional mortality differentials

Regions with a more favorable population composition, i.e. more people with lower mortality risks, have higher life expectancies. Next to population composition, the context in which people live, living conditions and the living environment in the regions, can affect health.

Social gradients are reflected in mortality inequalities between people and between regions. People with a higher socioeconomic status generally lead a more health-promoting lifestyle, are healthier and have lower mortality. At the regional level, we see that causes of death that are behavior-related and characterized by a social gradient (e.g. cardiovascular diseases, lung cancer, alcohol-related causes) dominate the regional mortality patterns in Germany and determine their changes over time.

My analysis of contextual mortality determinants shows that regions with a higher average income and more successful implementation of health policy—reflected in low mortality from causes of death directly linked to health behavior or health care—have the highest life expectancies. Regional improvements such as increasing average income level, improvements in health policy and other regional socioeconomic indicators are related to stronger gains in life expectancy in Germany’s regions over time.

How population composition is linked to regional mortality is hard to judge for Germany, mainly due to a lack of adequate data. A study done with Domantas Jasilionis and Vladimir Shkolnikov on the relationship between socioeconomic status among male pensioners and the remaining life expectancy at age 65 in eastern and western Germany gives some clues though. We found strong social gradients in life expectancy according to pension income. Mortality declines between 1995-1996 and 2007-2008 are not equally distributed across all population groups. Pensioners with a high socioeconomic status experience the largest mortality declines, even more so in eastern than in western Germany. By this, eastern German pensioners (especially those with a high socioeconomic status) greatly contributed to the life expectancy increase after reunification. Most likely, this also contributed to the observed changes in regional mortality patterns.

Lessons for the future

The change over time in regional mortality patterns in Germany has been remarkable. Part of the change is related to improvements in living conditions and the living environment in the decade after the German reunification.

The German case shows that regional mortality patterns can change rapidly. Contextual conditions oftentimes change slowly, but—as experienced by eastern Germany after reunification—strong improvements in living conditions can lead to strong mortality improvements. Governments can identify areas where health disadvantages exist or are likely to arise in the future not only by looking at the picture of population health, but also by looking at the determinants of regional mortality differences. Successful interventions, however, will require powerful (spatial) policies.