Results Acknowledgements

4. Discussion

It is tempting to attribute the apparent closing of the oldest old mortality gap between East and West Germany to the historical drama of political reunification. Putting an obvious cause to an obvious trend has a certain prima facie plausibility. However, the old-age patterns we have presented suggest that some of the mortality decline in East Germany actually started prior to reunification. We also observed considerable similarities between the two German states that were only gradually affected by reunification. For example, it appears that the increase in life expectancy after 1980 was dominated by the prolongation of life at older ages in both German states. Another similarity between East and West Germany was that the decline in old age mortality was greater among women than men.

This is not to say that reunification did not have any impact, or that differences between East and West Germany were negligible. One profound difference between the two German states was that decline in old age mortality prior to reunification was much more pronounced in West than in East Germany. Mortality at ages 80 and above started to decline in West Germany in the mid 1970s. Not until ten years later did oldest old mortality begin to decrease in East Germany. And it occurred at a slower pace. German reunification in 1990 had little, if any effect on the long-term trend of oldest old mortality in West Germany. In contrast, East German death rates at the oldest ages decreased markedly after 1990. It appears that this downward trend after reunification was not only a continuation of a trend started earlier, but that it reflects an accelerated pace of decline in old age mortality in East Germany.

How can we explain the late-life mortality patterns observed in the two German states? A growing body of research documents that early-life and mid-life conditions are important determinants of late-life mortality. Some researchers focused on the effects of mid-life events and exposure to health risk on late-life mortality [e.g. Manton, Stallard, and Corder 1997]. Others investigated the effects of malnutrition, infectious diseases and other types of biomedical and socioeconomic stressors early in life on adult health and mortality [e.g. Barker 1992, Davey Smith et al. 1998, Elo and Preston 1992, Fogel and Costa 1997]. However, there is also conflicting evidence that suggests that current conditions may be much more important than conditions earlier in life [Christensen et al. 1995, Kannisto, Christensen, and Vaupel 1997]. Kannisto [Kannisto 1994] studied the development of oldest old mortality in several developed countries, and Dinkel [Dinkel 1992] analyzed mortality trends in German cohorts. Both concluded that period factors with immediate effects were considerably more significant than cohort effects. Consistent with this conclusion, results from our study provide little evidence for the presence of cohort effects. Our central findings were that old-age mortality declined earlier and gradually in West Germany, and that East Germany was characterized by later and more abrupt decline that coincided with German reunification. These developments occurred simultaneously in all age groups studied (see Figure 6), and there was no evidence for a time lag which could be indicative of a cohort effect.

Of particular interest are the mortality trajectories of East German individuals who experienced the transition from a socialist planned economy to a free-market democracy late in their lives. Here we observed this rather sudden mortality decline that suggests a period effect. Moreover, it appears that this period factor operated without delay because the mortality decline became visible immediately after reunification. This is somewhat surprising, because traditional epidemiological risk factors such as nutrition or changes in the health care system are thought to operate over rather long time periods [Manton, Stallard, and Corder 1997]. However, there are also intervention studies suggesting that dietary changes can have immediate and profound effects on health [e.g. Stich et al. 1991]. It is also true that some of the changes that came with reunification came indeed rather quickly. The social and economic union between the two German states was established in July 1990, and pensions were paid in Western currency and raised to West German levels after that date [Frerich and Frey 1990]. Similarly, laws implementing the Western medical care system in East Germany were passed in the summer of 1990, and East Germans were eligible to receive health care according to Western standards after that date. Thus, it was possible to transfer patients to Western facilities if a particular treatment was not available in the East.

For these reasons, we restrict our discussion to migration as a selection factor and to three factors with presumably causal effects: medical and nursing care expenditures, economic resources, and life-style factors. The health care and pension systems were part of the institutional transfer of reunification and were altered overnight. Life-style factors were only indirectly affected by the historical event of unification, and changes in behavioral and life-style factors occurred probably less abrupt.

4.1. Migration

Some scholars [Häussler, Hempel, and Reschke 1995, Dinkel 1999] highlight a so-called "positive migration effect." They argue that between 1945 and 1961, when the Berlin Wall was built, many young adults and their families left East Germany and moved to West Germany while the elderly and unfit stayed. There is considerable empirical support for a healthy migration hypothesis in general [Fox, Goldblatt, and Adelstein 1982]. However, to our knowledge there is no empirical evidence that migration of the young and healthy in fact contributed to the difference in old-age mortality between East and West Germany.

In contrast, Schott et al. [Schott et al. 1994] focus on a so-called "negative migration effect." They argue that after the war millions of refugees fled from the Soviet army and most of them eventually settled down in West Germany. The hardship they met on their way to West Germany may have weakened their physical constitution, which in the long run may have contributed to higher mortality rates in West Germany. We are not aware that this hypothesis has been tested empirically. Both the positive and the negative migration hypothesis seem plausible, but no firm conclusions can be drawn in the absence of empirical support for either hypothesis. It is also possible that both hypotheses are true but that their effects cancel out.

4.2. Medical and nursing care

An analysis of the differences in the welfare regimes of East and West Germany may help to explain the observed mortality patterns. This is particularly true for the oldest age groups, which strongly depend on welfare transfers. In general, the welfare regime of the former German Democratic Republic can be characterized as "means tested" and "service heavy." That is, the welfare regime was targeted at fulfilling the basic needs of individuals and it operated primarily through the provision of services. In addition, this welfare system focused on the young and middle-aged population.

In contrast, the West German welfare regime can be characterized as "status preserving" and "transfer heavy." That is, the West German welfare system focused on preserving the status of individuals when they were confronted with hardships, and it operated primarily through monetary payments. It has been argued that the status preserving and transfer heavy West German system disproportionately favored the elderly [Hockerts 1998, Lampert 1996, Manow-Borgwardt 1994].

Transfer payments to the elderly - i.e., pension payments and health care expenditures - were several times higher in West than in East Germany [Statistisches Bundesamt 1994, Verband Deutscher Rentenversicherungsträger 1999]. However, an exact comparison is difficult because both countries defined their statistics differently. Relative trends in social expenditures may give a better picture of the extent of services rendered to the elderly population. Between 1970 and 1989 expenses for medical care quadrupled in West Germany. But even in the former German Democratic Republic, where the economy eventually went bankrupt [Ritschl 1995], health care expenditures more than tripled during the same period. It is noteworthy that increases in medical expenditures rose steeper between 1986-1988 than before [Statistisches Bundesamt 1994]. As women make more use of medical services than men do, they might have benefited more from medical care improvements in East Germany before reunification.

Starting in 1970 the former German Democratic Republic tried to improve the supply of old age care [Ziesemer 1990, Bardehle and Voß 1990, Schönfeld 1990]. Although the number of places in nursing homes increased from 96,000 in 1970 to 140,000 in 1988, it was still the case that more than 100,000 applicants could not be admitted to homes because of a lack of space. Further, the quality of care in those institutions remained relatively low. Regular medical check ups and rehabilitation were not possible [Schmidt 1990], and there was a chronic shortage of trained nurses.

Children who wanted to care for their frail parents were faced with several obstacles. Women were the major caregivers, and in East Germany nearly all women participated in the labor force. Giving up employment in order to care for an old parent implied that these women had to give up their social security benefits. There was also no market for social services or medical aid that could be relied upon, and appropriate apartments for frail elderly people were scarce.

With respect to old age mortality, it was probably crucial that the former German Democratic Republic did not keep pace with the international medical progress that took place in the field of chronic diseases. The fight against chronic diseases, from which many older persons suffer, is capital-intensive. Many scholars argue that the lack of economic dynamism is one of the main reasons why the health care regime of East Germany started to fall behind in the 1970s. The lack of domestic innovations and the lack of foreign currency to buy new innovations from the West led to a stratified, rationing health care system [Volpp 1991]. After reunification in 1990, the shortage of adequate medical equipment and treatment became obvious [Bause and Matauschek 1990, Sachverständigenrat für die Konzertierte Aktion im Gesundheitswesen 1991]. About 17% of hospitals were rundown to a greater or lesser extent, 30% of the beds used in clinics were beyond repair, and medical technology was trailing behind Western standards by 15 to 20 years [Mielck 1991]. It was estimated that 1.5 billion DM would be needed to update the medical technology [Becker 1990]. Further, the available amount of nearly 2,000 different drugs was not considered adequate, given the fact that 40,000 drugs were on the market in West Germany. Experts also estimated that the need for dialysis was only met in 38% of all cases, and the demand for kidney transplants and open-heart surgery was met in only 50% of all cases [Arnold and Schirmer 1990, Korbanka 1990, Thiele 1990].

Studies on mortality from conditions amenable to medical intervention confirm that medical resource deficiencies are decisive [Velkova, Wolleswinkel-Van den Bosch, and Mackenbach 1997]. It is well documented that a lack of appropriate medical care has immediate effects on mortality at older ages. We can speculate that the financial weakness of the socialist health care system in East Germany was one of the main reasons why the decline in old age mortality was relatively slow prior to reunification. After reunification the Western health care system was quickly installed in East Germany. Consequently, the accelerated decline in old age mortality described above occurred.

4.3. Economic resources

Pension payments made up the largest share of social expenditures in both German states. Due to the different welfare regimes, however, both the absolute amount and the relative increase were much smaller in East than in West Germany prior to 1989. Comparing the average income of households, we see that in both German states pensioners have considerably less income than people in the work force. In 1985, a household with a retired head had 36% in East Germany and 65% in West Germany of the income of a household with an employed head, respectively.

After reunification the West German pension scheme was transmitted to East Germany, which made retired people one of groups that benefited most from the transformation. In 1990 the monthly pension of an East German retired employee was 40% that of his or her West German counterpart. This income gap diminished quickly in the following years. In 1999 an East German pensioner received on average 87% of what a West German pensioner got [Presse- und Informationsamt der Bundesregierung 1999]. Particularly women from East Germany have benefited because they had, on average, considerably longer working biographies than their West German counterparts.

The shift from a relatively deprived to a relatively privileged living situation probably affected the health and mortality of the oldest old. There is an extended literature on socioeconomic differentials in mortality [Hummer, Rogers, and Eberstein 1998] that suggests that individual resource availability increases health chances and, ultimately, survival. It is quite likely that the increased individual resources and opportunities that came with reunification have also contributed to the accelerated decline in death rates in East Germany.

4.4. Life-style factors

The interaction between material resources, health, and longevity is probably mediated through various behavioral choices. Demographers and epidemiologists focus on eating and drinking habits, smoking behavior and exercise. Pre-unification comparisons between East and West German nutritional habits revealed a significantly lower consumption of milk, vegetable oil and fat, fresh vegetables and tropical fruits in East Germany, while the intake of sausages, baked goods, butter and spirits was significantly higher. The calorie intake in East Germany was also considerably higher for fat and lower for carbohydrates [Winkler, Holtz, and Döring 1992a, 1992b, Thiel and Heinemann 1996].

After 1989 consumption patterns changed. Individuals in East Germany consumed more carbohydrates, vitamins, calcium, and potassium. Consumption of fresh fruits increased while the intake of baked goods and meat decreased [Winkler, Brasche, and Heinrich 1997]. These consumption patterns may help to explain both why old age mortality patterns in East and West Germany diverged before reunification and why they then converged after reunification. One cannot, however, come to a conclusive interpretation here, since the nutritional studies cited above all involved individuals at younger ages.

There is evidence to suggest that older people rarely change their eating habits [Brockmann 1998]. Rather than improving their diet, they tend to avoid food that is difficult to chew, such as fresh fruit and vegetables. On the other hand, many people above the age of 80 do not cook for themselves. Some live in institutions, others make use of food delivery services. In this way, elderly people in East Germany might well have profited from a better food supply after reunification without actually changing their individual behavior.

4.5. Conclusion

During the past two decades there has been a substantial decline in old age mortality in both German states. The decline was more pronounced for women than for men. The decline in West Germany seems to follow a gradual, long-term trend. The decline in East Germany was accelerated after reunification, and it appears that the East-West German gap in old age mortality is closing. This effect of German reunification on old age mortality in East Germany attests to the plasticity of human life expectancy at older ages and to the importance of late-life events.

Many Germans are ambivalent about the balance of gains and losses that came with reunification [Schmitt, Maes, and Seiler 1999] and wonder what reunification will ultimately bring. Old age mortality is just one of many aspects of human development that might be used to evaluate the effects of reunification, and this aspect seems to suggest that reunification did have a beneficial effect: death rates of the oldest old in East Germany fell considerably after reunification. The specific mediating factors for this effect remain unknown, but it is likely that improvements in the health care system played a major role. It is also likely that there was not only one mediating factor. Rather, we believe that reunification and the many changes that came with it affected old age mortality through various pathways including individual economic resources and life-style factors.


Results Acknowledgements

Old-Age Mortality in Germany prior to and after Reunification
Arjan Gjonça, Hilke Brockmann, Heiner Maier
© 2000 Max-Planck-Gesellschaft ISSN 1435-9871