Estimating the contribution of mortality selection to the East–West German mortality convergence

Background

Before German reunification, old-age mortality was considerably higher in East Germany than West Germany but converged quickly afterward. Previous studies attributed this rapid catch-up to improved living conditions. We add to this discussion by quantifying for the first time the impact of mortality selection.

Methods

We use a gamma-Gompertz mortality model to estimate the contribution of selection to the East–West German mortality convergence before and after reunification.

Results

We find that, compared to the West, frailer East Germans died earlier due to deteriorating mortality conditions leading to converging mortality rates for women and men already over age 70 before 1990. After 1990, the selection of frailer individuals played only a minor role in closing the East–west German mortality gap. However, our study suggests that, after reunification, old-age mortality improved quickly because the more robust population in the East benefitted greatly from ameliorating external factors such as health care and better living standards.

Conclusion

Our results from a natural experiment show that selection of frail individuals plays an important role in population-level mortality dynamics. In the case of the German reunification, East German old-age mortality already converged before 1990 because of stronger selection pressure.

     

Unexplained inversion of the incidence ratio of colon and rectal cancer among men in East Germany. A time trend analysis including 147,790 cases

Introduction The incidence rate ratio of colon to rectal cancer is usually about 2:1. It has been observed for a while that the incidence of colon cancer among men (as opposed to women) in the Former German Democratic Republic (GDR) is lower than the rate of rectal cancer. Detailed analyses of this phenomenon have not been done so far. The aim was to give insights in this observation by detailed incidence and mortality analyses and to explore the worldwide ratio of colon and rectal cancers based on population-based cancer registry data. Methods We analyzed age-standardized incidence and mortality data of colorectal cancers in East Germany (1961–1989 and 1996–2002; mortality 1980–2002), West Germany, Saarland (1970–2002) and all over the world (1978–82 up to 1993–97). Results With the incidence increase of colorectal cancers in the GDR, the ratio of colon to rectal cancer incidence became larger and surpassed the reference value (ratio = 1) during the time of the reunification. Also the mortality data revealed a similar pattern. Estimated annual percentage increases of colon subsite incidences tended to be higher within the distal colon as compared to the proximal colon Conclusions Our analyses of international cancer registries over a period of 20 years show that the colon–rectum cancer ratio is positively associated with the overall incidence of colorectal cancer with a stronger association among women than men. Non-causal factors such as underdetection or registration artefacts are unlikely to explain the unusual colon/rectal rate ratio among men. A gradual decrease of the job-related physical activity among men may have contributed to the findings.     

Diet in residents of East and West Germany in 1991–1992 as ascertained by a retrospective food frequency questionnaire

In this study, we compared dietary habits of residents in East (N=76) and West Germany (N=266) using results obtained in 1992–1993 from a retrospective semi-quantitative food frequency questionnaire referring to 1991–1992. Nutrient intakes were calculated based on the German Federal Food Code. Univariate and multivariate logistic regression was used to determine whether dietary intakes varied according to residence in East and West Germany. At the food level, East German subjects reported a higher consumption of bread, spreadable fat, and sausage, whereas West German participants reported a higher intake of fruit, vegetables, and pasta and rice. At the macronutrient level, energy intake did not differ significantly between groups, nor did the percent contribution of protein, carbohydrate, fat, and alcohol to total energy intake. East German participants had a lower total water and fibre intake, the latter significant only after adjustment for confounders. At the micronutrient level, East German participants had a higher intake of cobalamin, retinol and retinol-equivalents (but not of beta-carotene). There were no differences in the intake of vitamins C, D, and E between groups. Less salt and more potassium, calcium, magnesium and zinc were consumed by West than by East German subjects. Overall, both groups showed disadvantageous dietary patterns. The results are discussed in the context of an overview of other dietary surveys performed in the two parts of Germany before and after reunification. In general our results are consistent with other observations showing that dietary habits in East Germany rapidly approached those in West Germany after reunification, although some residual differences seemed to persist.     

Pharmaceutical spending and German reunification: parity comes quickly to Berlin

As the Berlin Wall fell and the population of the Federal Republic of Germany (FRG, West Germany) swelled by 25 percent with the addition of the former German Democratic Republic (GDR, East Germany), the health care system struggled to keep pace. This article examines drug outlays by the statutory sickness funds during the first 2 years of unified operations. It shows that providing equivalent coverage quickly led to equal rates of pharmaceutical consumption nationwide, while in Berlin the former East outdistanced the West by a considerable margin.     

Violence and fear of violence in East and West Germany

The purpose of this research was to assess the effect of major social changes in Germany since 1989 on mortality due to intentional injury. Mechanisms and types of fatal intentional injury in East and West Germany between 1970 and 1995 were determined from death certificates and compared with judicial data on violent crime convictions and recent public survey data on citizen fear of crime. The number of homicides among East German males increased between 1989 and 1991, and the homicide rate remains high when compared with West German males (although lower than that of American males). Homicide among German females is less common, presently about equally likely in East and West. Violent crime in general has become more frequent in Germany, and citizen fear of crime has increased markedly, especially in the East. Non-citizens are convicted for an increasing number of homicides and assaults. Rates of suicide were declining in East and West before reunification, and these rates have continued to decline. Social changes in Europe since 1989 have led to noticeable increases in violence and homicide in Germany, which in turn have reduced feelings of security among German citizens, especially in the East. Suicide rates have not been affected.     

Entwicklung der Herz-Kreislauf-Morbidität und -Mortalität in Ostdeutschland nach der politisch-ökonomischen Wende

Cardiovascular mortality decreased in the GDR between 1980 and 1989 in men by 14 % and in women by 18 %. In 1990, however, among men as well as women the rates increased considerably, particularly for the age group 25-44 (18 % and 17 %, respectively), but also for the age group 45-64 (7 % for both sexes). Compared with the mortality rates of 1989 this increase resulted in an excess-mortality of approximately 1120 cardiovascular deaths in this age range in East Germany during the year of the reunification. The re-arrangement of the coding practice in this year is obviously not an explaination for this phenomenon. There were, on the other hand, very similar trends of the cardiovascular mortality and the myocardial infarction and stroke morbidity in the years before and after the reunification. The stroke morbidity developed quite parallel with the hypertension prevalence rates. But we observed no relationship between the trends in hypercholesterolemia and smoking, on the one hand, and the myocardial infarction attack rates, on the other hand. However, the prevalence of psychosocial risk factors (social network, job stress, life events) increased considerably. This fact seems to play an important role particularly in the increase of the incidence of myocardial infarctions after the political change. Cardiovascular mortality droped after the reunification to a faster rate than before the reunification especially in the age range below 65 years. Nevertheless, cardiovascular mortality is still currently much higher in East than in West Germany. Therefore, in order to bring the East German rates in line with the West German rates it will probably still take a long time.     

Uranium mining in East Germany ("Wismut"): health consequences, occupational medical care and workers' compensation

Underground uranium mining was performed in East Germany after World War II on a large scale. Working conditions were very poor during the post-war years from approx. 1946 to 1955. During later years mining conditions improved. In 1990, uranium production was generally stopped as a consequence of German reunification. A company-based health care system commenced in the early years with an annual routine medical check-up including chest X-ray. A central Wismut institution for occupational medicine was founded in 1968. Since reunification, the German Workers' Compensation Board is organizing post-exposural occupational medical care and compensation for former miners. Compensable occupational diseases include silicosis and Schneeberg lung disease (bronchial carcinoma of uranium miners). A current topic is the question of acknowledgement of extrapulmonary malignoma as a compensable disease in uranium miners. With a certain cumulated exposure as a prerequisite, bone and liver cancer and certain types of leukemia are likely to be accepted.     

Injury mortality in East Germany

OBJECTIVES: This study determined the effects of social changes in East Germany since 1989 on patterns of injury mortality. METHODS: Death certificate data regarding injuries from 1980 through 1995 and police data regarding traffic injuries in East Germany from 1980 through 1998 were compared with similar data from West Germany. RESULTS: The number of motor vehicle-related injuries and deaths in East Germany increased dramatically between 1989 and 1991, whereas those in West Germany declined slightly. The increased mortality in the more rural East has especially involved young men driving automobiles on rural roads and has persisted since reunification of East and West Germany. Falls, other accidents, and suicides have shown no such effect. Homicide among East German men has increased but remains uncommon. CONCLUSIONS: Recent social changes in East Germany, including increased access to motor vehicles and decreased restrictions on personal freedom, have been associated with increased motor vehicle crashes and mortality, especially among young men and on rural roads.     

Berliners' models of heart disease causation

Following the collapse of socialism and subsequent German reunification, cardiac mortality rose unexpectedly in the former East Germany; although rates improved by mid-decade, a West/East health gradient persisted. Psychosocial stress from regime change, postsocialism, was one hypothesis proposed to explain the health transition. Absent from the scholarly conversation were individuals' own assessments of their illness experiences in this time of social upheaval. I hypothesized that such data might illuminate processes linking illness and social change. I analyzed illness narratives of East and West Berliners with heart disease, attending to subjective notions of causation. Both groups cited nonmodifiable and modifiable risk factors; half of the East Berliners incorporated additional material that referenced processes associated with postsocialism. I propose that ethnographic investigations of illness experiences can contribute to the development of more culturally relevant, comprehensive hypotheses of nonbiologic risk factors for cardiovascular disease.     

Effekte der Masern-Mumps-Röteln (MMR)-Impfung auf die Epidemiologie von Mumps in Deutschland

Mumps is an acute viral infectious disease characterized by fever and swelling and tenderness of one or more salivary glands, usually the parotid gland. Since 1976, the German Standing Committee on Vaccination (STIKO) has recommended a mumps vaccination as part of the routine immunization schedule in former West Germany. In East Germany, the vaccination was only introduced in 1991 after reunification. In the preceding decades, no comprehensive surveillance system existed in Germany. However, for East Germany and the successional federal states of former East Germany, data on mumps incidence are available from different Eastern surveillance systems for the time period 1968–2012. According to these data, the incidence of mumps has dropped from >?200 cases/100,000 annually in the pre-vaccine era to currently <1/100,000. Recently, an age shift has been noted predominantly in the Western federal states. Based on data from school entry examinations and seroprevalence studies, the age shift is likely due to insufficient vaccination coverage and secondary vaccine failure (“waning immunity”). In view of the changes in mumps epidemiology and the increase of outbreaks among adolescents and young adults, the implementation of a nationwide mandatory notification was initiated and came into effect in March 2013. Mandatory notification enables the early detection of outbreaks and obtainment of comprehensive data for evaluation of the immunization program in place. Regarding the long-term prevention of mumps in Germany, it is hoped that—as part of the measles and rubella elimination effort—coverage rates for the second MMR dose among children will increase nationwide above 95% and existing vaccination gaps among adults will be closed.     

Social Epidemiology after the German Reunification: East vs. West or Poor vs. Rich?

Summary Objective: Social epidemiology has consistently demonstrated an association between socio-economic disadvantage and ill health. Seventeen years after reunification, economic disparities persist between former “East” and “West” Germany. We examine whether there are according health disparities and how they developed over time. Methods: Secondary analysis of socio-economic and health data for Germany. Results: Health disparities, for example in life expectancy, are decreasing between East and West. Throughout Germany, however, differences in living conditions and demographic trends are widening at city and county level. This development is easily missed when only East and West are compared. Conclusion: Small-area analyses are required to disentangle the association between socio-economic inequalities and health in Germany. In such analyses, not only individual but also contextual (e.g. area level) characteristics need to be included. Contextual variables can be used to group smaller areas such as counties into clusters with similar properties. Thus, individual survey data can be linked with contextual characteristics while maintaining data protection and at the same time achieving sufficiently large case numbers. Concurrently, theoretical models explaining health inequalities need to be further developed so that they embrace contextual characteristics. Submitted: 3 January 2007; Revised: 1 August 2007; Accepted: 11 September 2007 Based on an invited plenary lecture by Prof. Oliver Razum at the annual meeting of the German Association for Epidemiology (DGEpi) in Greifswald, 22^nd September 2006.     

Lessons From Unified Germany and Their Implications for Healthcare in the Unification of the Korean Peninsula

This study investigated the German experience in the transition to a unified health care system and suggests the following implications for Korea. First, Germany could have made use of the unification process better if there had been a good road map. Therefore Korea must develop a well prepared road map that considers all possible situations. Second, Germany saw an opportunity for the improvement of the health care system in the early stage of unification but could not take advantage of it because the situation changed dramatically and they had not sufficiently prepared for it. Korea should take into account the opportunity for improvement of the present health care system, such as the roles of public health and traditional medicine. Thirdly, the conditions f North Korea seem to be far worse than those of former East Germany and also worse than even those of other transition countries. Therefore Korea should design a long-term road map taking as many variables into account as possible, including the different rigid way of thinking and the interrelationship among the social sectors. Fourthly, during the German reunification unexpected factors changed the direction of the events. Korea should have a separate plan for the unexpected factors.     

The causal effect of income on health: evidence from German reunification

We investigate whether there was a causal effect of income changes on the health satisfaction of East and West Germans in the years following reunification. Our data source is the German Socio-Economic Panel (GSOEP) between 1984 and 2002, and we fit a recently proposed fixed-effects ordinal estimator to our health measures and use a causal decomposition technique to account for panel attrition. We find evidence of a significant positive effect of income changes on health satisfaction, but the quantitative size of this effect is small. This is the case with respect to current income and a measure of 'permanent' income.     

Inzidenz und Überleben bei Leukämien in Deutschland nach aktuellen standardisierten Kategorien

Background

Leukemias include a large number of diverse malignancies concerning the blood-forming system. Population-based comparisons and time trends are complicated by inconsistent definitions and classifications. In the course of the European HAEMACARE project, a consensus grouping system was created based on the morphology codes of the ICD-O-3 (International Classification of Diseases-Oncology, third revision), consistent with the WHO classification published in 2008 and useful for epidemiologic and public health purposes. For the first time leukemia incidence and survival in Germany are presented according to this system on the basis of cancer registry data..

Material and methods

A set of leukemia cases diagnosed during 2001–2010 was extracted from the data submitted by German population-based cancer registries to the Robert Koch Institute in early 2013 and grouped according to the HAEMACARE system. Direct age-standardized incidence rates were calculated. To estimate the prognosis of adult leukemia patients diagnosed during 2008–2010, the 5-year relative survival was computed using the period approach.

Results and discussion

Based on 23,328 predominantly leukemic malignancies ascertained for six federal states over a 10-year period, the age-standardized incidence rates were 4.1 (per 100,000) for chronic lymphocytic leukemia, 3.1 for acute myeloid leukemia, and 2.4 for myeloproliferative neoplasms, similar to other European regions. The 5-year relative survival of leukemia in Germany currently ranges between 8 and 95?% according to sex, age, and category, and is thus considerably better compared with results derived from a European data pool referring to 2000–2002.     

Twenty years of the German Environmental Survey (GerES): human biomonitoring--temporal and spatial (West Germany/East Germany) differences in population exposure

The German Environmental Surveys (GerESs) are nationwide population studies, which have repeatedly been carried out in Germany since the mid-1980s. The subjects were representatively selected from the regional registration offices with regard to age, gender and community size. The first survey for adults (GerES I) was carried out in 1985/1986 (West Germany) followed by GerES IIa in 1990/1991 (West Germany) and GerES IIb in 1991/1992 (East Germany). In GerES II children were also included to some extent. In 1998, the third GerES for adults was conducted in both parts of Germany (GerES III). The current survey 2003/2006 (GerES IV) is focussing exclusively on children. A 1-year pilot study was conducted in 2001-2002 to collect information on parameters influencing the response rate and to test the suitability of the different instruments intended to be used for the main study. The main goal of the surveys is to analyse and document the extent, distribution and determinants of exposure to environmental pollutants of the German general population. Three main instruments of investigation were comprised in GerES: human biomonitoring (HBM), monitoring of the domestic environment, and collecting information on exposure pathways and living conditions via questionnaires. This paper is focussed on the general design of the GerESs, the trend over time and spatial differences (West Germany and East Germany) for HBM data on arsenic, cadmium, lead, mercury, pentachlorophenol (PCP), and polycyclic aromatic hydrocarbons (PAH). These substances have been determined in blood and/or morning urine of adults and children. All GerESs have been conducted in close connection with the National Health Interview and Examination Surveys performed by the Robert Koch-Institute, Berlin.     

Food and nutrient intake in East and West Germany, 8 years after the reunification--The German Nutrition Survey 1998

OBJECTIVE: To explore differences in food and nutrient intake as well as cardiovascular risk factors between the eastern and western parts of Germany in 1998 and to compare food consumption information between 1991 and 1998. DESIGN AND SUBJECTS: In all, 4030 people, aged 18-79 y, sampled from the East and West parts of Germany participated in the German Nutrition Survey (1998) by completing dietary histories and being assessed for cardiovascular risk factors. In a separate analysis, two food frequency data sets were compared from National Health Surveys conducted in 1991 (n = 7466) and in 1998 (n = 4556). RESULTS: In 1998, East Germans consumed more bread, fruit, fish, sausage, offal, and men additionally more cakes/cookies, beer and soft drinks than West Germans. They consumed less cereals, pasta, sweets, leafy vegetables, tea and drinking water, and men less vegetables and wine and women less pastry/crackers, potatoes and animal fat compared with their counterparts in West Germany. East Germans had a higher intake of total vitamin A, retinol, vitamin D, vitamin B12 and chloride, and in addition men of alcohol, and women of monosaccharides. They had a lower intake of total water, vitamin K, calcium, magnesium and manganese, and men of linoleic acid, and women of vitamin E than their West German counterparts. In East Germany, higher mean systolic blood pressure, and total and high-density lipoprotein cholesterol concentrations were found in men, and a lower mean total serum cholesterol concentration found in women compared with West Germany. CONCLUSION: Differences in food intake between the eastern and western parts of Germany still existed in 1998, although these differences were smaller than those observed 1 y after the reunification.     

Reform of health care in Germany

For the past 45 years Germany has had two health care systems: one in the former Federal Republic of Germany and one in the former German Democratic Republic. The system in the Federal Republic was undergoing some important reforms when German reunification took place in October 1990. Now the system in eastern Germany is undergoing a major transformation to bring it more into line with that in western Germany.     

Weight gain in two adult cohorts in East and West Germany reunification

BACKGROUND: Several epidemiological studies have shown consistently higher prevalence rates of obesity and overweight in East German adults compared to West German adults before German reunification in 1990. If different lifestyle factors after German division contribute to these differences, one might speculate that trends of obesity and overweight in the East and West after German reunification in 1990 would be similar. OBJECTIVE: To examine weight gain in East and West German adult cohorts in the decade after German reunification. METHODS: The study population includes 554 individuals with complete data aged 20 - 47 years in 1990-92 participating in the ten year follow-up of the European Community Respiratory Health Survey (ECRHS) in the German centres Hamburg (West) and Erfurt (East). Age and occupation-adjusted prevalence and incidence rates, stratified for gender and centre, were calculated for the Erfurt and Hamburg cohorts. RESULTS: The prevalence of overweight increased in males and females in both cities, and was statistically significant for Hamburg males (32.7% to 44.9%), Hamburg females (12.3% to 25.4%) and Erfurt females (18.5% to 31.2%). The increase in the prevalence of obesity was statistically significant for males (Hamburg: 3.7% to 7.9%; Erfurt: 5.2% to 10.8%) and for females only in Hamburg (6.4% to 14.2%). The increase in the prevalence of overweight and obesity were larger in Hamburg than in Erfurt. Moreover, the incidence rates of obesity were higher in Hamburg for both sexes, but were not statistically significant CONCLUSION: Our findings indicate different patterns of weight gain in 2 study sites in East- and West-Germany. These results might reflect a convergence of initially higher prevalences of overweight and obesity in the East with initially lower prevalences in the West.     

Pertussis in Germany: regional differences in management and vaccination status of hospitalized cases

The incidence of pertussis requiring hospitalization in children younger than 16 years was estimated by the use of an active surveillance-system. Of special interest were differences between West and East Germany following different vaccination strategies before reunification. In 1997 and 1998, 754 pertussis cases required a total of 11,151 hospital inpatient days. The incidence of hospitalized pertussis was 2.68/100,000 person years and this was significantly higher in East than in West Germany. In East Germany an unusually high percentage of hospitalized cases was found in children aged 6-15 years (45% versus 13% in West Germany). The difference between the regions may be due either to a different perception of the disease or to an increased immunity induced by prior disease or vaccination. In East Germany, pertussis was rare until reunification but it has increased significantly since then. Older children may thus represent a population at risk of pertussis having not had previous exposure to pertussis antigens.     

Lebenserwartung, vorzeitig verlorene Lebensjahre und vermeidbare Sterblichkeit im Ost-West-Vergleich

The dynamics of convergence between East and West Germany in the life-prolonging process continued undiminished from 1990 until 2001. The regional differences in premature and avoidable mortality were clearly reduced, both between East and West and between the individual federal states. In the East and in the West there was an increase in life expectancy in all age groups and for both sexes, whereby the increase in life expectancy was considerably greater in East Germany and in all of the East German federal states. Also, the standardized potential years of life lost before the age of 65 decreased more intensively in East Germany. The women in East Germany achieved a lower premature mortality due to illness in the year 2001 than those in West Germany. In the initial year of 1990, the years of life lost were 27.2% greater. Unnatural premature mortality (especially due to accidents) was also relatively high in East Germany in the year 2001, but it is clearly being reduced. The avoidable mortality has been more than cut in half in all East German federal states since 1990. An almost complete alignment between East and West in regard to avoidable mortality was achieved in the year 2001. The phase of economic stagnation that can be observed in East Germany since 1997 has up to now not led to a worsening in the constitutive health references presented above.