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Avoidable Mortality in the German Baltic Sea Region Since Reunification: Convergence or Persistent Disparities?

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Abstract

The consequences of political reunification for health and mortality have the unique character of a ‘natural experiment’. This is particularly true for the formerly divided German Baltic Sea region due to its cultural and geographic commonalities. This paper ascertains the changes and differences in premature mortality at ages 0–74 in urban and rural areas of the German states of Mecklenburg–Vorpommern (MV) and Schleswig–Holstein (SH) since reunification and the contribution made by ‘avoidable’ mortality. Using official cause-of-death data, the effectiveness of health care and health policies was measured based on the concept of avoidable mortality in terms of both amenable and preventable conditions. Methods of decomposition and standardisation were employed in order to erase the compositional effect from the mortality trend. As a result, mortality differences relate primarily to men and the rural areas of the German Baltic Sea region. Whereas the mortality levels in the urban areas of MV and SH have converged, the rural areas of MV still show higher levels of preventable and amenable mortality. The results show that the accessibility and quality of medical care in the thinly populated areas of MV and the effectiveness of inter-sectoral health policies through primary prevention, particularly with regard to men, have room for improvement.

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Notes

  1. The only study that tried to estimate the connection between selective migration and mortality in Germany used the Billeter index as an indicator of selective migration (Luy and Caselli 2007). Surveys that include other explanatory variables, e.g. the German Life Expectancy Survey (LES) and the Socio-Economic Panel (SOEP), do not offer a sufficient number of cases for regional mortality analyses, whereas the Study of Health in Pomerania (SHIP) focuses on a very limited regional context. Data of the German Statutory Pension Insurance Scheme (FDZ-RV) only work sufficiently for elderly men who were not employed as officials in the civil service. Moreover, these datasets do not only allow for cause-specific mortality analyses. Multi-level studies that combine individual and macro-data are problematic from a causality point of view, particularly when the number of regional units is low.

  2. See Nolte and McKee (2004) for a detailed comparative description of all important works on the concept of avoidable mortality published prior to 2004.

  3. See Mackenbach et al. (2013) for the limitations of amenable mortality analysis in international comparisons.

  4. The notation of the equations in this paper is based on Canudas-Romo (2003).

  5. As the following chapter 3.2 will show, age-standardised mortality of men has never been significantly lower in urban MV than in urban SH since reunification.

  6. The regional smoking rates as surveyed in the 2005, 2009 and 2013 waves of the German Microcensus were provided by the Federal Statistical Office (DESTATIS) on request.

  7. Additional district-level analyses confirm that the main gap in rural mortality is between Mecklenburg and Vorpommern in MV and between the south and the north in SH.

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Acknowledgements

The author wishes to thank the staff of the research data centre of the German statistical offices and the staff of the statistical offices of Mecklenburg–Vorpommern and Schleswig–Holstein for providing the data, as well as Gabriele Doblhammer-Reiter for direction and guidance and Martin Bujard, Wiebke Hamann, Andreas Mergenthaler, Frank Micheel, Anton Peez, Heiko Rüger, Leighton Twigger, Ronny Westerman and two anonymous reviewers for helpful comments.

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    Michael Mühlichen

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Tables 4 and 5.

Table 4 Causes considered amenable to health carea, ages 0–74b (unless otherwise stated)
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Table 5 Causes considered avoidable through primary preventiona; ages 0–74b (unless otherwise stated)
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Mühlichen, M. Avoidable Mortality in the German Baltic Sea Region Since Reunification: Convergence or Persistent Disparities?. Eur J Population 35, 609–637 (2019). https://doi.org/10.1007/s10680-018-9496-y

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