The health impact of German unification: still much to learn.

The division of Germany after the second world war has often been recognised as providing a unique opportunity to evaluate “a natural experiment in history”, one in which a homogenous population had been artificially separated for 45 years. The possible consequences for health of exposure to two very diVerent social models have, however, received relatively little attention. When the Berlin Wall came down in November 1989, followed by the announcement by the West German Chancellor of a 10 point plan for “overcoming the division of Germany and Europe”, leading, eventually, to the unification of the German Democratic Republic (GDR) and the Federal Republic of Germany (FRG), the “natural experiment” entered its second phase. Unification led to a fundamental transformation in the East, and, initially, a massive economic decline. By the end of 1990 the industrial output had fallen to 49% of what it had been at the beginning of the year 1990. The new Länder de-industrialised. By 1991, Gross Domestic Product had dropped to about two thirds of the pre-unification level, accompanied by a massive decline in employment with a loss of about 3.5 million jobs (35% of the labour force) by the end of 1992; unemployment rose from almost zero at the beginning of 1990 to 15.4% of the labour force in 1992. Transformation also had enormous demographic consequences in the East. Birth rate fell by about 60% after the five years following the fall of the Wall. Marriages and divorces both declined sharply and, since 1989, about 1.7 million, mainly young East Germans migrated to the West. Changes of this scale might be expected to have consequences for health. Researchers have concentrated on the immediate eVects on objective health indicators such as life expectancy and mortality, reporting a remarkable, though temporary, increase in mortality in the GDR during the transition. This worsening of mortality patterns since 1989 represented a sharp departure from the past and was referred to as a “mortality crisis”. The deterioration aVected mainly young and middle aged men and was especially striking for deaths attributable to external causes. During the same period, however, mortality figures in the West remained largely unaVected or declined. In this issue of the journal Thomas Hillen et al examine self rated health in East and West Berlin shortly after unification. This is of particular interest as the Berlin population may be expected to have experienced the consequences of unification almost instantly. One key finding is that women in East Berlin rated their health worse than East Berlin men. Although this might reflect the particular circumstances of Berlin, comparable results have been reported for Germany as a whole, with East German women assessing their health worse than either their male counterparts or those in the West. 13 These findings may have been expected given the worsening conditions regarding labour market participation of East German women since unification. They are, however, somewhat contradicted by more objective measures such as all cause mortality and life expectancy, showing East German women to be better oV than their male counterparts, even though self rated health is a strong predictor of later mortality. And while women’s health has been aVected by the political transition, as shown by a transient increase in all cause mortality between 1989 and 1991, the deterioration was less than among East German men, accounting for a decline in life expectancy of only 0.1 year compared with men, who lost almost one year. Moreover, life expectancy has improved much more rapidly in East German women from 1991 onwards. A further key finding of the study presented by Hillen et al shows that the elderly in East Berlin rated their health significantly worse than those in the West. This finding may be consistent with the 1991 mortality data for Berlin as shown by the authors. It lacks, however, consistency with the observation that, since unification, all cause mortality among the elderly declined much steeper in East Berlin than in the West, with mortality rates among East Berlin men and women aged over 65 being lower in 1996. Overall, these findings show that even 10 years after the Berlin Wall came down, there is still a remarkable lack of research on the causes of the relatively good performance in the former GDR regarding mortality and life expectancy and also on the causes of the continuing gap between both parts of Germany.