Declining regional disparities in mortality in the context of persisting large inequalities in economic conditions: the case of Germany

Abstract

Background: Subnational regional mortality inequalities are large and appear to be mostly increasing within industrialized countries, although comparative studies across high-income countries are scarce. Germany is an important country to examine because it continues to experience considerable economic disparities between its federal states, in part resulting from its former division.

Methods: We analyse state-level mortality in Germany utilizing data from a newly constructed regional database based on the methodology of the Human Mortality Database. We compare time trends (1991-2015) in the German state-level standard deviation in life expectancy to that of other large, wealthy countries and examine the association between mortality and economic inequalities at the regional level. Finally, using contour-decomposition methods, we investigate the degree to which age patterns of mortality are converging across German federal states.

Results: Regional inequalities in life expectancy in Germany are comparatively low internationally, particularly among women, despite high state-level inequalities in economic conditions. These low regional mortality inequalities emerged 5-10 years after reunification. Mortality is converging over most ages between the longest- and shortest-living German state populations and across the former East-West political border, with the exception of an emerging East-West divergence in mortality among working-aged men.

Conclusions: The German example shows that large regional economic inequalities are not necessarily paralleled with large regional mortality disparities. Future research should investigate the factors that fostered the emergence of this unusual pattern in Germany.

Keywords: area analysis; economic status; inequalities; life expectancy; mortality; variation.

Figure 1

Life expectancy at age 5 years (e₅) for each German state (left panels) and the standard deviation in e₅ (right panel) by sex; 1982–2015 (in years). The lighter lines in the right panel refer to the subset of states in western Germany. The vertical line at 1990 demarks the German reunification—lines prior to 1990 are of a hypothetical united Germany.

Figure 2

State-level inequalities in life expectancy at age 5 years in Germany and selected countries by sex, 1991–2015 (in years). (i) Data are smoothed using a Loess filter to make trends for each country more visible. Ruptures in the time series are caused by missing data points. (ii) Data sources, the method description as well as unsmoothed trends are available in the Online Supplementary Appendix A, available as Supplementary data at IJE online.

Figure 3

Association between state-level inequalities in life expectancy at age 5 years and state-level inequalities in GDP per capita in Germany and in selected European countries. (i) Each point refers to a country value in a given year between 1991 and 2015. (ii) Data sources and method description are available in the Online Supplementary Appendix, available as Supplementary data at IJE online). The standard deviation in GDP per capita is for both sexes combined.

Figure 4

Contour decomposition of mortality differences over age, comparing population groupings with the frontier state Baden-Württemberg (BW). For details on population groupings (East High, East Low, West Low), see Online Supplementary Appendix A, available as Supplementary data at IJE online. The initial (1982–1984) and final (2010–2014) life expectancy at age 5 years values per state grouping were as follows: Women—East High (71.3, 78.4); East Low (70.9, 77.8); West Low (72.0, 77.7); Baden-Württemberg (74.1, 79.1). Men—East High (65.9, 72.6); East Low (64.9, 71.8); West Low (65.0, 72.6); Baden-Württemberg (67.8, 74.5).