Ten years of German unification

Ten years ago last month the postwar division of Germany came to an end. Less than a year after the fall of the Berlin Wall, the two halves of Germany became a single state. In a decade during which Europe was characterised by immense social and political transition, the experience of the people of the former German Democratic Republic was unique. Institutions and policies developed over 45 years of communist rule were swept away almost at once. Although neighbouring countries, such as Poland and the Czech Republic, underwent rapid change, none could compete with the scale of the East German transition. It would be surprising if social and economic transition on this scale had not had an impact on the health of those living in the former East Germany. Ten years on, it is beginning to be possible to assess what this impact has been.

The scenes in Berlin on the night the wall fell testify to the initial euphoria that accompanied unification. Access to the immense resources of the Federal German Republic seemed to offer the “best of all possible post-communist worlds.”¹ Within a few months a more realistic assessment emerged. Monetary union in July 1990 protected the savings of the former East Germans but also triggered collapse of the economy in the east. Low quality East German goods could not compete internationally when priced at western levels. Within a year industrial output had fallen by half. Over a third of the preunification workforce of 9.8 million were out of work by the end of 1992.

The pace of change required “pragmatic solutions.”² A transfer of the West German model of health care was almost inevitable, leaving little space for solutions that took account of local context. The basic elements of the Federal German model were adopted by early 1991. The old system of polyclinics and related facilities gained a five year reprieve, but otherwise the new system in the east was almost exactly the same as in the west. The eastern part of Germany still lags behind the west economically, but, in many respects, the two are now indistinguishable.

The immediate post-unification period was characterised by an increase in deaths in the east, with life expectancy falling by almost a year among men, although by only 0.1 year among women.³ This was owing primarily to a rise in deaths from injuries and violence, reflecting the sudden availability of western cars⁴ but also to an increase in homicides.⁵ This worsening mortality pattern has resolved, although deaths from injuries have only now returned to their pre-transition levels. The rapid transition did, however, usher in a period of sustained improvement in health that exceeded even the most optimistic predictions. Between 1992 and 1997, life expectancy at birth increased by 2.3 years in males and by 2.4 years in females, substantially more than in Poland, Hungary, or the Czech Republic.³ The improvement was mainly due to fewer deaths from injuries and violence among young men and from cardiovascular diseases among men and women aged 55 years and over. These changes were accompanied by a decline of a third in neonatal mortality, largely due to improved survival at low birth weights.⁶

What specific factors account for these changes? The reduction in deaths from cardiovascular disease is not unique and is also apparent in countries such as Poland and the Czech Republic.⁷,⁸ The most likely explanation is a rapid change in diet, reflecting greater availability of fruit and vegetable oils. Similar dietary changes have taken place in east Germany.⁹ The prevalence of hypertension has also fallen among eastern men, although it has increased slightly among women.¹⁰

A second factor seems to be an improvement in the quality of medical care. For example, a substantial decline in deaths from testicular cancer has been attributed to wider access to modern drugs.¹¹ Improvement in the quality of care provided to low birth weight babies seems the likely explanation for much of the improvement in neonatal mortality, a phenomenon also seen in the Czech Republic.¹² Finally, a general improvement in living standards among elderly people seems to have contributed to the fall in deaths at older ages.

The old system may, however, have had some advantages that now risk being lost. Smoking rates among eastern women increased from 20.5% in 1990-2 to 29.1% in 1998.¹³ Previously high immunisation rates against pertussis have fallen after unification, resulting in an increase in incidence rates of about 10-20 times in school aged children since 1989.

In all these areas there are, however, many unanswered questions. Ten years on much has been written about the political, social, economic, and industrial consequences of German unification. Perhaps it is now time to learn more about its consequences for health.