What Can We Learn from Regional Patterns of Mortality During the Covid-19 Pandemic?

Given the nature of the spread of the virus, strong regional patterns in fatal consequences of the Covid-19 pandemic are to be expected. This brief summarizes a detailed examination of the spatial correlation of deaths in the first year of the pandemic in two neighboring countries – Germany and Poland. Among high income European countries, these two seem particularly different in terms of the death toll associated with the pandemic, with many more excess deaths recorded in Poland as compared to Germany. Detailed spatial analysis of deaths at the regional level shows a consistent spatial pattern in deaths officially registered as related to Covid-19 in both countries. For excess deaths, however, we find a strong spatial correlation in Germany but little such evidence in Poland. These findings point towards important failures or neglect in the areas of healthcare and public health in Poland, which resulted in a massive loss of life.

Introduction

While almost all European countries currently refrain from imposing any Covid-19 related restrictions, the pandemic still takes a huge economic, health and social toll across societies worldwide. The regional variation of incidence and different consequences of the pandemic, observed over time, should be examined to draw lessons for ongoing challenges and future pandemics. This brief outlines a recently published paper by Myck et al. (2023) in which we take a closer look at two neighboring countries, Germany and Poland.  Within the pool of high-income countries, these are particularly different in terms of the death toll associated with the Covid-19 pandemic. In 2020 in Poland, the excess deaths rate (with reference to the 2016-2019 average) was as high as 194 per 100,000 inhabitants, over 3 times higher than the 62 deaths per 100,000 inhabitants in Germany (EUROSTAT, 2022a, 2022b). While, in relative terms, the death toll officially registered as resulting from Covid-19 infections in 2020 was also higher in Poland than in Germany, the difference was considerably lower (about 75 vs 61 deaths per 100,000 inhabitants, respectively) (Ministry of Health, 2022; RKI, 2021). Population-wise Germany is 2.2 times larger than Poland and, before the pandemic struck, the countries differed also in other relevant dimensions related to the socio-demographic structure of the population, healthcare and public health. The nature of Covid-19 and the high degree of regional variation between and within the two countries along some crucial dimensions thus make Germany and Poland an interesting international case for comparison of the pandemic’s consequences. We show that the differences in the spatial pattern of deaths between Germany and Poland may provide valuable insight to the reasons behind the dramatic differences in the aggregate numbers of fatalities (Myck et al., 2023).

Regional Variation in Pandemic-Related Mortality and Pre-Pandemic Characteristics

We examine three measures of mortality in the first year of the Covid-19 pandemic in 401 German and 380 Polish counties (Kreise and powiats, respectively): the officially recorded Covid-19 deaths, the total numbers of excessive deaths (measured as the difference in the number of total deaths in year 2020 and the 2015-2019 average) and the difference between the two measures. Figure 1 shows the regional distribution of these three measures calculated per 1000 county inhabitants. All examined indicators were generally much higher in Poland as compared to Germany. In Poland, deaths officially registered as caused by Covid-19 were concentrated in the central and south-eastern regions (łódzkie and lubelskie voivodeships), while in Germany they were concentrated in the east and the south (Sachsen and Bayern). Excess mortality was predominantly high in German regions with high numbers of Covid-19 deaths, but also in nearby regions. As a result, these same regions also show greater differences between excessive deaths and Covid-19 deaths. On the contrary, high excessive deaths can be noted throughout Poland, including the regions where the number of Covid-19 deaths were lower. In the case of Poland, spatial clusters are much less obvious for both excess deaths and the difference between excess and Covid-19 deaths. To further explore the degree of regional variation between and within countries with respect to the mortality outcomes, we link them to regional characteristics such as population, healthcare and economic conditions, which might be relevant for both the spread of the virus and the risk of death from Covid-19. In Figure 2 we illustrate the scope of regional disparities with examples of (a) age structure of the population, (b) the pattern of economic activity and (c) distribution of healthcare facilities in years prior to the pandemic.

Figure 1. Regional variation of death incidence in 2020: Germany and Poland.

Note: The panels share a common legend based on the quintile distribution of Covid-19 deaths, with two additional categories added at the top and bottom of the scale. County borders in white, regional borders in yellow and country border in grey. Source: Myck et al. (2023).

Figure 2. Pre-pandemic regional variation of socio-economic indicators: Germany and Poland.

Note: Two top and bottom categories in the legend cover 10% of observations each, the rest of categories cover 20% of observations each. County borders in white, regional borders in yellow and country border in grey. Source: Myck et al. (2023).

Shares of older population groups (aged 85+ years) are clearly substantially higher in Germany compared to Poland, and within both countries these shares are higher in the eastern regions. On the other hand, the proportion of labor force employed in agriculture is significantly higher in Poland and heavily concentrated in the eastern parts of the country. In Germany, this share is much lower and more evenly spread. This indicator illustrates that socio-economic conditions in 2020 were still substantially different between the two countries. The share of employed in agriculture is also important from the point of view of pandemic risks – it reflects lower levels of education, and specific working conditions that make it challenging to work remotely yet entail less personal contact and more outdoor labor. The distribution of hospital beds reflects the urban/rural divide in both countries. It is also a good proxy for detailing the differences in the overall quality of healthcare between the two countries, i.e. displaying significantly better healthcare infrastructure in German counties.

Uncovering the Spatial Nature of Excess Deaths in Germany and Poland

While spatial similarities among regions are present along many dimensions, they are particularly important when discussing such phenomena as pandemics, when infection spread affects nearby regions more than distant ones. With regard to the spatial nature of excess deaths in the first year of the pandemic, a natural hypothesis is thus that the pattern of these deaths should reflect the nature of contagion. This applies primarily to excess deaths directly caused by the pandemic (deaths resulting from infection with the virus). At the same time, some indirect consequences of Covid-19 such as limitations on the availability of hospital places and medical procedures, or lack of medical personnel to treat patients not affected by Covid-19, are also expected to be greater in regions with a higher incidence of Covid-19. On the other hand, spatial patterns are much less obvious in cases where excess deaths would result, for example, from externally or self-imposed restrictions such as access to primary health care, reduced contact with other people, diminished family support, or mental health problems due to isolation. While these should also be regarded as indirect consequences of the pandemic, as they would arguably not have realized in its absence, these consequences do not necessarily relate to the actual spread of the virus. Our in-depth analysis of the spatial distribution of the three examined mortality-related measures, therefore, allows us to make a crucial distinction in possible explanations for the dramatic differences in the observed death toll in the first year of the pandemic in Germany and Poland. We explore the degree of spatial correlation in the three mortality outcomes using multivariate spatial autoregressive models, controlling for a number of local characteristics (for more details see Myck et al., 2023).

We find that in Germany, all mortality measures show very strong spatial correlation. In Poland, we also confirm statistically significant spatial correlation of Covid-19 deaths. However, we find no evidence for such spatial pattern either in the total excess deaths or in the difference between excess deaths and Covid-19 deaths. In other words, in Poland, the deaths over and above the official Covid-19 deaths do not reflect the features to be expected during a pandemic. As the results of the spatial analysis show, these findings cannot be explained by the regional pre-pandemic characteristics but require alternative explanations. This suggests that a high proportion of deaths results from a combination of policy deficits and individual reactions to the pandemic in Poland. Firstly, during the pandemic, individuals in Poland may have principally withdrawn from various healthcare interventions as a result of fear of infection. Secondly, those with serious health conditions unrelated to the pandemic may have received insufficient care during the Covid-19 crisis in Poland, and, as a consequence, died prematurely. This may have been a result of lower effectiveness of online medical consultations, excessive limitations to hospital admissions – unjustified from the point of view of the spread of the virus, and/or worsened access to healthcare services as a result of country-wide lockdowns and mobility limitations. The deaths could also have resulted from reduced direct contact with other people (including family and friends as well as care personnel) and mental health deterioration as a consequence of (self)isolation. Our analysis does not allow us to differentiate between these hypotheses, but the aggregate excess deaths data suggests that a combination of the above reasons came at a massive cost in terms of loss of lives. The consequences reflect a very particular type of healthcare policy failure or policy neglect in the first year of the pandemic in Poland.

Our study also shows that a detailed analysis of country differences concerning the consequences of the ongoing pandemic can serve as a platform to set and test hypotheses about the effectiveness of policy responses to better tackle future global health crises.

Acknowledgement

The authors wish to acknowledge the support of the German Research Foundation (DFG, project no: BR 38.6816-1) and the Polish National Science Centre (NCN, project no: 2018/31/G/HS4/01511) in the joint international Beethoven Classic 3 funding scheme – project AGE-WELL. For the full list of acknowledgements see Myck et al. (2023).

References

• EUROSTAT. (2022a). Excess mortality—Statistics.
• EUROSTAT. (2022b). Mortality and life expectancy statistics.
• Ministry of Health. (2022). Death statistics due to COVID-19 in 2020.
• Myck, M., Oczkowska, M., Garten, C., Król, A., & Brandt, M. (2023). Deaths during the first year of the COVID-19 pandemic: Insights from regional patterns in Germany and Poland. BMC Public Health, 23(1), 177.
• RKI. (2021). SARS-CoV-2 Infektionen in Deutschland. 2.6.2021 (Version 2022-02-07) [Data set]. Zenodo.

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