The German coronavirus mystery Why have British people been dying at six times the rate of those in Germany?

The short version is that there are several factors, of varying importance — but, probably, none of them is magic, or hidden, or mysterious. There’s no obvious need to posit “immunological dark matter” or illegible cultural factors. Germany was better prepared and reacted faster than Britain did, and in some ways got lucky, while making some mistakes of its own; it had a political system and, of course, politicians, which were better suited to the moment; and together, those factors added up to keeping several tens of thousand Germans alive.

The key factors, in particular, appear to have been that they took measures earlier, and that they were better at protecting the most at-risk people. Those decisions came at significant cost, economically and to people’s lives – but, I think most of us would agree now, they were worth it.

Here’s the longer version.

First, the political system. Germany, unlike Britain, is very decentralised. It is a federal country of 16 states. Each state is itself broken down into smaller units, each with considerable autonomy over public health measures. The local health authorities all report into the centralised Robert Koch Institute, which is the main public health body, a bit like the US Centres for Disease Control, but often make decisions on their own.

According to Jens Spahn, the German health minister, speaking with Jeremy Hunt at a Policy Exchange event in July, this allowed more rapid responses at local level: “In this crisis, there are unforeseen things, and it means you have to handle things very pragmatically. It can help to have many different players who are self-organised.” If you have cases rising locally and the autonomy to do something about it, you don’t have to wait for central authority to order you to do so.

One direct example of this is the track, trace and isolate (TTI) system, which in Britain so far – I think I’m being fair in saying – has been an expensive failure. In Germany, the TTI system was always very obviously under the remit of the local public health authorities. “Doctors had to report a positive test to the public health authority; the authority had to report it to the Robert Koch Institute. Then there were manual forms that were given straight to the doctor, who had to get numbers and call everyone up, find out the symptoms, get them to isolate,” says one senior German public health expert I spoke to. There wasn’t a single central body trying to run a one-size-fits-all system across hundreds of disparate local authorities.

It also allowed different regions to try different things, which could then provide feedback on what works and what doesn’t. The public health expert told me that Jena, in eastern Germany, was the first “to implement a requirement to wear masks, which in Germany at the time was considered an infringement of personal freedom – silly when you think about it! – and they had much lower infections, so it led to it being implemented elsewhere”.

The health system had other advantages. Spahn pointed out to Hunt that Germany’s intensive care units (ICUs) had very high capacity by the standards of its peers, and – also important – most Covid-19 patients were not treated in hospital at all, but by community GPs. That prevented the hospitals getting overrun, and reduced hospital transmissions. 

One huge advantage Germany had early on was testing. In January 2020, shortly after China made the SARS-Cov2 genome public, researchers at the Charité hospital in Berlin developed one of the very first Covid-19 tests; it was swiftly adopted by the WHO. By 1 February, all the passengers on a flight from Wuhan landing at Frankfurt international airport were tested, and two of them were found to be asymptomatic carriers of the disease. Being able to check at the border like this so early meant it was much easier to keep the disease out of the country.

Germany imposed widespread testing early on and continued – Britain, overwhelmed in the early months and following a pandemic flu plan which assumed that it would be impossible to continue testing all at-risk people, limited testing to hospitals and other high-risk areas in early March. By 1 April, Britain had performed around 150,000 tests in total; Germany, around a million. Germany was much better able to see where its outbreaks were.

It was also much more able to follow them, because its contact tracing system was largely in place via the localised public health authorities and the Robert Koch Institute, as we mentioned above.” I’m not sure if this authority had a lot to do for the last 20 years,” says my public health expert, “but in this moment it was crucial.” They also kept it well-staffed, recruiting medical students, firefighters and other groups to stop it from becoming overwhelmed. It also developed a functioning app much earlier. This means that it is now able to trace essentially every case of Covid-19; Britain, as yet, is not.

No doubt it was also helpful to have a scientifically engaged leader who led by example. Angela Merkel declared early in March that Covid-19 was the biggest threat since the Second World War – my public health expert said that “she never does that, she’s not a drama queen”. She was very involved in the Ebola crisis and is interested in public health and global health; this played to her strengths. She also led by example: “She goes to some European summit and the Italian PM tries to hug her and she veers away.” The public health expert drew a comparison with examples given British politicians – Boris Johnson proudly shaking hands; Dominic Cummings breaking lockdown rules. It’s only speculation, however, whether it had a major effect.

But there do appear to have been two really crucial steps that Germany took. The first was protecting the elderly and vulnerable – in quite a severe way. Britain’s great mistake, well documented now, was discharging patients from hospital straight into nursing homes, with no quarantine or testing. In Germany, this was not allowed – no patient could go into a nursing home from hospital unless they were able to be quarantined for 14 days first, or, later, until a test came back negative.

Spahn said that these measures were stringent: “We had some big incidents where too many care home inhabitants died in an outbreak, and we could see how brutal this virus was for very old people.” So they prevented all contact – “no visitors at all, even your partner – 50 years of marriage, but still not allowed to see each other for days or weeks”.

It came at huge cost to mental health and happiness. “It was a choice between the devil and the deep blue sea,” said Spahn. “The social consequences and health consequences that came with the distancing were hard. You have to balance between the harm of the virus and the social distancing, and we were on the side of being very cautious.”

Schools were closed suddenly; nurseries too. Hospital visiting was limited to the point where fathers couldn’t attend their children’s birth. This was hard and painful – special-needs schools were shut down at short notice, support for parents of disabled children stopped coming with no warning. “It had a huge impact on mental health,” my health expert said. “There was a genuine attempt to protect vulnerable communities from superspreading events, but at the same time there was a lot of collateral damage on the health and happiness of everyone involved.” It was immensely controversial.

It seems, however, to have had a huge impact. Our World in Data reports that by late May, only 19% of Covid cases in Germany were among the over-70s, compared to 36% in Spain and 39% in Italy. And that meant that fewer people died: just 4.6% of those tested positive by May in Germany, compared to 14.1% and 12% in Spain and Italy respectively. Younger people are at much lower risk from the disease.

The other really key difference is that Germany simply acted faster than Britain did. Both countries were able to watch the progress of the disease in China, and then in Italy, at the same time. But as the virus started to arrive inside their own borders – more slowly in Germany, perhaps because of the more rapidly available testing system, perhaps because they imposed more stringent border controls earlier – Germany was ahead of Britain in every decision it took.

For instance, on 22 March 2020, a total of 252 people had died in this country, compared to 67 in Germany. But Germany introduced its own version of “lockdown” right then, on the 22nd; Britain didn’t enter full lockdown until the following day. According to an Oxford University index of how stringent government responses were – looking at measures such as school closures, stay-at-home orders, restrictions on gathering, and transport bans – Germany had stricter measures in place than the UK from late February right up until the 23 March lockdown, despite having a much more well-controlled outbreak. Britain, like the US, tried to avoid the economic consequences for as long as possible – Germany simply decided it would risk them, after seeing events in Italy and Spain. In hindsight, this appears to have been the wise decision, both from a public health point of view and an economic one.

We should note that “lockdown” in Germany meant something very different from what it meant here: Spahn said that it was closer to a Swedish model, where people were encouraged to remain home where possible and to avoid standing close to each other, than to a Spanish one, with troops in the streets and enforced curfews. But Germany did take measures earlier than its peers, and never needed to be as strict as some because its outbreak was always better-controlled.

Germany was also lucky in a lot of ways: the early outbreaks, for example, tended to be among healthy middle-aged people returning from skiing holidays in northern Italy. That meant the first patients tended to survive, and also avoided immediate outbreaks in the care system.

There may have been demographic advantages, too, – the epidemiologist Adam Kucharski of the London School of Hygiene and Tropical Medicine speculated to me that the smaller average household size in Germany may have been a factor, although likely only a small one.

Also, the fact that Germany was so well-set-up is partly the luck of the cultural draw. As the public health expert points out, the country has a proud tradition of public health, going all the way back to Robert Koch himself, the great 19th-century public health doctor and rival of Louis Pasteur. The strong pharma, epidemiology and virology landscape were all important, but the current German government can’t take a large fraction of the praise for them.

Finally, Spahn said, even the fact that Germany shut down when it did was, in part, luck. “We didn’t know back then if this is the right time,” he said. “If it’s too early, too late. But it seems to have been just the right moment to get it down before it could really spread.” He remembered a meeting with other health ministers shortly before lockdown, when Italy and France were the only ones having major problems. “Then Spain had to lock down, a week later. It was really a question of one, two, three weeks.” Small differences in time made a big difference in outcome, and, he says, Germany’s decision involved some good fortune.

It should also be pointed out that not everything went well for Germany. As well as the backlash over the strict and heartbreaking rules around nursing homes and hospitals, there was a shortage of PPE for a long time, just as in Britain; and also, there was long-lasting resistance to wearing masks. 

But we don’t know whether this is the whole story, and I’m not sure we ever will. It’s not as though we can run the experiment again, randomly assigning different policies to Germany each time, and without that almost all of this is little better than informed speculation. Certainly, though, the factors listed above are probably a large part of why so many Germans are now alive, when so many Britons are not.

Britain’s facing a resurgence now – as I write, another 143 deaths have been announced, roughly as many as died on 25 March, two days after lockdown (although note that I’m comparing deaths announced today with deaths that actually took place on that date, so not quite the same thing). In Germany, meanwhile, numbers are much lower – while the UK has seen numbers like 60, 70, 80 over the last few days, Germany has had numbers like 10, 12, 16. It’s about the one-to-six ratio that we’ve seen for the entire pandemic.

Can we learn from Germany’s success? Acting fast, protecting vulnerable people, giving autonomy to local and regional authorities – these seem to have worked there, and perhaps they’ll work here. But perhaps we don’t have the deeper structural and political arrangements (and the political personnel) that allowed Germany to move so fast and be so agile. I hope it’s the former. 

*Usual caveats about the ways deaths are recorded apply. These are confirmed deaths, not excess, so it’s an underestimate in both cases, but I think we’re dealing on roughly the correct scale.

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