Germany gets a lot of favorable Covid-19 press — and for good reason. Its daily new cases per million people have been persistently lower than any of its Western European neighbors, and its death rate, from the beginning of the outbreak, has been among the lowest in Western Europe: currently 0.15 deaths per million people, compared to France’s 1.15 and Spain’s 2.19.
Even as coronavirus cases surge across the continent — the week prior to October 11 saw the largest increase since the beginning of the pandemic — Germany’s latest wave is still small relative to other countries in the region.
Number of #coronavirus infections per 1 million inhabitants (7 day average). Germany is a giant, comparatively clean island smack in the middle of Europe. via @Welt pic.twitter.com/1jYAnrWczh— Bojan Pancevski (@bopanc) October 4, 2020
So what exactly is Germany getting right?
What’s often cited is an effective deployment of technology, such as a contact tracing app, to fight the pandemic. There’s the frequently praised mass testing program, which rivals South Korea’s, and the oversupply of ICU beds — controversial before the coronavirus, now lauded. It also helps that Angela Merkel has a doctorate in quantum chemistry and heads a country that treats scientists, like the Berlin-based virologist and podcaster Christian Drosten, like superstars.
Yet this is far from the whole story of Germany’s relative success.
Over the past few weeks, I talked to doctors, health officials, and researchers in Germany— including some of the country’s first Covid-19 responders — and elsewhere to get a deeper perspective on why Germany has had better-than-average pandemic performance in Europe.
I heard, again and again, four explanations for the country’s coronavirus success. They had nothing to do with tech, Merkel, or hospital beds. And they’ve been largely overlooked.
Let’s call them the L’s: luck, learning, local responses, and listening. While the pandemic certainly isn’t over, and Germany is facing a pivotal moment with a record number of new infections, these factors may be the reason Germany bends the curve quickly once again.
The power of luck
Günter Fröschl, a tropical medicine doctor at Munich University, has been leading Germany’s longest-running Covid-19 testing unit. He’s been at it so long, he swabbed four of the first five coronavirus patients in late January. At that time, his fiancée — another infectious disease specialist — happened to be working in Brescia, Italy, ground zero of Europe’s deadliest Covid-19 outbreak. The two were on the phone every day comparing notes, and Fröschl concluded the only reason the paths of the two countries diverged so widely early on in the pandemic was something both countries had no control over.
“We had a lot of luck in Germany,” Fröschl says.
The first known Covid-19 cases in Germany originated in a Munich-area auto parts firm called Webasto. There, an employee from China — who tested positive for the virus after returning home — infected several others during a visit to Munich. When she notified her German counterparts of her positive test result, the company informed its staff, including one employee who, despite not having serious symptoms, sought out a test.
“The patient came to us and said, ‘I had a common cold for a few days. I’m feeling fine — but we did have a Chinese colleague coming to visit us who tested positive,’” Fröschl recalls. The fact that this patient came forward meant public health officials were able to identify, trace, and isolate other cases, and instead of a large and silent outbreak early on in the pandemic, health authorities stopped the virus from spreading further at that point.
There was another element of luck involved: The Bundeswehr Institute of Microbiology in Munich is home to a biosafety level 3 lab — the kind that deals with highly infectious and deadly agents that can spread through inhalation, like SARS-CoV-2. When China released the genetic sequence of the new coronavirus in January, Fröschl’s colleagues at the institute got ready with coronavirus PCR tests. That meant the test was available in Munich when the first patients showed up there, and Fröschl was able to use it to quickly diagnose the first cases. “The index patient was meeting this unique situation in Europe,” Fröschl says. “That is luck. It’s not that we were so smart.”
It wasn’t just Munich that had tests ready. In Berlin, scientists created the test kit the World Health Organization and many countries ended up using even before China released the sequence of the virus. But Fröschl points out that if that first patient had shown up in a less prepared part of the country, the outcome may have been different — perhaps something more like what happened in Italy, where cases went undetected for weeks and then overwhelmed the health system. “I’m always emphasizing,” Fröschl says, “we were just lucky.”
The power of learning
Of course, the key to Germany’s coronavirus management isn’t only about luck. It’s also about learning and acting quickly on new knowledge. After the Webasto cluster came under control, Fröschl and his colleagues got to work applying what they learned from the experience — establishing protocols for diagnosing, isolating, and treating Covid-19 patients safely.
This meant that by the end of February, when travelers started returning from Austria, Italy, and other countries with outbreaks, they were ready. The Webasto outbreak gave doctors and public health officials “extremely valuable” experience dealing with the virus. “Everything was in place,” Fröschl says. “We had experience of how to treat people and remain calm.”
There was also learning from other countries. “We tried to take the strategy of South Korea, Japan, and Taiwan — all good examples of how a quick and fast response can reduce the number of positive cases,” said Nicolai Savaskan, the chief medical officer of a local health department in Berlin. One part of that fast response: Germany’s mass testing program. While Germany was quick to lock down, it also scaled up testing from the start of the pandemic, and then repeatedly adapted the program to respond to changes in the epidemic dynamics.
In anticipation of a rise in cases following summer travel, for example, labs across the country scaled up their supply. You can see the result of this in the country’s test positive — or cases divided by tests — rate. This metric tells you whether a country’s testing capacity is rising in step with the demand for testing and growth in real cases. Since the beginning of May, relatively early in the pandemic, Germany’s test positive rate has held steady even though cases have increased, while the rate started to rise in July and August in other European countries currently experiencing the worst outbreaks, including France, Spain, and the UK.
All of @OurWorldInData's data on COVID-19 testing has just been updated.— Edouard Mathieu (@redouad) October 14, 2020
Latest positive rates in Europe:
United Kingdom: 5.9%
(Source: https://t.co/z0HnOz4gb5) pic.twitter.com/rsK5lXMWEF
“There have been ups and downs in Germany’s [outbreak], but the difference is they managed to scale up testing,” said Edouard Mathieu, the Paris-based data manager of Oxford University’s Our World in Data project. From May to the present, Germany went from around 60,000 tests per day to a staggering 160,000. And even now, Germany is again adapting its testing approach: adding a new rapid, antigen-testing strategy that will launch this week, the Wall Street Journal reported, to increase capacity as cases rise going into winter.
This also helps explain why outbreaks in the country — or even screw-ups like failing to notify positive cases quickly — haven’t spun out of control yet, as we’ve seen in other countries. “They are testing more people every time they find a case, which means they haven’t lost touch with the epidemic,” Mathieu said. It also means they didn’t waste their early lockdown: They used it to build robust systems that will likely help them control the current uptick, too.
The power of local responses
Germany, a federal country made up of 16 states with some 400 municipal health departments, ran a localized coronavirus response.
Though this has sometimes led to a confusing array of policies, it’s also meant municipal governments could act quickly and tailor pandemic policies to the needs and challenges facing local populations across 16 federal states with 400-plus counties.
And this may be another reason for Germany’s success compared to neighbors with more centralized systems such as France, Spain, and the UK.
“The decentralized [approach to] managing the pandemic was maybe a good way to deal with a quickly changing situation,” said Berlin’s Savaskan. He explained that while local health authorities have to report cases to Germany’s national public health agency, the Robert Koch Institute (RKI), they could each tailor their pandemic responses to meet local needs in their region and react quickly whenever problems arose.
So, for example, while the RKI recommended a 14-day quarantine after contact with an infected person, in Berlin, health authorities decided that was too long to be acceptable for the population and that a seven-day quarantine with a coronavirus test at that point would do. “We could adapt what was recommended by RKI and then implement ... [to] locally fit the needs of the people,” Savaskan said.
Similarly, early on in the pandemic, in March, Berlin decided to shut down bars, dance halls, and nightclubs ahead of other regions, since they were local sources of contagion. When they reopened in June, municipal health authorities were in constant contact with the industry to encourage them to cooperate in contact tracing.
“We have a rate of contact tracing higher than 90 percent,” Savaskan said, meaning nearly all the contacts of infected people are being identified and followed up with.
When we talked at the end of September, Savaskan was heading to meet the health minister in Berlin. Outbreaks in bars and nightclub settings were on the rise again, and politicians wanted to engage local health departments on how to get the situation under control. By October 10, a midnight curfew for bars and clubs went into effect.
“The narrative so far in Germany concerning the public health departments is that people trust in them — they believe that when they give very detailed information about their life, this is taken very seriously. And I think this is the major impact of the success of the German response,” Savaskan said. It’s also allowed authorities to identify and stop chains of infection at an early stage.
The power of listening to scientists
There’s one other L that sets Germany apart. It’s the most straightforward of them all — but it’s certainly not being done in many countries, particularly the US. From the moment the coronavirus arrived in Germany, German authorities have been good about listening to scientists, says Clemens-Martin Wendtner, a Munich-based internal medicine doctor. Wendtner would know: He was also part of Germany’s coronavirus front line, overseeing the treatment of the country’s first patients in Munich.
He, too, didn’t mention Angela Merkel when I asked him how he explains how Germany managed to control the coronavirus. Instead, he said local politicians did something that now seems like a foreign concept in America: They listened to scientists.
Since February, Wendtner has been texting new findings and insights to the health minister in Bavaria — the German state that’s home to Munich — every week. And during the first weeks of the pandemic, before heading to the hospital, he’d join a 9 am briefing in the office of the health ministry to share his data there, too.
“Every [piece of] information we had from the hospital, they also had from the political decision side,” he said.
So that’s why Germany instituted a mandatory mask policy in public spaces in the spring and shut down schools. That’s why Jens Spahn, the federal minister of health, retracted the idea of Covid-19 immunity passports after listening to scientists. “He used the direct approach, just calling me here in my office,” Wendtner said.
As the science evolved and leaders listened to scientists, the policies keep changing. Recently, the Bavarian government decided to invest 50 million euros in hepafilters that deactivate infectious aerosols for use in classrooms across the state. “It’s not reasonable to open the window in Bavaria every 20 minutes” in winter, Wendtner said. So as temperatures drop, filters might help keep schools open at a time when we know the coronavirus can spread through aerosols, especially in poorly ventilated rooms.
Of course, science hasn’t been free of politics in Germany. And in the race to find a successor for Merkel, state politicians have certainly used the pandemic to increase their profile. But the big picture, Wendtner says, is that the public trusted German politicians “because they didn’t lie in the beginning and [they] built up trust,” following science, not denying it.