The country that got coronavirus right

From extensive testing to early track and trace, Germany is a model for tackling the disease.

This April, Walther Leonhard got an unusual call from the authorities in Rosenheim, his hometown in southern Germany. He was being given a new job, in a new field, with a title that had just been invented, "containment scout".

Leonhard, 33, who had been working as a court officer in Munich, was soon back home and hitting the phones. He was the latest recruit into Germany's army of Kontaktmanagers (tracers) — the foot soldiers of its strategy for containing coronavirus.

Leonhard's job is to call people who have tested positive — and all those they have recently come into contact with — to tell them to self-isolate for a fortnight. It's not much fun. A lot of people are scared and confused when he breaks the news.

"They ask how they'll be able to feed themselves, what they should tell their boss, whether they can go for a walk — and you tell them, 'No, you have to stay inside your four walls,' " he says. "And you say, 'This isn't some mean, vile thing the government is doing to you — it's for your own protection, and to protect those around you.'"

Combined with its six-week shutdown, Germany's "track and trace" system has been instrumental in stalling the spread of Covid-19 and preventing it from overwhelming the health system.

It has also helped that the country has a well-oiled government, led by Angela Merkel, a physicist, that has avoided the screeching policy zigzags seen elsewhere. On April 17, authorities announced that the pandemic was under control — less than six weeks after Germany's first deaths from Covid-19.

The country saw its first outbreak in January at the headquarters of Webasto, an automotive supplier near Munich. The source was quickly identified as a Chinese employee who had been attending in-house workshops there.

Some 10 employees ended up getting infected — one after using a salt shaker handed to him by a colleague with the virus. After extensive detective work, those with coronavirus were swiftly isolated, their friends and relatives found and alerted.

"Contact tracing has been important ever since Webasto," Jens Spahn, Germany's health minister, tells the FT. "With Webasto, we managed to quickly recognise all the chains of infection and interrupt them. And that meant we were able to stop it spreading all over the country."

It has also helped that the country has a well-oiled government, led by Angela Merkel, a physicist. Photo / AP

Some experts think it's not entirely fair to hold Germany up as an exemplar of crisis management. "There are other model countries that have received much less attention, such as Vietnam, which has seen no deaths at all from Covid-19," says Hendrik Streeck, professor of virology at Bonn University.

A lot of Germany's relatively good performance was down to luck. "[We] had the advantage that we had more time to prepare," he says. "We saw the images from China and Italy before the wave hit us too." But it also reacted more quickly to those images than other countries, he says, with "consistent testing and track and trace".

The figures bear that out. By June 1, Germany had 183,508 confirmed Covid-19 cases, according to data from Johns Hopkins University, making it the world's ninth-worst-hit country.

But the number of infected people who have died is remarkably low — just 8,546, or about 4.7 per cent of the total. That works out at roughly 103 deaths per million inhabitants, compared with 430 for France, 554 for Italy and 579 for the UK.

It makes a difference that the chancellor is a scientist and her chief of staff a doctor. That has shaped our response to this pandemic." - Reinhard Busse, physician and health economist

This occurred despite one of Europe's least draconian shutdowns. Though schools, non-essential shops and restaurants were closed for weeks, a large proportion of businesses and factories continued to operate as normal. Germany also left lockdown more quickly than many of its neighbours.

More importantly, the health system never came under too much pressure. "We never reached the point where we had too many people in intensive care," says Streeck. "That meant we were never faced with the need for triage — when you only treat those patients with a greater chance of survival. For us, triage was only ever a theoretical possibility, never a real one."

In Rosenheim, it could have been very different. A short drive from the Austrian border, this bustling, affluent town, with its medieval centre and grand 19th-century facades, was one of the hardest hit parts of the country. Locals returning from Shrovetide skiing holidays in nearby South Tyrol brought coronavirus home with them, while a three-day "strong beer" festival that started on March 6 acted as a "super-spreader".

By late May, Rosenheim district had suffered 183 deaths from Covid-19 and 864 coronavirus infections per 100,000 people — one of the highest ratios in Germany.

Katharina Lenherr is senior physician at Rosenheim hospital's internal intensive care department, a heavily fortified space packed full of ventilators and monitors and stacks of protective gloves and gowns. During a break from her shift, she recalls the sense of dread that staff experienced in late March when their first patient, a man in his fifties, died of the disease.

Medical staff wearing protective masks and clothing bring a patient to the emergency room at the St. Josef Hospital on April 1, 2020 in Bochum, Germany. Photo / Getty Images

"It was one of my most emotional moments, because it was so unexpected and happened so quickly," she says. "We did everything we could for him. We spent an hour trying to revive him. And it didn't help." She recalls the feeling of bewilderment that settled on the ward. "We stood there and said, 'OK, coronavirus has arrived here now, with full force,'" she recalls. By mid-April, 64 of Rosenheim's Covid-19 patients had died of the disease.

But the hospital was well-prepared for the coming storm. It increased the number of intensive care beds for coronavirus patients, from seven to 63, commandeering ventilators from elsewhere, merging wards, rebuilding whole clinics and constructing makeshift isolation areas. "Within a week, we had the first additional intensive care wing, and within the second week another," Lenherr says.

The office of Jens Deerberg-Wittram, managing director of RoMed Kliniken, a not-for-profit group that runs Rosenheim's hospital, resembles a war room. Behind his desk hangs a detailed map of the region and a complex, colour-coded chart showing where the town's various ICU beds — blue for high care, green for medium and red for low — are distributed.

Just as in a war, he oversaw a mass mobilisation of personnel. "We employed 150 more people, medical students, retired doctors," who were put through a crash course in intensive care medicine and the use of ventilators, he says.

Meanwhile, locals rallied round. The head of a children's orthopaedic clinic, closed during the shutdown, sent respirators and staff to operate them. A local plastics manufacturer donated a 300m roll of sheeting, used to create protective shields around infectious patients.

Still, the scale of the onslaught was scary. At its April peak, Rosenheim had an alarming 200 cases — a lot for a town of 63,000. One Friday that month, seven patients were put into intensive care in the space of just nine hours.

Worried by the rising toll of infections, Deerberg-Wittram had called Markus Söder, Bavaria's prime minister, in early April and pleaded for help. "I told him, 'If it gets bad, we won't just need beds with respirators — we'll need helicopters to take patients to other hospitals,' " he says. Söder said he'd do what he could.

In the end, though, it never came to that: Rosenheim always had enough ICU capacity. That was partly due to a grim truth about Covid-19: at least half the patients artificially ventilated died within four to five days, some of multiple organ failure — a phenomenon that has been seen in many other hotspots. This meant beds were freeing up more quickly than expected.

Rosenheim was also able to transfer patients whose conditions had stabilised to smaller clinics, where they were weaned off their ventilators and brought out of artificial comas. "Because of that we could withstand the pressure of patients, prevent a catastrophe and avoid the situation you saw in Italy," says Lenherr.

This pattern was being replicated across Germany. A key role in ramping up preparations was played by the country's health ministry, led by Spahn, a 40-year-old politician who has long been seen as a potential chancellor. His department intervened early, telling hospitals to postpone all elective procedures. "That freed up a lot of intensive care capacity, which gave us an important buffer at the peak of the crisis," says Spahn.

The call was backed by financial incentives: the ministry promised hospitals €560 ($970) a day for every bed they kept vacant for a potential Covid patient and €50,000 ($87,000) for each additional intensive care bed they created. Even before those measures were introduced, Germany had many more intensive care beds than other big European countries — 34 per 100,000 people, compared with 9.7 in Spain and 8.6 in Italy. This ratio increased in the pandemic, with the number of ICU beds rising from 28,000 to 40,000. There were so many that, in the end, a large number stood empty.

More broadly, the pandemic hit at a time when Germany's healthcare system was in an excellent state. "There have been no austerity policies in our health service," Spahn says. "Apart from a small dip in 2008-09, spending has been rising steadily every year for 15 years."

Indeed, while the financial crisis forced its neighbours to tighten their belts, Germany lavished money on healthcare. Between 1993 and 2017, state spending on health rose 130 per cent to €230bn a year. A big reason is demographics: social care of Germany's ageing population claims ever greater sums.

Outside of the US and Switzerland, Germany now spends more than any other country on health — equivalent to 12 per cent of its economic output.

Part of the German system's strength is how uniform it is in terms of financial resources and the quality of care — a factor that contributed to combating coronavirus. "Our hospital landscape is extremely homogeneous," says Deerberg-Wittram, who has worked across the UK and knows about regional disparities in the NHS. "There are no real weak spots — the standard of care is the same everywhere."

Germany's system also benefits from being much more decentralised than, say, the NHS. Town hospitals are often controlled by elected local mayors, rather than by regional or central government. "The mayor of Rosenheim needs great schools, swimming pools and a great hospital, and that's the same for the mayors of Hamelin and Münster too," says Deerberg-Wittram.

Spahn sees the decentralised nature of health provision as an asset. The hundreds of mayors "don't just get orders from above . . . A lot more people have to take on responsibility and make independent decisions," he says. "And if they didn't, they'd have to answer to their voters."

Rosenheim provides a perfect example. As the crisis worsened, a "civil protection management team" was formed, made up of local officials and senior doctors from all the regional hospitals. It decided which patients were sent where, how to share out scarce protective equipment and where to create additional capacity. "There were really no instructions from Berlin," says Deerberg-Wittram. "Decisions were made locally, on the spot."

The dispersed nature of decision-making also played a big role in the rapid expansion of testing — a key feature of Germany's pandemic response. The UK abandoned mass testing in March, concentrating limited testing resources on hospitals instead.

German chancellor Angela Merkel with health minister Jens Spahn in April. Spahn's department played a key role in ramping up preparations to tackle the pandemic. Photo / AP

That same month, Germany conducted about 160,000 tests every week, based on a diagnostic test pioneered by the Charité hospital in Berlin. By mid-May, that figure had risen to more than 360,000 tests carried out by 128 private and public labs.

Testing was widespread in Rosenheim. In early March, Fritz Ihler, a local GP, helped set up a drive-in centre, manned by people in white and orange protective suits, in a central car park. It was soon inundated. "At its peak, we were doing 100 tests a day here," he says.
Later, he adds, local GP practices got together, rented premises and set up their own diagnostic centres. This relieved local hospitals, "which in any case didn't have the capacity to do so many tests themselves".

The prevalence of testing meant cases were identified at a much earlier stage, and people could be admitted to hospital before their condition worsened — one of the reasons why Germany's death rate has been relatively low.

"In Italy, people waited far too long and by the time they got to hospital they were seriously ill," says Deerberg-Wittram. "That just overwhelmed the health service there. In Germany it was the opposite."

Meanwhile, the authorities were gradually ratcheting up restrictions on public life. On March 8, they recommended the cancellation of all big public events. Five days later, most of Germany's 16 states closed their schools and kindergartens. Then, on March 22, the government closed shops and restaurants and banned meetings of more than two people.

At the same time, Berlin launched a massive economic aid package that, according to the Bruegel think-tank, is equivalent to 10.1 per cent of the nation's gross domestic product — larger than that of any other western country.

It included a €100bn fund to buy stakes in affected companies, €50bn in direct grants to distressed small businesses and €10bn for an expanded furloughed worker scheme. The aid came in very useful — according to government forecasts, Germany will this year face the worst recession in its postwar history.

While the emergency fiscal response was spearheaded by the federal government in Berlin, shutdown measures were co-ordinated in a series of teleconferences between Merkel and the governors of the federal states, in which the chancellor, whose approval ratings soared during the crisis, deployed her powers of persuasion to reach a national consensus.

"This isn't in our constitution — it was newly invented for corona," says Reinhard Busse, head of the department of healthcare management at Berlin's Technical University. "It became the central organ of crisis management, and ensured that at least at the height of the pandemic, the response was highly uniform."

Though there were occasional tensions, vicious bust-ups of the kind seen between US president Donald Trump and state governors are unheard-of in Germany.

Much policy was overseen by Helge Braun, head of the chancellor's office. A trained anaesthesiologist, he worked for years in an intensive care and pain management clinic. "It makes a difference that the chancellor is a scientist and her chief of staff a doctor," says Busse. "That has shaped our response to this pandemic."

Jens Deerberg-Wittram says Merkel's heavy reliance on experts was a critical factor in the crisis. "She said, 'Before I do anything, I have to understand what's going on here,'" he says. This meant Germany's leading virologists played an outsized role in shaping policy. "There was a kind of 'no bullshit' attitude that dominated all decision-making," he says.

Merkel also had a secret weapon — Germany's network of 400 local health authorities, the so-called Gesundheitsämter, which have been doing contact-tracing for years. Underfunded and understaffed, they long led something of a shadow existence. Few people had much of an idea what they were there for, apart from measuring drinking water quality and tackling measles outbreaks.

Ministers admit they were under-appreciated. "Over the years they have not received the attention they needed," says Spahn. "A lot of savings were made and staffing levels reduced." But when the pandemic hit, they were beefed up with money and manpower, becoming one of the central pillars of Germany's crisis response.

When coronavirus came to Rosenheim, it was the local Gesundheitsamt that felt the full brunt. "We were seeing 130 to 150 new cases a day," says Wolfgang Hierl, its head, a tall, rangy man who works out of a spartan office festooned with charts of Covid cases. "It was like an avalanche."

The authority immediately embarked on the task of tracing and quarantining cases, as well as all their contacts. Staff were seconded from other parts of County Hall to help. "We got a forestry official, someone from the water authority, and even an employee of the state-run casino," Hierl says. But it soon became clear that more were needed.

On March 19, the Robert Koch Institute, Germany's main public health body, advertised for 525 "containment scouts" to help. It received more than 11,000 applications. Spahn's ministry earmarked €11.25m to finance the programme, and pledged that each district in Germany would ultimately have five scouts per 20,000 people.

Rosenheim automatically received back-up, including new recruits such as Walther Leonhard. "We got all kinds — from management students to future tax inspectors," says Hierl. Germany's record contrasts with the UK's sluggish response, with NHS Test and Trace launched only last week.

Leonhard admits the work was stressful to begin with. "The time factor was really important — the sooner you find the contacts, the more effectively you slow the infection," he says. "And there was a lot of pressure because each infected person had up to 10 contact people you had to reach."

Much of the job entails explaining the rules of self-isolation, and then checking up on people during their quarantine, asking if they have any symptoms, and if they have, whether they're getting worse. "I've had people who have stinging eyes or facial paralysis and [they] think it means they've got Covid-19," he says. "They need a lot of reassurance — they're very fearful."

Leonhard has less to do these days. But the authorities are keeping him on anyway. "Now with the numbers of new cases falling, contact tracing will become even more important," says Spahn. "It will allow us to identify every small outbreak and put out every little fire."

While Rosenheim's scouts were getting to work, the town's hospital was adapting to a new grim reality. ICU staff were enduring seven-hour shifts in full protective gear — respirator masks, plastic caps, face guards, surgical gowns and two pairs of gloves. Some suffered skin irritation and eczema. Lenherr admits that at the start she "nearly passed out" from having to wear so much PPE. "It's very, very exhausting," she says.

But a much bigger burden was the ban on visitors to Covid wards. "That really weighed on us," she says. She recalls the wrenching phone calls with relatives: "You tell them your loved one is about to pass away, but for your own protection you can't come to say goodbye."

Staff tried to compensate as best they could. In a patient's last moments, the medics who treated them would gather at their bedside. "In our ICU, no one died alone," she says.

Germany may have been more effective than other countries in containing the coronavirus pandemic. But the crisis also shone a spotlight on some deep deficiencies in the system.

One major issue: the acute shortage of PPE, especially masks — at least at the start of the onslaught. Like other countries, Germany found itself having to scour the world for increasingly scarce supplies just as its hospitals needed them most.

"We discovered how dependent we are on China for the supply of masks," says Hendrik Streeck. "It might have made sense to have a central distribution centre, with centralised purchasing of PPE."

Lenherr recalls scrambling to buy diving goggles and welders' masks. She and her colleagues now carefully store masks they would once have thrown away after use. "FFP masks cost €13 each now when they used to go for a couple of cents," she says.

Spahn recognises the flaws. "Should we have had more protective masks in Germany? In retrospect, yes," he says. He has sought to rectify the situation: in April, about 50 companies won a government-run tender to produce 50 million masks a week from August.

Germany has also proved slow off the mark when it comes to producing a tracking app, which is supposed to alert users if they have come into contact with anyone infected. One will be ready at some point in June — about two months later than planned.

Even when it's up and running, there is no certainty that Germans — who, with their memories of the Gestapo and the Stasi, are more concerned about data privacy than many of their neighbours — will embrace it. Old-fashioned contact tracers with pen and phone in hand will probably remain the mainstay of the system for some time to come.

Meanwhile, infection rates have slowed: Germany is now reporting a few hundred cases a day, compared with 6,000 a day in early April. As the crisis eases, the unity of purpose that defined the country's initial approach has broken down. In April, Merkel expressed frustration at the "unthinking" way some states were rushing to ease the shutdown.

These differences broke out into the open late last month when the chancellery sought to extend Germany's restrictions on social contact till July 5. The states rebelled, insisting they be scrapped by June 29. Some states are now increasingly ignoring Berlin and setting their own rules.

In Rosenheim, tough curbs remain in place: only people from two households can meet at a time, either in public or private. But other restrictions have been relaxed. Late last month, the streets were filling again with families and shops reopened.

"People are experiencing a second spring," says Hierl. "They're going out again, they're shopping, they're sitting in the beer gardens. That's all great." But he worries that they will forget about social distancing — and then the pandemic may flare up again. "I don't want to go back to having 150 cases a day," he says. "That was a truly terrible time."

Written by: Guy Chazan
© Financial Times