The Covid-19 pandemic isn’t over in Germany, but the country has managed its first wave of infections effectively. As a surgeon, I’ve been asked why Germany has lower mortality rates among infected patients compared with many other nations, in Europe and elsewhere. Most people assume that Germany’s resilience stems from its health system’s ample supply of mechanical ventilators and hospital beds for intensive care. Germany’s success thus far, however, isn’t related to the quality of its health-care system—German hospitals haven’t been overwhelmed by demand at any point. The answer lies in a combination of good fortune and good planning.
One major factor is the age of most infected individuals when the outbreak began in the country. The first reported infections in Germany occurred six weeks after the official reports of Covid-19 in Wuhan and about two weeks after the disease’s onset in Lombardy, Italy. In addition to a minor outbreak near Munich, the virus was also identified in a small Rhine Valley town during the region’s carnival season. Most cases, though, occurred shortly thereafter among young and middle-aged Germans returning from skiing vacations in the Alps. These individuals spread the disease, mostly within their age groups. For a period of more than two weeks, the mean age of infected citizens remained at about 46 years; individuals 60 years and older represented no more than 16 percent to 18 percent of cases during that time. A fraction of those were admitted to the hospital. Few required ICU treatment, and only a small number died.
Thus, the initial presentation of Covid-19 in Germany was among middle-aged people at low risk—a matter of pure luck. This reality allowed government leaders and hospitals to prepare for the risk of viral spread to the country’s more vulnerable and elderly populations. So far, this scenario hasn’t occurred.
Few German families of more than two generations live in the same household. Only in rural, agricultural areas do families enjoy the luxury of housing children and grandparents under one roof. Most of Germany’s elderly couples live on their own, often far from their children. Even when one partner dies, the survivor will remain in the house as long as possible. When living alone becomes difficult, home care is usually provided by mobile nurses who specialize in helping senior citizens.
This system protected Germany’s elderly population from the early onslaught of Covid-19. Limited outbreaks in nursing homes were likely caused by staff. In response, groups of nurses decided to stay inside their respective institutions to avoid spreading the virus further. German hospitals thus didn’t see large numbers of elderly citizens during the first wave. Even now, toward the end of that first wave, the rate of people infected above age 60 remains below 25 percent.
The age of Germans dying from Covid-19, however, tracks similar figures in Italy and Spain—its mean being just above 80 years. If a second wave arrives, Germany will need to focus on protecting this age group. For now, we have experienced a lower death rate thanks to existing demographic and societal factors.
In my clinical unit, two young surgeons from Northern Italy provided daily reports about the crisis in Lombardy. In the beginning, Italy was about 12 to 14 days ahead of Germany with the spread of infections. I received pertinent information about Italy’s shortage of ICU beds and personal protective equipment (PPE) for medical staff; the neglect of social distancing among certain population groups; and daily figures on new infections and death rates. In the early going, we assumed that rising cases in Germany would parallel Italy’s figures from two weeks before, and we accepted the prognoses that health experts offered regarding the rate of transmission and the threat that the disease posed to the elderly.
Political decision making proved crucial during the early stages of the crisis. Chancellor Angela Merkel, herself a research scientist in quantum chemistry, was eager to hear from epidemiologists, as were cabinet members and prime ministers of Germany’s federal states. These leaders took early measures. On the twelfth day of the outbreak, for example, larger gatherings like sports and cultural events were cancelled. Five days later, Merkel and the prime ministers declared a nationwide shutdown. Schools, universities, and restaurants closed, and visitation at seniors’ private residences, nursing homes, and institutions for handicapped people was suspended.
Public compliance is perhaps the most significant factor in Germany’s success up to now. Information about Covid-19 was shared rapidly and widely, and the restrictive measures were clearly explained, often through public political discussions. The German public supported and adhered to the new arrangements. It appears, then, that concerted action of Germany’s scientists, politicians, media figures, and the public has prevented the wider outbreak of infection seen in other countries. In Hannover, where I practice, the Covid-19 hospital that we planned and constructed on the local fairgrounds hasn’t been used. I hope that it remains empty.
As a cardiac surgeon, I didn’t have much involvement in the care of Covid-19 patients unless they needed high-end oxygenation strategies for pneumonia. But it seems to me that Germany’s reliance on a strong social system of public services has proved successful, at least through the first stage of this crisis.
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