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COVID-19 in Germany: Explaining a Low Death Rate

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Photo: privately owned by the author and the man in the picture.

On 31st March 2020, www.worldometers.info calculated the global death toll from Corona tallied 38,000. Among comparable European countries, Italy (population 60 million) had 11,600 Corona deaths, Spain (46,6 million) registered 7,700, France (67 million) 3,000, the UK (67 million) noted 1,400 deaths, the Netherlands (17 million) 740, the USA (330 million) 3,000, and Germany (83 million) just 645 deaths. In other words, despite Germany’s relative high population, it registered a surprisingly low number of Corona deaths. Seen as death per one million people, Italy had 192 deaths per million and Germany just 8.

Surprisingly, Italy has 28% less people compared to Germany but a staggering 1,800% higher Coronavirus death rate. To many, this is highly perplexing. The number of Corona deaths in Germany is astonishingly low. Why this is the case remains somewhat of a mystery. Not unexpectedly, Germans have started debating the reasons for this. Is it because of the age of those affected, the testing or have Germans just been lucky so far?

Italy had more than twice as many cases as Germany. To be honest, we still know too little, says Richard Pebody (WHO). The case mortality rate is puzzling, he noted. Mr Pegody also warned against comparing countries. The health framework and conditions are different in each country. It is a bit like comparing apples to pears. However, there are still several explanations, all of which play a role and many Germans look to Italy and Spain.

Italy and Spain are already further into the epidemic than Germany. Their first cases may have appeared undetected, occurred much earlier, and the virus probably spread unnoticed in the population of both countries. It takes a while for complications to occur after the infection. Then, many patients are in intensive care for weeks before they die.

Secondly, in many countries very little testing has been carried out and often only the average age of those shown to be infected is known. Among the uncounted cases are likely to be many younger people who have already had the virus but have not experienced any or only mild symptoms. Among those shown to be infected, the average age in Italy is much higher than in other countries, including Germany. Whilst the average age of Corona cases in Germany is 45 years, in Italy it is 63. On the other hand, according to Bloomberg’s Global Health Index, Italians live a much healthier life compared to Germans. And unlike Italy, Germany has only limited post-mortem testing of Corona virus cases.

Germany’s Robert Koch Institute, for example, only counted the age group over 60 for one study. Yet even in this study, the proportion in Germany is well below the Italian figures. 19% of those who were proven to be infected in Germany were over 60 and more than half were between 35 and 59. With regard to Italy, it is important to stress that we are only talking about proven cases.

The age structure of cases is different in both countries. Another unknown is the testing regime in any given country. If more recent cases were tested in Italy, the case mortality would probably be quite different. Yet there is a very aggressive testing strategy in Germany so there are likely to be more mild cases among the total number of confirmed cases.

Quality of health care

The better prepared hospitals are, the more lives can be saved. When hospitals are overwhelmed by the number of patients, it is a simple question of how care can be provided and whether doctors can respond to any change in the patient’s condition in the intensive care unit. Three factors are crucial: the number of intensive care beds, sufficient protective clothing, and well-trained staff in the intensive care units.

Italy had 5,000 intensive care beds before the crisis. More have been created since. Britain had 4,100 intensive care beds. In Germany, there are about 28,000. Germany’s number is to be doubled in the near future. Meanwhile military hospitals have been opened to the German public. Overall, experts agree that rigorous testing, isolating infected people, and quarantine for people who have been in contact with infected people are holding back the epidemic. The mortality rate currently is at about 0.4% in Germany.

Meanwhile, there is a drastic reduction in social contacts throughout the country. In the first week of March, about two weeks before Germany’s contact ban was declared, up to three quarters of the population met with friends and relatives only privately. To date, the proportion of those who continue to meet has fallen to about half of the population. The other half follow the government’s Social Distancing request and no longer meet with other people in close contact. 97% support the ban on public events; 95% think it makes sense to close public facilities and borders. A quarter of Germans would welcome a termination of public transport for local and long-distance transport. 

Just one quarter of Germans work from home

As far as everyday work is concerned, the crisis has not brought any significant change for the majority of the population. Just over half of all Germans work on site at their place of employment. One quarter has changed from their workplace office to a home office. Around 10% are exempt from work and continue to receive wages.

The vast majority of those infected in Germany are younger than 60. This is partly due to the many tests that Germany carries out and good equipment to treat the seriously ill patients. However, experts have repeatedly warned that the death rate will continue to rise in Germany even though the number of deaths is always a reflection of what happened some time ago.

On Monday (23rd March), more than 26,000 Germans were infected by the Corona virus. Germany and Italy have a similar age structure, with just under a fifth of the population aged 65 or over. But Germany responded quickly to the virus outbreak. It also tested people with mild symptoms if they had contact with an infected person or were themselves in a high-risk area. Many younger Italians are infected or have been infected without ever being recorded. This also explains the supposedly higher mortality rate caused by the virus there. In Germany, the highest number of deaths were recorded in the most affected states of Bavaria, Baden-Württemberg, and North Rhine-Westphalia. Some of these had a chronic disease before being infected by Corona. Several of those infected with Corona virus lived in old people’s or nursing homes.

In Germany, some presume that rising temperatures to be experienced during the coming spring and summer months will only have a small impact on the spread of the virus. Still, epidemic viruses such as influenza are sensitive to UV light and even drought. In addition, many in the population will have built up immunity to the viruses during the winter months. In combination, this contributes to the fact that influenza viruses do not multiply as much in warmer weather.

Germany’s government is trying to slow down the spread of the virus, but not necessarily stopping its spread. This scenario aims to relieve Germany’s health system and protect patients at risk. To curb the virus, researchers have combined a number of measures in their calculations: symptomatically ill people would be isolated, household members should go into voluntary quarantine. In addition, social distancing should be maintained with people over seventy years of age.

Germany believes that if the pandemic is to be consistently suppressed, the number of infections will be kept low in the long term. This however will only work if the entire population isolates itself, regardless of what it means for the economy and people’s social life. If the spread of Covid-19 is slowed down, scientists expect half as many deaths. But even when slowed down, the epidemic will still kill hundreds of thousands of people, globally.

If the epidemic is to be suppressed by means of isolation measures for the entire population, these measures would have to be sustained for 18 months or more. After all, if the measures were relaxed without an available vaccine, the number of people infected would quickly rise again due to a lack of immunity in the population.

If the Corona virus pandemic is slowed down, the need for people in need of intensive care at any one time will decrease by two-thirds. If countries resort to even more drastic measures, hospitals could more easily deal with patients. This would require isolating people with symptoms while schools and universities are to be closed for five months. In addition, everyone would have to limit their social contacts by 75%. These calculations are made without considering the economic price society, business, and capitalism as a whole would have to pay.

Covid-19 survives up to 24 hours and on plastics and stainless steel two to three days. However, the so-called infection dose of the virus is significantly reduced on all surfaces over these periods. According to Germany’s Health Ministry, a lubrication infection is possible. In general however, human coronaviruses are not particularly stable on dry surfaces. So far, there have been no cases in Germany in which people have been shown to have been infected by contact with contaminated objects.

Almost all the infected people have several days of loss of taste. Still, the loss of taste is a comparatively mild and common symptom during respiratory infections. Meanwhile 91% of those infected with Corona had shown only mild to moderate symptoms such as dry cough and fever. In addition, 30% had diarrhea. This is found to be more common than previously thought. At the same time, Germany’s Robert Koch Institute has dampened hopes for an early vaccine against the virus. It considers it realistic that we will have a vaccine by spring of 2021. Still, Germany’s government said that anything that is bureaucratically feasible will be done. Clinical testing periods, however, cannot be shortened. After all, the vaccines should be one thing above all: safe.

In recent days, Germany registered approximately 40,000 infected people. In harsh mathematical terms, the key issue is lethality – the technical term for the death rate, about 0.4% in Germany. Part of Germany’s low death rate is due to very reliable methods of assessing and reporting Corona deaths. In addition, one should take into account how long the outbreak has lasted already. Diseases and deaths do not occur at the same time. Furthermore, there are often large numbers of unknown cases when registering infections.

In Germany, the number of undiscovered cases is likely to be lower than in many other countries. Germany’s Robert Koch Institute regularly points out that in Germany comparatively many people are tested. Many infected people with mild or no symptoms are also recorded. But even beyond statistical distortions, there are explanations related to other differences. This includes the age of the sick. In Germany, Sars-CoV-2 had hit younger people during the SARS epidemics in the early 2000s, while in Italy and Spain the older had had a higher rate of infection.

Smoking is suspected to be another factor. Damaged lungs from cigarette use could favor severe gradients of Covid-19. This link may explain why men, among whom smoking is more prevalent, are more likely to become infected and die more often than women. Differences between Italy and Germany cannot, however, be explained on a blanket basis. Smoking rates in both countries are roughly the same.

The impact of air pollution is also discussed. In northern Italy, the concentration of particulate matter is considerably high. Dirt particles can exacerbate chronic lung disease, making it harder for patients to fight pneumonia.

In the end, three key issues made Germany different compared to Italy. Firstly, Italy’s government waited too long to contain the spread of the Corona virus. Early detection and fast action can successfully restrict the spread of the virus. This is a mistake Germany has largely avoided while other counties seem to make the same mistake. By claiming Corona to be just a little flu and fostering inaction for a staggering six weeks, Donald Trump has aided the spread of the virus in the USA. Similarly, his right-wing populist counterpart Alexander Boris de Pfeffel Johnson initially fancied the out-dated and disproven l’idée fixe of herd immunity. As a typical concept of the nasty ideology of Social Darwinism, herd immunity will, most likely, kill the weak and the elderly until immunity is established. It is unlikely to kill the Eton and Oxbridge trained elite like Boris Johnson himself. Johnson was very recently going around hospitals shaking hands to show that Corona isn’t dangerous. The hypocrisy of right-wing populist leaders towards their very own electorate is mind numbing.

Secondly, for decades Italian fashion companies have imported sweatshop labor from China to manufacture garments. Some of these workers have imported the Corona virus to Northern Italy. There is nothing wrong with workers from China. What is wrong, however, is the right-wing propaganda of protecting Italy’s borders from people in leaking boats (e.g. Salvini), while at the same time allowing capital to operate sweatshops with insufficient hygiene standards, slave wages, and inhuman working conditions. Today, these workers together with elderly Italians have to pay a bitter price for the glamor and profits of Italy’s fashion industry.

Thirdly and finally, there is a difference in the capacity and quality of the health system. Unlike Berlusconi and entourage, German conservatives – from Bismarck to Hindenburg, Hitler, Adenauer and more recently, Helmut Kohl and “his girl” Angela Merkel – have always favoured the strong state over Neoliberalism’s free market. Countries where neoliberalism has hold sway have damaged their health care system in the course of it. The USA and the UK are prime examples. An insufficient health system is also likely to be particularly relevant in poorer countries. What is certain is that, despite its good health care system, Germany is not immune from more dramatic developments. We are still only at the beginning of the epidemic

Thomas Klikauer is the author of Managerialism (Palgrave, 2013).