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Covid-19 Sentry

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From Preprints

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From Clinical Trials

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From PubMed

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Daily-Dose

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Contents

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From New Yorker

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From Vox

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+No country has had a perfect response to Covid-19. But nations around the world took steps to successfully limit the pandemic’s damage. In this series, the Pandemic Playbook, Vox is exploring the victories and setbacks in six places, including Germany, where a summer of virus suppression eventually gave way to fall, winter, and now spring waves. Unified, clear public health communication saved lives — but as the months dragged on, it was no match for shifting national politics, a fragmented system of government, and a public so tired of the pandemic that they came up with a word for the exhaustion: “coronamüde.” +

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+Germany still reports about two-thirds the Covid-19 deaths per capita as the rest of the EU, and about half the per capita death toll of the US. But its lead has shrunk over time, and at some points in the past few months, the country has reported more deaths relative to its population than either the EU or the US. +

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+So what happened? Germany’s federalist system — in broad strokes, similar to the US’s division between federal and state governments — allowed discord among the country’s leaders to have a major impact on the country’s response, slowing down major decisions. Politics played a growing role as well: In 2018, well before the pandemic, Chancellor Angela Merkel announced she would retire in 2021; the political jostling to replace her featured politicians trying to draw contrasts, often with a less cautious approach to Covid-19 than Merkel’s. +

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+All of this turned a nationwide response that was once marked by unity into one that was fragmented, dividing both the public and its leaders. +

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+“It was very much complacency,” Ilona Kickbusch, a political scientist focused on global health at the Graduate Institute of International and Development Studies in Geneva, Switzerland, told me. “There was a feeling that we’ll get through this relatively quickly. Many, many countries made that mistake — they thought this pandemic response would be a question of three to six months, but it’s turning out to be between 18 months and two to three years.” +

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+Germany’s experience during the coronavirus pandemic shows how a country can unite behind a single public health message and mission. But it also shows how fragile that victory can be — and how quickly an initial success can collapse once something goes wrong. +

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+Germany was initially united on Covid-19 +

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+Merkel’s first major speech on Covid-19 could be summarized in three words: “Es ist ernst.” This is serious. +

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+With the Reichstag parliamentary building and German and EU flags behind her, Merkel delivered a speech in her standard, matter-of-fact terms. “Take it seriously,” she urged. “Since German unification — no, since the Second World War — no challenge to our nation has ever demanded such a degree of common and united action.” +

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+In my interviews with people in Germany, they all described tuning in to Merkel’s speech. It was even a family affair. “We were all sitting in front of the TV, listening to her,” Klaus Wälde, an economist who’s done Covid-19 research at the Johannes-Gutenberg University Mainz, told me. +

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+ Steffen Kugler/Bundesregierung/Getty Images +
+German Chancellor Angela Merkel addresses the nation about the Covid-19 pandemic on March 18, 2020. +
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+Merkel knew what she was doing. A scientist herself, with a doctorate in quantum chemistry, she explained the need for open communication on scientific and public health issues: “This is part of an open democracy: that we make political decisions transparent, and explain them, that we establish and communicate our actions as well as possible, so that it becomes relatable.” +

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+She would continue to deliver these direct messages, breaking down what was going on and why Germany needed to take action. In another moment that went viral worldwide, Merkel explained the epidemiological concept of a pathogen’s reproductive number, or its R0, used by scientists to measure a virus’s potential spread. She warned that letting the virus spread at even a 10 or 20 percent higher rate could doom the country’s health care system months earlier than would otherwise be the case. +

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+The message trickled down to the local level. Cities and states were eager to avoid the horrors reported at the time in Italy, where hospitals were overwhelmed and death rates were high. +

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+One of those places was Jena, a city of around 110,000 located in the southern part of former East Germany. It had a major university hospital that left it well-positioned to confront the pandemic. In March, the Jena University Hospital made a crucial decision: It required staff involved in patient care to wear masks, well before mask mandates became the norm outside of East Asia. It subsequently found that masks sharply decreased Covid-19 infections among health care workers. +

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+ Christina Animashaun/Vox +
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+It wasn’t perfect evidence — certainly not a gold-standard randomized controlled trial — but it was good enough during an emergency, and public health officials took it to Jena Mayor Thomas Nitzsche. +

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+“In a pandemic, you cannot wait for the evidence,” Mathias Pletz, director of the Institute for Infectious Diseases and Infection Control and a doctor at Jena University Hospital, told me. “Sometimes, you have to make pragmatic decisions.” +

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+The mayor embraced the idea of masks. He told me he knew he wanted to get ahead of Covid-19. So he and his team devised what was in the spring a solution untried in Germany: a mask mandate. +

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+Nitzsche’s decision, announced on March 30, was not without risks. As in the US and other parts of the world, there were concerns across Germany about shortages of protective equipment, including masks, for health care workers. Some worried the public would reject a mask mandate as a violation of their freedoms. +

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+The mayor of Jena, Thomas Nitzsche, implemented a mask mandate early on during the pandemic. +
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+Petra Dickmann, an intensive care doctor with a focus on public health, helped Jena with risk communication during the early stages of the city’s pandemic response. +
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+Mathias Pletz, director of the Institute for Infectious Diseases and Infection Control and a doctor at Jena University Hospital, has been a key member of the city’s Covid-19 task force. +
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+Nitzsche knew the key to avoiding both these problems would likely come down to how the city’s leaders told the public about the policy. The government would need to transparently communicate the benefits of masks while acknowledging the downsides: Yes, they can be uncomfortable, but masks could flatten the curve, save your family and neighbors, and get life back to normal quicker. And to avoid a run on surgical masks, the local government would emphasize the value of cloth coverings, and encourage people to make masks not just for themselves but for others, too. +

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+“This took a lot of arguing and a lot of information campaigning,” Nitzsche said. “It’s very important to do this together with the people and not on the people. They need to understand. They need to accept. They need to intrinsically want to participate. Then it can work.” +

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+The city took a week before the mandate went into effect to persuade the public through its “Jena zeigt Maske” campaign. The local government blanketed public streets and walls with posters encouraging people to make and wear masks. City officials appeared on local and national media to explain their thinking and to push everyone to take the mandate seriously. Nitzsche posted his own messages on social media and YouTube. +

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+The city was also helped by two factors: The university hospital, a local economic engine, made the population more receptive to public health action. And the national media took a deep interest in Jena’s first-in-the-country experiment, giving the city’s campaign free publicity. +

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+When the mandate took effect in April, Nitzsche was at first surprised, then relieved. It seemed to work. People quickly and eagerly adopted cloth coverings. In public, mask use was nearly universal, as documented by media outlets in videos and photos that proliferated across the country. +

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+Then the numbers came in: Jena was successfully keeping its curve flat. As a study by Wälde and three other researchers for the nonprofit institute IZA in June 2020 found, the difference between actual coronavirus cases in Jena and the number estimated without a mask mandate, as predicted by a mathematical model, widened over time. After 20 days, the level of Covid-19 cases was 23 percent below the predicted level. +

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+ Christina Animashaun/Vox +
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+Nitzsche began receiving calls from his peers who saw the results in Jena: How did you persuade people? How did you get masks to the public? What were the challenges? +

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+By the end of April, each of Germany’s 16 states made masks compulsory. (By then, only seven states in the US had mandated masks; the total would never climb above 39.) +

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+Wälde’s study also found the nationwide adoption of mask mandates worked: The policies “reduced the cumulative number of registered Covid-19 cases between 2.3% and 13% over a period of 10 days after they became compulsory” and reduced “the daily growth rate of reported infections by around 40%.” +

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+Germany’s quick adoption of mask mandates shows what can happen in a united country. Germany’s federalist system, like the US’s, splits governing powers along local and state channels — a structure built, in part, to safeguard the former Third Reich against the risk of a takeover by a tyrannical leader. +

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+In good times, the system enabled local experiments, like Jena’s mask mandate. With the public on board and public officials following Merkel’s lead, one city’s success could spread to the entire country in just a few weeks’ time. +

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+A Red Cross rapid testing site located in the beer garden of a hotel in Jena. +
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+By midsummer, as the US saw its second surge of the coronavirus, Germany reported less than 5 percent the Covid-19 deaths per day as America. It was a culmination of its quick embrace of mask mandates, but also of other efforts: a lengthy lockdown lasting until early May, a scaled-up testing and tracing system that caught outbreaks before they exploded out of control, and a generally cautious public. Merkel pushed to take the pandemic seriously, and Germany did so with a range of actions. +

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+These kinds of numbers, enabled by the spirit of collective action, allowed Germany to open for the later parts of the summer. The warmer weather helped, as people were pushed outdoors and the virus struggled to spread in the open air and extra heat and humidity. But the change of seasons clearly wasn’t enough on its own. While the US suffered a unique second wave last summer, Germans had flattened the curve to the point that they could go back to restaurants and movie theaters without worrying so much about the coronavirus. +

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+“The first wave was managed quite well,” Clemens Wendtner, a doctor and researcher affiliated with Ludwig-Maximilian University in Munich, Germany, told me. “There was a very close interaction between scientists, physicians, and politicians. All of these things were coordinated.” In contrast to the US, he added, “we faced the facts. We knew exactly what was going on. No one was denying anything.” +

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+Over time, Germany became more fragmented +

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+In September, after Germany’s summer of freedom, Oktoberfest arrived. Munich’s iconic festival was canceled, but some beer halls around Germany held their own celebrations. Organizers claimed the gatherings were regulated with masking and social distancing requirements. +

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+But in reality, many Germans came together, maskless, by the dozens in indoor spaces, sitting tightly across long tables as they drank beer, yelled, and laughed — spitting all over each other particles that can carry the coronavirus and transmit the disease. +

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+It was emblematic of the kind of freedom, beyond Oktoberfest, that Germans embraced when they came back home from summer holidays, pouring into risky indoor spaces and disregarding some of the precautions recommended by experts and officials to contain Covid-19. +

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+So Germany’s Covid-19 cases, along with much of Europe’s, began rising once again. It matched what experts had warned about for months: As the weather cooled and people were pushed indoors, countries needed to step up their precautions, reeling back summer freedoms to prevent a fall surge. Merkel had told Germans that the months to follow would be “even more difficult than now.” +

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+ Christian Ender/Getty Images +
+People gather at the beach in Hamburg, Germany, on August 11, 2020. +
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+But now, much of the country didn’t heed the warnings. +

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+Case numbers were still low compared to worse-hit nations, but they were rising, with daily new cases roughly tripling from July to August. Officials seemed content to keep letting the virus spread at a faster rate, letting things get worse bit by bit. Some state leaders resisted anything resembling a lockdown; North Rhine-Westphalia School Minister Yvonne Gebauer, bolstered by regional cases dropping to the national average, argued masks in classrooms were “no longer necessary.” +

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+These state leaders were backed by vocal anti-lockdown segments of the population, which marched in the streets in August to oppose Covid-related restrictions. The initial success against the virus — and the short-term economic damage a lockdown would bring — had also left more of the public cool on the need for harsher rules. +

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+By the end of October, the scenario Merkel warned about early in the pandemic when she explained exponential spread to a worldwide audience, came true: Daily new Covid-19 cases in Germany multiplied by seven times in the span of the month. +

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+The success of the past few months had built complacency, and the federal system that allowed Jena to experiment with masks now suffocated further progress. The country’s 16 state governments and Merkel’s federal government couldn’t come to an agreement until it was too late, after they saw the results of exponential spread firsthand. +

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+Even then, the country’s governments by November only agreed to what they called a “lockdown lite,” which closed bars, restaurants, and several other indoor spaces. Cases remained stubbornly high throughout November — more than triple the spring peak of Covid-19. It wasn’t until late November that Merkel finally got the 16 state governments to sign on to a stricter lockdown. +

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+ Ying Tang/NurPhoto/Getty Images +
+Police enforce social distancing rules in front of the central railway station in Cologne, Germany, on October 9, 2020. +
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+Shoppers during the Christmas shopping season in Cologne, on November 8, 2020. +
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+“That’s a federalist problem,” Fabian Hattke, a public policy expert at the University of Hamburg, told me. Until later in the fall, “the heads of states did not agree on common measures — some went stricter, some went looser.” +

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+Public fatigue with Covid-19 — that coronamüde — also played a role. Based on his own analysis, Christian Karagiannidis, a researcher and ICU doctor at Witten/Herdecke University, told me that the second set of lockdowns was only “50 percent [as effective] as that from the first wave.” He added, “People are more or less fed up. They are tired. They are not adherent to the measures that were implemented by the German government.” +

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+Even after the new lockdowns, Covid-19 cases spiked around Christmas and then again in early January. An increasingly strict lockdown wasn’t enough to stop the foundation that the coronavirus had been allowed to build just before the perfect time to strike. +

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+Merkel appeared to see much of this coming. As Germany prepared to reopen last summer, she called the country’s success in fighting Covid-19 at the time “fragile,” adding that Germany should be “smart and careful” in the coming months, regularly reevaluating the rules it set in place. But Merkel’s constant message of caution ultimately wasn’t enough to counter a fragmented federalist system — especially as politicians began competing to eventually replace her. +

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+A power vacuum made things even worse +

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+In Germany, the current political era is sometimes referred to as “Merkeldammerung” — the twilight of Merkel. After more than a decade and a half as chancellor, and nearly two decades as leader of the center-right Christian Democratic Union of Germany, she said in her retirement announcement that it was time for the country and her party “to start a new chapter.” Elections in September 2021 will decide the country’s new leader. +

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+Merkel’s long grip on power had made her a defining force in German politics. But all of a sudden, the country found itself on the brink of a power vacuum. Politicians both in and out of Merkel’s party had a chance to vie for the country’s top political position. And many criticized her policies, in part to contrast themselves and bolster their own political fortunes. +

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+All of that became apparent during the week of Ash Wednesday in February, which is traditionally used by German politicians to preview their electoral messaging for the year ahead and criticize their opponents. This year, the hot topic was the country’s continuing months-long lockdown. +

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+Armin Laschet, who had been recently elected to head Merkel’s Christian Democrat party, criticized the lockdown — describing Merkel’s push for communal restrictions as the government treating voters like “underaged children.” +

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+ Michael Kappeler/picture alliance/Getty Images +
+Armin Laschet, head of Merkel’s party, the Christian Democrats, criticized the government’s lockdown efforts to contain the coronavirus. +
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+Markus Söder, who heads the Christian Democrats’ sister party and, like Laschet, is vying to lead the country after Merkel retires following September elections, fired back: “Everybody who plans to profit from Merkel in September must know that these votes will only come in combination with Merkel’s policy and not by positioning oneself against it.” +

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+Nearly a year before, Germans who turned on the news would typically see a united front from Merkel down to the local level. Now, with the start of an election year, they saw some of the country’s top politicians — and members of the chancellor’s own party — debating whether Merkel had the right idea to begin with. +

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+Without a strong leader at the federal level, it fell more to the lower levels of government to make decisions about Covid-19 — federalism ran wild. +

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+Yet these leaders didn’t always have fully developed visions. During the summer, Michael Kretschmer, the governor of the state of Saxony, argued that the initial lockdown shouldn’t have been so strict. He said there would be “no tightening” of restrictions in September. By December, Kretschmer not only backed Germany’s new lockdown but enacted even tighter restrictions across Saxony, saying, “We have to bring this country to rest.” In January, Kretschmer called for a February end to the lockdown. By the end of March, he at least briefly supported a stricter Easter lockdown. +

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+Now multiply this 16 times over. That’s the political back-and-forth that has engulfed Germany during Covid-19. +

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+As I’ve asked experts in and out of Germany if anything could have averted the country’s recent failures, I’ve been met with a lot of shrugs and caveats. In theory, Germany may have avoided its second and third waves if the country continued to unite under Merkel — that worked in the first wave, and it’s an approach that seemed to work in much more consistent countries like Australia and New Zealand. +

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+Albert Ngwa (left) and Özlem Abbasov staff a mobile Covid-19 testing station in Berlin’s Neukölln neighborhood, one of the most diverse neighborhoods in the city. +
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+The mobile station has been rotating through public spaces, providing Covid-19 quick tests and general advice. Neukölln’s health department started this pilot earlier this year to bring medical care to people who might be hesitant to see a doctor. +
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+But German solidarity had major systemic forces stacked against it: a federalist system, a political battle to replace Merkel as head of the government, and a long pandemic that fatigued populations across Europe and the rest of the globe. +

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+Countries might be able to overcome one or two of these factors at once — Australia has a federalist system; New Zealand had general elections in 2020 — but it could be that the full trifecta is too difficult to beat simultaneously. +

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+The crisis “became more of a cooperation problem, in which everyone has a strong incentive to deviate from a common solution,” Hattke, of the University of Hamburg, said. +

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+Some experts also argue Germany could have better used the time it bought with lockdowns and restrictions. It could have built more expansive test-and-trace systems to handle a higher caseload before the fall. Or it could have tried to procure some of its own vaccine supply, instead of relying on the EU’s ultimately botched approach — an approach that has left Germany with roughly half as many people receiving at least one vaccine dose as the US, and a third as many as world leader Israel, as of April 19. +

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+“That time wasn’t used to put strategies in place that would support Germany in a second, third, or fourth wave, or whatever’s coming,” Kickbusch, of the Graduate Institute, said. “It was clear that Germany’s health system was very good — hospital beds and all of that. But Germany’s public health system was much too weak.” +

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+As the lockdown that began in November drags on and officials clash over it, public opinion has shifted. Shortly after Merkel’s primetime speech in March 2020, only 14 percent of the German population called the Covid-19 restrictions excessive; a year later, 35 percent said the measures in place were too much, according to public surveys. +

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+“We interpret this with the fact that politicians were less unified in their statements [and] stopped speaking with one voice,” Rolf van Dick, a social psychologist at Goethe University in Frankfurt, Germany, told me, citing his own research on Covid-19 and public opinion. As politicians split in their public stances, van Dick added, the public “got more fragmented.” +

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+Even Merkel eventually caved. In the lead-up to Easter on April 4, Merkel and the governors had agreed to tight restrictions — discouraging domestic travel, closing down more businesses, and prohibiting larger gatherings, including in churches, from April 1 to 5. +

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+Empty streets in Jena, as daily new Covid-19 cases in Germany remain around 50 times higher than they were last summer. +
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+The backlash was fierce. Churches demanded the ability to celebrate one of their holiest days. Businesses claimed that a stricter lockdown during a typically busy season would bring financial ruin. State leaders started to buckle under the opposition, calling for a redo on the agreement. +

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+Under all this pressure, Merkel revoked the plan roughly 36 hours after it was announced. “This mistake is mine alone,” she said. “The whole process has caused additional uncertainty, for which I ask all citizens to forgive me.” Merkel added, “There were good reasons for it, but it could not be implemented well enough in this short time.” +

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+One year before, Merkel had been the voice of Germany on Covid-19, with news of her speeches getting families to gather around the TV to listen to what she had to say. The public and politicians followed her lead, anxious to take the cautious approach that she advocated for against the coronavirus. That unity let the country crush Covid-19 during the early days of the pandemic, with headlines praising “A German Exception” and much of Germany, from restaurants to movie theaters, reopening and bustling in the summer. +

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+In the spring of 2021, Merkel was forced to apologize for her caution. Now she hopes to adjust her plan to prevent another potential surge — perhaps by seizing powers originally held by the states. Meanwhile, daily new Covid-19 cases in Germany remain around 50 times higher than they were for much of last summer. +

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+Jacobia Dahm is an independent photographer based in Berlin, with a focus on portraiture and reportage. +

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