One of the peculiarities of the Covid-19 outbreak is the recorded fatality rate. The proportion of those infected who die seems to vary greatly between countries. It is highest in Italy, at around 10%, and around 7% in Spain and Iran. In the UK, France and the Netherlands it is around 5%, and in Denmark, Sweden, Switzerland, South Korea and the US between about 1.5% and 3%. But it is lowest of all in Germany and Austria, at around 0.7% in both countries. According to the Johns Hopkins Coronavirus Resource Centre, of 53,340 Germans infected only 395 have died; of 7,712 infected Austrians only 58 have succumbed to the virus.
What could explain this? Germans and Austrians are not unusually healthy by western European standards. They take places 26 and 27 (just behind Belgium and just ahead of Britain) in the UN’s ranking of life expectancies; cigarette consumption in both is higher than in Italy. Nor have they contained the outbreak much more than others. Germany has more infected people than anywhere apart from America, Italy, China and Spain. Austria has about as many cases as more-populous Turkey, Canada and the Netherlands. Indeed an Austrian ski-resort, Ischgl in the Tirol, was one of the hotspots from which coronavirus spread to other parts of Europe. And nor can the explanation be that Germany and Austria have imposed unusually tough lockdowns: Austria moved fast to stop public gatherings, but Germany did so more slowly and current social-distancing measures in both countries are milder than in France, Spain or Italy.
Rates of testing, however, are clearly a major factor. According to health minister Jens Spahn, Germany is now testing up to 500,000 people a week for the coronavirus; Britain, by contrast, has conducted just 104,800 tests in the entire period since the end of January. Austria too is testing heavily and plans to hit 15,000 tests a day soon where Britain, with almost eight times the population, is aiming for 10,000 a day by the end of this month.
All of which points to three, mutually compatible possible explanations, the reality probably comprising some combination of them. The first two involve some aspect of the international fatality statistics being wrong, the third involves Germany and Austria being outliers.
The first possibility is that Germany’s and Austria’s numbers are more accurate than those for other countries because they are testing lots of people, and people of all ages. In Germany over 80% of those confirmed to have the disease are under 60 and in Austria the largest group affected is those aged 45-54; both contrast starkly with recorded figures from places like Italy suggesting that the virus and its lethal effects overwhelmingly hit the old. Perhaps more concentrated or limited testing practices in other countries give an overly gloomy picture and large parts of their populations are experiencing mild forms of the virus without being counted in infection rates. If that is the case we can expect the fatality rates elsewhere to fall towards the low ones in Germany and Austria.
The second possibility is that the numbers elsewhere are more accurate than those in Germany and Austria. It has been widely noted that the way deaths are counted varies from place to place. Coronavirus seems to become lethal, particularly to older sufferers, when it combines with other, pre-existing health problems (respiratory conditions for example). Some authorities appear more prone than those in Germany and Austria to ascribe such comorbidity deaths specifically to the virus; the health ministry in Vienna for example stresses that Austrians dying from other causes are only tested if there is an infection risk. Combined with the lower average age of those tested in Germany and Austria, that may suggest that a higher proportion of elderly people are dying from the virus, or will die as it spreads, in those countries than the current numbers imply. Medical experts in both Germany and Austria have stated that they do not expect their countries’ fatality rates to end up much lower than those of other countries.
The third possibility is that there is some truth to the picture painted by the numbers and that Germany and Austria genuinely are seeing lower fatality rates.
Certain medical factors support this argument. High testing rates do not just help authorities monitor coronavirus’s spread but also help them fight its lethality: by quarantining people who have or may have the virus, by shielding the most vulnerable and by getting medical attention to people early to increase their chances of survival. Thanks partly to its decentralised health system (where providers can get on with things on their own initiative) Germany was able to introduce testing and contact-tracing in early February and ramp up the measures quickly. “Germany recognised its own outbreak very early on,” Christian Drosten, a top virologist, tells Die Zeit newspaper: “We’re two or three weeks ahead of some of our neighbours.” And Berlin wants to continue expanding testing. A leaked confidential paper from the federal interior ministry, which has apparently been presented to Spahn and Angela Merkel, proposes adopting the South Korean model of mass testing and increasing the rate to 200,000 a day by the end of April. Austria is on a similar course under chancellor Sebastian Kurz’s mantra of “testing, testing, testing”.
And that is all taking place within health systems that are relatively well-placed to cope. The German and Austrian models work along similar social-insurance lines; employees and employers contribute to public health insurance and the state provides an insurance safety-net, but hospitals and clinics are relatively decentralised. The combination of generous universal coverage and pluralist provision creates lots of spare capacity. Germany has 621 hospital beds per 100,000 people and Austria has 580 per 100,000 people; the second and fourth highest densities in Europe after tiny Lithuania and multiples of Britain’s 228 beds per 100,000. Germany has 28,000 intensive care beds – now set to double – compared with Britain’s 4,100. It has 25,000 ventilators, compared with France’s 5,000. (It is also home to Drägerwerk, the world’s leading manufacturer of ventilators, from which the federal government has ordered an additional 10,000.) So even with its rapidly rising infection numbers Germany has the capacity to take in coronavirus patients from overstretched hospitals in Italy and France – and is doing so.
The biggest unknown is the possibility of cultural explanations – though here the line between stereotype and reality is difficult to tread. Germans and Austrians, it is true, do tend to respect experts. Even in this anti-authority age a certain reverence still surrounds those with doctorates, and academic titles are commonly used as forms of address. Drosten – Prof. Dr. Drosten to be Germanic about it – has become a national star and semi-ironic heartthrob, with Die Zeit even suggesting tongue-in-cheek that he is Germany’s real chancellor. (For their part the chancellors de jure, Merkel and Kurz, have been relatively clear, calm and authoritative in their communications with the public.)
It is also true that Germans and Austrians are fairly rule-oriented. Cross the road on a red light here, even when no cars are coming, and someone may well shout at you for setting a bad example to children. Berlin’s police force recently had to request residents stop clogging up its lines with calls denouncing neighbours for defying lockdown rules. It is, to be fair, also easier for Germans and Austrians to stick to social-distancing and self-isolation ordinances: urban public transport here tends not to experience the crowding levels of a London or a Paris; according to Eurostat average dwellings are larger and average households are smaller than in housing-pressured Britain; it is less common for different generations to live together than in Italy or Spain.
And it is at least somewhat true that Germanics are good at knuckling down to things. Decisions are generally made and executed in a more consensus-oriented and decentralised way than in many other countries. That might – might – help systems cope better in moments like this. It says something about Germany’s ability to deal with crises that it took in over one million migrants during the refugee crisis of 2015-16 and has since integrated them more rapidly than even some optimistic predictions suggested. Reuters reports that some German state authorities are now inviting migrants with medical training, many of whom arrived during that crisis, to apply for jobs to help health services through the coronavirus crisis.
Still, much of the above also applies to Switzerland and Scandinavia, where fatality rates are closer to international norms. If culture is indeed a factor, it cannot be the only one.
Only time will tell. Writing without any medical expertise, I confess that my uninformed hunch is that elements of all three possible explanations are in play: that numbers elsewhere sometimes paint a too negative picture; and that Germany’s and Austria’s numbers paint a too positive picture; and that other countries can usefully adapt aspects – investment in medical capacity, respect for expertise, consensus-based public policy – of their responses. But I make no predictions. The “mystery”, as it has been misleadingly termed, of low German and Austrian fatality rates is merely an expression of just how new this all is and how much we have to learn. It is natural that international differences in numbers, patterns, policies and recording metrics are taking more than a few weeks to shake out. The real mystery is not why Germany and Austria have so few deaths but why we expect answers to such questions in the early stages of a fiendishly complex global health crisis.