By Jörg Blech, Matthias Gebauer, Kristina Gnirke, Julia Amalia Heyer, Christoph Hickmann, Christiane Hoffmann, Nils Klawitter, Martin U. Müller, Cornelia Schmergal und Christoph Schult
When Hamburg dentist Norman von Sternberg ran out of face masks in late February, it looked as if he would have to close his practice. The market for masks has been swept clean. Frustrated, Sternberg got creative: He borrowed a mask made of black rubber, with attachable filters to keep out gases and vapors, from a friend who paints cars. He equipped his assistant with a snorkel mask. This, at least, allowed him to continue treating patients with emergencies.
As is the case everywhere in the country, the 1,300 employees of the St. Antonius Hospital in Eschweiler, in Germany’s Rhineland region, lack the protective coverings they need. In desperation, the facility’s director of nursing asked people on Facebook to sew fabric masks -- the very item that has become the symbol of the corona crisis -- for hospital staff.
Necessity is the mother of invention. And that necessity is as intense as it is because, so far, the German government has done far too little to ensure the protection of doctors and nurses. It initially missed the opportunity to build up sufficient stockpiles, in particular for doctor’s offices, hospitals and nursing homes. And now it is leaving Germans confused about whether wearing masks in their everyday lives is a logical measure for limiting the spread of coronavirus infections.
In contrast to Germany, as of last Monday, Austrians have needed to cover large parts of their faces while shopping. The simple masks they are required to wear may not fully keep them from infecting others with the coronavirus, but it does lower the risk. Alexander Kekulé, a prominent virologist with the university hospital in Halle, Germany, believes mandatory mask-wearing "makes absolute sense.” He argues that even placing a T-shirt in front of one’s nose and mouth helps keep out droplets.
In some Asian countries -- including South Korea, Taiwan and Japan -- that have made it through the crisis fairly successfully so far, the mask has long been a key factor in minimizing the spread of the virus while simultaneously keeping the economy alive. George Gao, the director-general of the Chinese Center for Disease Control and Prevention (CDC), told the magazine Science, "The big mistake in the U.S. and Europe, in my opinion, is that people aren’t wearing masks."
Growing Social Pressure
In Germany, there is growing social pressure to protect others from infection by wearing a mask. According to a survey conducted by the pollster Forsa on behalf of the German TV stations RTL and n-tv, 57 percent of Germans are in favor of mandatory mask-wearing for people shopping and using public transport, while 35 percent were against it.
Thus far, however, the German government has refused to institute such a rule. German Health Minister Jens Spahn believes that "in the current situation, there is no need for such a requirement.” A mask requirement was not seriously considered during a video conference between Chancellor Angela Merkel, several government ministers and Germany’s state governors either. The main argument was not that it wouldn’t make any sense, but that it wouldn't be possible because of the sheer lack of masks.
They argued that a requirement forcing people to wear masks could not be implemented because the government hasn’t managed to procure sufficient face-coverings. If 80 million Germans were required to wear masks, there wouldn’t be enough for those who need them the most: doctors, nurses and the staff in nursing homes. During the chancellor’s meeting, some cited the example of South Korea, where electronics manufacturer Samsung provides each of its employees with two masks a day. This wouldn't be possible in Germany.
It’s now clear that the German government was ill-prepared for this pandemic, even though a 2012 risk analysis by the federal government sketched out a crisis scenario that is eerily similar to the current situation. The lack of masks has medical consequences, but also social ones. If more masks were available, the country’s current limitations on social contact could potentially be loosened earlier.
"The question of whether we can once again lead normal lives also depends on whether the government can make enough protective masks available,” says Karl Lauterbach, the health policy pointman in parliament for the center-left Social Democrats (SPD). "There should be a mask requirement during shopping or in public transit,” he argues. And growing numbers of German political voices agree.
"Countries like Taiwan or South Korea show that masks can be an important tool, also when considering the steps for getting out of lockdown,” agrees Green Party leader Annalena Baerbock. But she argues that it doesn’t make any sense to talk of a nationwide mask requirement if there is a "huge shortage of masks.” Baerbock says that, "at the moment, all efforts need to be aimed at developing a pandemic economy that produces the necessary equipment as fast as possible and makes it available to the whole country.”
Even the pro-business Free Democrats (FDP) are open to it. "If people aren’t following rules and masks are available to all, we might consider a temporary requirement,” says FDP lawmaker Andrew Ullmann, himself a physician. "In an effort to bring back a bit of normality, a mask requirement in pharmacies and grocery stores, but also in other stores, would make sense.”
The German virologists who are advising the federal government have long been restrained on the issue of whether the broader population should wear masks in their everyday lives. Their confusing and contradictory statements have sowed doubt about whether the masks constitute an effective measure against the spread of the virus.
This has left countless Germans uncertain about what is actually helpful. Many, justifiably, are asking why something that is right for doctors and medical personnel is wrong for them.
Fundamentally, there are two different kinds of masks: One kind protects the wearer, and the other protects those nearby.
Masks known as FFP masks (FFP stands for filtering face piece), protect people from breathing in small particles or droplets, and are meant to be used by medical personnel who treat patients with infectious diseases. There are three variants of increasing thickness and protective quality: FFP1, FFP2 and FFP3. When a person is in contact with COVID-19 patients, FFP2 is the lowest acceptable standard. During high-risk procedures, like a bronchoscopy, FFP3-level protection is considered indispensible.
A simple mask that covers the nose and mouth and is made of a light fabric -- known as a surgical mask -- is meant to protect others from infection. Nurses and doctors wear them, for example, during operations, so that droplets from their noses or mouths don’t hit the patient. The self-made masks made of fabric, like the ones currently being sewn in Eschweiler and elsewhere, are also only meant to protect others.
Opponents of mandatory masks fear that the face coverings create a false sense of security and could lead people to stop maintaining a safe distance from one another. They also argue that masks can themselves spread the virus if they are worn incorrectly, a concern apparently shared by the chancellor. During her conversation with the governors, Angela Merkel argued that self-made masks could even increase the danger of infection if they are used for too long or worn wrong.
What is clear is that there are too few scientific studies on the use of masks and that there is no evidence of their effectiveness. Walter Popp, the vice president of the German Society of Hospital Hygiene (DGKH), argues that it is one of the least researched areas of the hygiene field. Nevertheless, the doctor is certain that "any mask is better than no mask.” Germany’s National Pandemic Plan also states that a mask covering the nose and mouth "can, in principle, provide protection to a third person (if the mask-wearer is infected) as well as for the wearer themselves.”
The Robert Koch Institute (RKI), Germany’s centers for disease control, officially revised its assessment of masks last week. According to the RKI website, a simple mask of this kind can reduce the danger of "infecting another person through coughing, sneezing or talking.” On Friday, the U.S. Centers for Disease Control issued the recommendation that people wear masks – and even the World Health Organization (WHO), belatedly, changed its recommendations to include masks.
Last Monday, Michael Ryan, the executive director of the WHO’s Health Emergencies Program, had advised against wearing a facemask if you are not yourself sick. By Friday, however, he too appeared to have shifted positions, saying, "We can certainly see circumstances on which the use of masks, both home-made and cloth masks, at the community level may help with an overall comprehensive response to this disease.”
Given that an estimated 25 percent of people infected with the virus don’t show any symptoms, an unwitting carrier could spread the infection to dozens of other people. A number of "superspreaders” have already been documented. If all of them had worn masks, it’s likely they would have caused less damage.
Health Minister Spahn is at the center of the federal government’s mistakes when it comes to protective masks. In early February, a manufacturer had pointed out that the situation in China could cause Germany to run into mask shortages. Nine percent of the global supply is manufactured there, and Wuhan, of all places, is an important center for their production.
But Spahn’s officials didn't pay enough heed to the warnings. Although the joint crisis group of the Health and Interior Ministries broached the subject at their first meeting in late February, it initially decided on taking protectionist measures and soon after implemented a ban on the export of masks.
Then prices exploded. In early March, the crisis group instructed the Procurement Office of the German Armed Forces and the General Customs Directorate to look for protective masks around the world. But their success was limited, with only about 30,000 masks ultimately getting delivered.
Since then, the federal government has assembled its own task force, internally known as the "troubleshooting agency,” to ensure that ordered items actually arrive. The German Foreign Office now intervenes when other countries confiscate masks and the Transport Ministry ensures planes carrying the items are able to land.
In recent days, Spahn picked up the phone himself to convince textile companies in the country to transition to sewing personal protective gear – and to ask large companies like Volkswagen to make their stockpiles of masks available. Spahn’s team said at the start of this week that the ministry had obtained and distributed 20 million masks. But that’s not enough. According to estimates, German hospitals alone need 17 million FFP2 masks per month, along with 45 million simple protective masks. As the pandemic progresses, that need could grow considerably.
SPD health expert Lauterbach now argues that a federal authority needs to centrally coordinate mask manufacturing in Germany. "That’s not something a politician can do as a side job,” he says. The fact that Bavarian Governor Markus Söder is now also calling for the federal government to intervene is a sign that he views Spahn’s moves critically. Söder, who represents the Christian Social Union (CSU), the Bavarian sister party of Merkel’s center-right Christian Democrats (CDU), said, "We now need to shift production capacities to this emergency economy.”
"Wild West" Competition
During the meeting between Merkel and the governors on Wednesday, Spahn explained the current situation on the global market. He argued that the conditions were like the "Wild West.” But that's putting it mildly. Masks have become the subject of a global battle and an object of speculation for fortune hunters and scammers. Many are demanding extortionate prices, with the price going up almost 50-fold in some places.
Everyone is trying to get their hands on what they can. The U.S. has been particularly aggressive on the Chinese market. "The Americans are currently taking a lot of money and buying up the global production of masks and other protective gear. That drives the prices even higher,” says Reinhard Wiedemann, the lead buyer for Asklepios, a private hospital chain. Hospitals say that suppliers are now backing out of their agreements on items that were ordered long ago.
In Germany, the federal government is competing against the states, which are competing with each other. Hospitals, doctors’ offices and nursing homes are fighting over the last stocks of masks. It is a veritable free for all. Hospital managers also claim that hundreds of thousands of masks have been stolen across Germany.
The health minister and the Robert Koch Institute now recommend that single-use masks be cleaned and reused when worse comes to worst. Many hospital workers are afraid. What happens if the number of COVID-19 cases rises and they run out of masks? "Should I then send my doctors and nurses to see patients without masks?” asks the head physician at a large hospital. Some fear a situation like the one in Italy, where doctors needed to work without mouth-coverings in some cases. Many got sick themselves. "In an emergency, our employees will also need to work without protection,” says one hospital manager.
The anger and disappointment directed at politicians, including by doctors in private practice, is growing. Matthias Soyka, an orthopedist in Hamburg, argues that physicians are incurring great personal risk: "To allow us to work now without enough protective equipment is irresponsible. Politicians are abandoning us.”
"The federal government made a big announcement about buying protective masks. The result is disappointing,” says Wiedemann, the buyer at Asklepios. Thus far, he argues, only a small number have arrived, and they were only enough for individual facilities and for a few days. And part of what arrived was unusable, with dried-out fabric. Holding straps fell off. "Those were very old items, maybe from the armed forces or the police.”
But the hospitals aren’t entirely innocent either. The National Pandemic Plan instructs hospitals to take into account "the increased need for personal protective equipment.” But many hospitals didn’t build up a stockpile of masks due to the cost.
Out of Control
ClinicPartner, a company based in Gelsenkirchen, in western Germany, is a national buying syndicate for hospitals and seniors- and nursing homes. For years, ClinicPartner has been buying protective masks from China through agents and trade partners. The company is experiencing how the market is spinning out of control from the front lines.
"In January, we saw how the Chinese were buying huge amounts of masks in Europe,” says CEO Wolfgang Appelstiel. He says they were willing to pay almost any price. "In January and February, when we still thought the virus was far away, the market here was almost emptied out.” Appelstiel accuses the federal government, especially Health Minister Spahn, of negligence. "By February, they must have seen that there needed to be a massive build-up in Germany in order to improve the supply of masks. We felt too secure,” says Appelstiel.
He accuses Spahn of not having sought out the advice of knowledgeable people. "Mr. Spahn wants to solve the problem using conventional means, but he didn’t understand at all how to do business in China,” Appelstiel says. As a result, he argues, a lot of time was wasted on calls for bids that didn't work.
One person who knows how this works is Ming Gutsche. Over 20 years ago, the Chinese-born woman founded a company that makes personal protective equipment, based in the southern German city of Rastatt. It can now manufacture up to 20 million masks per year, and is among the market leaders. Three weeks ago, Gutsche was invited to meet Spahn in the Health Ministry in Berlin. This past week, the ministry made a request to the company, saying that it needed large numbers of masks.
"I spoke with the government in the city of Shenzhen and begged,” Gutsche says. She reminded Chinese officials that her company had delivered protective gowns to China after the start of the crisis. Shortly thereafter, she got approval for over 300,000 protective masks and 3 million surgical masks, which were delivered this week.
The failed bulk delivery of 6 million FFP2 masks to Germany is a prime example of how unwieldy German bureaucracy can be. In early March, an online mail-order company from the state of Lower Saxony contacted the General Customs Directorate with an offer of protective masks. The company offered to procure 6 million masks from 3M, which produces protective products in Kenya for the African market, for around 40 million euros. A few days later, a preliminary contract was signed. The items were packed for transport to Germany in a warehouse near the Nairobi airport and scheduled to be transported on March 20.
From the online retailer’s perspective, the deal primarily failed because of the General Customs Directorate’s bureaucracy. It argued that, in violation of the preliminary terms, the authority had refused to make an advance payment of 50 percent of the order value. As a result, the partner in Kenya withdrew from the deal. The company suspects that the items, which are desperately needed in Germany, have been sold to other potential buyers.
"It’s really dramatic,” says Michael Koch, product manager at Medika, one of Germany’s largest medical-device distributors, which is based in Hof, Bavaria. He estimates that FFP3 protective masks won’t be available on the global market until July, even with family connections. "We have personal contacts at a manufacturer in China,” says Koch. "Even they are telling us they can’t help.”
At the same time, the market is being flooded with dubious product offerings. "Companies are now making masks that normally make clothing for dogs," warns Koch. "This can be life-threatening." Lots of things that are available for purchase aren't suitable. "There so many swindlers out there peddling fakes. Authenticity certificates are being falsified and sometimes the packaging is done so clumsily that the box has something different written on it than the product."
Koch says that air freight prices have increased many times over. German national airline Lufthansa is already loading protective masks onto passenger planes, with boxes sitting on seats in economy class and in hand-luggage bins. Appelstiel of ClinicPartner says air freight is 300 percent more expensive right now because there are simply too few planes in the air. "We have offers where one flight costs $1 million,” he says. He says that there had been a request to use German Air Force planes, but it was rejected.
The German government was far too late in starting to focus on its own production in Germany. Since last week, Spahn has been promising manufacturers a purchase guarantee, which is valid until the end of 2021. The minimum delivery quantity per week is 100,000 items. A number of companies have now converted to manufacturing protective gear, including the textiles company Trigema, the underwear specialist Triumph and Bavarian car parts supplier Zettl, which normally produces seat upholstery. The fashion label Prada is also making masks. The costume department at the local Cottbus State Theater has even began producing this good in short supply.
Some startups have also made a virtue out of necessity. The company Wooden, for example, which normally makes fashion accessories like wooden brooches, is now offering face masks so that it can continue to employ its seamstresses at its small factory in the Czech Republic. Company founder Henrik Roth believes that masks could soon become an "everyday accessory.”
However, ClinicPartner chairman Appelstiel is still skeptical. "We welcome the fact that production facilities are being set up in Germany,” he says. "But with the billions in demand that now exists worldwide, only China can solve the problem.” Appelstiel assumes that China will soon be manufacturing more masks than it did before the corona crisis. "The government has decreed that an unlimited number of masks be made in order to serve the global market.”
In Germany, meanwhile, there is a growing demand for a swift loosening of the limits that have been imposed on public life. At that point, at the latest, the question will be raised as to whether a mask requirement should be put in place for all people in Germany. The city of Jena has already announced it would implement a limited version of that requirement. A random sampling of mayors surveyed by DER SPIEGEL found that many other municipalities do not want to impose the requirement but would recommend that residents wear masks.
One argument against the mandatory wearing of masks is the sheer lack of their availability. How can you make it compulsory to wear a mask if you can’t even get one? Many stores that are still open are now fearing that the government will soon issue that requirement in order to offer protection to their customers, just as Austria has done.
Retail establishments like the German drugstore chains Rossmann and dm, for example, are each visited by around 2 million customers each day. "I don’t believe it would be feasible if we had to provide customers with masks,” says Rossmann CEO Raoul Rossmann. "Where are we supposed to get that number of masks?”
That’s just one of many justified questions for the German government.