By Matthias Bartsch, Jörg Blech, Annette Bruhns, Lukas Eberle, Katrin Elger, Markus Feldenkirchen, Kristina Gnirke, Annette Großbongardt, Hubert Gude, Veronika Hackenbroch, Julia Jüttner, Martin U. Müller, Cornelia Schmergal and Steffen Winter
The man with the white shock of hair in Room 4 of the intensive care unit wasn’t able to breathe. But now, a tube has been placed in his throat and oxygen is flowing into his lungs. You can see through the window on the door to the room how his chest is moving up and down in time with the ventilator, 28 times a minute. The 83-year-old is fighting the SARS-CoV-2 virus.
It’s Monday, and during the course of the day, nurses and doctors have to watch as his condition deteriorates. They notify his wife and daughter, who arrive around noon. Under the new rules for these corona times, only one relative is allowed into the isolation room for 30 minutes. The woman sits beside her husband in full protective clothing and gloves and places one hand on his forehead and one near his heart. The head of the ward responsible for care decides to bring the daughter in as well. He equips her with protective clothing and lets her go to her father. Both are permitted to sit there for as long as they want.
The man passes away at 3:15 p.m., with the resident issuing the death certificate. The immediate cause of death given: "Hypoxic respiratory failure. A complication stemming from COVID-19 pneumonia."
The man passed away at St. Antonius Hospital in Eschweiler, North Rhine-Westphalia, only 30 kilometers (19 miles) from Heinsberg, the largest known cluster of infections in Germany to date. A ventilator was available for him, but the help came too late.
There’s some good news and some bad news for people in Germany right now. The good news is that Germany is home to one of the most modern, richest and most powerful health-care systems in the world. We have an "excellent health-care system, perhaps one of the best in the world,” German Chancellor Angela Merkel said in her address to the nation on Wednesday night. It is better equipped for dealing with the corona epidemic than the systems of many other countries.
The bad news is that large parts of this system are already overwhelmed. Depending on how fast the number of infections increases in the days and weeks to come, we could experience a collapse and failure of the system. And it will be deemed to have failed if people have to die because of a shortage in staff, beds and equipment -- and not because this illness is incurable.
In northern Italy, the collapse of the health-care system has been evident for weeks. "Soon, we will no longer be able to provide treatment for the sick,” Attilio Fontana, the president of Lombardy said. There aren’t enough ventilators in the Italian crisis region, and doctors are forced to make new decisions each day over who gets access to a ventilator and who is left to die.
"Triage” is the term given to this cruel choice, and it is a procedure that originated in military medicine. If there are suddenly masses of injured people, priorities have to be assigned. Rescue workers sift through the victims and then hand out bracelets or tags that are usually color-coded.
Red is for patients requiring immediate treatment. Yellow is for patients who can wait. Those given green are the lowest priority and have to wait the longest for help. The helpers do little for patients in the blue category. They are so seriously injured or ill that any effort would be futile under those circumstances.
Germany may soon have to take a similar approach.
In recent days, a chief physician from the Rhineland had to admit to a colleague that he only has seven ventilators at his hospital. He said he needs 13 in order to get through a major wave of serious infections.
And that wave will come - that much is certain. "We expect that things will really heat up in the next two weeks, also here in Germany," says Axel Fischer, managing director of the München Klinik, a Munich-based chain of hospitals. His hospital treated the first patients infected with the coronavirus in January. He fears the crisis will have a "massive impact.”
The coronavirus is mercilessly exposing the problems that have been burdening the German health-care system for years: the pitfalls of profit-driven hospital financing. The pressure to cut spending. The chronic shortage of nursing staff. The often poor equipping of public health departments. The lag in digitalization.
"We are preparing for imminent catastrophe,” says Rudolf Mintrop, head of the Dortmund Klinikum, the city’s main hospital. He calculates that the wave of sick will hit hospitals at full force in 10 to 14 days. The chancellor has warned that German hospitals will be "completely overwhelmed" if too many patients with serious coronavirus infections have to be admitted within a very short period.
Ultimately, the question of life and death will be decided in the intensive care units. The answer will depend on how many ventilator beds there are, how many doctors are on call and how many nurses are able to provide care for critically ill patients.
To prevent a collapse of intensive care units, the German federal and state governments have taken drastic measures that are bringing public life in the country to an almost complete standstill. They have closed stores, sealed borders and shuttered schools, daycare centers and playgrounds.
One of the primary reasons for the steps taken is the imminent shortage of ventilators. German hospitals currently have access to around 25,000 deploy-able ventilators. The federal government is making efforts to acquire thousands of additional devices, but their manufacture and delivery may take time. There are far more of the devices available in Germany than in Italy and there are also more health-care workers to operate them. But doctors and medical experts still fear supplies could fall short here.
The number of infected in Germany who will have to be provided with artificial respiration will depend on whether people get serious about what virologists and politicians have been warning about for weeks: social distancing. The more consistently all contact is avoided, the greater the chances are of slowing down the rapid rise in new infections.
Another determining factor will be whether doctors and hospital directors go along with the government’s request that they clear their wards in preparation for the expected onslaught of coronavirus patients, particularly given that there is often already a lack of nursing staff and equipment even at hospitals that are operating under normal circumstances.
Under the German Social Code, health-care providers are required to promise every insured patient an economical and efficient treatment based on state-of-the-art knowledge. It does not entail any restrictions. "Rationing” is a word that has never been heard before in our postwar health-care system. But it appears to be one that people in Germany might have to get used to, right along with the even scarier word "triage.”
In any case, the fight against the virus in German hospitals has already begun. The coming weeks will determine whether it can be won.
Intensive Care Beds
Last week, German Health Minister Jens Spahn sent a personal letter to the managing directors of almost 2,000 hospitals in Germany. To keep enough intensive care beds free, he requested: "In principal, all operations and procedures that can be planned in advance are to be postponed and suspended immediately in all hospitals, from Monday onward.” Almost pleadingly, Spahn asked for doctors to be brought out of retirement, for students to be hired to help and for more intensive care beds to be made available. "Now!"
Some hospital bosses like Michael Albrecht at University Hospital in Dresden followed suit. The hospital said beds would be deliberately cleared and operations postponed if possible. "But it’s hard to decide sometimes,” says Albrecht. "Should a necessary tumor operation be postponed because of corona?" He says you can set priorities, but you can’t make overly hasty decisions.
"Right now, we’re only postponing operations if the patients won’t suffer disproportionately as a result,” says Andreas Meier-Hellmann, the head of the coronavirus crisis team at the Helios Kliniken chain of private hospitals. Helios is also permitting tumor operations to go on "even if the patients might have to be put in the intensive care unit afterward.”
Many hospital managers are actively ignoring Spahn's appeal. This could in part be due to the fact that their facilities are under economic pressure and depend on the revenues provided by procedures like knee prostheses, hip replacements or heart catheter examinations. These kinds of procedures, which experts say are often unnecessary, are the most lucrative for the hospitals.
"Our hospitals will remain in normal operation for the time being, despite the government’s decision" one church hospital operator wrote to his staff on March 13, after Spahn's appeal. After all, he noted, it "isn’t law.” Planned admissions are not to be cancelled for the time being, the memo stated. "Contrary to what some in the government have seemed to believe for quite some time now, hospital admissions are not some leisure activity that you can simply dispense with."
The federal government has assured the clinics several times they will not be left alone in dealing with the costs relating to the corona crisis. Spahn promised he will ensure that the "resulting economic consequences" would be offset if hospitals postponed planned operations. "You can count on that," Spahn wrote in his letter. But hospital directors are still wary.
Hospitals will only be able to focus their efforts on the treatment of corona patients if they have the absolute certainty "that the cancellation of other treatments will not lead to liquidity problems," says German Hospital Federation President Gerald Gass. He says that a financial "backstop is needed for all hospitals” – otherwise some could be facing bankruptcy. "Anyone who still thinks that the German health-care system can easily cope with a situation like Italy's hasn't understood a thing."
Susanne Johna, the head of the doctors' union Marburger Bund, says she is dismayed that some hospitals are continuing to perform operations that could be postponed. Beds are being occupied that will soon be urgently needed for COVID-19 patients. If such non-acute procedures were postponed, she says nurses and doctors would also have more time for the necessary training, because not everyone is familiar with ventilators. "We need to be using this time,” Johna says. It’s unacceptable to go on with operations as if nothing is happening here.”
The staffs at many hospitals and clinics are already being stretched to their limits. In some places, there’s also too little regard for the fact that doctors or nurses who become infected also become a risk for patients and colleagues alike. Despite all efforts to recruit students and retired doctors for the peak of the crisis, it is impossible to compensate for a loss of staff. "Everyone works until they have symptoms. Otherwise, it’s impossible to cope with the situation,” says a senior physician at one private hospital in Bavaria.
It’s in the nursing divisions that Germany is currently the most ill-equipped for dealing with the crisis. One 50-year-old nurse who works in an intensive care unit at a university hospital in Lower Saxony says she and her colleagues were already pushed to their limits before the coronavirus struck. She asked to remain anonymous out of fear of reprisals. "The system actually doesn't have any buffers anymore, and we often exceed our capacity."
She says some of the intensive care beds in her hospital can’t be used because of a lack of staff. When she first started working in the field 25 years ago, she says, one nurse was responsible for taking care of one or two ICU patients, but now that number is two or three. "We're writing overload reports that should be called danger reports." At the end of the shift, she sometimes feels her feet are "three times as thick, and as if somebody beat me up. Then I practically crawl home.”
The nurse sees serious ethical conflicts ahead for society. "Everyone has become accustomed to the maximum care system, under which everyone gets everything they can." But this cannot be sustained if the number of critically ill people increases as feared.
It’s a problem that Health Minister Spahn has identified. A law was passed requiring hospitals to have a minimum number of nursing staff in 2018. But it has barely gone into effect, and Spahn will now have to suspend it again -- otherwise the hospitals won’t be able to cope
The staff shortage in German hospitals is chronic, with at least 17,000 nursing positions vacant in the country. The hospitals share some of the blame for this state of affairs. They’ve been cutting back spending in recent years, especially on nursing staff. At the same time, the German states have withheld billions of euros from the hospitals that should have been spent on investments in infrastructure.
"The reductions in beds and staff shortages didn’t occur suddenly and unexpectedly," says Asklepios Group works council Chairman Martin Schwärzel, whose organization represents employees in the hospital chain. "The number of nursing staff in the clinics was used as a key financial figure in the hospitals and was reduced as far as possible. Now, everyone is working at their limit."
This is also the view of Germany's most famous nurse, Alexander Jorde. During the election campaign in 2017, the now 23-year-old explained the catastrophic situation for hospital workers to Chancellor Merkel on live television. "Far too little has happened” since then, Jorde says. That’s now coming back to haunt Germany in the crisis.
In some hospitals, patients are already receiving inadequate care due to staff shortages. Jorde is calling for better daycare possibilities for the children of nurses, so that they don’t have to miss work as well as for regular tests for colleagues who come into contact with corona patients. The virus is hitting hospital workers in an extreme situation. "Nursing care in Germany is totally overburdened,” says Jorde.
In some cases, the current procedures can be extremely chaotic, complains one fellow nurse. "Patients just get pushed directly into the intensive care unit without anyone checking to see if they might be contagious. By the time a diagnosis is made, we will all have had contact with that patient – and without protective clothing.” In theory, at least, the entire ward could become infected.
He says he knows a few colleagues who called in sick because they didn’t want to be a part of this any longer. "It's also a question of our own health," says the nurse. He says the only reason the hospital system is still functioning is because workers are doing everything they can to keep it from collapsing. "And the catastrophe is only just beginning," he says.
The fear doctors and nurses have of being infected is justified, because even when it comes to protective gear, Germany's doctor’s offices, public health departments and hospitals are in bad shape. Many hospitals lack special protective gowns, face masks and disinfectants. The suture material used in operations could also become scarce.
This will require extraordinary measures. At the intensive care unit in Eschweiler, FFP2 respirator masks can no longer be disposed of after a single use. Each worker writes their name on the mask, hangs it up to dry and uses it for an entire shift.
Visitors have now been banned entirely at the hospital and uniformed workers with the Office for Public Order are stopping people at the entrance – to protect patients and staff.
All across Germany, thefts have been reported in recent weeks of respiratory masks and disinfectants, in some cases by employees. It was reported that an operating-room nurse at a hospital in Hamburg stole around 100 respiratory masks. Several hospitals have reported that disinfectant has been tapped in patients’ rooms and carried away in water bottles. In some cases, the thieves are pouring water into the disinfectant dispensers instead so that nobody notices the theft, one hospital employee reports.
Michael Dischinger, the purchasing manager at the Eschweiler hospital laments that procuring supplies is still difficult. He ordered the collection of all the respirator masks in the hospital and now keeps all 8,000 of them stored under lock and key. But those stocks will only be enough to last another 14 days. The hospital contacted local workshops that provide employment for the handicapped and asked if it would be possible for them to make respirator masks, but they have been unable to obtain the materials needed to make them. But 200 green fabric masks did just arrive that are washable. Dischinger has also ordered 45,000 respiratory masks from a manufacturer in Turkey, but they are not due to arrive for five weeks. "And they want prepayment for everything. It’s a risky move."
DKG President Gass has been critical of the fact that, in some cases, hospitals are currently having to pay 25 times the normal price for respirator masks. Respirator masks used to cost 69 cents each, one doctor reports, but today they cost around 18 euros. At times, suppliers have even been demanding 30 euros.
"We can’t order any employee to treat a coronavirus patient without protective clothing,” says Elmar Wagenbach, the managing director of the Eschweiler hospital. "We will have to close the hospital at that point."
Disinfectants are running low at his medical facility, too. The contract supplier is refusing to increase allocations and is instead supplying pharmacies because they’re willing to pay more. So, the hospital has instead begun its own "in-house production.” It purchased 2,000 liters of rubbing alcohol from an industrial painter in Heinsberg and, through personal contacts, from the German meat processing company Tönnies. "We are creating a catastrophe pharmacy of a kind I have never experienced in 35 years,” says Jörg Gildehaus, the hospital’s chief pharmacist.
Hospitals are finding it increasingly difficult to protect their own employees from infection, and the nationwide infection rate among medical staff is rising. München Klinik clinic Managing Director Fischer is upset that it took politicians and the government so long to react to the crisis. "You could see early on that there was a shortage of materials," he says, critically. "At the moment, it doesn’t really matter how much they cost. We have to get them. But once this crisis passes, we are all going to have to think about how to deal with the companies that are driving up prices now. This is a question of the health of other humans and the common good.”
The district administrator in Heinsberg, the district in Germany that has been hardest-hit by the coronavirus, is also upset about the lack of respirator masks and protective suits at the three hospitals in his district. "This is our Achilles’ heel,” Stephan Pusch says by phone. He describes the coronavirus as a "testament to the inadequacy of the health-care system.”
Meanwhile, the situation with the coronavirus tests is extremely confusing. In many public health departments, workers’ nerves are frayed. They can’t keep up with the rising number of infected people, or with the search for those they came into contact with. "We have a significant delay in compiling infection figures,” says Ute Teichert, the head of the Federal Association of Physicians of German Public Health Departments.
She says that officials in state public health departments are already calling for help. Several authorities, she says, have employees working multiple shifts, and some employees are even working overnight. "We desperately need staff reinforcements,” argues Teichert.
Over the years, staffing at public health departments has been hollowed out. In the past 20 years, the number of staff doctor positions in those departments has been reduced by a third. Teichert claims that they are short at least 1,000 employees, and that it is almost impossible to find new ones. Physicians working at public health departments earn 1,000 to 1,500 euros less per month there than they would at a hospital.
This makes it impossible to monitor many of those infected with the virus, a decisive factor in the course this epidemic will take. Ambulatory areas for potential coronavirus patients have been set up in several hospitals to allow staff to carry out tests. Most are separated from normal hospital operations, and located in a different building. At some, however, absurdly long lines form in front of them, in which potentially infected people stand at close proximity to one another. This was the case this past Monday at Dresden’s University Hospital, where more than 500 people stood in line for a test.
Many people prefer to get help from their family doctor or other physicians with their own practices, putting the continuing operation of those offices at risk. The Berlin Association of Statutory Health Insurance Physicians (KV Berlin) warned this week of a "collapse of ambulatory care” in the German capital. Contrary to the federal government’s promises, Berlin’s more than 6,500 doctor’s offices were not equipped with respiratory masks and protective clothing by the middle of this week. An announcement was made on Thursday that 10 million masks and further equipment would be available shortly and distributed under police protection.
Officials at KV Berlin report receiving calls from distraught doctors saying they had to close their practices due to the epidemic -- a paradoxical turn of events, given the sudden need for physicians.
Some are simply letting their reception phones ring and posting notes on their doors, like the one displayed by a Berlin general practitioner: "Were you in China, Italy, Iran or South Korea? Do you have fever, a cough and shortness of breath? If yes to both: Please do not enter the office.” It said that such patients should instead turn to the public health department or a hotline provided by the national chapter of the Federation of Statutory Health Insurance Physicians, KBV.
Unfortunately, that number is unreachable for hours at a time, not only in Berlin, but also in other cities. Across the country, worried residents report endless waiting times and overwhelmed telephone hotlines. This past Monday alone, the group’s call centers across the country received around 165,000 inquiries. Before the coronavirus crisis, they received 25,000 a day. KBV describes it as being an "absolute emergency situation.” On their website, they instruct doctors to refer all patients with fever and a cough to a health department if the case seems suspicious. The system seems to go in a circle.
Almost every German now has heard of a story like 41-year-old Axel Weber’s. During a trip to Norway in early March, Weber came into close contact with travelers from the United States, China, Spain and Italy. After he returned home, he displayed possible COVID-19 symptoms – fever and a cough – and wanted to have himself tested. His odyssey began when he tried to get through to the KBV hotline, unsuccessfully. Weber then turned to the Office for Public Order pointing out that, as someone who runs an events space, he had been in contact with a lot of people since his return. For this reason, he argued, he had to know as soon as possible if he was infected so that he could warn these people. "I got really annoyed,” he says. But nothing happened.
Weber eventually found his way to the city’s public health department, which made arrangements for him to be tested. Unfortunately, the lab that took the smear and analyzed it was totally overwhelmed. "This past Monday, I got an appointment for this coming Monday, at 12:25 p.m.,” says Weber. "That will be almost exactly 11 days after my first symptoms appeared.” He says he will still go to the appointment, even if he no longer has any symptoms. Maybe, Weber argues, an authority will still be interested in whom he had contact with after he returned from Norway.
Thousands of similar stories illustrate the system’s failures. Every missed test, every un-prevented infection, will potentially play a crucial role in determining whether the country’s ICUs will soon be overrun, if the system will collapse. In any case, Germany has no fast and comprehensive coronavirus testing process like the one in South Korea, for example, which managed to successfully limit the virus’ spread.
Germany, which exalts about having one of the world’s best health-care systems, has a number of dangerous weak spots. Contrary to popular belief, the system has not been starved by budget cuts. Instead, health spending has been going up for years. Between 2009 and 2019, Germany’s spending on public health insurance has risen from 167 billion to 246 billion euros.
But the money was often channeled to the wrong places, to radiologists and orthopedists instead of general practitioners, who represent a desperately needed place of first resort for rattled patients. And the money has definitely not gone to the nurses.
The article you are reading originally appeared in German in issue 13/2020 (March 21, 2020) of DER SPIEGEL.
The poor monetary distribution has a lot to do with the financing of German hospitals. Since 2003, hospital services have been remunerated on the basis of set prices for procedures, according to which hospitals receive a set amount of money for every knee or spinal surgery -- no matter how many days the patient has to spend in the hospital, or the extent of his or her care. For hospital managers, this means pre-scheduled operations are the best way to make money, provided that as little as possible is spent on care.
And as a result, Germany, one of the world’s richest industrialized nations, has operating rooms with cutting-edge technology, but fewer nurses per hospital bed than Estonia or Slovakia. Karl Lauterbach, a respected health-care policy expert with the center-left Social Democrats, puts it in dramatic terms: "Since the implementation of the set prices, a doctor has become an investment, but nurses are a financial burden.” For years, the health economist has warned that the set-price policy increases incentives for poor care.
Doctors are also suffering under the system. "For years now, hospitals have been subjected to an industrial logic. But it doesn’t make any sense to run hospitals like factories. It cannot primarily be about money,” says Peter Hoffmann, the chief physician at a Munich hospital and chairman of the Association of Democratic Doctors, which views itself as a counterpoint to the traditional doctor’s associations.
"We will not simply be able to return to everyday life after this,” says München Klinik Managing Director Fischer. "We will need to conduct a review of our entire health-care system."
Perhaps a pandemic was needed to come to that realization.