NIRA OPINION PAPER
No. 54 | October 2020

NIRA OPINION PAPER
No.54 | October 2020

What Can We Learn From Germany’s
Response to COVID-19?
- Medical Preparedness / Flexible Responses / Management of Public FundsYuri Okina

Executive Vice President, NIRA／Chairperson, The Japan
Research Institute, Limited

Ortwin Renn

Director, Institute for Advanced Sustainability Studies

Ansgar Lohse Chairman, Department of Medicine, The University Medical
Centre Hamburg-Eppendorf (UKE)

Germany is said to be one of the most successful countries in the world inresponding to COVID-19. In this paper, we look at the case of Germany, andattempt to identify points in the nation’s response that might be of use to Japan.
The first thing that should be noted is Germany’s medical preparedness. In
Germany, intensive care capacity was well-established even before the COVID-19
crisis. The utilization of data such as the status of hospital beds has also beenpromoted, making it possible to provide severely ill patients with ICU spaces
rapidly and effectively. In addition, medical institutions were offered incentives by
the government to encourage them to significantly increase their number of ICU
beds in order to respond to COVID-19.
Further, flexible cooperation between the federal and state governments andthe reinforcement of the role of specialist institutions by the passage of legislationthat encourages the utilization of scientific information allowed the early
realization of infection prevention measures.
Nevertheless, although it can be judged that measures were put into effectin accord with the actual status of each regional area and a good balance with local
autonomy was maintained, a certain amount of dissatisfaction is smoldering as aresult of severe restrictions on the activities of citizens due to lockdown measuresand additional state regulations.
We should also give attention to the fact that ensuring fiscal soundness prior
to the crisis enabled bold and rapid expenditure of public funds. Compared to other
European nations, Germany has experienced only a minor economic downturn, andthe nation is flexibly altering its course to a focus on environment-oriented policies.
These German initiatives will certainly provide a significant reference forJapan as it responds to COVID-19.

Copyright Ⓒ 2020 by Nippon Institute for Research Advancement
This is a translation of a paper originally published in Japanese. NIRA bears full responsibility for the translation
presented here.

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NIRA OPINION PAPER
No. 54 | October 2020

What Can We Learn From Germany’s
Response to COVID-19?
- Medical Preparedness / Flexible Responses / Management of Public Funds-1
Yuri Okina

Executive Vice President, NIRA／Chairperson, The Japan Research Institute, Limited

Germany’s COVID-19 fatality rate is conspicuously lower than those of other
European nations (Table 1). While the infection rate increased over summer in many nations,the number of people showing positive results for PCR tests began to stabilize in Germany(Table 2). Germany can be pointed to as one of the most successful nations in responding to
COVID-19. Germany also played an important role in Europe by increasing PCR testingfrom an early stage and accepting patients from other European nations into its ICUs.
In this paper I would like to consider the background to Germany’s success in
responding to COVID-19 and explore factors that may be useful for Japan, with reference tothe discussions offered below by Ortwin Renn, a specialist in risk management, and Ansgar
Lohse, a German physician1.
Table 1 COVID-19 deaths per 100,000 people – European nations and Japan
Belgium

Spain

United Kingdom

Italy

SwedenFranceGermany

Japan

865

684

621

594

583

490

113

12

(Note) As of October 1.
Source: Formulated by the author based on data published by the European Centre for Disease Prevention andControl

In writing this paper, I received numerous valuable suggestions from Professor Dr. Franz Waldenberger,
Director of the German Institute for Japanese Studies, and Philipp Reiher, a Research Assistant for the same
institution. I would like to take this opportunity to thank them both.
This paper was edited by Kozue Sekijima (Research Coordinator, Researcher), Ayumi Kitajima (Research
Coordinator, Researcher), and Jonathan Webb of the Nippon Institute for Research Advancement.
Copyright Ⓒ 2020 by Nippon Institute for Research Advancement
This is a translation of a paper originally published in Japanese. NIRA bears full responsibility for the translation
presented here.

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NIRA OPINION PAPER
No. 54 | October 2020

Table 2 Trends in number of COVID-19 patients (patients with positive PCR test
results) in European nations

Source: Formulated by the author based on data published by the European Centre for Disease Prevention andControl

A Well-developed Intensive Care System and “Visualization” of the Status of
Bed Use in ICUs are the Keys
Germany has 1.7 times the number of doctors per population as Japan (Table 3),
and the nation’s family physician system is known to be well-developed. However, it isGermany’s intensive care system that has proven to be most effective in responding to the
COVID-19 pandemic. Germany’s ICU network has more than six times the number of beds
per population as Japan’s, at 33.9 against 5.2 in Japan. The high number of ICU beds inGermany has been the subject of criticism as a factor in the nation’s high medical costs, but
it has contributed to allowing Germany to avoid the collapse of its medical system in thecurrent crisis. Another point that we should take note of is the large number of intensive
care specialists working at German hospitals. Looking at total numbers, Germany has 8,328
specialists (as of 2018), while Japan has 1,850 (as of 2019), clearly a significant difference(figures taken from a survey conducted by the Japan Medical Association). Considered bypopulation, there is actually a sevenfold difference between the number of intensive carespecialists in Germany and Japan. Furthermore, the promotion of the utilization of data andthe ability to grasp the status of vacant beds in ICUs and other wards in each of the nation’s
hospitals online increases the possibility of providing ICU beds for severely ill patients

Copyright Ⓒ 2020 by Nippon Institute for Research Advancement
This is a translation of a paper originally published in Japanese. NIRA bears full responsibility for the translation
presented here.

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NIRA OPINION PAPER
No. 54 | October 2020

quickly and effectively. With regard to considering the resilience of its medical system in atime of crisis, Japan can certainly learn from Germany’s well-prepared intensive care system(from both physical and personnel perspectives) and the efficient data-based operation ofthat system.
(Table 3) Comparison of medical preparedness in Germany and Japan
GermanyJapan

Number of hospital beds per 1,000 population

8

12.98

Number of doctors per 1,000 population
Number of pharmacists per 1,000 population
Number of CT units per million population
Number of MRI units per million population

4.31
0.66
35.13
34.71

2.49
1.90
111.4955.21

Number of ICUs per 100,000 population

33.9

Number of hospitals per million population

37.3

As of time of survey
OECD average
Germany︓2017, Japan︓2018
4.5
3.4
0.9
27.6
17.3

5.2

2018
2018
2017
2017
Germany︓2017, Japan︓2019

66.2

Germany︓2017, Japan︓2018

28.9

12

Source: Formulated by the author based on OECD data

Advance Preparation by Experts and a Flexible Response that made use of
Government Incentives
Germany has had a crisis response plan that projects risk scenarios in place foreight years, since it experienced severe acute respiratory syndrome (SARS). Because of this,the nation was able to rapidly implement response measures when the true nature of
COVID-19 began to become clear. First, Germany established the principle that
understanding the status of viral infection would be directly related to the prevention offurther infections, and therefore enhanced its PCR testing system from the earliest stage.
Tests were also conducted on asymptomatic people. By March 15, 18,000 tests per day werebeing conducted, but this figure rapidly increased to reach 50,000 per day by March 22.
Following this, the number of tests conducted remained constant until mid-June, but thenincreased significantly, exceeding 160,000 a day over the course of September.
Several factors have been indicated as reasons that Germany was able to establish
a PCR testing system in such a short period. First, in mid-February, 300 laboratories anduniversity hospitals throughout the country participated in a “testing scheme.” In addition,
the Robert Koch Institute, a federal agency, issued a recommendation regarding thenecessity for testing, and most states followed this recommendation. Testing was also madethe subject of government medical insurance, and 250 private sector testing companies are
conducting tests, with the result that large numbers of citizens have been able to receive
tests2. In Japan also, former Prime Minister Abe announced a policy for the expansion of
testing; it will, however, be necessary to examine why this policy was not realized at an earlystage. The German government succeeded in actively providing support for medical
institutions that created ICU to respond to severely ill patients. In concrete terms, looking
Copyright Ⓒ 2020 by Nippon Institute for Research Advancement
This is a translation of a paper originally published in Japanese. NIRA bears full responsibility for the translation
presented here.

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NIRA OPINION PAPER
No. 54 | October 2020

at the incentives provided to hospitals, the government provided subsidies of 50,000 euros
per bed (equivalent to 6 million yen), enabling it to rapidly increase the nation’s ICU capacityfrom 25,000 beds to 40,000 beds.

A Focus on Scientific Opinion
In addition, the German government created a system under which the Federal
Cabinet has been advised on a weekly basis by epidemiologists and other experts since theearly stages of the spread of COVID-19, allowing expert knowledge to be incorporated inpolicy. In particular, specialists at the Robert Koch Institute have played a central role in
the provision of expert opinion, and have supported measures to prevent the spread of theinfection through diverse and constant cooperative initiatives conducted with thegovernment. A mechanism that allows scientific experts to provide advice to the government
has existed in Germany since the 19th century. Today, numerous advisory bodies are active,and experts play a variety of roles in the presentation of advice. With regard to the current
measures to prevent the spread of COVID-19, the experts have been scrupulous in providing
verified and evidence-based opinions, but judgment on policy measures and the
responsibility for the formulation of policy has ultimately rested with the government.
The role of the Robert Koch Institute was enhanced in late March based on the Law for theProtection of the Population in the Event of an Epidemic Situation of National Significance(Gesetz zum Schutz der Bevölkerung bei einer epidemischen Lage von nationaler Tragweite).
Specifically, the Federal Ministry of Health has established the authority to makerecommendations regarding cooperative actions within the government based onrecommendations from the Institute; the Institute has also been authorized to coordinate
cooperation with the federal government, states, and other institutes, and to exchange
information with these entities.
Other experts are actively providing advice to the government in addition to thespecialists associated with the Robert Koch Institute. The world-renowned virologist
Christian Drosten, for example, directly advised Chancellor? Angela Merkel regarding thenecessity for PCR testing. Dr. Drosten also explained issues including COVID-19 andmeasures to prevent its spread from an expert perspective for the general public in a podcast
which was downloaded by large numbers of people, becoming, it is said, the most-listenedto podcast in Germany.

Efforts to realize a Balance between Cooperation at the Federal Level and a
Respect for Regional Autonomy
In Germany, the federal and state governments have worked together to promotemeasures to prevent the spread of infection based on guidelines agreed between them. Since

Copyright Ⓒ 2020 by Nippon Institute for Research Advancement
This is a translation of a paper originally published in Japanese. NIRA bears full responsibility for the translation
presented here.

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NIRA OPINION PAPER
No. 54 | October 2020

March, Chancellor Merkel has issued messages to the entire nation, and has intensified
initiatives at the federal level.
Federal and state governments have cooperated in order to flexibly advancemeasures against COVID-19 in a process of trial and error. On March 12, the first guidelines
were established based on agreement between the federal government and state
governments. At the federal level, these guidelines banned gatherings of more than 100
people, and also closed schools. In the middle of the month the states issued ordinances
based on theProtection against Infection Act(IfSG)3, deciding to close nursery schools andstores (restaurants and drinking establishments, hairdressers, entertainment venues, etc.),
but the status of implementation of these measures varied depending on the state. Becauseof this, a new agreement was established between the federal government and the states on
March 22, and integrated federal government guidelines were established, for example
restricting the freedom of movement of citizens (i.e., establishing a lockdown) 4 . And on
March 27, the abovementioned Law for the Protection of the Population in the Event of an
Epidemic Situation of National Significance, consisting of seven articles, was established.
This made it possible for the federal government to more easily respond to infections thattranscended state borders, and strengthened the role of the Robert Koch Institute5.
In this way, while cooperating with the federal government, each of Germany’s
states enacted regulations that were supplemental to the government’s integrated
guidelines, responding to the status of COVID-19 infections in their state and the specificcharacteristics of their region. The situation continued to vary from state to state as a resultof these additional regulations, but in some cases policies enacted in states that responded
particularly well provided models that allowed the improvement of other states’ initiatives.
As Drs. Renn and Lohse indicate, many people are appreciative of the fact that measures
have been implemented with consideration of the actual conditions in specific regions.

The Importance of Maintaining Sound Fiscal Management before a Crisis
We must also give attention to the fact that the German government maintainedsound public finances from before this crisis, enabling it to respond boldly and rapidly when
the crisis did occur, for example through public expenditure (grants for the curtailment ofbusiness operations, subsidies, etc.) and the ability to offer tax cuts. In addition, the use of
taxpayer identification numbers and other identifiers for the provision of subsidies andsimilar payments made it possible for the government to respond rapidly via the Internet.
In addition to a temporary reduction in value-added tax from July6, the government has also
increased expenditure on subsidies for the purchase of environmentally-friendly vehicles,
and is promoting policies that emphasize responses to environmental issues and theadvancement of digitalization7. These policies have resulted in a 2.9-fold increase in thenumber of newly-registered EVs and PHVs against last year in July this year. Consumption
is also displaying a recovering tendency, and Germany’s economic downturn in 2020 is
Copyright Ⓒ 2020 by Nippon Institute for Research Advancement
This is a translation of a paper originally published in Japanese. NIRA bears full responsibility for the translation
presented here.

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NIRA OPINION PAPER
No. 54 | October 2020

expected to be lower than that of other European nations
Germany’s federal government has issued government bonds totaling 218.5 billion
euros, corresponding to 60% of its initial budget amount, in order to respond to COVID-19.
This represents a debt-to-GDP ratio of 77%, an extremely large-scale issue of government
debt for Germany, which has always maintained a balance of public expenditure. However,at the same time as this issue of government bonds, the government has established a plan
to make up the shortfall in revenue represented by the project cost for COVID-19 responses
and the decline in tax revenues, and the Cabinet has already decided on a 20-year
government bond redemption scheme to be commenced from 2023. This should provide foodfor thought to Japan with regard to the nation’s fulfillment of its responsibility to future
generations.
It should be noted that in July, Germany actively supported the 750 billion-euro(equivalent to 92 trillion yen) EU recovery fund that will benefit nations such as Italy andSpain. This may be cause for concern over the future soundness of Germany’s public finances,
but is also viewed as a step in the direction of the nation’s leadership in the fiscal integrationof the EU.

Germany has also experienced Skepticism regarding the Imposition of
Lockdown
According to a recent survey of public opinion, between 60 and 70% of German
citizens support the responses to COVID-19 implemented by the federal and state
governments. At the same time, the lockdown enforced between March and May, and thestate regulations established in addition to this, placed severe restrictions on citizens’
freedom of behavior, resulting in a smoldering resentment among a certain segment of the
population. State authorities and police were intolerant of violations of the regulations, andimposed fines in these cases. The imposition of strict regulations in Germany differs greatly
from the situation in, for example, Sweden and Japan, where citizens were requested tomake voluntary changes in their behavior. As a result, there have been suits in the nation’s
states arguing that lockdown violates the freedoms guaranteed by Germany’s constitution.
In the initial stage of the pandemic, the judgments of the courts in these cases largely
favored the government, but as time has passed, rulings have become more diverse.
Opposition to the lockdown has also included a demonstration held in Berlin on August 1
that was attended by around 20,000 protestors.
Some are also skeptical that lockdown was necessary from an epidemiologicalperspective. Below, Dr. Lohse points out that the infection rate in Germany was stabilizing
prior to the imposition of lockdown, that it was unnecessary to close kindergartens andschools, and that in Europe and the US as a whole, the fear of COVID-19 has reduced
emergency hospitalization by 40% and had a significant impact on the health of heart attack
patients. With regard to lockdown, it appears that the view that a comprehensive evaluation
Copyright Ⓒ 2020 by Nippon Institute for Research Advancement
This is a translation of a paper originally published in Japanese. NIRA bears full responsibility for the translation
presented here.

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NIRA OPINION PAPER
No. 54 | October 2020is necessary is also gaining ground in Germany.
As has been demonstrated above, it is clear that Germany’s approach offers
numerous points of reference for Japan’s own response, including the maintenance of a welldeveloped intensive care system, the data-driven coordination of beds and patients, theprovision of incentives to promote rapid crisis response, the utilization of scientificknowledge, the realization of a balance between cooperation at the federal level and a respect
for regional autonomy, and the maintenance of fiscal soundness before a crisis strikes.

Main References
Kai Kupferschmidt (2020), “How the pandemic made this virologist an unlikely cult figure”,
Apr.28, Science, AAAS
Sebastian von Münchow (2020), “COVID-19: How to Implement a Lockdown in a DemocraticContext”, Security Insights, George C. Marshall Center European Center for Security Studies
Constantin Eckner (2020), “How Germany has managed to perform so many Covid-19 tests”,
THE SPECTATOR
Tooru Kumagai（2020）, The State of the Nation as revealed by a Pandemic – 150 Days in the
Battle against the Coronavirus in Europe, NHK Publishing Co., Ltd. (In Japanese)
Eiji Tajika （2020）, “Fiscal Policy in the Era of COVID-19 – Suggestions from Germany,” July
14, 2020, The Tokyo Foundation for Policy Research (In Japanese)
Akemi Yokota and Kazufumi Abe （2020）,“Legislative Responses to COVID-19 (the Novel
Coronavirus) in Germany – From the Perspectives of the Division of Authority between Federal
and State Governments and the Administrative Information Law,” JILIS Report, Vol. 3, No. 2,
Japan Institute of Law and Information Systems (In Japanese)

Yuri Okina

Dr. Okina is an Executive Vice-President of the Nippon Institute for
Research Advancement and the Chairperson of the Japan ResearchInstitute, Ltd. She holds a Ph.D. in economics from Kyoto University, andis the author of publications including Financial Crises and Prudential
Policy (Nihon Keizai Shinbun Shuppansha, 2010; in Japanese). She holds
a variety of public positions, including as a member of the Financial
System Council and the Industrial Structure Council.

Copyright Ⓒ 2020 by Nippon Institute for Research Advancement
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presented here.

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NIRA OPINION PAPER
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Note
The discussions by Drs. Renn and Lohse are based on their presentations at the following
two seminars:

1

https://www.dijtokyo.org/event/national-approaches-to-systemic-riskgermany-and-japanunder-the-covid-19-crisis/
https://www.dijtokyo.org/event/how-real-are-numbersmaking-sense-of-national-covid-19statistics/
2

See Kumagai（2020）, Eckner（2020）, etc.

Article 28 of the Protection against Infection Act(IfSG) states that when an individual isbeing treated for an infectious disease or is suspected of being infected, the authority withjurisdiction shall apply the necessary preventive measures, including prohibition of
movement and restrictions on entry to buildings, etc., in addition to quarantine andoccupational restrictions. This Article also includes provisions regarding measures such as
restrictions on gatherings and the closure or partial closure of child welfare facilities. The
fundamental rights that are restricted are freedom of the person, freedom of assembly,
freedom of movement, and inviolability of the home.

3

An outline of the guidelines is as follows: 1. The minimum possible contact with others who
are not part of the same household; 2. Maintenance of a minimum distance of 1.5 meters fromother people in public spaces; 3. If spending an extended period in a public space, one shouldbe by oneself, with a member or members of the same household, or with a maximum of one
person who is not a member of the same household; 4. Essential activities may be conducted(examples include commuting, seeking emergency care [care for children, elders, etc.],
shopping, visits to hospitals, fulfilling important commitments such as exams and attendanceat meetings, provision of support for others, practicing individual sports, and performing
outdoor activities in the fresh air); 5. Prohibition on gatherings of groups of people in bothpublic and private spaces. Prosecution of violations of restrictions on contact by relevant
authorities or police, and application of fines; 6. Closure of all eating and drinking
establishments; 7. Complete closure of all service businesses related to personal care(hairdressers, beauty salons, etc.) other than providers of essential medical care; 8.
Compliance with hygiene regulations at all places of business. Implementation of effective
protective measures for employees and visitors; 9. A two-week minimum period of applicationof the measures described above.

4

Specifically, in addition to enhancing the functions of the Institute, the law has allowed
details to be decided by the federal government in accordance with general administrative
rules, with the approval of the Bundesrat. In addition, the law has made it possible to provide
compensation for the closure of businesses such as childcare facilities, and has clarified thebasis for the previously vague application of fines. It has been assumed that the states do not
lose any authority, but in actual fact, the interpretation has been that federal law has greater
authority than state law.

5

The tax rate has been reduced from 19% to 16% from July 1. The tax on foodstuffs, etc. has
been reduced from 7% to 5%.

6

Financial incentives for the purchase of electric vehicles (EVs) and plug-in hybrid vehicles(PHVs) (available until the end of 2021).

7

Copyright Ⓒ 2020 by Nippon Institute for Research Advancement
This is a translation of a paper originally published in Japanese. NIRA bears full responsibility for the translation
presented here.

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NIRA OPINION PAPER
No. 54 | October 2020

Analyzing Germany’s Approachto the Pandemic
Ortwin Renn

Director, Institute for Advanced Sustainability Studies
I would like to review and offer some insights regarding Germany’s performancewith respect to the COVID-19 crisis.
First of all, based on the number of fatalities, we can say that Germany has been
fairly effective and mobile in managing the crisis. Recent studies show that excess mortality
in Germany is less than one percent above average while in the US, excess mortality isalmost 20% above average. Germany was not sufficiently prepared for this unprecedented
pandemic at the beginning, and lost at least a week before taking action. Most experts,
including myself, thought that the pandemic was not as problematic as it appeared, because
we thought that the virus would be less infectious than most other flu viruses, and less fatal
than SARS and other recent epidemics. We also thought that risk managers would be able
to contain the spread of the virus within China and surrounding countries. Over time, we
corrected this notion and the central government acted swiftly within a short period of time.

One of the Countries with the Best Record
In Germany, we have been testing as many people as possible to get accurate
numbers, which I think is contributing to the containment of the disease, although mass
testing alone does not explain the significant difference between Germany and countries likethe United States or Italy. Testing in itself does not change anything in terms of risk
management, but it gives us more certainty about how widespread the threat actually is. It
is critical to know where and how the infection has spread in the population.
Like many other countries, we isolated the infected from the rest of the population
to avoid stress on the healthcare system. We engaged in a fairly strict lockdown from theend of February, implementing what I call physical rather than social distancing measures.
These measures were not as strict as they were in many East Asian countries. Families
could visit parks for a walk; however, no more than two individuals were allowed to gather
unless they were members of the same family. Travel was banned and many businesses wereclosed. Germany has gradually lifted its six weeks of strict regulations starting from midApril, based on the condition that there were fewer than 50 infected people per 100,000
inhabitants. At present, the federal and regional governments agreed in July to allow

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tougher and more targeted lockdown measures to contain local outbreaks, following a cluster
infection in a local community. In late August, the number of newly infected individuals wason the rise again but the threshold has not been reached to adopt more stringent measures(i.e. 50 infected per 100,000 people) throughout Germany. However, the threshold has beensurpassed in some regions and more severe measures have been enacted locally.
As part of its strategy, the government planned to launch a centralized tracing app
but there was a backlash due to concerns over privacy, reflecting the fact that Germans are
fairly sensitive to civil rights issues and privacy, probably more so than the citizens of manyother countries. The app that has now been developed and freely distributed is based on adecentralized tracking system by means of which individuals are warned if they have comeclose to infected persons. This information is not centrally stored or transmitted to public
institutions. Furthermore, the use of the app is voluntary. At this point in time, a little morethan a quarter of the German population has been reported to have activated the app.

Tensions between Central and Regional Governments
Germany has a federal structure that divides authority between the central andregional governments. Despite the existence of tensions, the division of government roles
seems to be effective overall, and allows for flexible approaches given the fact that different
regions are affected differently.
The federal government is responsible for the overall strategy, but standards andrestrictions are set by state-level governments. Furthermore, there are municipal-levelgovernments that can modify these standards, and which are responsible for theirimplementation and oversight.
The state governments were very much in accord with the federal government in
the beginning. As some states were more affected than others, it became difficult to set
standards nationwide, which produced tensions among the federal, state and municipal
levels due to their inability to align. Because there are different levels of risk in different
regions, it makes sense to shy away from standardized regulations. States are now acting
more independently in setting their own regulations.
It should be added that some state leaders saw this as an opportunity to achieve a
better public profile, and maneuvered the crisis at the expense of strategical coherence,
productivity and people’s trust in the government. Many state and municipal leaders arepressing for the removal of all restrictions, although the majority of the public still supports
strict measures.

The Role of Scientists and Specialists
The German policymaking process is highly influenced by scientific advice.

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What could be regarded as a specific characteristic in Germany is the nation’s
strong reliance on scientific institutions, in particular the Robert Koch Institute, which is
the government's central scientific institution in the field of biomedicine and is responsible
for safeguarding public health in Germany. It plays a major role in framing the debate andsuggesting measures and rules. Scientists, specifically virologists and epidemiologists, also
have a significant role in policymaking as well as in the public debate about what should be
done. The debate was strongly dominated by virologists and epidemiologists in the beginning,but this meant that economic ramifications, psychological consequences and social impacts
were not always considered. This situation has been changing since May 2020 and otherexperts from the economic, social sciences and management fields have become more vocal
in evaluating the adopted measures. To respond to frequent debates regarding whether thecurrent regulations are proportional to the threat, as the principle of proportionality is very
important in German law, the government has often consulted institutions like the National
Academy of Sciences for advice. Science plays a major role and the government adheres toevidence-based policymaking.
The approval ratings of the federal government as well as state governments,
including the main ruling party, the conservative Christian Democrat Union, have increased
dramatically and are still at a high level. The Christian Democrat Union had lost public
support over the past two and a half years, but now they would gain between 30 - 40% of thevote in an election. It is not unusual that ruling parties increase in popularity during a crisis,
but in this case it has been apparent that Chancellor Merkel was given credit for being an
excellent crisis manager. The strict measures applied were approved by the vast majority,
despite a vocal and sometimes even violent protest movement led by so-called “Querdenker”(“mavericks”).

The Public’s Response to the Crisis
The general public supported the government in the first phase of the crisis, but isgradually becoming more impatient and more polarized with the continuation of theregulations.
In the beginning in early January, there was considerable diversity of viewpoints,
ranging from downplaying the risk to dramatizing the risk. However, that changed
dramatically at the end of January and the beginning of February, as the general publicreached a strong consensus in its support of the government’s decisions. The lockdown was
welcomed by the vast majority (at least 70%) of the population.
Following this, public responses pluralized, and many are now questioning thevalidity of the current government strategy, with the continuation of strict social distancing
rules but otherwise relaxed measures. We now face many local protests of up to 10,000
people who are opposed to the government rules and organize demonstrations in large cities
such as Stuttgart and Berlin. People are becoming more familiar with the large numbers of
Copyright Ⓒ 2020 by Nippon Institute for Research Advancement

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cases and deaths, which I think is an interesting psychological phenomenon and signals atrend towards the re-calibration of normality. COVID-19 has become a familiar and almost
expected concomitant of modern life.
People do understand that the top priority is to save lives, but once they get used tothe crisis and see figures drop, they pressure the government to remove the restrictions.
Yet national opinion polls reveal that more than 70% of the public are still
supporting the central government’s policies and are in favour of a cautious approach inremoving the restrictions.

The Major Future Challenges
Finally, I would like to address the major future challenges for Germany’s recovery
programme – whether it will move in the direction of sustainability, of redirecting funds into
improved resilience, and how to compensate for inequitable consequences nationally andinternationally.
Germany has announced an ambitious economic recovery programme. The planned
programme has been exposed to many conflicting expectations, for example whether itshould boost the economy regardless of purpose, or give it a specific direction such as green
and sustainable economic development. Should the government merely hand Germans moremoney to boost consumption for a specific industry that is suffering severely, like theautomobile industry? There has also been a huge debate involving the automobile industry,green NGOs and the general public, as to whether the government should only subsidize
electric vehicles, should include vehicles using hydrogen or synthetic fuel, or should
subsidize any type of car, and these have become sensitive issues. In the end the government
decided to launch a recovery program that shows clear indications of directing economic
growth towards sustainability, for example by subsidizing the purchase of electric cars but
not of cars with conventional internal combustion engines.
With regard to investment in public health, the German health system was well
prepared for emergencies, and most of those infected with COVID-19 were brought tohospitals at an early stage. Equipped with a large number of hospital beds, Germany’s
intensive care units (ICU) were far from being over-taxed, and in fact, we have made ICU
beds available to patients from other EU countries. In the past, our health system wascriticized for its overcapacity, because the investment of public funds brought up issues of
efficiency versus resilience, but it now seems that the investment in resilience has paid off.
To reduce systemic risks like the pandemic, more investments are likely to be madein resilient public health structures including social support systems as well as criticaltechnical infrastructure, for example for the nation’s electric power system. Many hospitals
in Germany are run privately but receive public funds. Under public supervision, the basic
quality of rural and city hospitals does not differ significantly, but there is debate on how toprovide hospitals with equal expertise to ensure equal access to treatment for this new virus.
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I must add that there were hospitals as well as elderly care homes that failed fairly badly interms of limiting the disease, but these were fortunately exceptions to the rule. Investments
towards resilient infrastructures may be accompanied by a re-nationalisation of criticalsupply chains. This could also become an issue between the right and the left of the political
spectrum.
With regard to international relationships, it is expected that there will be strong
pleas for solidarity with nations that are more affected than Germany, specifically thesouthern states of Europe, i.e. Italy, Spain and in part France, but also from third world
nations in Africa and South America. Italy was already in debt, and is asking the EU for
support; the EU is also asking for solidarity. Germany has pledged to provide support toneighbouring countries through EU mechanisms. In a tough negotiation, the EU countries
finally agreed to provide a substantial support fund for recovery based mostly on a regular
EU budget and additional loans that need to be paid back over a long period of time. This
EU policy is still controversial in Germany. Traditionally, there has been a major reluctanceto utilize taxpayer funds for supporting other EU countries. Nevertheless, the new EU
compromise has received overall approval from Germany’s political parties, other than theright wing AfD, and the public at large. International concerns extend to the growing conflict
between the US and China, as Germany is one of China’s major trading partners.
We continue in our pursuit of a future vision and recovery.
Ortwin Renn
Ortwin Renn is an internationally renowned risk researcher. As ascientific director at the Institute for Advanced Sustainability Studies(IASS) in Potsdam, Germany, his research focuses on the role of systemicrisks as threats to sustainable development, and structures for sustainabletransformations in Germany and beyond. He continues to serve as acting
chair of the Stuttgart Research Center for Interdisciplinary Risk andInnovation Studies at the University of Stuttgart (ZIRIUS) and as
scientific director of DIALOGIK, a non-profit research institute for theinvestigation of communication and participation processes. He has a PhD
in social psychology from the University of Cologne. His honors include the
National Cross of Merit Order, an honorary doctorate from the Swiss
Institute of Technology and the Distinguished Achievement Award of theSociety for Risk Analysis (SRA).

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Rethinking Lockdown: The Lessons, Limitations,& Future of Germany’s COVID-19 Response
Ansgar Lohse

University Medical Center Hamburg-Eppendorf

Under the Surface of Germany’s Test, Trace, and Lockdown Regime
The hallmark of Germany’s response to COVID-19 has, since the earliest days ofthe pandemic, been a high testing rate. The result has been a good understanding of theviruses spread, and a relatively low incidence of undetected clinical disease. However,
because only a small portion of those infected develop symptoms, some regional studies
suggest that even in Germany the actual infection rate is probably 10 times higher than theofficially registered case load. Consequently we believe that the official death rate inGermany of 4.7% is probably an overestimate of around 10 times. This is supported bypostmortem analyses at our hospital of COVID-19 positive patients who died, showing thatat least 20% of “COVID-19 deaths” were actually not directly attributable to the virus but tounrelated preexisting deadly conditions.
Tracing the course of infections in Germany over time, a fairly rapid rise in the
reproduction rate in early March is evident, but I believe a closer analysis of the way the
curve developed contradicts much of what is commonly believed about lockdown: The
maximum infection reproduction rate in Germany was reached around the 10th of March.
Lockdown measures were subsequently put in place between the 15th and 17th of March,depending on the region and state responsible. However, by that time the reproduction rate
had already dropped dramatically and started to fall below the critical figure of R=1. Clearly
other factors such as improvements in hand washing, sneezing and coughing etiquette andincreased testing contributed to Germany’s impressive success in bending the curve quickly,
even before lockdown. This begs the question, was lockdown really necessary and was it
necessary in the way it was done? I think there is plenty of space for discussion on that going
forward, and much will remain speculative.

Exploring the Impact of Age on COVID-19 Mortality and Transmissions
Another important point is the age distribution of cases, because both the casefatality and infection rates differ dramatically with age. Looking at the number of positive
cases per population, the younger more socially active people, and most notably young
children, have much lower rates of disease compared to the higher age groups. What we areseeing here is actually the rate of virus detection, not the actual disease rate, as many people
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NIRA OPINION PAPER
No. 54 | October 2020are asymptomatic and thus never tested even in Germany. Thus the data have a certain bias.
Looking at mortality data, COVID-19 induced mortality only starts to be statisticallydetectable above the age 50, and only becoming more relevant from the age of 60 onwards.
Extremely few people below the age of 40 died, and these were primarily patients with othersevere underlying diseases such as advanced malignancies.
Further highlighting the importance of age distribution, a lot of attention was given
to the recent research by Professor Drosten, the virologist who discovered the SARS virus
and was one of the first to develop PCR testing for COVID-19: Major differences between
age groups were identified in the amount of viral material isolated from the throat of infected
people. While the data is still preliminary, it suggests that children and young people underage 20 seem to become infected at far lower rates, and when they do catch the virus they
have significantly lower viral loads than people above 20 and older. Furthermore, it isincreasingly clear that this virus is spread primarily by a small number of so called“superspreaders,” who infect a lot of other people, rather than being spread equally byinfected persons. These superspreaders are probably those with a very high viral load andsubsequently a lot of viral material in their throat, and with coughing and other behaviour
facilitating viral spread. What is clear is that while case numbers are reported as if every
infection were equal, this is not clinically and epidemiologically the case. The highly
differentiated age distribution should guide policies when going forward.

German Health Care System is Federally organized and backed by a HighLevel of Per Capita Intensive Care beds
Stepping back for a moment, tracing infections in Germany demonstrates theimpact of a regional methodology on data collection. In Germany, healthcare is organized ona federal basis around the states, with Regional Health Offices (“Gesundheitsamt”) being
responsible for both data collection and local health regulations. While the National Centreof Disease Control, the Robert Koch Institute, advises the national government and compiles
national guidelines, it is fundamentally reliant on the cooperation of local health offices. The
main advantages of this regional approach are that it preserves flexibility, can take into
account specific local conditions, enables direct communication between local healthcare
providers and regulators, and empowers local agencies to react quickly to a change in thesituation. The importance of this is clear when looking at the regional distribution of casesin Germany. In some areas, the rate of infection is very low. However, at the same time there
are also regional hotspots: in the south of Germany related to travel and trade with northern
Italy, in the west from commerce with France, and in Hamburg, in the north due to its
wealthy population traveling to skiing resorts and other tourism hotspots. This variability
across regions begs the question, did the whole country really need to lockdown?
The disadvantage of a localized approach like Germany’s is that national reporting
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is delayed. Much like in Japan, Germany always reports a drop in cases on Monday and anincrease on Tuesday, because over the weekend local offices often do not report in.
Furthermore, this regional organization also leads to incoherent vertical data collection. For
example Germany lacks reliable national mortality figures, as they are always highly
delayed, the local offices that prepare them often have limited expertise and there is always
the risk of local political interference. Nonetheless, I believe that with what we know now,reacting regionally is the much more appropriate course of action.
A highly praised aspect of the German pandemic response has been its highintensive care and ventilator capacity. This is actually a symptom of structural deficiencies
that, in normal times, make the healthcare system extremely expensive due to overuse of
intensive care beds, and as it encourages lengthy inpatient care because hospitals get moremoney the longer a patient stays, especially the longer a patient is being ventilated.
Nonetheless, in the case of COVID-19 these disadvantages were enormous advantages. At
25,000, German ICU capacity far surpassed that of the United Kingdom at 5,000,
quadrupling it on a per capita basis. The result was that through the pandemic Germany
had 12,000 unused intensive care beds. This means we could easily deal with far more cases
than we have actually had to deal with.

Pandemic Response Must Go Beyond “Fear” & “Waiting for a Vaccine”
This brings us to a very important question underlying the global COVID-19
response, and what is the appropriate level of fearfulness. I believe that in Germany the way
in which deaths were initially reported fueled an overabundance of concern. Every day it
was “the number of deaths has increased,” but, logically there is no way that the number ofdeaths could decrease. It is only now, later in the pandemic, that the death rate per day is
being regularly reported despite the fact that, after a short initial rise, the number has
declined very rapidly.
The overabundance of fear surrounding COVID-19 has obscured the ways in which
our pandemic response has created other problems. For example, across Western countries,
emergency admissions dropped 40%, so people with, for example, myocardial infarction did
not receive the necessary emergency care. Increased mortality may therefore be related tothe pandemic much more indirectly, because of reduced availability of, or willingness topursue, health care for people with other diseases. At the same time, the economic
consequences of our response are also very real, with one easy example being an increase inhunger worldwide. Very few, if any epidemiologists have adequately addressed thepossibility of an increase in total mortality, resulting from not only COVID-19, but from our
response to it. It remains an open question whether increased morbidity and mortality
during and following the pandemic will be more due to the virus directly, or more due to theindirect secondary effects.
Because we have not been discussing the longer term consequences of our response,
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in Germany people have been saying “we will do a lockdown until we have a vaccine, andonce we have a vaccine we will reopen the schools .” However, a vaccine against this virus
will be complicated, probably delayed, and the question of who actually gets it, controversial.
For example, should priority be given to the elderly, who are most at risk, but whose immune
response to vaccines is weakest, or to younger people who are less at risk, but who will havea better chance of developing immunity and thus help in stopping the viruses spread?
In consideration of the above, I proposed in late March that we should open
kindergartens and primary schools. The children are not really in danger and are not reallya major spreader of the disease. At the same time I argued that we need a much stronger
protective response for the really endangered population, the elderly and chronicallydiseased persons, who continued to be put at risk due to a lack of face masks and protective
clothing in nursing homes. We should have better protected the elderly, while allowing
infections in the younger population so that at least some degree of herd immunity could
have developed to better protect all of us from future infection waves.
In conclusion, Germany’s pandemic response so far has had clear positives andnegatives. Relatively low rates of infection and mortality, a high rate of testing, and a
fortunate excess of ICU capacity have enabled Germany to effectively steer through thecrisis so far. However, Germany missed the chance to develop a limited herd immunity, while
also failing to adequately protect the vulnerable earlier in the crisis. Furthermore, children
were kept out of schools leading to learning and social disadvantages without adequate
medical justification. Going forward, a reassessment of Germany’s pandemic policy thatincorporates the latest research to mitigate the high level of collateral damage, which
includes children’s education, research activity, and long term economic vitality, is desirable
Ansgar Lohse
Ansgar Lohse is a specialist in internal medicine, gastroenterology andinfectious diseases, with a special interest in basic and clinicalimmunology. He studied medicine and philosophy in Göttingen, London
and Boston and received his Doctorate at the University of Marburg. He is
Chairman of the Department of Medicine at the University Medical Centre
Hamburg-Eppendorf (UKE), Germany. He is head of the Hamburg
University Research Centre for Inflammation, Immunology and Infection.
He serves on many scientific boards, is editor or associate editor of various
clinical and scientific journals and member of the Hamburg Academy of
Sciences. where he chairs the commission "Infection research & Society".
Photo by Axel Kirchhoff/UKE

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