How German Perfectionism Waylaid Its Covid Vaccine Program

What works most efficiently for Mercedes-Benz and Porsche production is not necessarily most productive for people. 

The perfect is the enemy of the good. JL

Philip Oltermann reports in The Guardian:

Berlin unveiled its immunisation drive with German precision engineering. Jabs would be mass-administered in purpose-built vaccination centres where patients could be queuing like cars through a car wash. A Lego display demonstrated the complex system’s efficiency. “It all looked very logical in theory. But looking at it as a doctor, that’s not how vaccinations work in practice." Germany’s stockpile of unused vaccines had grown to 3.5 million doses, partially because the health ministry insists on holding between 20% and 50% of doses for the second jab.

In December, two weeks before the European Medicines Agency authorised the first vaccine against Covid-19 for use across the European Union, Berlin unveiled a plan to rocket-fuel its immunisation drive with German precision engineering. Jabs would be mass-administered in purpose-built vaccination centres where patients could be shuttled through queuing lanes like cars through a car wash.

A Lego display demonstrating the complex system’s efficiency impressed journalists at a press launch, but set off alarm bells in the head of Janosch Dahmen, a former doctor turned Green party MP. “It all looked very logical in theory,” says Dahmen, who worked on the pandemic frontline until November. “But looking at it as a doctor, I thought: that’s not how vaccinations work in practice.

“You want your grandmother to get a call from the family doctor who has been treating her for 20 years and tells her not to worry about those side-effects she has heard of on the radio. People are not cars.”

Three months on, the alarm bells are ringing loud enough for the whole of Germany to hear.

Last spring, at the start of the pandemic, the country looked like a role model for how to deal with the viral threat. It was managing to contain outbreaks thanks to a high rate of testing and an advanced contact-tracing system. In mid-April, its case fatality rate for Covid-19 infections was less than 3%, compared with 14% in the UK and 13% in France, in spite of a lockdown that was softer than elsewhere on the continent. Levels of compliance were high, as were the government’s approval ratings.

Yet on Friday the head of Germany’s disease control agency warned that the country was heading for a third wave of the pandemic that was likely to be its worst one yet, while the government looked lost for answers, U-turning within 48 hours on a strict Easter lockdown plan without offering alternative restrictions in its place.

Frustration runs high with a complex, ever harder to follow patchwork of rules, issued following increasingly acrimonious video conferences between Angela Merkel and the heads of Germany’s 16 federal states. 

Worst of all, the immunisation hyperdrive remains stuck in first gear: 90 days since the first jab was administered, only 10% of Germany’s population have received their first dose, compared with 42% in the UK and 26% in the US. Even France, once seen as Europe’s vaccine laggard, has given a higher share of its population a first dose than Germany.

From the outside, Germany’s relatively successful management of the pandemic’s first wave was often linked to the wise decision-making of its chancellor, a trained quantum chemist who could calmly explain complex scientific calculations where other leaders reached for martial metaphors.

“Macron’s response to the pandemic was ‘Nous sommes en guerre,’” said Andreas Rödder, a historian at the university of Mainz. “Merkel’s was: ‘Remember to wash your mask at 60 degrees.’”

Seen from inside Germany, both the country’s early victories and current malaise were more easily explained by structural factors, cultural priorities and a degree of fortune – good in 2020, less so in 2021.

When Germany imposed its first lockdown on 22 March last year, it was lucky that, unlike in Italy, the virus had not yet silently spread around the country and into care homes for the elderly. In the highly decentralised country, Covid-19 also came up against a political system that was surprisingly well-placed to cope with the initial challenges.

People wait to receive a Covid vaccine at a centre temporarily set up in a trade fair hall in Cologne. Photograph: Thilo Schmülgen/Reuters

With health one of the policy areas devolved to the country’s federal states, Germany had more than 400 local health authorities that were already experienced in running contact-tracing schemes. And a competitive network of regional university and private laboratories gave the country a head start on testing.

“German federalism in its current form may historically have been designed as a straitjacket for a notoriously aggressive state,” said Siegfried Weichlein, a historian of federalism at the university of Freiburg. “But it is a popular straitjacket. At its best, as we saw at the start of the pandemic, it is a dynamic system that can lead to a competition to the top and a higher average acceptance of political decisions.”

By some measures, Germany still excels: its relative pandemic death toll remains considerably lower than in comparable western European states such as France or the UK. But the fear of losing face in the immunisation race has come to dominate the national conversation.

A joint procurement programme that placed too much faith in the wrong vaccine candidates has created supply shortfalls across the EU. Yet Europe’s largest economy has been slow to administer even the doses it has got its hands on, injecting vaccines into people’s arms at a slower rate than 13 other EU states.

Germany’s stockpile of unused vaccines had grown to 3.5 million doses by the start of last week – partially, but not just, because the health ministry insists on holding between 20% and 50% of doses for the second jab, depending on the manufacturer.

In some cases, the immunisation drive has seen the positives of federalism converted into negatives. The western city of Wuppertal announced on Wednesday that it was left with 2,000 unused doses of vaccine, because it had finished inoculating all residents aged over 80, but had been stopped from moving on to the next age group by the authorities in North Rhine-Westphalia, which wanted the entire state to move in sync.

Far from seeing a race to the top, the immunisation programme had created a scenario were “the laggards are setting the pace”, as the head of the city’s crisis taskforce put it.

“Whether you are dealing with a bleeding patient or with a pandemic: speed trumps perfection,” Dahmen told the Observer. “In Germany, we tried to reinvent the wheel with the vaccine rollout, to perfect a system before we put it into practice. That kind of thoroughness is now becoming self-defeating.”

The rationale behind running the programme solely through vaccine centres, Dahmen said, was partly that mRNA vaccines like BioNTech/Pfizer and Moderna were thought to require high-tech storage facilities, but also out of a fear of too much decentralisation: family doctors, authorities worried, might have been tempted to stray from the priority order and administer precious jabs to private patients or friends instead.

Without using GPs, each German state has had to build its own system for finding the right people in the right age groups for a jab appointment, with some inviting patients by letter, while others rely on being contacted via overburdened hotlines and creaky online portals. In Lower Saxony, authorities used post office records to seek out candidates for the first round of jabs, guessing people’s ages on the basis of their first names.

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These woes may be locally made, but public anger is now also arriving at the doorstep of the chancellory in Berlin. Cautious pragmatism has served Merkel well throughout most of her 15 years in power. But among a 90% unvaccinated public, many are now calling for bolder leadership.

Hopes that Germany’s doctors’ practices could soon join in the vaccination effort were dashed earlier this month when the vaccine authority recommended a temporary halt on using the AstraZeneca jab over reports of blood-clot disorders in a small number of recipients.

Contrary to some speculation in Britain, Merkel’s decision to heed the regulator’s advice had little to do with attempts to politicise the vaccine developed in Oxford University. Rather, it was the opposite: an affirmation of the belief that a cut-no-corners bureaucratic management culture can still win out against the virus. Not pausing the rollout of the vaccine in spite of the medical regulator’s caution would have constituted political action – but a risk that many Germans would have forgiven their chancellor for taking.

“Instead of making a mistake, it seems, we preferred to stand still,” said ex-doctor Dahmen. “If you want an effective crisis management, fear of committing errors is a toxic attitude.”