Over-treatment, under-assistance

Dear Reader,

In case you are wondering what this strange new email in your inbox is, The German Review is the new name of the Hochhaus newsletter.

I’m back from my summer break and as you will have gathered if you read the last email, I’m continuing the newsletter alone in the future. The major change is that I’ve decided to give it a new name. Other than that, the content will stay the same.

From now on the newsletter will simply be called “the German Review” as that is exactly what the ambition is: to give readers an overview and (hopefully) informed opinion on the latest developments in German politics and society.

So without further ado…

ECMO machines

One of the first hints that I received that everything was not as it seemed in the statistics on hospitalization during the pandemic came last November when a veteran palliative care specialist told me that hospitals were putting elderly COVID patients on ventilators, not out of care for their health, but because of the financial incentives involved.

The way the German health system is set up means that hospitals receive money from the statutory insurance companies based on bed occupancy and treatment. That is a system that risks putting financial interests over the interests of the patients. Putting a patient on an expensively acquired artificial lung can bring in upwards of €50,000.

The problem is that there is almost no chance of proving that hospitals are doing this - and other doctors are very reluctant to point the finger of blame at colleagues.

So I was interested to read an article this week by one of the standout German journalists of the past year, Die Welt’s Elke Bodderas.

As is the case in many countries, doctors have attained a hero status in Germany over the past 18 months. While it is undoubtedly true that individual medics have done their profession proud, there has been a tendency in much of the German media to fence off all criticism of the medical profession as a taboo subject.

Ms Bodderas has been perhaps the only journalist prepared to stick her neck out and ask whether certain hospitals were exploiting the crisis for their own needs.

In May she brought to national attention a report by a small group of public health professionals who found that hospitals had been inventing beds in order to gain access to special subsidies for COVID patients.

This week she has taken a closer look at ECMO machines, life support equipment that injects oxygen directly into the blood system when a patient’s lungs are failing.

Some 184 German hospitals are equipped with these state-of-the-art machines compared to just six in the UK. But, whereas just 37 percent of patients in the UK put on artificial breathing systems died, in Germany over 70 percent never survived the treatment.

The reasons for why Germany has such a dismal record of survival are likely to be several. ECMO machines depend on highly trained personnel and they also require large teams to run them. Both of these conditions appear to have been lacking in some hospitals.

But, more troublingly, some clinics might have been putting people who were too weak through this stressful treatment even though they knew that it risked doing more harm than good. The incentive could have been financial or it could have been a decision made under pressure to be seen to be doing something, Dr. Thomas Bein of Regensburg University Hospital told Bodderas.

Ultimately, there is a reluctance in Germany, with its lavishly equipped hospitals, to talk about when doctors would be better advised to not treat at all.

Or, in the words of Uwe Jansen, head of the National Society of Intensive Care Specialists: “We need medicine that recognizes its limitations. But no politician has the courage to address that.”

The Afghan debacle

While accusing doctors of doing too much to save the lives of seriously ill patients is a highly delicate subject, there are few shades of grey when it comes to the lack of support Germany has been offering to Afghans who worked with its NATO contingent over the past two decades.

Whether one believes that the twenty-year mission in Afghanistan was an act of doomed neo-imperial hubris or one is of the persuasion that western armies were guarantors of a slow and messy progress, no one can deny that Germany has a moral duty to the locals who worked with them and whose lives are now at risk.

But Berlin has been particularly slow to offer refuge to people whom the Taliban have accused of collaboration. When the Bundeswehr left the country in a Nacht und Nebel operation in early July they offered local employees and their families the chance of a new life in the Bundesrepublik - but only if they could organize their own exit from their blighted homeland.

Afghans who worked with the International Development Ministry were even less fortunate. They have been told that they will only be given a visa if they have been employed by the German government in the past two years. 

Meanwhile, adult sons of people who worked with the German state have been told that they aren’t welcome in Germany at all.

These stringent rules have led to several reports of people stranded in Kabul fearing for their lives. And those are likely to be just the tip of the iceberg. (See this reporting by the Washington Post.)

The German government is clearly still haunted by the spectre of 2015, when an attempt to take in a few thousand Syrian refugees stranded in Hungary spiralled into an influx of over a million people (many of whom were genuine refugees but many of whom were economic migrants) whom Berlin felt helpless to stop or control.

Development Minister Gerd Müller recently warned of a ‘pull effect’ should Germany loosen its rules for which Afghans now get visas.

Sticking to this line is moral cowardice. The Geneva Convention on Refugees is specifically designed to protect people who face direct political persecution in their homeland. While Germany’s lax interpretation of the rules in 2015 led to the rise of the AfD, that doesn’t excuse it from making them too tight this time around.