Thursday 26 March 2020

Covid-19 pandemic : The German Paradox

Deaths per million population seems to be the most robust and useful measure of the impact of the Covid-19 pandemic.

But not always – there are some countries in which deaths per million is surprisingly low. The most obvious one is Germany, deaths per million remaining much lower than its neighbours, only a tenth of the deaths per million in Belgium

We have seen that disease incidence, cases per million, can include well people testing positive, or on the other hand just sick or dead people testing positive. Understanding this is helped by a view of tests per million population.

Norway is top of the list of nations with population testing, with more than 8,000 tests per million population (UK 957). Norway has a relatively high level of cases per million (591.1, UK 141.2). This is likely to be the result of extensive testing of people who are not ill, and these are included as “cases”. 

Norway experiences a low death rate of “cases”, 0.4%. There is also a low number of deaths at 2.6 per million population, UK 6.9.

Germany also has a low number of deaths from Covid-19, 2.7 per million. Why is this? It cannot explained in the same way as Norway, as the testing rate in Germany is only 2000 per million, a quarter that of Norway.

Germany has a lot of “cases” 474.1 per million, with a low death rate of 0.5%. What is going on? The number of deaths from Covid-19 is low, compared to a high incidence rate (more than three times that of the UK). How can this be explained? This has been questioned in the media, but without an explanation, even in Germany.

This is not a mathematical aberration, but it is obvious that somehow the deaths from Covid-19 are being under-reported in Germany. It is not a deliberate conspiracy to hide deaths, but the reason lies in medical culture in Germany, and probably in a few other countries with relatively few deaths.

Certified Cause of Death

This has troubled me for a long time. 

The death certificate works on the basis of a single disease causing death.
This is usually straightforward in a younger or middle-aged person. It could be myocardial infarction (heart attack), cerebral infarction or haemorrhage (stroke), road traffic accident, shooting, meningitis, tuberculosis, lung or other cancers, for example. 

The layout of the UK Death Certificate is shown below.

Things became less clear in older people, especially those who die after their 80th birthday. They might have several conditions simultaneously, none being life-threatening on its own, but they add together to create a burden of illness that leads to death. Example are diabetes, hypertension (high blood pressure), heart failure (controlled), obesity, Parkinson’s disease, osteoarthritis, impaired mobility, COPD, dementia.

When the elderly person dies it is often difficult to identify the single disease responsible. In reality the main reason for death is “old age”, in that without disease we will all “conk out” at about the age of 100 (give or take ten years). But the coroner will not like “old age” as a certified cause of death, even though arguably the whole purpose of medicine to to enable people to die from old age rather from disease. It is interesting to note that in the obituaries in the British Medical Journal, “Old Age” is the most common of the given causes of death (in 2020 so far, 20 out of 63, cancers second with 14).

It is mainly the elderly with pre-existing chronic disease who are dying from Covid-19. If this happens in the UK, Covid-19 will be registered as the cause of death (Category I), with important pre-existing conditions being recorded in Category II (not entered into national statistics).

In Germany it appears that things are different. It is the chronic conditions (dementia, heart failure, COPD etc) that will be recorded as the cause of death. Covid-19 would be regarded as the final blow, “the straw that broke the camel’s back”. There is good reason for this if the final event were broncho-pneumonia, developing in the frail individual who is unable to cough. This is called “opportunistic” pneumonia. 

However whereas broncho-pneumonia would not have occurred without the patient being frail, weak, and perhaps bed-bound, we cannot say that about Covid-19. It is not “opportunistic” but it can attack anyone, whether weak or strong, whether old or young. The elderly tend to die following Covid-19 infection because being they (we) are intrinsically weak internally, with reduced vitality or physiological reserve. They have reduced immunity and weak body defence mechanisms in general.

Death statistics

If the average age at death in a population of a million is 100 years, it means that 10,000 people will die on average each year (one million divided by 100). If the average age at death is 80, approximately 12,000 will die each year. So we expect that in the UK with a population of 67.5 million there will be about 810,000 deaths per year, or 2220 per day.  National statistics should be able to display this day by day but I have been unable to identify such data presentation. 

During the month of March 2020 we would see an increase as 422 people have died from Covid-19. 

The graph show theoretical average deaths per day in February 2020, with real UK deaths from Covid-19 added for March. The increase is not clearly seen. However we are interested in excess deaths, those greater than expected. In early 1969 there were 80,000 excess deaths in the UK as a result of Hong Kong flu, but I cannot access day by day data.

The excess deaths become more visible if we adjust the baseline of the graph to just below the theoretical average. We can see the excess deaths and it is these that will identify the Covid-19 pandemic.

Germany has a population of 83.5 million, leading to a theoretic average death rate of 2745 per day. Once again, this could be plotted as a daily number by German national statistics. We would then need to look at the pattern during March 2020. Would it show a cumulative increase of just 157 deaths above what is expected (average 10 per day)?  Perhaps it would show more, indicating the true number deaths resulting from the Clovid-19 pandemic.

Retrospective analysis in various countries will be more informative.


  1. Hi David
    Thanks for this brilliant bit of analysis. According to the OECD Germany has 20% more doctors and 50% more nurses than the OECD average. It also has 8 beds per 1000 population compared to the UK's 2.5. May help explain their low death rate. Annette

  2. Very plausible, but one needs to exclude better survival once in ITU due to much higher staffing levels first. Is there data available on death rates for Covid29 in ITU for different countries available for comparison.

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