08/24/2011 - 04:04

How a deadly E. coli outbreak revealed Germany’s dysfunctional public health system

Laura H. Kahn

Laura H. Kahn

A general internist who began her career in health care as a registered nurse, Kahn works on the research staff of Princeton University's ...

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The plot just kept getting thicker. First, the culprit was cucumbers and tomatoes from Spain. Then it was bean sprouts from northern Germany. Then it wasn't. Then it was bean sprouts from northern Germany again -- this time, an organic farm. Finally, the perpetrator appeared to be imported fenugreek seeds from Egypt.

The recent food-borne, Shiga-toxin-producing bacterium Escherichia coli (E. coli) outbreak centered in northern Germany was particularly virulent. According to the European Center for Disease Prevention and Control, as of July 22 the toll stood at 44 dead and 4,000 seriously ill. The Robert Koch Institute declared the outbreak officially over in Germany on July 26.

Unfortunately, this novel E. coli strain (0104:H4) incorporated the characteristics of two other virulent E. coli strains -- making it especially deadly.

What can be learned from this outbreak?

  • With food comes risk. There are inherent risks with a globalized food-supply system, despite international trade standards for animal and plant products. Not only is it impossible to test every single shipment of food, but products can also be tainted (remember the melamine contamination of pet food from China?). In other words, contamination can -- and will -- occur.
  • Take personal precautions. Consumers should wash raw fruits and vegetables before eating them. Though obviously this task is not easy to do in a restaurant. One can only hope that food-handlers know what they are doing. But, admittedly, intricate food items like bean sprouts are virtually impossible to decontaminate.
  • Take national precautions. Given the risks inherent with a globalized food supply, nations need to have efficient systems in place to investigate food-borne outbreaks and to provide timely information to the public.

What went wrong in Germany?

Unfortunately the German government does not have an efficient system in place. Instead, its archaic, piecemeal infrastructure with multiple layers of bureaucracies slowed response to the outbreak to a snail's pace.

The Robert Koch Institute in Berlin is part of the Ministry of Health and is responsible for the country's disease control and prevention efforts. Germany has more than 400 district health offices, which send information to their respective state ministries. These state ministries then send the information on to the Koch Institute, which performs the laboratory investigation -- but not the outbreak investigation. The Federal Institute for Risk Assessment -- part of the Ministry of Food, Agriculture, and Consumer Protection -- does the outbreak investigation.

Imagine if the US Centers for Disease Control and Prevention (CDC) only provided laboratory support while the US Department of Agriculture conducted the outbreak investigation. Two different agencies working for two different departments: Communication and collaboration would be cumbersome, if not downright confusing. This is the situation in Germany.

There is a reason for this arrangement. Just as the founders of the United States wanted to spread power across government in order to prevent another tyrant such as King George III from taking control, so too did the framer's of Germany's post-World War II constitution. The Germans and Allies wanted to prevent another Adolf Hitler from taking power. This makes sense from a political perspective, but from a public health perspective, it's dangerous. Microbes don't recognize political boundaries.

The end result: Power was distributed across two parts of the German government, which slowed the investigation. And Germany's CDC-equivalent agency, the Robert Koch Institute, had very little power during the E. coli crisis. To make matters worse, the two different ministries didn't coordinate their message to the public, which contributed to the confusion. This situation was similar to the problems Toronto faced during the 2003 SARS crisis. Back then, two different ministries and four different experts gave a half-dozen different messages to the public. This arrangement is virtually guaranteed to fail.

And it's not as though the United States doesn't have its own bureaucratic problems when responding to disease outbreaks: The CDC conducts outbreak and laboratory investigations only after the states send them a formal invitation. But the CDC is still a single aggregate power center that can streamline research and communication in times of crisis.

Meanwhile, in Germany, the rapid spread of confusing information and poor messaging contributed to the spread of unnecessary fear across the nation and a serious economic fallout for the affected agriculture and food industries. Germany would do well to adopt a more simplified disease reporting and investigation system. The Robert Koch Institute should become more like the CDC: It should be the sole federal entity responsible for outbreak identification, response, and prevention.