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OPINION AND ANALYSIS

OPINION: Berlin needs more understanding for people who can’t wear face masks

It's easy to jump to conclusions when we see people breaking the mask-wearing rule. But with some medical conditions making wearing face-coverings almost unbearable, it's high time that Berlin took a more understanding approach, writes David Matthews.

BVG mask sign
A sign for the Berlin transport network BVG informs people of the 3G and mask-wearing rules on-board. Photo: picture alliance/dpa | Carsten Koall

Germany is breathing a cautious but audible sigh of relief. Omicron appears to have peaked without overwhelming hospitals with patients, and at the state and federal level, politicians are now discussing which restrictions should be lifted first. 

Of all the pandemic precautions we’ve gotten used to these past two years, masks are likely to be the last to go. That’s if we ever take them off – it’s possible parts of Europe might follow Japan and make them a social norm on public transport, even after the pandemic has long since faded away.  

During most of the pandemic, I thought of mask-wearing as a no-brainer. I could see why closing restaurants and bars or restricting travel was controversial, but masks? What’s the big deal? They seem to be such a simple, cost-free way of reducing infection, which is why occasional mask-refuseniks on the U-Bahn come across as bafflingly stubborn and anti-social to the rest of us.  

READ ALSO: OPINION: Germany is stuck in Covid Groundhog Day – it’s time to move on

But last December, my eyes were opened to the hidden costs of a masked society when a friend of mine, Hannah Bestley Burt, an artist from London, came to visit Berlin for a long weekend. 

Hannah is autistic, and for her at least, wearing a mask is far from simple – it’s practically impossible. She has problems with sensory processing, and so finds certain clothes, like jeans or items with high necklines, labels or seams, unbearably irritating to wear.

When coronavirus struck, she tried to find a comfortable kind of mask, but they triggered panic attacks. “It’s like having a bright and hot light shone directly in your face, or someone yelling numbers at you while you try to do maths,” says Hannah, whose art deals with her autism. “At best it’s distracting, at worst it is intolerable, it makes me angry, panicked, afraid, I can’t think about anything but its presence on my face.”  

A world of judgement

In London where she lives, this hasn’t been such a problem. There, mask compliance is pretty patchy, and there are regular reminders on public transport that some people are medically incapable of masking up.  

But arriving in Berlin unmasked, Hannah experienced a world of judgement and rejection as she tried to enjoy the city. This was despite bringing a letter from her therapist explaining her autism, and a digital exemption badge from the UK government. 

In one incident, a café initially tried to turn her away, despite having empty tables. In another, she was forced to wear a mask when getting a Covid test in a shopping centre. And when she tried to go to the spa Vabali she was flatly refused entry. I asked Vabali about this, and they simply referred me to their website FAQs, which bluntly says: “face coverings are required”. 

It wasn’t just being turned away that was painful for Hannah; it was the seeming lack of understanding or sympathy in Berlin about her condition. I don’t think the language barrier can be used as an excuse: she was either turned away from these places in English or was accompanied by a fluent German speaker.   

Things weren’t much better on public transport. Generally she tried to avoid it, but when she had to take the U-Bahn, people sometimes tutted, stared and spoke about her.

It don’t want to give the impression the trip was all bad: we managed to go to Christmas markets, bars, restaurants and a nightclub where staff were understanding. 

Public shaming 

But this doesn’t remove the anxiety that in the next café or U-Bahn, you’ll be publicly shamed for not wearing a mask. “I’m an artist and had been considering moving to Berlin, it could be a wonderful move for my practice,” Hannah told me afterwards. “But I realised that I couldn’t live there, I couldn’t have a full life there.”  

How many autistic people are there in Berlin like Hannah, excluded from public spaces through official rules or the glares of strangers? 

It’s impossible to know for sure, but Germany’s Federal Office for the Environment estimates that 0.6 – 1% of people globally have the condition. That would equate to tens of thousands in Berlin alone. 

Of course, many autistic people are able to wear masks without a problem, Bärbel Wohlleben, vice chair of Autism Germany, told me. But the organisation also knows of sufferers who like Hannah simply cannot mask up. “There is not a lot of tolerance,” she said. 

People sit on the Berlin U-Bahn wearing masks

People sit on the Berlin U-Bahn wearing masks. Local transport is often a hotspot for public shaming of perceived ‘mask avoiders’. Photo: picture alliance/dpa | Christoph Soeder

How could Berlin become a little more tolerant? Transport for London regularly reminds passengers that it may not be obvious why someone cannot wear a mask, and sends free exemption badges to passengers who want them, no questions asked. 

I asked BVG if they had considered doing something similar. They told me that they make sure their staff know about Berlin’s mask exemption rules, which do allow you to go maskless if you have a medically certified health impairment, chronic illness or disability. 

Yet they decided not to broadcast public reminders “in order to minimise the risk of abuse” of the rules, a spokesman told me. Reminders would “not entirely solve” the problem of unmasked people getting dirty looks on the U-Bahn, he added. 

READ ALSO: OPINION: The pandemic has revealed Germany’s deep obsession with rules and compliance

A forgiving middle ground

The problem here, as BVG suggests, is that if we don’t tut and stare at unmasked people like Hannah, we also won’t challenge diehard mask refusers who are unmasked for political, not medical reasons. The whole system of social pressure risks collapsing. 

But surely there has to be a more forgiving middle ground where, if it bothers us, we politely ask someone on the U-Bahn why they aren’t wearing a mask, rather than assuming the worst of them. I’ve certainly done my bit of public shaming during the pandemic, staring at a maskless person on the train or tram without knowing their backstory. 

And every café, bar, and restaurant should make sure their staff know that mental health can be a perfectly valid reason not to wear a mask. 

For most of the last two years, I’ve counted my lucky stars that I live in near universally masked, rule-following Berlin, rather than what I thought of as selfish and maskless London. But as we edge back into normality, Hannah’s experience should remind us that for a small but significant minority, masks are far from a harmless measure – they amount to a semi-lockdown of the entire city.

Member comments

  1. “And every café, bar, and restaurant should make sure their staff know that mental health can be a perfectly valid reason not to wear a mask. ”

    I don’t disagree with your statement…but only after a diagnosis by a qualified mental health professional. Otherwise, this becomes a free ticket to not wearing a mask.

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OPINION AND ANALYSIS

OPINION: Why it’s becoming harder to get a doctor’s appointment in Germany

Germany's health service is known as one of the best in the world but securing a timely appointment with a doctor is getting harder. A creaking system and the culture around excessive doctor visits are part of the problem, argues Brian Melican.

OPINION: Why it's becoming harder to get a doctor's appointment in Germany

Germans have always been known for being health-conscious – some would even say hypochondriacs. That has its down-sides (see Covid…), but also some notable advantages. One is the ability to go to any doctor’s practice and request treatment, skipping general practitioners, referrals, and all of the attendant bother.

As a result, in any well-to-do area of a major German city, you’ll have a bewildering array of medical practitioners within walking distance, from general physicians (Allgemeinmedizin) and orthopaedic practices (Orthopädie) to ones that will have you Googling (HNO stands for Hals-Nase-Ohren – ears, nose, and throat – by the way. You’re welcome.)

The strength of this patient-choice system is that it allows people to manage their own care. So if one doctor can’t see you, you go and find another. And if you’ve moved towns or fall ill away from home, you can still access care. In theory, this spreads demand and keeps people with non-urgent complaints out of casualty wards. Yet in practice, the system is now creaking audibly. 

In recent months, I’ve tried to get appointments for several routine procedures with doctors’ offices I have been visiting for years – and the earliest I could get anything was, to my surprise, now several months off. Both dentists and dermatologists are currently, it would seem, planning their schedules for September and October. And when a rather unpleasant case of shoulder pain struck earlier this year (fittingly, just ahead of my 39th birthday…), the earliest appointment I could get at any of the three(!) local orthopaedic practices was at least a month off.

This isn’t just me getting unlucky here. In a recent representative survey, only 25 percent of respondents reported having no trouble getting a doctor’s appointment. The rest are having to wait anything between two weeks and two months – and I’m clearly now one of the 15 percent who report even longer delays. 

I’m not alone in thinking – knowing – that it didn’t used to be this way. So what has gone wrong? 

READ ALSO: Seven things to know about visiting a doctor in Germany

Structural changes in medical practice: fewer doctors working fewer hours

First off, there are changes afoot among Germany’s niedergelassene Ärzte – literally ‘settled doctors’ with surgeries, called so in order to distinguish them from hospital medics. For one, these doctors are getting old and retiring – just like the population they serve (or rather: have served). And as younger cohorts are less numerous, physicians looking to pass on their practices are having difficulty finding takers – especially in disadvantaged urban areas or out in the sticks.

A patient undergoes a consultation with his doctor.

A patient undergoes a consultation with his doctor. Photo: picture alliance/dpa/AbbVie Deutschland GmbH & Co. KG | AbbVie Deutschland GmbH & Co. KG

Even where there is no shortage of potential successors, ever fewer of them actually want to set up in business for themselves. For most young medics’ taste, there’s too much paperwork, too much commercial risk, and far too much work involved in running their own surgery. Instead, they prefer to merge with others or sell on to management companies who will, in turn, employ them (often part-time, with no annoying evenings or weekends on call). 

The results of all of this are as follows. Within the space of just one year, between 2022 and 2023, the number of surgeries fell by 1,987 – a drop of over two percent. Meanwhile, in 2023, for the first time ever, more than one third of Germany’s 150,000 non-hospital doctors were employees, not self-employed. That’s twice the number in 2013. Moreover, over the same period, the number of medics opting to go part-time has gone up by 235 percent to 60,000. This means that, if your local surgeries haven’t closed, the likelihood is that the doctors there are now working fewer hours – and so there are fewer appointments left to go round.

READ ALSO: Do doctors in Germany have too little time for their patients?

This would be bad news for any society, but it hits particularly hard in Germany. As a rapidly-ageing society with a relatively unhealthy population (high rates of smoking and obesity), our demand for medical services – often for complex chronic illnesses – is rising just as provision is declining.

Cultural differences in consulting doctors

Another problem is that Germans are accustomed to a historically high number of available doctors – and as serial worriers (and passionate sick-note seekers) make excessive use of them. Your average German racks up almost 10 consultations a year – not including visits to the dentists! The OECD average is closer to six. And the stoic Swedes, strong silent types that they are, go the doctor’s just 2.3 times a year.

Even if I wanted (or needed) to, I simply couldn’t to get to the quack’s almost once a month: I don’t have the time and they don’t have the appointments. But in conversation, I notice that others clearly do manage to find both. Increasingly, I’m wondering how many of them, unlike me, have private health insurance. 

This brings us to the third major issue facing non-hospital care in Germany. When the figures in the representative survey I quoted above are broken down, it transpires that almost 60 percent of people who are insured in the state system (gesetzlich versichert) are now waiting longer than two weeks for an appointment; among those who are privately insured (privat versichert), that figure is only 37 percent.

Doctors ‘keen on private patients’ 

Doctors are keen on private patients because their insurers pay more for the same procedures and will also cover all sorts of supplementary stuff – from the clinically-proven through to the just plain wacky. As such, practices reserve as many appointments as possible for private patients and try to keep the rest of us at bay.

Given that around four in five people in Germany are in the state system, however, this leaves the majority of patients competing for the minority of slots. If you want to see how the other fifth live, try “accidentally” clicking privat on surgeries’ online booking tools: you will now see a range of appointments available within days while the rest of us are being fobbed off for weeks or even months.

Not only is this, as my grandmother used to say, enough to make you want to join the Communist Party – it’s wildly inefficient. By restricting the hoi-polloi to slots often months off, doctors are creating their own appointment-management problems: sometimes, the complaint in question will have disappeared by the time the consultation rolls around; more often, it will have actually been dealt with – not infrequently by the same physician – if the patient presents as an acute case earlier.

As such, slots weeks away are booked, only to be cancelled later by conscientious patients (and left blocked by others), while those same patients crowd into waiting rooms begging to be seen urgently at an open surgery. (That’s how I got my shoulder looked at.)

A German health insurance card.

A German health insurance card. Photo: picture alliance/dpa | Jens Kalaene

The cynic in me says that, in the long run, this might not be such a bad thing. If the increasing scarcity of doctor’s appointments gets Germans thinking about whether they really, really need to be seen for yet another case of the common cold (“No, Christian, it isn’t pneumonia this time, either!”) or various nebulous self-diagnosed ills (Kreislaufbeschwerden (circulatory problems) is the day-off-work-one I love to hate), maybe it’s not a bad thing.

Swedes don’t die unnecessarily because they avoid the doctor’s: in fact, they live a good year longer than us on average. The German in me, though, says: “My shoulder hurts. Maybe I’ve got early-onset arthritis. I should probably go and get it checked out…” And even though I don’t go too often, I’ve got used to being able to see a specialist when I need one. It’s a shame that this is becoming markedly more difficult.

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