Germany’s “Reha” clinics aren’t set up for Long COVID. And patients are reporting harm.

The country’s pension insurance system pushes people to go through rehabilitation (“Reha”) clinics before they can access disability supports.

The fluorescent lights burned her eyes, and the frequent visits to the dining hall were noisy and chaotic, filled with other patients jostling trays and engaging in small talk. Similar to a shabby school camp, the environment was anything but restful. 

Sandy, 43, who developed Long COVID in August 2022, had feared this exact scenario. She could feel the drain of her limited energy, and her concerns about the rehabilitation clinic her health insurer had thrust her into were confirmed. The rigid schedules and constant activity in the facility completely overwhelmed her.

“For five months I asked, can we please check my blood? And he refused because he thought it’s just in my head,” Sandy said about her primary care doctor, who had repeatedly dismissed her in her search for medical help. Since developing dysautonomia and post-exertional malaise (PEM), Sandy had no choice but to go on extended sick leave. As someone who had paid into German statutory health insurance, she was eligible for up to 78 weeks of long-term paid sick leave, known as Krankengeld. 

But Sandy was pressured to apply for rehabilitation after only seven months, a step that could push her into disability pension or back to work too early.

In Germany, people with Long COVID and myalgic encephalomyelitis (ME) are being urged into rehabilitation clinics (called “Reha”) before they can access disability support payments, even though these programs are often harmful. The country’s “rehab-before-pension” regulation prioritizes reintegration into the workforce through an exercise-focused program called “activation,” ignoring research that shows the approach is detrimental to people with PEM. As a result, people are not merely neglected by the system — they are actively harmed by it.

The Sick Times spoke with twelve people who went to Reha and found that, on top of being pressured to partake in exercise-based therapies that can make their disease worse, patients at these centers faced reinfection with SARS-CoV-2 and other pathogens during the ongoing pandemic. They regularly experienced gaslighting from medical providers and fellow patients alike, many of whom falsely claimed Long COVID was “in their heads.” Others fought to avoid rehab, citing the risk of permanent health deterioration.

Many who attended rehab faced long travel to get to the centers, packed clinics, rigid, intense schedules, and “cognitive training” that triggered crashes due to mental exertion and overstimulation. 

To protect their identities, the people interviewed for this article asked that only their first names or pseudonyms be used.

Sandy wasn’t surprised to encounter hostility from medical staff in the rehabilitation clinic, but she was disappointed to also find it coming from other patients. “You’re so weak, you should die,” one told her. 

She faced constant scrutiny from others who didn’t understand PEM, and had to repeatedly explain her limitations and boundaries. She recalled that people would confront her about her decision to wear a mask to avoid infection. Despite trying to advocate for herself, Sandy’s health deteriorated during her five-week stay: the stress, physical exertion, and two infections set her back significantly.

In response to questions about their Long COVID protocols, spokespeople from multiple German insurance providers said that rehabilitation services are tailored to specific patients’ needs. “Many affected individuals fear that rehabilitation facilities will not adequately accommodate their limited tolerance for exertion. However, some rehab centers now have concepts tailored to the specific needs of people with Post-COVID syndrome,” said a spokesperson from Medizinischer Dienst Bund. (Read the full responses from these spokespeople on DocumentCloud.)

German “Reha” poses multiple risks to people with PEM

Despite long-established risks, with several studies indicating that graded exercise therapy (GET) is harmful to people who have PEM, German rehabilitation clinics have failed to adequately update their approach to Long COVID and ME. Their use of exercise ignores long-standing warnings from several patient advocacy groups and researchers, as well as numerous clinical care guidelines for ME and Long COVID.

A recent study by advocacy group Long COVID Deutschland showed a detailed overview of this misalignment. Based on the responses of 733 people who went through Germany’s rehabilitation system after developing Long COVID, the study found that over 50% of participants reported their condition worsened during or after their stay.

At these rehab centers, many are subjected to unsuitable interventions like endurance training and strength exercises, modalities that are damaging for people who have PEM, sources told The Sick Times.

PEM, a common health issue for some with Long COVID and the defining feature of ME, causes an excessive worsening of symptoms after physical, cognitive, sensory, or emotional exertion — including exertion that most people would consider minor. Prescribing activity-focused rehabilitation to those with PEM can lead to long-term health deterioration, a reality many people with Long COVID in Germany are forced to confront as they navigate a system that is unsuitable for their circumstances.

“From a scientific point of view, medical rehabilitation should not be recommended for patients with PEM,” said Sabine Hammer, lead author of the study and a social researcher at Fresenius University,  in an interview with The Sick Times. She added that many facilities admitted people with Long COVID despite a lack of understanding of the disease, lumping them into pulmonary, oncology, or even psychosomatic programs without comprehensive evaluation.

Hannah Becker, from the German advocacy group startaMEvolution, agreed that the system’s design is fundamentally flawed. “We are very, very critical of forcing people into rehab,” she said. 

Becker noted that most facilities lack an understanding of PEM and that there are no nationwide standards to protect patients. “It’s sort of a hit-or-miss situation, and it’s too much for most people,” she said.

We are very, very critical of forcing people into rehab.

Hannah Becker, StartaMEvolution

Hammer stressed that the problem reflects deeper issues within the German medical system. “There is dogma and it has done a lot of harm,” she said: for years, medical providers have recommended cognitive behavioral therapy (CBT) aimed at convincing patients they weren’t unwell. 

She warned that the paradigm is deeply entrenched and still influences how rehab is provided. Given the mounting evidence against exercise and CBT, as well as widespread patient opposition and concern, it’s hard to digest that German rehabilitation centres are still treating the condition as if it’s primarily psychological or the result of physical deconditioning.

A recent preprint from researchers in the Netherlands showed that neither Long COVID nor ME was a result of deconditioning, but rather that those with PEM had mitochondrial dysfunction as well as altered muscle fiber composition and blood flow.

Leah, another Berliner with Long COVID, directly experienced the consequences of outdated approaches that failed to consider PEM. The month she spent in a rehab facility triggered recurring episodes of PEM due to an overwhelming schedule she struggled to keep up with. Her condition deteriorated to the point where she could no longer manage basic daily activities. 

“I was so weak, but I was still expected to do laundry and change bed sheets. I asked the nurses for help once … they rolled their eyes and [said they] didn’t want to,” she said. “It was humiliating.”

Leah realized that the German rehab program isn’t designed to treat or heal people; it’s an endurance test to assess an individual’s ability to work, and staff at the clinics don’t seem to care if it leaves people in a state of worse health, she said. “I was so much better before. It’s almost a year later now, and I am still not back to how I was.”

Instead of adapting programs to accommodate newer scientific insights or canceling the requirement altogether, rehabilitation clinics don’t seem inclined to give up on activation. In Germany, the term Aktivierung (“activation”) is often used instead of GET, but the underlying approach — pushing patients to increase activity levels — is similar.

“Feedback from affected people shows that many rehabilitation clinics still adhere to the concept of GET,” Long COVID Deutschland said in a statement to The Sick Times. Overall, the clinics’ resistance to change reinforces a dangerous, incorrect assumption that deconditioning is at the root of PEM. In fact, these energy limitations aren’t caused by inactivity but by fundamental dysfunctions in cellular energy production.

The risk of reinfection

During her time in one rehab center, Sandy noted that the clinic enforced no mitigations to decrease the spread of airborne infections like SARS-CoV-2, despite the ongoing pandemic and the fact that reinfection can further disable people with Long COVID and ME. She said she was even encouraged to mingle with others during the acute infections she contracted in the clinic. 

None of the people who went to rehab centers whom The Sick Times interviewed for this piece said they felt protected from SARS-C0V-2 reinfection during their time there, even though the virus led them to those clinics in the first place. 

After struggling throughout 2023 to find doctors who wouldn’t dismiss him as his health slowly declined following a second COVID-19 infection, Andy, 37, spent several weeks in a psychosomatic clinic in Hamburg during the autumn of 2024. 

Psychosomatic clinics are widespread in Germany and are intended to treat the interaction between physical and psychological symptoms. People with post-infectious diseases like ME and Long COVID are often sent to such clinics inappropriately, as they don’t offer the specialized care patients need. Andy’s experience reflected that misalignment.

“ME/CFS was brought up, but they said, ‘We don’t really believe in that disease,’” he explained. The standard program in the clinic failed to consider the nature of his illness, and he was repeatedly pushed beyond his energy envelope. “They left me really bedbound.”

Beyond the medical neglect, Andy witnessed blatant discrimination in the clinic. “A lot of the people who [were immigrants] were really treated much worse than me,” he said. He observed that many of the foreign-born patients in the clinic faced more skepticism from medical staff, with their symptoms frequently dismissed as psychological.

ME/CFS was brought up, but they said, ‘We don’t really believe in that disease.’

Andy, about his time in a psychosomatic clinic

Long COVID and ME are falsely psychologized

While many Germans with Long COVID and ME feel like they’re left with no choice but to attend rehab, others, like Patrick and Felicia, fight to avoid it. German pension insurance allows people to object to rehabilitation, but it isn’t always easy. The burden of proof is entirely on the affected person, who must provide extensive documentation to justify their inability to attend.

Patrick, who developed Long COVID in his mid-thirties, had the advantage of supportive parents, savings, and the ability to hire a lawyer. Even with those resources, he has found seeking medical support and navigating bureaucracy nearly impossible to manage. His health insurer immediately questioned his long-term sick leave, ignoring guidelines that recommend against rehab for people as severely affected as he is. Patrick is almost wholly confined to bed and is only able to get up to use the bathroom a few times a day; alongside his physical weakness, he has extreme food restrictions due to a particularly profound case of mast cell activation syndrome (MCAS). 

Felicia faced similar obstacles; her health insurer ignored her doctor’s statement that explained she was unfit for rehab. “They threatened to cut my Krankengeld [sick leave payments],” she said. 

Felicia spent months on a bureaucratic odyssey that would be inconceivable for many people with severe energy limits. On the same night that one of the letters from her health insurer arrived, she was rushed to the ER with tachycardia. Today, Felicia works at a significantly reduced capacity, despite the risk of decreasing her moderate baseline, just to steer clear of rehab. Like many people with Long COVID, avoiding reinfection is a priority for her.

These struggles against an unfit system aren’t isolated incidents. Gabriel, a 41-year-old film producer from Munich, was also subjected to harmful rehabilitation practices after he developed Long COVID in November 2020. Initially trying to seek help from various specialists, he says he was labeled a “hypochondriac” by a psychologist and sent to a rehab facility under false pretenses.

Gabriel called to confirm that the rehab clinic could treat Long COVID, and they assured him they were knowledgeable. He stayed for three weeks and underwent unproven treatments like “sunlight exposure” and long group therapy sessions in which he sat upright, which led to agonizing crashes. He tried to participate in scheduled sessions until he was crashing so often that he became entirely confined to bed.

For Gabriel, it was clear that the time spent in rehab increased the severity of his symptoms and ultimately left him feeling traumatized. He described the experience as emotionally destabilizing: Gabriel’s discharge report included a long list of psychological diagnoses and never mentioned Long COVID.

[Gabriel] stayed for three weeks and underwent unproven treatments like “sunlight exposure” and long group therapy sessions in which he sat upright, which led to agonizing crashes. He tried to participate in scheduled sessions until he was crashing so often that he became entirely confined to bed.

Years later, his condition remains severe, and he believes the time spent in the clinic contributed to his long-term decline in health. While empathetic, his current doctor lacks the authority to prescribe off-label treatments that could provide some symptomatic relief. “I’m just lying in bed, waiting,” he said.

Alongside the enormous personal suffering of those impacted, Long COVID poses a tremendous economic challenge to an already stumbling German economy. A 2023 study from the Frankfurt School of Finance & Management estimated that the country has lost billions of euros due to decreased productivity, increased healthcare costs, long-term sick leave, and disability claims.

A newer report from the ME/CFS Research Foundation and analytics firm Risklayer similarly estimates that Long COVID and ME/CFS cost Germany more than €63 billion ($74 billion) in 2024 — approximately 1.5% of Germany’s GDP — and more than €250 billion ($293 billion) from 2020 through 2024. The authors say this figure likely underestimates the actual burden, given inadequate care structures and the deterioration caused by mismanagement.

By forcing affected people into inappropriate, unsafe rehab and worsening their conditions, instead of alleviating the economic burden, advocates and people with the disease say the German system is paradoxically making this crisis worse.

“I’m always at my fucking limit, even with all the support that I get,” Patrick said. Patrick recognizes that many others in his situation aren’t as lucky. “If I didn’t have my lawyer, I don’t think I would have made it to the end of my Krankengeld. I would have lost thousands of euros simply because I wasn’t well enough to navigate this system.”

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Sophie Dimitriou is a Greek Australian designer with Long COVID based in Berlin, Germany. She is the founder of Berlin Buyers Club, an art collective that raises awareness of Long COVID and ME/CFS.

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