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| Busy Stockholm main street April 1, with COVID awareness sign |
SWEDEN:
LOW INTERVENTION, NO SYSTEM
SUMMARY
To deal with COVID-19, Sweden opted for a low-level
voluntary social distancing policy without backing it up with a test, trace and
isolate system or by instituting proper nursing home protocols and support. This
was a high-risk strategy that exposed weaknesses in its aged care system.
Unlike its neighbours, Sweden has not suppressed the virus, and the lives of around 2500 mostly elderly people have been lost in excess of what might have been expected under a different strategy. There also appears to have been little economic advantage to ‘Swedish exceptionalism’.
Unlike its neighbours, Sweden has not suppressed the virus, and the lives of around 2500 mostly elderly people have been lost in excess of what might have been expected under a different strategy. There also appears to have been little economic advantage to ‘Swedish exceptionalism’.
The public rhetoric used in Sweden has also been different to other countries. While claiming it had an evidence-based approach and countries
with lockdowns did not, Swedish officials all stated Stockholm had ‘neared herd
immunity’ when it likely was nowhere near it. This seems to have been done to
garner legitimacy for their approach.
Sweden became the focus of controversy and challenge
globally between all those who wanted lockdown to end in their own countries and
those who did not, rather than using the more successful but more “foreign” South Korea as a benchmark.
The Swedish example represents a lost opportunity to make an
alternative low-impact approach to managing COVID work in a Western democracy.
It shows the danger of placing a few non-elected individuals with a narrow
world view in charge of a crisis that has affected millions of people.
Governance in Sweden – siloing and the rise of privatisation
On my first visit to Sweden in 1986, I asked my host why the
Swedes seemed to have a system for everything. He thought and said, “it is so
cold in winter that you can’t go out and there is nothing to do. So you will
either commit suicide or make up a system.” Those systems however no longer
seem to work so well in a country divided by the immigration question and by the
market liberal approach to economic management.
Since the 1980s the Swedish commitment to the welfare state
and central planning has been eroded. What was once a socialist welfare state
with a strong commitment to democratic involvement from all levels of the
community has turned into something different. According to critics, years of austerity and right-wing policies have
seriously undermined the social fabric of Swedish society.
According
to one measure, Sweden had a more rapid liberalisation than any other
advanced economy from 1995 to 2001. The
Economist in 2013 confirmed that Sweden had dismantled the welfare state to
the point that the country was far more privatised than even the United States,
with private companies running schools, elderly homes and nurseries, and a fully
deregulated transport and utility system. A coalition right-wing government
from 2006-2014 cut corporate taxes, lowered property tax and abolished wealth
and heritage taxes – all heavily regressive measures. Sweden became one of few countries where
pensions are taxed at a higher rate than wages. Since 2014 the country has been
governed by a minority coalition of Social Democrats and Greens, but they have
not reversed the ‘market reforms'.
Apart from changing its economic approach, Sweden also appears
to be an extreme example of technocratic ‘siloing’ among democracies, in that
the Constitution mandates a single expert agency must initiate all actions
without political interference or community scrutiny. It is uncommon for
multidisciplinary advisory bodies to be assembled or for politicians to
override the recommendations of the key agency.
COVID-19 Outbreak – Level 2 distancing
The early progress of the outbreak in Sweden followed a
similar timetable to that observed in other European countries – though a
little later. On 31 January a woman returning from Wuhan tested positive. On 26
February, multiple travel-related clusters appeared. Community transmission was
confirmed on 9 March in Stockholm, and the first death took place two days
later.
While the activity of the virus in different countries is
modified only by a few demographic variables like average age and population density,
the epidemic response can be strongly affected by the institutional framework, and
quite often it has been dominated by the opinions of a few leading figures.
Sweden immediately departed from other countries, both in
the institutional response and in the rhetoric employed. Conduct of the
response was given unilaterally to the Public Health Agency, and within it, a
single discipline took control of the process. The main architect of
the response has been Sweden’s State Epidemiologist Anders Tegnell.
Tegnell is a highly experienced epidemiologist, a global
authority on pandemics who has worked with WHO on Ebola outbreaks and on other vaccination
programs, and with the EU on preparedness for a whole range of possible
outbreaks. He had a key role in Sweden’s large-scale vaccination programme for
the HIN1 swine flu pandemic of 2009.
Tegnell’s strategy was based on his idea that Sweden had a
homogeneous and cooperative population, that people would assume social
responsibility more readily than other countries and did not need to be
coerced. Like others in Sweden, he believed (without proof) that COVID-19 was not a disease that could be stopped or
eradicated, and
that the strategies of all other countries were in error.
Compared with some others engaged in “Swedish
exceptionalism”, Tegnell’s language has mostly been moderate. He did not intend
to expose the population deliberately to the virus but to apply a more limited
social distancing, what has come to be called a ‘Level 2 lockdown’ similar to
South Korea’s. This typically involves
voluntary trust-based distancing measures with no penalties or
enforcement. Sweden’s recommendations were for
- Older people to avoid social contact. No visitors in aged care homes (from 3 April)
- People to work from home, wash their hands regularly, and avoid non-essential travel.
- No gatherings of over 50 people (from 27 March)
- Restaurants and bars closed for bar service, open for seated service only, while obeying social distancing (from 17 March),
- Senior high schools and universities to be closed (from 24 March) and to employ distance learning
A Level 2 strategy is largely designed to prevent major
superspreading episodes while maintaining social distancing on an advisory
basis and keeping the economy open. It is a minimal response, a far cry from
the enforced confinement imposed in other parts of Europe.
In Sweden, extensions and innovations from a base of minimum
intervention have been grudging. Even typical L2 measures such as prohibiting
large gatherings and closing age care homes to visitors took some time to
introduce – quite out of character for a country usually so organised. Despite
denials, it really did seem the authorities were intent on exposing the whole
population to ‘get coronavirus out of the way’.
One other country, South Korea, successfully employed a Level 2
lockdown strategy.[1] The Swedish response differed from Korea’s in several important
respects. Korea developed an elaborate test, trace and isolate system, and the people
were constantly reminded of the need to pursue social distancing. By contrast the
Swedish response was lax and diffident for such a disciplined country. Testing
was low, and there were not even recommendations for PPE in
age care centres.
The main visible difference between the Swedish solution and
a more comprehensive Level 3 lockdown as used in Australia is that few
activities are proscribed. In Sweden people are walking round unconcerned in shopping
centres, markets, gyms, and public transport, allowing most recreational and
shopping facilities to stay open. The police had no responsibilities to enforce
distancing.
Outcome
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| Figure 1. Mobility from Feb 13 to May 2, Sweden and other Nordic countries |
By and large, the Swedish public did follow the guidelines,
and their behaviour was not too different from the citizens of other Nordic countries
under heavy lockdown. Figure 1 shows that mobility for retail and recreation
fell by about 20% from early March, though less than the 40% observed in other
countries.
However, the Level 2 lockdown did not suppress the
epidemic, and it led to a very high number of deaths of elderly people.
Cases
As of 23 May, Sweden had registered 3,925 coronavirus-related deaths and more than 32,800 confirmed cases. The number of
confirmed daily cases has plateaued for over a month but does not seem to be falling away.
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| Figure 2. Cases per million population in Nordic countries |
Figure
2 shows total cases (adjusted for population) in Nordic countries. Norway’s
epidemic started first by about two weeks, then Denmark and Sweden advanced
together. Lockdowns in Norway and Denmark caused their curves to flatten, but
Sweden has continued upwards.
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| Figure 3. Daily cases, Nordic countries, 7 day moving average |
In Sweden, after a brief hiatus in early April when
distancing had some effect, cases continued upward, and appear to have plateaued
since April 21.[1]
As a primary focus of its strategy, Sweden did make necessary medical adjustments, doubling its ICU capacity since the start of the
outbreak and managing to keep excess hospital capacity, according to a
speech at WHO on 23 April by Health Minister Lena Hallengren. However, its
other stated aim, to protect the elderly, failed outright.
Sweden has also been considerably less attentive to the pandemic
than its neighbours in testing, despite being more at risk. The number
of tests conducted per thousand people at 17 May was 20.8 per thousand, whereas
in Norway it was 40.6 and in Denmark it was 67.1. With a relatively low level
of testing, it is possible that Sweden’s cases are considerably greater than
shown in Figures 2 and 3.
Death rate
Although cases have not reached the dystopian level of its
southern neighbours, the death rate in Sweden has been one
of the highest in Europe and has been largely confined to the elderly. At
371 deaths per million, the mortality rate in Sweden is four times that of its
neighbours Denmark and Germany, and nine times that of Norway. Ninety per cent
of those who had died as of April 28 were above the age of 70, according to
official figures. Half
were nursing home residents, and another quarter were receiving care at
home.
The death rate in Sweden has been well below that of the
‘Big Five’ disaster countries: Belgium, the UK, Italy, Spain and France, but since
the beginning it has been higher than that of the USA and
it has moved higher than the Netherlands.
If deaths in Sweden had been at the same rate per million as
in Denmark and Germany, about 2750 fewer lives would have been lost up to the
present (with more to come).[2]
There is no reason apart from its specific choice of strategy and lack of will
why Sweden should have had more deaths than its Nordic neighbours.
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| Stockholm: in memoriam for coronavirus deaths |
It is not sufficient to argue that these lives ‘would have been lost anyway’ on the path to herd immunity. In the meantime, a vaccine might have been developed, or an improved treatment regime might have been found, so that many of these 2750 people would still be alive when the epidemic finally abated.
The expected monetary saving through limiting lockdown has also proved eluisive, and Sweden is expected to suffer just as badly as its neighbours. All countries in the region are economically interlocked, and the disruption of supply chains is enough to enough to bring any ‘exceptionalist’ country into line with the rest. The contraction of GDP for Sweden during 2020 is estimated to be 6.9%, similar to the declines across the EU, and unemployment is expected to reach 8.8%. The other Nordic countries now have an undesirable neighbour in which COVID-19 is endemic and continuing.
Nursing homes
Swedish age care centres have been a matter of concern for a long time. Many of the establishments are often large complexes with hundreds of residents, and entry is only available to those in very poor health and unable to care for themselves. Otherwise care takes place at home, where it is also very difficult to protect old people and their relatives from infection.
In greater Stockholm, 55% of nursing homes have so far confirmed Covid-19 cases, and nationally, 541 care homes have infections. At first most of the infections in nursing homes probably came from visitors, but later the virus was brought in, and probably transferred between patients, by staff. Some elderly have reportedly been infected while admitted to hospital for other treatments and then sent back to care homes where they unwittingly spread the disease.
Staff in age care centres have been poorly paid and are often immigrant labour. As elsewhere, people working in nursing homes do not have the same level of education and training as those working in hospitals. Many of them tend to move in and out of these jobs, and some entered their jobs without receiving proper medical training or proper protective gear. Some hold down several jobs, working at more than one nursing home.
About 40 percent of staff at Stockholm nursing homes were unskilled workers employed on short-term contracts, with hourly wages and no job security, while 23 percent were temps. These low-income people have from their own perspective needed to come to work even when ill.
Sweden did not mandate masks to be used except where dealing with a confirmed patient, and it did not conduct COVID-19 testing in residential care homes. Without protocols to isolate or any government direction, workers also have moved between patients who might have been infected and others who were not, contributing to the spread of the virus.
The homes have also been unwilling to send COVID patients to hospital. Unlike other countries, care home workers have been asked to prioritise patients, and the more fragile are not sent to hospital and often do not even get to see a doctor. Care home workers are unable to administer oxygen themselves as they have received no training, instead of having to wait for specialised response teams. “They never make it to the hospital. They suffocate to death. And it's a lot of panic and it's very hard to just stand by and watch."
Rhetoric
The technocratic approach of Tegnell and colleagues and the
kinds of language they have employed has closely resembled those initially used
in the other recently market-liberated countries, the Netherlands and the
United Kingdom.
The Swedes took it for granted from the beginning that
COVID-19 could not be eradicated and would only stop according to the ‘natural
logic’ of epidemics. This was unjustified as much earlier, the two predecessors
SARS and MERS had been eradicated. Cases of COVID-19 had been falling rapidly
in China since the beginning of March, and the virus was actually eliminated in
many areas, so it was premature to assume the same could not be done in Sweden.
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| Anders Tegnell, regular briefing April |
The ’herd immunity’ controversy
At first, Swedes frequently used epidemiological language
like ‘herd immunity’ – an unpleasant Malthusian prime directive as it
implied condemning tens of thousands of people to death while making no real
attempt to save them.
Tegnell said on April 22 that ‘sampling and modelling had shown that “about 20% of the population had been infected“, and herd immunity would be reached in a few weeks. This ‘sampling and modelling’ has not been forthcoming.
The assertion was extended by other prominent Swedish spokespersons. Sweden's ambassador to the United States has said the capital of the Nordic country could reach herd immunity by May. "About 30 percent of people in Stockholm have reached a level of immunity," Karin Ulrika Olofsdotter told National Public Radio "We could reach herd immunity in the capital as early as next month."
Similar claims were made in a
Lancet paper by lockdown denier Johan Giesecke, a predecessor of
Tegnell as Chief Epidemiologist, who cited ‘PCR testing and some straightforward
assumptions’ as the source of the 30%.
Antibody tests carried out in Stockholm by 3 May suggested that 7.3% had developed antibodies to the disease. These antibody tests have not been reliable and this is probably an overestimate, although still far short of the promised 30%. At this rate, the epidemic could continue for years before ‘herd immunity’ is reached.
Backdown
"We failed to protect our elderly. That's really serious, and a failure for society as a whole. We have to learn from this, we're not done with this pandemic yet," Health and Social Affairs Minister Lena Hallengren told Swedish Television.
On 12 May the UN ambassador
Olofsdotter also reneged on her earlier language, citing “misconceptions” and
saying “this is a marathon, this is not over by any means”. She now considered Sweden’s
strategy was “not
a herd immunity strategy,” but rather an approach officials believed would
both save lives and help “keep the country’s health-care system working.” The
decision not to close schools, she said, was a matter of “public health”. “Our biggest failure has been for our elderly
population,” Olofsdotter acknowledged.
Tegnell continues to argue Sweden is not so far from herd immunity. At a time when other European countries are relieved at their falling daily cases and beginning to re-open their economies, it is perverse to see Sweden stubbornly trying to claim more cases than it actually has.
Tegnell continues to argue Sweden is not so far from herd immunity. At a time when other European countries are relieved at their falling daily cases and beginning to re-open their economies, it is perverse to see Sweden stubbornly trying to claim more cases than it actually has.
The majority of Swedes continue
to support their government’s approach, and Tegnell is no longer an obscure
public servant but a national icon. “Everybody loves him”.
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| Stockholm restaurant, March 28 |
Supporters and critics
Some have argued that Swedes practice social distancing as a
cultural habit anyway. As such, they can act responsibly in the manner that the
government is asking them to do, without lockdowns. This is seen as an example
of the mutual trust between the State and the people that ‘makes Sweden unique’.
Unfortunately, this trust has turned out to be nowhere near enough to suppress the
epidemic.
The public in other countries like South Korea and Australia have
shown an equal level of trust, and their governments taking the proper care have
managed to suppress their epidemics as well. Australia, with two and a half
times as many people, has had 100 deaths.
Other Swedes have proselytised for the wordwide anti-lockdown
movement. One of Tegnell’s predecessors as Chief Epidemiologist, Johan Giesecke,
has made Tegnell seem like a well-meaning moderate. He has spearheaded the
anti-lockdown movement around the world, which one commentator unkindly termed a
“libertarian death cult”. He has appeared frequently on TV shows and publishing
his opinions even in the prestigious Lancet journal. Even
as late as May 8, he attacked the United Kingdom repeatedly for doing a U-turn
on lockdown, citing the large death rate in Britain’s care homes.
Giesecke continues to maintain there was a ’lack of proof’
for the more extreme Level 4 enforced lockdowns in place across Europe, saying
that without evidence these measures could not be economically justified – even
though the effectiveness of lockdowns has been firmly demonstrated as being successful
in arresting the pandemic. He claimed “Everyone will be exposed to severe acute
respiratory syndrome coronavirus 2, and most people will become infected” and
that all strategies should follow his charismatic vision of universal infection.
Sweden’s seemingly lax measures attracted the attention of international
lockdown skeptics who hailed the “Swedish model” as an example of how a Western
democracy ought to deal with the pandemic. It became a cause celebre among American conservatives,
who resent the economic toll exacted by social distancing restrictions. Even
for non-conservatives, the Swedish approach has been invoked as an “obvious
alternative” to the lockdowns that have prevailed elsewhere.
It is not entirely surprising that for their best practice the anti-lockdown brigade did not choose South
Korea, an East Asian country that has actually managed to suppress the disease while
imposing a similar Level 2 lockdown, accompanied by ingenuity, planning and
hard work.
On the negative,
critics voiced their dismay with the whole ‘herd immunity’ play. “This idea
that, ‘Well, maybe countries who had lax measures and haven’t done anything
will all of a sudden magically reach some herd immunity, and so what if we lose
a few old people along the way?’ This is a really dangerous, dangerous
calculation,” WHO’s executive director of health emergencies Mike
Ryan said.
Others have made even
stronger statements, saying the idea of allowing people to become infected
deliberately was “offensive” and akin to murder. Australia’s conservative Prime
Minister Prime Minister Scott Morrison has railed against the
herd immunity strategy,
likening it to a “death sentence”.
The message that
Sweden is different from other countries, that it respects individual
liberties, and that it did not require lockdowns could be seen as arrogant. EU
states that are forcing lockdowns have done it not because they are less
liberal or supportive of individual rights than Sweden but because they had no
other choice.
Conclusions
Using a low level
of voluntary social distancing has been regarded by medical authorities and
governments worldwide as a high-risk strategy, only to be embarked on with working
test-and-trace systems and strong quarantine measures for the sick or vulnerable.
These precautions are to be ignored at peril.
In the country with systems for everything, it is surprising that Sweden did not take any of these necessary fail-safe measures – given the quality of Sweden’s medical establishment and its technical skills. This
has been unfortunate, because first it has played into the hands of the lockdown
deniers, and perhaps more importantly - because now a proper, effective European
version of the low-impact strategy has not been trialled, which may well lead many countries
to delay re-opening longer than they should.
The question is why
was Sweden prepared to go it alone, in disregard for what epidemiological and
medical fraternities were saying all over the world?
It is tempting to attribute Sweden’s lackadaisical approach to ‘born-again’ market liberalism, which places ‘personal freedom’, economic activity and ultimately profit above community safety. Certainly, privatisation has played a big role in the care homes controversy, since private firms inevitably try to maximise profits by employing the cheapest staff and following safety regulations to the minimum extent. Even the most ardent market liberal would agree that strong regulation by government is the only way to preserve public and employee safety, and this seems to have not been done in Sweden's care homes.
Sweden’s institutional arrangements have also been found wanting, where a few individuals in a single technocratically-inclined profession were able to take control of the process through a sole empowered agency, bypassing representatives of the people and alternative professional attitudes that might have proven more humane.
It is tempting to attribute Sweden’s lackadaisical approach to ‘born-again’ market liberalism, which places ‘personal freedom’, economic activity and ultimately profit above community safety. Certainly, privatisation has played a big role in the care homes controversy, since private firms inevitably try to maximise profits by employing the cheapest staff and following safety regulations to the minimum extent. Even the most ardent market liberal would agree that strong regulation by government is the only way to preserve public and employee safety, and this seems to have not been done in Sweden's care homes.
Sweden’s institutional arrangements have also been found wanting, where a few individuals in a single technocratically-inclined profession were able to take control of the process through a sole empowered agency, bypassing representatives of the people and alternative professional attitudes that might have proven more humane.
The Swedish claims of 30% infection in Stockholm
were presumably intended to show that COVID-19 was a much less damaging disease
than others believe, with a tiny mortality rate. It also implied that Sweden
would not have to put up with future epidemics, since its epidemic was
finished, while everyone else would prolong the agony and continue to suffer
economically. Unfortunately, the evidence is not there and it is surprising Sweden should continue with this line.
If its neighbours do manage to eradicate the disease, the
irresponsibility of Sweden’s approach in making COVID-19 endemic will be all
too obvious. The chance of establishing a COVID-free Nordic area will be lost
as it is very unlikely the other countries can keep their borders closed to
Sweden indefinitely, though they might have done to mainland Europe. If a
vaccine does become available, Sweden’s short-term sacrifice of its population
will prove to be a long-term source of sorrow.
Sweden’s approach will only prove to have merit if the
present situation continues - the disease cannot be eradicated, and no new
methods are found to combat the disease.
At any rate, a
disaster that seems to have been partially preventable has been the outcome, and
Sweden’s coronavirus exceptionalism will not be forgotten.
[3] If
the loss of life was at Norway’s lower rate, there would have been 3300 deaths
less in Sweden
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