Sweden’s Coronavirus Failure Started Long Before the Pandemic
Many countries have criticized the Swedish government’s lax lockdown, but the deadly mistakes of defunding elder care and decentralizing public health oversight were made before anyone had heard of COVID-19.
The world has long looked to Sweden as a model society. The Nordic country of 10 million is known for its robust welfare state—where citizens enjoy a high standard of living, equal rights, and social security. In the past few decades, Sweden has also taken a place on the international stage as a humanitarian superpower, starting in the 1990s when it accepted 100,000 refugees fleeing the carnage of the Balkans and later during the Syrian crisis when it took in more refugees per capita than any other European country.
But that image has been questioned over the past few months. Sweden has become a global outlier in ignoring calls for coronavirus lockdowns. While Italy’s piazzas were empty and the French needed a permit to go jogging, Swedes were still sitting knee-to-knee drinking beers in Stockholm’s trendy Sodermalm district. As more countries imposed lockdowns, many public health experts argued that Sweden was giving priority to its economy rather than protecting the lives of its citizens.
Swedish authorities have repeatedly disputed that claim, arguing that the country’s goal is no different from that of other countries, namely to make sure its health care system is not overburdened, while protecting society’s most vulnerable—the only difference being that the government’s public health agency has issued recommendations rather than mandating certain behaviors, what’s considered a “light-touch strategy.”
In the past month, the criticism has grown louder as Sweden’s death toll, which last week passed 5,000, has raced beyond that of its Scandinavian neighbors, eclipsing the second-hardest hit country in the region, Denmark, with more than three times as many deaths per million residents. The high numbers have led Norway and Denmark, which opened up tourism between their countries in mid-June, to exclude Sweden from the travel bubble.
Even more detrimental to Sweden’s credibility is the fact that a large portion of deaths has occurred among the elderly—the very people the strategy was meant to protect. To many, this is proof that Sweden’s strategy has failed. Even Anders Tegnell, Sweden’s state epidemiologist and the architect of the light-touch strategy, has admitted that too many people have died and that, if he’d had the information available today back in March, he might have supported stricter measures within certain sectors of society. However, Tegnell still maintains that his overall strategy has not failed and that no one knows exactly what measures should have been taken.
Of course, it would be easy to dismiss Tegnell’s comments about “potential for improvement” as an abdication of responsibility. But a closer look reveals a more complex reality. Some criticisms of the Swedish COVID-19 response may still be premature, and others should rather be directed at mistakes made long before the current health crisis—namely the decline of central government oversight and, especially, a decadelong neglect of Sweden’s elderly population.
The chief claim made by critics of the Swedish approach is that the country’s goal is herd immunity. Herd immunity is when a full population is protected before all of its members are immune. This occurs when those infected are surrounded by people who have achieved immunity either through vaccination or by catching and recovering from a disease; while the occasional contact is still susceptible and the odd transmission happens, it’s not enough to sustain the disease. Exactly what level of immunity will protect the herd depends on the transmissibility of the disease, which is often described through a metric known as the basic reproductive number, R0.
“Influenza, for example, has an R0 of about 2, which means that, on average, one infected person would transmit the virus to two others,” said Stephen Morse, professor of epidemiology at the Columbia University Medical Center. That means that half the population would need to be infected with the disease to gain herd immunity. Assuming that the novel coronavirus’s R0 is a bit higher than influenza, Morse reckons that 60 to 70 percent of a population would have to contract the virus, assuming that infection provides lasting immunity.
A pure herd-immunity approach would simply let COVID-19 burn through the population unhindered, which is not the approach in Sweden, where large crowds are banned and people have been encouraged to practice social distancing. Rather, Tegnell, the head of the Public Health Agency of Sweden, has repeated ad nauseam that the strategy is to slow the spread while achieving herd immunity as a byproduct.
However, debating who is following a herd-immunity approach might be missing the point. After the now-infamous Imperial College London study was released in March, predicting a grim 510,000 deaths in Britain and 2.2 million in the United States in the event of an unmitigated spread, both British Prime Minister Boris Johnson and U.S. President Donald Trump dropped their initial plans to keep their economies open. Tegnell—even though he dismissed the Imperial study as flawed—would for political reasons want to avoid courting international opprobrium by explicitly embracing a herd-immunity approach.
Terminology and politics aside, critics should focus on the scientific argument behind Sweden’s light-touch strategy, namely that there is no satisfying evidence that draconian lockdowns reduce long-term mortality rates.
This was summed up by Johan Giesecke, Sweden’s former state epidemiologist and a current advisor to the Public Health Agency, in a recent article published in The Lancet.
“There is very little we can do to prevent this spread: a lockdown might delay severe cases for a while, but once restrictions are eased, cases will reappear,” he wrote. “I expect that when we count the number of deaths from COVID-19 in each country in 1 year from now, the figures will be similar, regardless of measures taken.”
This might appear odd, considering the whole world has been told that social distancing is the chief tool in limiting loss of life. But this might, as Giesecke argued, only be true in the short term.
“Most of what we know about the social distancing and lockdown measures are analogies from the 1918 influenza outbreak, where social distancing measures, like closing restaurants and banning large gatherings, seemed to reduce mortality in mostly big cities as these lockdowns went into place,” said Tara Smith, epidemiologist and professor at the College of Public Health at Kent State University.
But without proper data on how mortality rates developed over a longer period of time after restrictions were lifted, previous pandemics offer a poor blueprint, especially because governments’ capabilities to track, test, and treat infections have changed dramatically since the aftermath of World War I.
Instead, the Swedish argument is that if a country can maintain adequate health care capacity throughout the crisis, the only benefit of a lockdown would be to delay deaths as the curve equals out across countries over time—assuming that governments that flattened the curve through lockdowns will inevitably face a second wave. On April 29, a modeling study from the Public Health Agency estimated that more than half a million people in Stockholm County, which is about 20 to 25 percent of its population, had been infected. But the results from the first antibody tests, published May 20, show that only 7.3 percent have developed antibodies in Stockholm.
As antibody development is typically delayed by a few weeks, the number might be slightly higher today, but it’s still considerably lower than what the Public Health Agency had predicted. And, perhaps more importantly, scientists still don’t know what kind of immunity people gain after recovering from a COVID-19 infection. A recent preprint from the Icahn School of Medicine at Mount Sinai in New York City found that more than 99 percent of the 1,300 study participants who had been infected eventually developed antibodies. While this is encouraging, Linda Saif, a virologist and immunologist at Ohio State University, pointed out that studies on common cold-causing viruses and SARS suggest that the severity of the infection correlates with the level of future immunity.
“Particularly younger people may develop asymptomatic or milder infections,” Saif explained. “If those infections are mainly in the upper respiratory tract—so that they don’t develop the whole lung pathology but more like a superficial lung infection—the immunity is often short-lived.”
For hospitalized patients with severe symptoms, some evidence suggests they may develop stronger immune responses with higher levels of antibodies. This has been the case with the related SARS virus, where it’s been predicted that immunity lasts for two to three years. “I think the burning issue is the asymptomatic population,” Saif said. “How many of those people have in fact developed antibodies? Once you know that, you can base your strategy on that number.”
Sweden, however, does not know that number yet—and the lack of data strains the credibility of an argument assuming that asymptomatic individuals will develop enough antibodies to gain immunity and thereby help neutralize the virus in the broader population.
A scenario where asymptomatic infections don’t produce immunity raises the question of what the alternative would be—in the absence of a vaccine—as perpetual lockdowns could eventually translate into economic meltdown.
“If lockdowns become economically as well as socially unsustainable and authorities are forced to suddenly ease regulation, many new cases can rapidly flare up and overload the health care system,” said Carl Fredrik Barrenäs, a researcher at the Department of Cell and Molecular Biology at Sweden’s Uppsala University. “But if the spread increases drastically, it might be hard to reimpose quarantine measures.”
On the other hand, as pointed out by Pieter Trapman, a professor of mathematics at Stockholm University who specializes in the modeling of infectious diseases, more stringent quarantine measures could have delayed or prevented deaths among the most vulnerable until there was better testing, tracing, and treatment and more conclusive scientific data had been collected—something governments that imposed stricter lockdowns will benefit from. “Sweden doesn’t have the time to learn now,” he said. “There might be information coming about which gives hospitalized people a better chance of survival, which Denmark could then apply if they reach their peak at a later stage.”
With so many known unknowns, there is currently only one viable measurement for success: how well the most vulnerable have been protected.
On May 6, a report showed that in Stockholm County, residents had been infected in 212 out of 400 nursing homes. An ensuing report showed that as of June 1, 2,036 people age 70 or older had died from COVID-19 in nursing homes across the country, while an additional 1,062 who died of the coronavirus received professional care at home.
Yet, in a recent press conference, Tegnell rejected the idea that a lockdown could have prevented this problem: “We have a hard time understanding how a lockdown would stop the introduction of the disease into the nursing homes,” he said.
But Tegnell’s argument ignores a very basic observation based on readily available data. Eleanor Murray, an assistant professor of epidemiology at Boston University, argues that “Lockdowns probably did help in many places to reduce the infection spreading in nursing homes.” Murray said that there are essentially two factors at play, the first being whether or not the virus is introduced to a nursing home at all and the second being how it spreads once introduced.
In the case of Sweden, a report from one of the country’s largest labor unions shows that 40 percent of its members working at Stockholm nursing homes are unskilled workers employed on short-term contracts with hourly wages, while 23 percent are temps. That means younger people working multiple jobs, which means more points of contact and higher risk of transmission. Certainly, a lockdown would have reduced the risk of these workers getting infected while having drinks or traveling on crowded buses, and it would also have kept family visitors—some of whom may have been asymptomatic—out of nursing homes.
However, instead of shutting down the whole economy, Swedish authorities chose the more surgical approach of banning visitors and issuing health, safety, and hygiene recommendations to nursing homes. The problem was twofold: Visitors were banned too late and the elderly care sector lacked the resources and training to follow the government’s guidelines.
Why the government didn’t close the doors to nursing homes nationally until April 1—when the virus was already inside one of three nursing homes in Stockholm—is perplexing. The risk that low-paid workers—who often live with large numbers of people and take public transport to work—might be exposed was clear. Likewise, the fact that some visitors would ignore government recommendations was always obvious. Sure, it’s true that Swedish culture has a conformist streak, but assuming that young people, who believed they were healthy, would not go see their parents and grandparents is the type of fantasy about Swedish exceptionalism usually reserved for the outside world, rather than the country’s own government.
Either way, by the end of April, authorities admitted to failure, with Health and Social Affairs Minister Lena Hallengren stating: “We failed to protect our elderly. That’s really serious and a failure for society as a whole.”
In February, when Tegnell’s Public Health Agency still claimed there was a small risk of the virus spreading in Sweden—viewing the spread of public panic as the greater risk—authorities assured citizens that Sweden’s preparations were “currently” good. Not everyone bought it.
A hailstorm of opinion articles pointed out that preparation for the current situation is no preparation at all; epidemics grow exponentially, so authorities must prepare for several weeks or months ahead of the curve. A prominent medical journal noted in late February that Sweden had Europe’s lowest number of ICU beds per capita and that current PPE supplies would reach maximum capacity at 100 additional patients assuming 14 days of emergency care. Similarly, Sweden’s military reserves of protective equipment, including gas masks, have progressively shrunk since the end of the Cold War at a much higher rate than in neighboring Finland, where large reserves have been kept and materials maintained. As late as 2014, the Swedish government burned 7.3 million masks, which had been left to deteriorate for decades.
Unsurprisingly, the elderly care sector has been part of this larger systemic pattern of neglect and lack of oversight. In 2017, data from the National Board of Health and Welfare shared with daily Svenska Dagbladet showed that 40,000 people, or 15.6 percent of all who received some type of elderly care, were undernourished, partly owing to lack of manpower and training.
Following the heatwave of 2018, another study showed that some 600 additional deaths had occurred compared to the previous year—the majority of which happened in nursing homes and hospitals lacking air conditioning. In the past few months, reports of scarce resources and inadequate training have multiplied, a ripe example coming from a large conglomerate owning 30 nursing homes across the country, where staff members have testified about a lack of protective equipment and workers moving between healthy and infected residents. One of the homes is now under criminal investigation for misconduct, but the group’s CEO has said that proper preparations in nursing homes were not possible, as “the elderly care sector and the broader society were not prepared.”
Sweden’s 5,161 fatalities from COVID-19, as of June 23, represent a death toll of 511 per million inhabitants, compared to 46 in Norway, 104 in Denmark, and 59 in Finland. Swedes, and the rest of the world, are now wondering why Sweden failed where its neighbors did not. And, indeed, the partial explanations and overall sense of confusion are far from satisfying. Tegnell says nursing home residents in Sweden are older than in Norway, Giesecke says nursing homes are larger than in Norway, Prime Minister Stefan Löfven says assuring adequate emergency resources are the responsibility of the regions, and when confronted with evidence of the elderly care sector’s lack of preparedness, the Public Health Agency’s general director, Johan Carlson, said he was surprised.
It’s probably all true. And while it’s frustrating that everyone admits failure but no one admits fault, looking for a scapegoat is futile. This isn’t the mistake of one person or a failure of the Swedish strategy as a whole. The Löfven administration did right by granting experts power free from political interference. But even the best leaders can’t repair a larger systemic failure in a matter of months.
The crisis Sweden is seeing today is the consequence of a government that has handed over responsibility to regions and counties at the expense of central oversight and, more importantly, a social democracy that has progressively abandoned its chief mission: protecting the most vulnerable.
The Swedish government has now decided to allocate 2.2 billion Swedish krona ($220 million) to training and resources for the elderly care sector. This is a welcome initiative, but it’s regrettable that it took the largest health crisis in recent memory to get there.