The Inside Story of How Sweden Botched Its Coronavirus Response
Stockholm denies pursuing herd immunity. But internal emails show Swedish officials were resigned to mass infections all along.
One month after declaring the coronavirus a “socially dangerous” disease in February, the Swedish Public Health Agency essentially threw up its hands and chose to seek herd immunity rather than take serious steps to mitigate the virus’s spread, confidential internal documents show. That fateful—and fatalistic—early decision shaped Sweden’s entire response to the pandemic, from a refusal to mandate masks to a haphazard testing regime.
Sweden’s botched coronavirus response is no longer news: Even the country’s king, Carl XVI Gustaf, admitted in his annual Christmas address that the Swedish government had “failed.” But private emails seen by Foreign Policy, some of which have been previously reported in the Swedish press, reveal that Sweden’s health authorities were resigned to mass infections—so called herd immunity—all along, and no matter the costs. Throughout the pandemic, Sweden’s health authorities have said one thing publicly and something different in private about nearly every aspect of their management of the crisis. There were repeated public denials from the government that it deliberately sought to achieve herd immunity, even though that was the strategy pursued behind closed doors. There were misleading statements on the availability of testing. There was even continued public denial (despite private acknowledgement) of how the virus spreads, part of a pattern of apparent official obfuscation that’s lasted the whole pandemic.
And the result has been deadly. While countries such as the United States, Brazil, and India have made headlines for recording the highest number of coronavirus-related fatalities, Sweden’s death rate of over 80 per 100,000 people is among Europe’s highest and is around 10 times as great as those of Norway and Finland, and over four times Denmark’s. COVID-19 hospitalizations are now rising faster there than in most European countries, and Sweden is caring for more patients in hospital now than it did at the height of its first wave. By Dec. 21, Sweden had surpassed the United States and all major European countries in its daily confirmed cases per million. Things have gotten so out of control in Sweden that neighboring Norway, for the first time since World War II, put troops on the border to prevent Swedes from crossing over.
The Organization for Economic Cooperation and Development’s Nov. 19 report concluded that Sweden fared worst among 35 European countries in multiple coronavirus management metrics including lowering the spread of infection, reducing people’s mobility, and discharging patients from intensive care units.
Sweden’s true handling of the pandemic matters, and not just because of how it has impacted its population of just over 10 million. Around much of Europe, and especially in the United States, Sweden’s hands-off approach to a deadly pandemic was, for some, a model to emulate. U.S. President Donald Trump’s coronavirus advisor Scott Atlas, for example, publicly hailed Sweden’s approach as a model, even as its catastrophic performance—especially when compared to its neighbors—becomes ever clearer.
When the Swedish government categorized COVID-19 as a socially dangerous disease on Feb. 2, Peet Tull was sitting on a lonely farm on the Swedish island of Gotland, watching developments with concern. Tull was one of the people who built up the country’s infection control unit: He had been Public Health Agency Director Johan Carlson’s boss and also given assignments to Anders Tegnell, the agency’s chief epidemiologist, whom he knows well. Another thing Tull knows well is the Infection Control Act, because he participated in drafting it—and he wondered why Sweden hadn’t implemented a contact-tracing system or put travelers from international COVID-19 hot spots in quarantine.
As he observed global coronavirus cases surge, Tull wrote an email to Tegnell on March 15, proposing three possible options to deal with the pandemic. Option one, he said, would be to “stop all movement and contacts for a four-week period.” Another option, one recommended by the World Health Organization, would be to conduct intensive testing, tracking, and quarantine of infected patients. Or, he said, Sweden could pursue a third option: “Let the spread of infection take place, slowly or quickly, to achieve a hypothetical herd immunity.”
Tull warned: “One thing is known that with option three Sweden will probably have thousands of deaths,” and concluded that “option three appears to me as a defeatist and headless strategy, which I would never have accepted in my previous role.”
Tegnell, the state epidemiologist, answered him the same day: “Well, we have walked through this and after everything landed on [option] three. We probably have a fairly extensive silent spread, which would mean that the first two would probably not work.”
Tull outlined actions to take including issuing general advice and regulations for testing and contact-tracing. Tegnell demurred, arguing that such a strategy hadn’t worked in Italy. Tull countered that it worked in China and South Korea—so why not in Sweden?
Right from the start of the pandemic, according to recently declassified internal emails seen by Foreign Policy, Tegnell seemed resigned to pursuing herd immunity for Swedes, seeing little chance of stopping COVID-19 through the means successfully employed in other countries such as South Korea or Vietnam.
Whether or not Sweden publicly admitted its strategy was to pursue herd immunity, other countries began to cite its approach as such. In July, according to a report in Politico, White House advisors promoting herd immunity referenced a June study by Sweden’s pandemic modeler, Tom Britton, which said that herd immunity could occur after just 43 percent of a population became infected—an estimate far lower than what most other epidemiologists have put forward. Britton told Foreign Policy that his calculations that Sweden would reach herd immunity turned out to be incorrect. Britton now says that U.S. government officials misinterpreted his study and that using his June research to promote herd immunity was wrong, adding that “too many people will die in order to reach herd immunity.”
The Swedish and international public, though, were repeatedly told that herd immunity was not Stockholm’s objective.
On March 15, the day Tegnell wrote Tull they had landed on option three, Tegnell said the Public Health Agency’s “main tactic” was not herd immunity, adding that its goal and herd immunity were “not contradictory.” But in public, Tegnell frequently argued that herd immunity was “definitely not” a goal. As recently as Nov. 18, Minister of Health and Social Affairs Lena Hallengren said that the idea that Sweden had pursued a herd immunity strategy was a “rumor.”
The day before his correspondence with Tull, Tegnell forwarded an email to his Finnish counterpart, Mika Salminen, which contained a recommendation from a doctor to allow people to become infected with COVID-19. “One point would be to keep schools open to reach herd immunity more quickly,” Tegnell wrote.
Salminen said his agency had ultimately rejected such an approach, realizing children would still spread the virus, whereas closing schools could limit the disease’s impact on the elderly by about 10 percent. Tegnell, who still thought that quickly achieving herd immunity was the best strategy, responded: “10 percent might be worth it?”
The next day, Tegnell forwarded a study on Italy’s experience with COVID-19 to Jan Albert, a professor of microbiology, who was part of a coronavirus expert group assembled a few weeks earlier by the Karolinska Institute, a university and the center of Sweden’s medical research community. Tegnell pointed to what seemed to be a “flattening of new cases” there.
Albert replied: “Exactly. But most people think it’s just the lockdown. How much [is because of] lockdown and how much [is because of] herd immunity is really the key issue.” Tegnell answered: “If anyone had time, you should look at the various lockdowns that have been made and what the development looks like afterwards. I believe more in herd immunity.’’
Tegnell remained convinced that a rapid spread of the virus would shield Sweden, a belief that seemed to lead the country’s whole response to the crisis. A month after corresponding with Tull, Tegnell said Stockholm could achieve herd immunity in May. Three weeks later, he said: “In the autumn there will be a second wave. Sweden will have a high level of immunity and the number of cases will probably be quite low,” a claim he repeated into mid-October.
Carlson, Tegnell’s boss, echoed on Aug. 30 what Tegnell wrote Tull: “It is not about us sacrificing a lot of people to achieve immunity. This model was the only one that was feasible. Our assessment has proven to be correct. The strategy must last over time. We are one of the few countries with a limited spread of infection, unlike several countries in Europe where the infection returns sharply.”
It didn’t work out that way. Sweden is facing an increase in cases, hospitalizations, and deaths. On Nov. 5, the country reached the grim statistic of 6,000 deaths. In the six weeks since, nearly 2,000 more have died. In the week ending Dec. 18, Sweden registered 479 new deaths, more than Norway has during the entire pandemic.
The fatalistic approach taken by Sweden’s health authorities beginning in March shaped nearly every aspect of the country’s response to the pandemic for the rest of the year: If the coronavirus can’t be successfully contained, as Tegnell and others argued in private, then why implement measures such as mask mandates, limits on retirement home visits, or restricting people’s movements?
From the very beginning, Sweden sought a different approach—even if it said publicly that it was following the same strategy as other countries. On March 4, before Sweden’s first official death from COVID-19, the European Centre for Disease Prevention and Control convened a meeting for European Union countries and WHO. Sweden did not participate.
A day after Tegnell corresponded with Tull, he discussed the EU’s not-yet-released border recommendations, including health checks, with Andreas Johansson and others at the Ministry of Health and Social Affairs. “This table contains a long list of details where we have a completely different strategy in Sweden,” he wrote. Tegnell opposed border health screenings and did not support EU measures to limit case importation or exportation, arguing that since domestic spread had already begun in most countries, border limits would be relatively meaningless.
The very next day, March 17, Tegnell said on television that he did not think there was any difference between what other countries were doing and what Sweden was attempting. “I do not think these strategies are different, we are talking about exactly the same thing in both strategies,” he said.
That was the same day that countries such as the United Kingdom, which had flirted with a strategy of herd immunity, switched to a strategy of suppression after the release of a study by Imperial College that concluded that such an approach was “the only viable strategy at the current time” to prevent 250,000 British deaths. But the Swedish Public Health Agency and advisory health experts discounted the study’s findings and kept seeking herd immunity, emails show.
Sweden relied on advice to wash hands; other voluntary measures, such as that people stay home when sick, limit unnecessary travel, and work from home if possible, were advised only after there was already community spread in the country. The government limited public gatherings to 50 people—but not until March 27. And then, as the country began to see a rise of cases in October, the government increased the event limit to 300 people on Oct. 22, which the government then decreased to eight effective on Nov. 24 as cases, hospitalizations, and deaths continued to rise.
Throughout the pandemic, Stockholm issued no general national mask recommendations, not even for general elder care, unless there was evidence patients had the coronavirus. The government’s official health guidance still casts doubt on the efficacy of wearing masks, even as authorities in most other countries have come to appreciate the role that masks play in limiting the spread of an airborne virus. But then Swedish health authorities remain unconvinced the virus even is airborne, officially telling citizens “COVID-19 does not count as an airborne infection.” On Dec. 18, the government announced that the Public Health Agency would draw up recommendations for wearing masks during crowded commuting hours on public transit, but those will only come into force after Jan. 7. The updated official advice includes the line, “We do not currently recommend a broad use of masks in society,” and continues to cast doubt on the scientific evidence for masks, even saying that masks may provide a false sense of security.
Unlike in neighboring countries, bars, restaurants, and gyms remained open. Compulsory in-person schooling continued through middle school; high school and post-secondary education moved online on March 17. Not until March 24, two weeks after the risk level was raised to the highest level, was the general public encouraged to socially distance if possible. Nursing homes stayed open to visitors until April 1.
While neighbors began to introduce curbs on public life and speed up testing, Sweden did neither. Denmark, which entered a short lockdown on March 17, began easing it when it announced the beginning of widespread testing on March 30. Internal emails show it wasn’t until Denmark implemented its testing plan that the Swedish government and the Public Health Agency even began discussing one.
Whether authorities were talking about herd immunity, access to hospital care, how the virus spreads, or how testing was determined, Sweden told one story in public and a different one in private.
Prime Minister Stefan Lofven declined to be interviewed, but a spokesperson said: “Herd immunity is not a strategy, but a potential consequence of how the spread of the virus develops. Herd immunity has never been a part of the Swedish Government’s strategy.” Lofven, through a spokesperson, previously said that Sweden’s “strategy is not much different from other countries,” yet Sweden is the only democratic country in the world that does not mandate even limited use of masks.
A full government reckoning of the handling of the pandemic won’t be made public until 2022, but an interim report on the spread of the virus in nursing homes was released on Dec. 15. It noted that government measures were late and inadequate, and called the spread of the virus in society the “single most important factor behind the major outbreaks and the high number of deaths in residential care.”
Carlson, Tegnell, and Hallengren did not respond to requests for comment. Ebba Busch, the leader of the opposition Christian Democrats party, said in June that “the government actively and openly chose a strategy that would mean a higher degree of contagion in society,” calling the quest for herd immunity “naive.”
The results of that quest for elusive herd immunity are sadly well known. By the end of May, when some neighbors reopened without seeing big spikes, Swedes were restricted from traveling to many countries.
Contrary to the expectations of Tegnell and others, the quest for herd immunity neither materialized nor shielded Sweden from the ravages of a second wave in the autumn. The Public Health Agency’s reports from June showed the level of people with coronavirus nationwide to be 7.1 percent, far from the 60-75 percent experts say is needed.
Finally, on Nov. 24, Tegnell said that Sweden may be ‘’in the peak of a second wave,’’ despite having argued the opposite along with Carlson for months.
One man at least, Tull, had seen what was coming and tried to warn experts not to make matters worse. In his final email to Tegnell on March 15, Tull, who had worked to eradicate smallpox in Bangladesh, implored health authorities not to throw up their hands and to give science and precautionary measures a chance.
“You cannot just watch when you fear that a large number of people may die,” he wrote. “Every effort must be made to prevent this from happening. It is not enough to ‘believe’ that it is not possible.”