What looks like a picture of a parallel universe is, in fact, Sweden. Its citizens are seemingly living their everyday lives during a global pandemic that has halted the rest of the world. If it seems rather unbelievable, it is because, unlike its neighbouring and many other countries, there is no lockdown in Sweden—a strategy that has received both praise and criticism.
As countries around the world are trying to fight the ongoing COVID-19 pandemic through lockdowns, Sweden has gone the opposite direction, choosing not to impose any strict restrictions on public life. Instead, it requested its citizens to work from home if possible, avoid unnecessary travel within the country, maintain social distancing, and stay indoors if they are elderly or feeling ill. In addition, it has banned all gatherings of over 50 people, shut down universities and secondary schools, outlawed all private visits to nursing homes, and instructed bars and restaurants to implement a “table service only” rule and increase the space between those tables. But other than that, Sweden remains open for business.
The bedrock of this unique approach seems to lie in one of the deeply rooted characteristics of the Swedish culture—a high level of trust. The authorities trust citizens to voluntarily adhere to social distancing rules; and the citizens, in turn, trust their authorities to devise the right strategy. In a recent survey, three out of four Swedes trusted the Public Health Agency (Folkhälsomyndigheten), and nearly half of the people surveyed said they had “very high trust” in the agency. Not only this relaxed and voluntary approach to fighting the virus has been largely endorsed by the Swedish citizens, many of them even consider the chief state epidemiologist, Anders Tegnell—the architect of this strategy—a national hero.
“I think he’s doing quite a good job because he has been standing straight in the frontline and he’s just been doing his job great,” said Gustav Lloyd Agerblad, a 32-year-old Swede, admiring the tattoo of Tegnell’s face on his arm.
However, not everyone shares the same view. Sweden’s lack of lockdown measures has generated global controversy. Many international media outlets, scientists, and public health authorities criticized the country’s refusal to impose a lockdown and argued that it did not take the pandemic seriously. Sweden, however, disagrees.
“It’s a great myth that Sweden hasn’t really taken very serious steps to address this very very serious pandemic,” Sweden’s Deputy Prime Minister, Isabella Lovin, responded to the criticism by defending Sweden’s decision to keep the country largely open. “Every country needs to take its own measures according to its traditions and its systems of governance. It’s a real fear that if you have too harsh measures, then they can’t be sustained over time, and you can get a counter-reaction, and people would not respect the voluntary recommendations that will need to be respected for a very long time.”
Sweden’s COVID-19 policies have also been heavily debated within the country’s own scientific and healthcare communities. In a joint debate article published in Dagens Nyheter on April 14, a group of 22 researchers from various top Swedish universities and research institutes criticized the Swedish Public Health Agency, saying that “officials without talent” had been put in charge of decision-making and the strategy of the agency would lead to “chaos in the healthcare system.” Just weeks before that, more than 2,000 doctors, scientists, and professors urged the government to take more aggressive lockdown measures by signing a petition. Sweden has repeatedly defended itself against these criticisms by saying that though its approach has been different, the country shares “the same goals as all other countries—save lives and protect public health.”
But the death toll in Sweden—which much of this controversy is centred on—shows that the country is far from achieving its goals.
Sweden—a country with a population of 10 million—has over 25,000 confirmed COVID-19 cases and over 3,000 deaths (as of May 9, 2020), i.e. over 300 deaths per million people. Even though Sweden’s numbers look good compared to some of the hardest-hit countries like Italy, Spain, France, and the United Kingdom (UK), the country’s death rate is significantly higher than its neighboring countries like Denmark, Norway, and Finland—all of which have imposed strict lockdowns.
As in many other countries, minorities in Sweden—in particular immigrants from Somalia—have been hit disproportionately. The country believes this is due to the socio-economic differences in those communities, their wider exposure to people, and multi-generational households living in close proximity. However, it is the elderly who have been hit the hardest. Of the total victims, about 90% are aged over 70, and deaths in nursing homes account for almost half of the total deaths Sweden has seen so far due to COVID-19. Tegnell thinks that the nursing homes were not prepared and the issues at those homes were underestimated.
“About 70,000 people in Sweden live in these homes. And these are the 70,000 people of the Swedish population who are definitely the oldest and the sickest of them,” Tegnell said. “We have known for a long time that the quality of care in those facilities has not always been up to standard, especially in the area of hygiene.”
Many nursing home workers, on the other hand, have complained about not getting enough personal protective equipment (PPE), such as gloves and face masks.
“Where I’m working, we don’t have face masks at all, and we are working with the most vulnerable people,” said one Swedish nursing home worker. “Everybody’s concerned about it. We are all worried.”
While most of the countries around the world agree that face masks provide essential aid in preventing the spread of the virus, Sweden thinks that “the science behind this [face masks] is not very strong.” Moreover, the country fears that if it mandates all citizens to wear masks, people—even those with COVID-19 symptoms—will be more likely to put on a mask and go out in public, instead of staying home and self-isolating.
Besides hygiene, Sweden has also pointed out the need for staff in the nursing homes to stay at home if they have the slightest respiratory or other symptoms of COVID-19.
But Lena Einhorn, a virologist and one of the 22 scientists who criticized Sweden’s COVID-19 policies in the newspaper article, argues that the reason why Sweden has such a high number of cases in care homes is not because of the homes themselves or personnel working with symptoms, but because of Sweden’s decision to keep the country largely open.
“It’s not like it [COVID-19] goes from one old age home to another. It comes in separately to all of these old age homes, so there’s no way it can be all be attributed to the personnel going in and working when they are sick. There’s a basic system fault in their recommendations. There’s no other explanation for it.”
The Public Health Agency, on the other hand, thinks it is not as simple as that. According to the agency, though there is no clear common factor that points to how the infection got into care homes in Stockholm and Sörmland—two of the hardest-hit regions in Sweden, some of the possibilities the agency has pointed to after speaking with care homes include new arrivals to the homes or residents returning from hospital stays, family visits, and hourly employees. In addition, physician Per Follin of Stockholm regional council’s unit for infectious disease control noted the difficulty of ensuring a safe distance between residents in nursing homes.
“Many of the elderly people find it difficult to remember and understand instructions, which is often the reason why they have moved to a retirement home. Not least people with dementia,” he said. “Many homes state that this makes it makes it difficult to stop the spread of infection, so this is a priority area.”
However, though the country admits its failure to protect the elderly, according to Tegnell, it “does not disqualify Sweden’s strategy as a whole.”
But Einhorn thinks it does.
“They have to admit that it’s a huge failure, since they have said the whole time that their main aim has been to protect the elderly,” she said. “But what is really strange is that they still do not acknowledge the likely route. They say it’s very unfortunate, that they are investigating, and that it’s a matter of the training personnel, but they will not acknowledge that presymptomatic or asymptomatic spread is a factor.”
Sweden is not the only country where care homes have seen devastating levels of infection spread. Residents of elderly care homes have also accounted for a large proportion of fatalities in countries like Spain and France.
While there is a consensus among countries that a lockdown can minimize the spread of the virus, Jan Albert, a professor in the Department of Microbiology, Tumor and Cell Biology at the Karolinska Institutet, thinks that lockdowns “only serve to flatten the curve and flattening the curve doesn’t mean that cases disappear—they are just moved in time. And as long as the healthcare system can reasonably cope with and give good care to the ones that need care, it’s not clear that having the cases later in time is better.”
Albert believes that Sweden’s healthcare system is coping, as does Tegnell.
“Swedish healthcare keeps on working, basically with a lot of stress, but not in a way that they turn patients away,” said Tegnell. “Everybody in Sweden who needs a hospital bed has gotten a hospital bed for COVID-19 or for other diseases—so it’s kept on working. And intensive care has even had at least 20% of the beds free at any given time.”
But Anders Vahlne, a professor in clinical virology and another of the 22 scientists who criticized the Swedish Public Health Agency’s approach, has fired back at this claim.
“We have good treatment statistics in our intensive care units (ICUs),” he said. “However, that is probably because we only admit those to ICU who have a good chance of surviving.”
However, free ICU beds or not, critics who are confident that a vaccine or effective drugs for this virus are coming very soon believe that imposing a lockdown till such vaccines or drugs arrive can reduce the number of preventable deaths.
“Already there are a couple of drugs that have shown very very promising results in small trials,” said Einhorn. “Within the next few weeks and months, most likely we will be able to lower the mortality. That to me is the most important reason to push this epidemic in front of you as far as you can.”
Meanwhile, some critics have also accused the Public Health Agency of gambling with people’s lives by trying to achieve herd immunity, i.e. when such a large percentage of a population becomes immune to a disease that it cannot spread anymore. This strategy was once shared by the UK, only to backpedal and issue a lockdown after receiving widespread criticism. Though the country denied its strategy being based on the overall goal of herd immunity, 20-25% of Sweden’s population is reportedly reaching immunity, which the country believes will have a significant impact in tackling the virus until a vaccine is developed. Sweden acknowledges that there is not enough data to evaluate how strong the protection is or how long it will last. At the same time, it is certain that “immunity does exist,” citing the absence of any reinfection cases in Sweden and the gradual decline of the daily number of cases as evidence.
Sweden has also weighed concerns that have been taken as inevitable, if unfortunate, collateral damage in other countries, such as the mental health risks of being stuck inside, rising rates of domestic abuse, and substance use disorders.
“It’s good for people to be outdoors,” said Swedish Foreign Minister, Ann Linde. “If you’re locked inside there’s a risk of depression, domestic violence, and alcohol abuse.”
Moreover, with children under 16 attending schools, Sweden is also expecting to see much less impact of the pandemic on education than other countries.
As for Sweden’s economy, it is expected to suffer just as badly as its European neighbors. According to the Swedish Public Employment Service, 8% of the population is now unemployed—a figure that is projected to continue to rise, possibly hitting 10% by this summer. Furthermore, depending on how long the spread of the virus continues, the Riksbank, Sweden’s central bank, predicted Sweden’s export-oriented economy to contract by 6.9-9.7%. Other European countries, including Sweden’s neighbors, are also expected to see their economies shrink by similar rates. But there have been speculations that Sweden’s relaxed measures to this pandemic will help its economy bounce back faster than countries with strict lockdowns.
So, what does this mean? Is Sweden’s strategy working? Or has the country lost lives that could have been saved had it taken the same approach as other countries? In answer to these questions, the country thinks “it is still too early” to tell. And it might be right.
For one thing, when and how other countries, including Sweden’s neighbors with lower death rates, lift or ease their lockdowns (not to mention a possible second wave of the pandemic) can affect and push the number of cases and deaths substantially higher, possibly than that of Sweden. At the same time, since Sweden is much earlier in its curve than other countries, its own death rate can explode in the coming weeks.
The second reason why it is still too early to evaluate Sweden’s strategy is that the international comparisons drawn from individual statistics currently overlook the differences in demographics, testing programs, healthcare capacity, and how countries record COVID-19 deaths and measure death rates. For instance, Sweden has seen half of its deaths taking place in nursing homes. Death figures in the UK, on the other hand, only referred to deaths in hospitals until April 29. Similarly, the UK has mainly tested people who are ill enough to be admitted to hospital, which can make the death rate appear much higher than in a country which had a wider testing program.
For now, what the future holds for Sweden remains to be seen. If its approach proves to be more efficient in handling the Coronavirus crisis than that of other countries, Sweden will undoubtedly—as the World Health Organization (WHO) phrased it—represent “a future model.” In the meantime, countries that are devising their lockdown exit strategies can learn from the areas in which Sweden’s strategy has so far yielded relatively positive results and the areas in which it did not. Each country, however, has to be mindful of the differences it has with Sweden where more than half of the population lives in single-person households, working from home is common, access to fast broadband is everywhere, and perhaps most importantly, where citizens’ trust in its authorities is remarkably high—demographic and cultural defenses many countries, especially developing ones, do not share.
Mehid Hasan Munna is a Copy Editor at BIGD.
Photo 1 : An outdoor restaurant in Stockholm on March 26, 2020. Photo: Janerik Henriksson/TT
Photo 2 : Gustav Lloyd Akerblad (32), getting a tattoo onto his arm in the shape of the face of Anders Tegnell, Stockholm, April 27, 2020. REUTERS/Philip O’Connor
Photo 3 : An elderly woman eating her meal in a nursing home. Henrik Montgomery/SCANPIX/TT
