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Why is the Swedish strategy so different? The most frequently asked questions about Sweden’s Coronavirus strategy

Everyone’s talking about it, yet almost everyone is equally confused: why is Sweden so different from other countries? And how do we make sense of the potential consequences of this unique strategy?

A recurring set of questions and statements have been forming the conversation both in Sweden, and internationally. This is an attempt to give all of these statements some context.

Frequently occurring statements:

Sweden’s strategy is to achieve herd immunity

Sweden’s high death toll is due to the spread of infection in nursing homes

Sweden does not believe in using face masks

Had Sweden closed down at the same time as our neighboring countries, we would have had their low death rates

Sweden didn’t take any measures against the pandemic

Sweden chose not to lock down in order to save the economy

Sweden’s strategy is to achieve herd immunity

Both yes and no.

No, because Sweden’s declared strategy is to ”flatten the curve”, and to protect the elderly and other risk groups. That is to say, keep control over the spread of infection so that it doesn’t overload the Swedish healthcare system. Sweden doesn’t believe it possible to stop the virus, and anticipates that the pandemic will continue into the foreseeable future. As such, attempts have been made to introduce measures that can be sustainable over a longer period of time. Recommendations rather than laws, and calls for social distancing instead of closures.

The Swedish Public Health Agency is responsible not only for infection control, but also for a holistic perspective on health, and believes that locking down for a long time would create other tough societal stresses that in the long run can lead to worsened health effects. Children kept out of school feel worse, incidences of domestic violence can escalate and mental illness can increase due to loneliness.

Yes, because that’s what the whole world is striving for. Herd immunity occurs when a sufficiently large proportion of the population is immune, for example through vaccines. In early emails, which I obtained through a freedom of information request, it appeared that the Swedish Public Health Agency calculated that a completed infection creates immunity and that it therefore needs to be included as a factor when building a strategy against the virus. There was also a discussion around how keeping schools open could help increase herd immunity.

Herd immunity can be likened to gravity: a pilot landing an aircraft doesn’t have gravity as a goal, but gravity is a scientific fact that the pilot can lean on when shaping the strategy for landing the plane.

At the same time, the term and concept have been controversial in Sweden and state epidemiologist Anders Tegnell is careful not to use it, on account of it sounding as if one ”accepts illness and death”.

Sweden’s high death toll is due to the spread of infection in nursing homes

It’s true that the infection spread to nursing homes and led to many fatalities, and it’s also one of the few areas in which Sweden and the Swedish Public Health Agency have admitted failure. But what is also true is that Sweden is hardly alone in this. Most countries have seen a large proportion of their deaths occur in nursing homes, including Norway, for example. In Sweden, about 50 percent of those who died with Covid-19 had lived in nursing homes. In Norway, that figure is 60 percent.

There is also a recurring debate over whether such high death rates are due to Sweden’s privatization of care for the elderly. In 1992, the law was changed so that the elderly care remit was passed to local authorities, leading to the elderly to a greater extent receiving care at home. Private companies were brought into the market, and hourly temps have become more commonplace alongside a reduction in wages. Working with elderly care today is a low-salary, low-status job. Despite this, a number of reviews show that private nursing homes haven’t been any harder hit by Covid-19 than municipal ones. When a newspaper in Gothenburg examined the situation on the west coast, it turned out on the contrary that for-profit nursing homes did better than municipal ones.

Beyond all this, there’s an important question that perhaps reveals something even more serious: how much have we cared before when the elderly die?

When Statistics Sweden charted the mortality rate in Sweden during the pandemic, it appears that it was significantly higher for several periods further back in time, measured in both absolute numbers and relative to population. However, if we only look at absolute numbers, there are several monthly pairs that were more lethal than April/May 2020:

The two-month periods with most fatalities in Sweden since the Spanish Flu

Almost all of the deadliest two-month periods came immediately before and after the new legislation on nursing homes. Thus, it seems to be more a case of attitudes towards death and Sweden’s elderly, than organization. Åke Nilsson was a population statistician at Statistics Sweden at the time, and has previously spoken to this blog about how strange it is that this has been allowed to continue unchecked for decades:

“The statistics have been around for all these years, but still nothing has been done about it. There’s a nonchalance displayed towards elderly care”, says Åke Nilsson.

It should also be noted that several regions have subsequently analyzed the deaths in nursing homes, and established that many of the elderly who had Covid-19 listed in their cause of death certificate, had actually died of something else. In Östergötland, a review showed that only 15 percent of the cases had Covid-19 as the direct cause of death. In another 15 percent, there were completely different causes that contributed to the death and in 70 percent, Covid-19 was just one of several contributing factors. In other regions, the figure is even higher.

With all that said, this is the area that the Swedish government and authorities have categorized as the strategy’s biggest failure.

Sweden does not believe in using face masks

Well, that it works in, for example, healthcare is indisputable. The public health authority has also said that it may be worth wearing a mask in crowded spaces, but hasn’t given any general recommendation to that effect. This is because they think that there is little scientific basis for the benefits of mask wearing at general population level, meaning they question whether it prevents social spread. The risks they associate with masks are that they could be worn incorrectly and that it can lead to a false sense of security; those who are otherwise worried about being or becoming ill shift to feeling safer and less risk-averse behind a mask. As such, they consider it more prudent to advise staying at home at the slightest hint of illness and otherwise maintaining distance.

Had Sweden closed down at the same time as our neighboring countries, we would have had their low death rates

No. And the numbers say as much. Firstly, it’s true that Sweden saw higher excess mortality than our neighboring countries, but if we look more closely at the dates on which various measures were implemented, the beginning seems to have had little significance. This has previously been pointed out by commentator Jacob Guidol, whose graph from Euromomo I use below. By highlighting the dates other countries went into lockdown, and the date on which Swedes were asked to work from home, it becomes clear that a lockdown would’ve had minimal impact on the first three weeks’ high death toll. It wouldn’t matter if we’d have locked down every last Swede; the virus had already infected these people.

Sweden would’ve needed to take action as early as February, something that would have been impossible given the meager knowledge base.

On the other hand, it is clear that our high death rates did not initially fall as fast as countries with harsher closures. It can therefore be argued that a lockdown or other more stringent measures could have curtailed the death toll as time went on, but that still would have meant that in total, we would have had far more deaths than our neighbors.

Sweden didn’t take any measures against the pandemic

It is true that Sweden introduced few laws, instead using recommendations. ”Recommendations” is the strongest word Swedish authorities can use and in Sweden there is a tradition and culture of following such advice.

Measures issued to the public were as follows:
March 10:
Anybody with mild symptoms is recommended to limit all social contact and everyone is encouraged to refrain from unnecessary visits to nursing homes.
March 11:
A limit of 500 participants in public gatherings is invoked.
March 13:
Even those with very mild symptoms are encouraged to stay at home. In Sweden, the first day of any period of paid sick leave from a job (known in Swedish as ‘karensdag’) would usually go without ordinary pay or entitlement to sick pay. This rule was temporarily thrown out.
March 16:
Risk groups and those over 70 are recommended to remain in isolation, others are recommended to ”consider” working from home.
March 17:
Online lessons are recommended for universities and high schools.
March 19:
The public is advised to avoid unnecessary domestic travel.
March 23:
Everyone who can is recommended to work from home.
March 24: Regulations
introduced for special measures for restaurants.
March 27:
A limit of 50 participants in public gatherings is invoked.
April 1: Recommendation
that the public maintain social distancing.

Well worth noting is that the recommendation to maintain distance came very late. Despite this, data on Swedes’ movement and travel patterns show that we began to isolate ourselves as early as March and for several periods, Sweden was on a par with countries under lockdown. But, according to the chart below, we generally scaled down our movement and travel patterns less than neighboring countries under lockdown (yellow line is Sweden).

Bi-weekly rolling average

Sweden chose not to lock down in order to save the economy

No. Saving the economy has not been stated as a reason for Sweden’s choice of strategy and moreover, the economy hasn’t been saved. Sweden is a small, export-dependent country and so to that degree, it matters less if the Swedish economy is open if everyone else is locked down, thus impeding trade with other countries. Sweden showed positive economic development during the first quarter of the year, but since then no report has shown that Sweden has managed the economy very much better than neighboring countries that are experiencing downturns. Of course, the government has provided crisis assistance to businesses with a number of support packages from the state to stimulate an economy that would otherwise have been completely wiped out.

Have you seen any other frequently occurring questions or statements? Maybe you think something else is missing from the above text? If so, leave a comment suggesting what you think should also be included!

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Här ansvarar den som skriver kommentarer för sitt eget innehåll
  • PEC oktober 29, 2020, 18:45

    This is great!

    But ‘ On the other hand, it is clear that our high death rates are not falling as fast as countries with harsher closures‘

    Should that not be ‘did not initially fall….’?

    • Emanuel Karlsten oktober 29, 2020, 18:56

      You are very right! Thank you, its updated now. Please let me know if you find anything else!

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