How Sweden’s Coronavirus Strategy Makes Sense
And why it may not be applicable in other countries — a Swedish doctor’s perspective.
This is April 3rd. As the coronavirus rages all over the world, our attention is greatly focused on the countries affected the most, currently Italy and Spain, both stacking more and more CoViD-19 deaths, significantly surpassing China. Worry turns to intense anxiety and for many to panic as we see constantly escalating numbers on the news and social media. In response to this global situation many governments have proactively chosen to impose strict quarantine measures for their citizens and close their borders for all foreigners.
This applies to most countries in Europe, but Sweden stands out by still withholding many such measures, facing more and more harsh critique and backlash from within the country and beyond. It comes even from my colleagues at the hospital, with a hint of deep worry in their social media posts and in our conversations. I have therefore felt the need to try and answer the burning question: Are these criticisms valid or baseless? Is there cause for panic?
Before I go any further, let me make a very important point.
Every assessment about the coronavirus is extremely time-sensitive
We have both limited and constantly changing data on the coronavirus pandemic. This inevitably means that our calculations and predictions on what measures are enough, how the virus will spread or how many might be affected, are going to change many times in the coming weeks or even days. This is why I started with the date. April 3rd. Tomorrow we will wake to a different reality, forcing us to rethink and reevaluate. That is what local, national and international committees of experts and officials around the world are doing every day right now. Checking the daily numbers ourselves is practically useless right now.
A few months down the road we will be able to look back and see what we missed, what we could have foreseen. But right now, we can only adjust our assessments based on the ever-growing pile of data that is accumulated by the minute from around the world. This will certainly make many official statements seem self-contradicting or like gross miscalculations in retrospect. That is often not the case.
In reality, it is the lack of data and the rapidly changing situation that demands that we do not remain rigidly stuck to our initial assessments, when the facts have changed again and again. That is why most experts avoid making any specific predictions or rendering any definitive judgements so early in the course of the coronavirus pandemic. It may not look good and make you feel uncertain, but it definitely costs less lives in the long run. Changing the ship’s direction according to the weather is the safest course of action for any responsible captain.
It is not that simple
You have probably read in news stories and social media posts about what Sweden is (not) doing in relation to the coronavirus. The fact that primary schools are still open, much like bars, restaurants and cafes is the main if not sole focus. This gives the impression of “business as usual” and that the Swedish government does not care about limiting the spread of the virus, not nearly as much as other countries. This must mean that they are careless, irresponsible or just plain cynical, right? My mantra when coming across such simplistic claims is: It is always more complicated than that.
It is first of all important to point out that the Swedish government has from the start relied on the assessments of the country’s Public Health Agency (Folkhälsomyndigheten), where some of Sweden’s leading epidemiologists, microbiologists, infection specialists and other experts are constantly evaluating the data coming in from around the world in order to recommend health policies on the coronavirus, much like other matters concerning public health. Unlike in most other countries, the national Agencies in Sweden - the Public Health Agency among them - are not a part of the government and thus make (in theory at least) independent assessments and recommendations. It is these recommendations that the Swedish government is following and the parliament supporting across party lines.
This of course doesn’t mean the measures taken are immune from criticism, quite the opposite. But before we get there, let’s see what they look like and what the rationale behind them might be.
Soft restrictions…
So far the Public Health Agency recommendations to the government in Sweden have largely been for guidelines and advice for the Swedish people. These are in line with WHO guidelines and include:
1. limit your social contacts as much as possible
2. keep your distance and avoid direct physical contact in all social settings
3. follow rigorous personal hygiene measures, mainly washing your hands properly and frequently, sneezing and coughing in your elbow or a handkerchief and avoiding touching your face
4. work from home if possible
5. do not travel within the country if you don’t have to
6. isolate yourself if you have even the mildest symptoms or if you are in a high-risk group (an elder and/or with serious underlying medical conditions)
These sound good and reasonable, but are still just recommendations. What about some actual restrictions?
Sweden started about the same time as other European countries with forbidding large crowd gatherings (more than 500 people) but has after that rolled in more restrictive measures significantly later (if at all so far). There is no law or emergency order in place to bar people from going out or from visiting their favorite restaurants and shops which have not been ordered to close either. Does this mean that they have done nothing more? Far from it.
Senior high schools and universities (for which significant daily commute within or between cities takes place) have been closed for weeks, classes continuing through the internet. This week, public gatherings have been restricted to 50 people and bars, restaurants and cafes are now only allowed to serve people sitting at their separate tables, not on the bar or counter.
What? Is that all?
… extensive compliance.
This set of measures does indeed sound quite lax, if you think that people are challenging the limits of these restrictions. Are gatherings of 20, 30, 49 people taking place and people going to bars and restaurants as usual, simply avoiding standing by the counter? That sounds absurd in a pandemic like this, right? Well, have you seen images of crowded indoors (or outdoors for that matter) places in Sweden? Even if you have, I assure you they are the exception and not the rule.
Most courses (take both my dancing classes and obligatory courses for my specialty training for example, with 20–30 participants each) have been cancelled long before the latest restrictions rolled in. Most places where people previously gathered are either empty (shops and restaurants forced to close or at least lay off many of their staff already) or with way fewer people than usual. Barely any elderly people among them. And many chose to self-quarantine even if they are young and perfectly healthy for fear of helping the virus spread.
The flow of people in the emergency department (both for children and adults) in the hospital where I work has gone down by 60% these past couple of weeks. Practically no one comes in without a seriously good reason, because they fear getting infected.
But however well these recommendations are (or aren’t) being followed, they can’t hope to stop the spread of the virus, right?
Of course, but that is not the goal here.
Planing (a little bit further) ahead
What do you expect to happen with the coronavirus across the world in the coming months? Sure, your country will have done a great job at containing the virus (and bringing society to its knees) by summer 2020 and the warm weather will give the virus another push to finally leave your country alone. Life can slowly start going back to normal. But what happens in the rest of the world?
Do you honestly believe all the countries will have done such a good job? Even the southern hemisphere where winter will be raging during Europe’s, North America’s and China’s summer? We can count on the fact that they won’t. And what happens when autumn comes, the coronavirus imported one way or the other again in your country and the whole charade starts all over again? We can arguably be somewhat better prepared by then, but an actual solution, namely a coronavirus vaccine won’t be available until the middle of 2021 at best.
In other words, Sweden is working with the given that the coronavirus will, sooner or later, spread to a significant part of the population (in this case estimated at 60–70%) before it can be definitively stopped. Herd immunity is thus our only hope, either by mass vaccination (wait a year and a half for that) or by infection. In this scenario we have control of only two aspects:
1. how fast the virus will spread
2. what part of the population will be infected
Let it spread too fast for the healthcare system to handle or to infect a significant number of your senior and chronically ill citizens and the death toll is expected to touch horrible 6- and 7-digit numbers.
Therefore our best bet to minimize the casualties is to slow the spread of the coronavirus enough to not overwhelm our healthcare systems’ capacities (otherwise known as flattening the curve) and to isolate the vulnerable part of the population as best as possible - which is by the way Italy’s probably biggest failing: allowing its disproportionally large elder population to get infected.
Mind you, this does not mean that broader quarantines are out of the question. The Swedish officials have repeatedly warned that such measures are on the table. They will be used when deemed necessary and for as short periods as possible. The primary goal is not to keep the country open but to avoid the overflow of critically ill patients in the Swedish hospitals’ ICU’s. And to that goal, total quarantines with fuzzy expiration dates would simply be an overkill. With the associated consequences.
I’ll leave for another article the effects total quarantine could have on our societies, but they are not to be overlooked or underestimated in this complex equation either. My sincere hope is that we will not have to choose between the one or the other kind of devastating effects. In any country.
But if this reasoning stands, you are probably wondering, how come no other European country is following the same strategy? Not even the proud United Kingdom, their prime minister waving herd immunity pompously at first, only to withdraw it and drastically change course soon thereafter, in response to horrific scientific predictions. Does Sweden know something the world doesn’t? Maybe not, but it has some particular characteristics (especially in contrast to countries like Italy) that might just make this strategy work better than any other in the long run.
What makes Sweden special?
Let’s start with the Swedish lifestyle. Compared to most countries, people in Sweden lead relatively lonely lives. Young adults move away from their families much earlier, having the economic capacity to live by themselves. Most families live in max 4–5 people households, usually not including their elders, who typically prefer (and - see a pattern here?- are economically able) to live independently. If they cannot do that, elder homes are preferable to what is seen as becoming a burden for your children's families and having to adjust to their way of life.
Going out in groups is not either that popular of an activity. Sure, Swedes enjoy having fun out with friends, but many of them as much if not less than chilling at home on a cold Friday night. The popular word for that in Swedish is “Fredagsmys”. Even direct physical contact, hugs and kisses on the cheeks, are refrained for those in their closer circle, not all aunts and colleagues. To sit on the buss or train next to another passenger who is not your acquaintance, when there are free double seats, is almost considered absurd. You could say that personal space is significantly more well-defined here. By default.
For reasons too complex for me to understand, Sweden is also unusually sparsly populated. Any way you measure it, Sweden just doesn’t have nearly the same population density as other countries (compare for example top city sizes between Sweden and Italy). I live in Sweden’s 10th largest city, which boasts the underwhelmingly small population of 70.000 people. Limiting traveling between the cities can thus have a much greater effect on the spread of the virus than in other countries.
Another very important factor is the tradition the public has in Sweden with trusting the authorities. They trust that the government and national agencies have their best interests in mind when forming policies or making important decisions, if not universally in economic matters for example, at the very least in the field of public health. That level of trust is partly what makes Swedes comply to such a degree with only soft restrictions. Even in these times of great uncertainty, with inside and outside critical voices growing by the day, people’s trust in their institutions doesn’t seem to have wavered.
The first graph below is from a national survey done in the middle of March, asking: “How much trust do you have for these institutions in the management of the coronavirus?”, the Public Health Agency (Folkhälsomyndigheten) being second from the bottom, performing worse only by the healthcare system itself, right below.
The second is asking on March 23rd how safe people felt after the prime minister’s adress to the country, where he talked more about personal responsibility than collective restrictive measures. Numbers 1. and 2. are the ones feeling “quite or very unsafe”. These are numbers touching 80% faith in the authorities. These are not numbers indicative of a country in the midst of such an uprecedented international crisis.
The effect of this profound public trust is reflected in many other aspects of public health. For example, observe how well Sweden has managed to keep the measles vaccination rates very high (95% needed) in the face of the dangerous global anti-vaccination movement, avoiding reemerging deadly outbreaks unlike many other countries in recent years. And that without having any law in place forcing child vaccinations. Guidelines from the authorities are more than enough here.
I would therefore say that a relatively lonely lifestyle, well-defined personal spaces, a spread-out population and the public’s trust for its institutions coupled with an overall good healthcare system gives Sweden a somewhat different capacity to handle this pandemic with measures that would have easily crumbled and failed in other countries. That is what we are counting on. If we at any point judge that our system’s capacity is going to overflow, Sweden will most definitely change course. The government has repeatedly warned that the possibility for escalating measures continues to be on the table. That is the strategy.
The right strategy?
The question however remains: Does Sweden know best or are we heading straight towards Italy’s grave coronavirus outcomes? Anyone who claims to be certain of the answer is either misleading you or grossly oversimplifying the few known facts. Common logic or simple mathematics are not nearly enough to make predictions or to really understand the situation. This is an unprecedented pandemic where no one has prior experience, no one knows what is the best course of action. As Anders Tengell, the head of the Swedish Public Health Agency stated in a mini-interview with the BBC on Wednesday:
“I don’t think anyone can be seriously confident about getting this right since this has never happened before.”
I am therefore not going to show any numbers, mathematical projections or experts’ opinions to support or discredit the validity of Sweden’s strategy. Because despite what some otherwise reliable media sources might have you think, data and opinions exist both for and against this strategy. That is because we know too little to able to extrapolate the data with any satisfying measure of certainty in order to see what is going to happen with the coronavirus and when.
If someone has all the current data however and is best equipped to interpret them for the best of the people of Sweden, for me it is our leading experts of the Public Health Agency. And I, much like a majority of the Swedish people right now trust that they are doing their best to take us out of this crisis with as little a cost as possible.
A little hope in the sea of uncertainty
So, no one can be sure of anything on the long run right now, this is not something we have been up against before. On the contrary, this is a first-of-its-kind serious global-scale pandemic with a previously unknown pathogen which spreads like wildfire. First that is, for our modern age of effortless international travel and unlimited worldwide interconnectivity. These help both the virus and the uncertainty around it (together with all the other various strong emotions that they produce) to spread in an unprecedented way with all new kinds of consequences.
Despite that, we can take some kind of solace in the fact that humanity has, in numerous ways through the centuries, been here before in one way or the other. This crisis will, like the ones before it, invariably help us change focus in many ways. It reminds us, as many other catastrophes and tragedies have (often in smaller scales) that we are not invulnerable. We are human. We are small in the background of the grand majesty that is the universe. If you think about it, it is kind of a miracle we have come so far. And our best bet right now is to get through this together. Maybe not in agreement, but together.
If you are interested, you can read my follow-up article “Sweden’s Coronavirus Strategy: Is It Working?” for an update on the situation near the end of May 2020.
