Covid-19: What Sweden taught Scandinavia for the second waveBMJ 2020; 371 doi: https://doi.org/10.1136/bmj.m4456 (Published 27 November 2020) Cite this as: BMJ 2020;371:m4456
More than half a year since the pandemic began, the Public Health Agency of Sweden still insists that the core of their strategy was not about building natural “herd immunity.”
Sweden’s controversial pandemic policy has been both lambasted and praised around the world.1 The Nordic country adopted what its public health authority described as a “soft” approach of keeping bars, restaurants, and schools (for pupils up to the age of 16) open and giving only recommendations to wash hands, maintain social distance, and keep gatherings to under 50 people. This is in marked contrast to neighbouring nations Denmark, Norway, and Finland, that went swiftly into lockdown.
In July and August, the number of infections dwindled, but much like the rest of Europe autumn has brought an upsurge in cases and the country’s highest ever daily case numbers. According to the European Centre for Disease Prevention and Control, as of 12 November Sweden had a 14 day cumulative number of 472.9 cases of infection per 100 000 inhabitants—in comparison, Norway had just 135.5.2 Sweden’s death toll is over 6000, surpassing all of its Scandinavian neighbours combined, though mortality remains lower than Belgium, Spain, and the UK.
It’s the latter comparison that has some experts in favour of Sweden’s light touch approach, pointing to the still relatively low infection rates despite no mandatory lockdown. With a second wave sweeping through Europe and countries struggling to balance economic recovery with ongoing pandemic measures, Scandinavia as a whole seems to be taking the lessons of Sweden to heart—the good and the bad.
“The Swedish approach taught us what to do and what not to do in other Nordic countries,” says Søren Riis Paludan, professor of biomedicine at Aarhus University in Denmark. “Now we don’t have to go into lockdown but know where to be more careful, particularly with the elderly.”
Statistics show that 89% of Sweden’s covid-19 deaths were in people over 69. During the first six months of 2020 over 2000 people died in nursing homes as a result of what Sweden’s Health and Social Care Inspectorate, Ivo, described as “serious failings,” including a lack of protective equipment and inadequate access to doctors. “These fatalities could have been prevented,” Paludan told The BMJ.
In contrast, Norway, with about half the population of Sweden, has had 267 deaths from covid-19, with 90% in people over the age of 70. In similarly sized Denmark, 697 people have died from covid-19, and the country has surprisingly registered the lowest number of deaths in its population for six years, according to Statens Serum Institut, the national infectious diseases agency.
While countries all over Europe go back into national lockdowns, no Nordic country has yet opted to do so. “Based on Swedish data, we learned that keeping schools open does not contribute to spreading the virus,” says Paludan, “There are certain groups that need to be protected, which now means we have a society that is relatively open save some restrictions on how many people can gather, restaurants close early, and restrictions with facemasks.”
Masks remain a point of contention, however. In contrast to its neighbours, the Swedish public health authority is still against the use of masks except in hospitals where covid-19 patients are being treated, a stance that puzzles Anders Vahlne, a professor of virology at the Karolinska Institute in Sweden.
“It is an extremely effective and inexpensive measure, while at the same time being simple, and the majority of studies have shown how effective it is,” he told The BMJ. “It’s unclear why this measure shouldn’t be taken.”
Masks aside, Sweden now seems to be joining the rest of Scandinavia in being more restrictive in its guidance as the number of cases soars in the second wave.
“We are going in the wrong direction,” said Swedish Prime Minister Stefan Lofven at a news conference on 3 November. “The situation is very serious . . . Every citizen needs to take responsibility. We know how dangerous this is.”
As of 12 November, the government had rolled out stricter local restrictions in 13 of Sweden’s 21 regions, which include avoiding public transport, physical contact with people from outside your household, and limiting restaurants and cafés to a maximum of eight people at tables.
Joacim Rocklöv, professor in epidemiology and public health at Umeå University, says there are multiple reasons for this change, including that herd immunity as projected was not reached. In April, the Public Health Agency of Sweden predicted that 40% of the Stockholm population would have the disease and acquire protective antibodies by May. But according to the agency’s own antibody studies published on 3 September for samples collected up until late June, the actual figure for random testing of antibodies was only 11.4% for Stockholm, 6.3% for Gothenburg, and 7.1% across Sweden.3
Another reason for Sweden’s shift, according to Rocklöv, is evidence that the more restrictive policies in neighbouring countries “worked better” and did not have deleterious economic effects as feared.
Debate over semantics remains. Johan Nöjd, head of infectious disease control for Uppsala—the first Swedish region to voluntarily impose harsher restrictions—defined their rules as a “local lockdown.” But the Public Health Authority of Sweden still refuses to call it that, insisting on labelling them “stricter guidelines.” This has led to a lot of confusion over the country’s strategy, says Rocklöv. “What it actually was, and if we actually changed, or not.”
Contributing to the confusion was an announcement from the public health authority on 22 October that some national restrictions were to be eased. This included the removal of special recommendations for over-70s and risk groups to stay at home and shield themselves, permitting visits to nursing homes, and allowing up to 300 people to attend cultural and sporting events as long as they were seated far apart.
“Even now when there has been a change, the media in Sweden probably will continue to report on the Swedish strategy as if it was constant,” Rocklöv says. “In fact, the strategy changed in the spring as well when the approach to testing and tracing was refined.” Sweden initially refused to increase testing levels but later relented, recently ramping up to 190 000 tests a week from 32 700 in May. However, on 10 November Reuters reported that several regions were struggling to keep up with rising demand, forcing authorities to restrict bookings.4 Swedish opposition parties are also claiming that testing is far from the level it should be.
Neighbouring Finland has an infection level five times below the European Union average. This is partly the result of an extremely effective testing and tracing policy, including a smartphone app “corona flash,” which has been downloaded 2.5 million times in a country of 5.5 million people. Norway had a similar app but was forced by its data protection authority to stop using it in June owing to concerns about user privacy.5 Denmark has also credited its low numbers with its track and trace strategies, setting up a telephone hotline for those infected.
Trust is key
Vahlne told The BMJ that he remains “deeply concerned” about the Swedish situation. He is one of 200 scientists in Sweden who have been outspoken critics of the country’s approach to the pandemic since March.
On the day of the 22 October announcement, they published an open letter in the Swedish newspaper Aftonbladet condemning the loosening of restrictions as “absurd and deadly” and questioning the wisdom of “encouraging those most at risk of dying to start living their lives like everyone else” in the midst of the sharpest increase in the number of infections since the spring.
It threatens perhaps the most important commodity when pandemic measures are voluntary, not mandatory: public trust.
Paludan believes that one reason the Nordic countries, including Sweden, have avoided the alarming infection rates and deaths of the rest of Europe is that Scandinavians are “willing to obey the rules and follow politicians and authorities.” This meant that despite the lack of enforcement in Sweden, most citizens still followed the advice, socially distancing themselves and washing hands.
“I guess you could argue that we are now benefiting from decades of social democracy,” he says. A study conducted in May by the European Commission indicated that Denmark and Finland have the highest levels of trust in their governments in Europe and, despite experiencing a dip in June owing to the mounting death toll, trust in Swedish authorities also remains high.6
Rocklöv hopes this will not be wasted. “[If infections do rise] I really hope we will not act too late again, leading to unnecessary suffering and risks,” he says.
Nordic intensive care units surviving
Although total mortality is higher than in the rest of Scandinavia, Sweden’s current rates are relatively low, with an average of only three fatalities a day compared with 100 a day in early April. Nationally, new intensive care unit (ICU) intake averaged around two a day in October, compared with a peak of 40-50 a day between late March and early April.
These falls are partly due toimproved treatment protocols in Swedish hospitals, which include giving higher doses of anticoagulants and cortisone to patients as well as turning patients on to their stomachs (known as proning).
Thomas Linden, of the Swedish National Board of Health and Welfare, said at a press conference that the number of covid-19 patients in intensive care units was still relatively small at about 15% of capacity. Both the National Board of Health and Welfare and the Public Health Agency of Sweden describe the health service’s preparedness for a spike in infections as “good.”
However, Sineva Ribeiro, chairman of the Swedish healthcare workers union, told Aftonbladet that there was still “concern and increased complaints from healthcare professionals of not being able to cope with a second wave.” As Sweden sees a record surge in cases, on 29 October Sweden’s chief epidemiologist, Anders Tegnell, told a news conference: “We’re beginning to approach the ceiling for what the healthcare system can handle.”
Over the border, Finland has also experienced a drop in ICU admissions, while Denmark has maintained a very low rate throughout the pandemic, where only 0.5% of all infected people are at risk of being admitted to an ICU.7
Still, Nordic countries are continuing with emergency measures despite experiencing much less strain on health services than Sweden. Danish health authorities predict that the number of admissions will increase, so hospitals are training doctors and nurses in other specialties to work in ICUs, while Finland has reassigned 1500 hospital employees to units treating covid-19 patients.
And with around 80 000 Swedish citizens living and working in Norway, the Norwegian government is strengthening border patrols to prevent imported cases. No one is taking any chances.
Provenance and peer review: Commissioned, not peer reviewed.
Competing interests: I have read and understood the BMJ policy on declaration of interests and have no relevant interests to declare.