Sweden’s management of Covid-19 stood out. Unlike the rest of Europe, it did not shutdown. But did it work? Let’s hear from state epidemiologist ANDERS TEGNELL and former inhabitant ALISON ALLFREY…
Sweden’s State Epidemiologist
As the world went into lockdown, one man convinced Sweden to try a different approach. Anders Tegnell, the country’s state epidemiologist, persuaded Swedes to keep going. He insisted that borders be kept open, though the Danes refused, and the Volvo factory closed only when it couldn’t source new parts from abroad. Swedes can still sit in cafés and are encouraged to take as much exercise as possible. Tegnell has been lambasted abroad, but the mild-mannered civil servant is unrepentant. Opinion polls show Swedes are in favour and daily deaths are on a declining path.
“We are all trying to keep the spread low, to prevent our healthcare system being overstretched, but we have not gone for the complete lockdown. We have managed to keep the number of cases low enough that the intensive care units have kept working and there has always been 20 per cent of beds empty and enough protective equipment. So in that way the strategy has worked.”
Why didn’t he go for the full lockdown? “Because we really believed the methods we used would reach the same effect. We don’t have huge gatherings or sport and music events. We have quite strict rules even for those organising gatherings for fewer than fifty people. They should be outside if possible and there should be handwashing and disinfectant.” Schools are open but there are restrictions. The elderly are advised not to drop off grandchildren, nor is anyone feeling ill.
Tegnell won’t criticise other countries. “That’s for history to judge,” he says, sounding more serious than smug. Yet Sweden has a higher death rate than its neighbour, Norway. “The high mortality rate in Sweden is very closely linked to our elderly homes. That has happened far less in Norway and Finland. We have looked at the death rates very closely and we are trying to work out why, because there was already a ban on visiting care homes.” There is no policy to ration healthcare for the most frail and elderly, Tegnell insists, making it clear that this would be immoral. “If the doctor’s opinion is that this person can benefit from hospital care, of course they will go to hospital. If there is a decision that this is an elderly person with multiple diseases, they can end their life in a care home, but that is how it has always been, we have changed nothing.”
According to his calculations, there has been no higher rate of mortality in the rest of the population than in neighbouring countries. “It’s difficult because countries can’t give accurate figures with the elderly in care homes. Sweden is one of the few being rigorous.” However, fewer may die in Sweden from other diseases because the hospitals have remained open to all. “Fewer are coming for cancer and cardiac diseases, but we try to encourage them. We have a death rate increase in Sweden very closely connected to Covid-19 so I think we have persuaded most to take their other illnesses just as seriously.”
There was a letter from twenty two scientists criticising Tegnell’s methods last week, but he remains unshaken. “We also have a lot of scientists behind us, expressing their views in a much more coherent manner than these people. We all agree the death toll is high, but we are working very hard to understand why, and our initial analysis shows it’s not the partial lockdown, but the care homes where we have the problems and the solutions.”
Meanwhile, the Swedish economy has been far less badly hit than those of other European countries, expected to contract by only 4 per cent this year. “I’m not an economist, but the UK is far more affected with more out of work,” Tegnell says, although he insists that he would never want to sacrifice lives to protect GDP. “None of our decisions are taken on economic grounds, but on having the most effective way of diminishing the number of people dying. We are now spending enormous resources protecting our elderly homes.”
Does he think other countries are infantalising their citizens? “I think it’s a question of traditions. In Sweden we have a history of crisis-management; you are taught as much as possible to use the tools you use in normal times to keep going. It gives a lot of responsibility to individuals.” Laws, he says, are culture-dependent. “The Swedes have fewer regulations than most countries and their laws are a lot less prescriptive. The state directs their citizens with a light touch.” The strategy is to “nudge” people into taking precautions rather than requiring them to stay at home. “If you feel ill in the morning, stay home. We keep on adding small adjustments to our recommendations all the time because we feel that keeps people aware that the danger isn’t over,” Tegnell explains, saying he doesn’t like to “shove”.
Fewer than two hundred of the 15,000 cases in Sweden are among those under 20, he says, “so schoolchildren in Sweden, as in other places, are not very much affected by the disease. Closing the schools would not have much of an effect. We feel quite confident that that was the correct decision.” Universities are teaching remotely, but exams are still going ahead to keep children grounded. “Ministers have told schools that all children should expect to have an exam this spring, just that it might be in a slightly different manner than usual.”
The British Government has been heavily influenced by epidemiologists at Imperial College, London, led by Neil Ferguson. He predicted 500,000 British people could die if nothing was done. Tegnell says their dire warnings could be wrong. “Modelling is not a truth. You can very easily tell the Swedish model has already been proved wrong. You need to realise that models are only as good as what you put into them, and when you put into them very uncertain variables… you should be careful of seeing them as projections of the future.” There is, in his view, little chance of a vaccine in the short term. “Even the most optimistic people seem to say that if we have a vaccine available in the next eighteen months we’d be lucky.” So the lockdown strategy, he says, will prove unsustainable. “To keep schools closed until we have a vaccine in place is not be possible. You are going to see big damage to a whole cohort of children.” In any case, the elderly and vulnerable often respond less well to vaccines so “we don’t know if it’s going to work for the people we need to protect”. That means countries around the world are gradually going to have to open up and allow their populations to develop a herd immunity like Sweden, he suggests. “Personally I think that is the only thing that is going to slow this down when we have a considerable proportion of the population in most countries who are immune to the disease, because these diseases are not stopped by anything else really if you don’t have a vaccine.”
A growing number of Tory MPs are arguing that the cure is in danger of becoming worse than the disease, and that Britain should copy Sweden. “It’s difficult because we are not at the end of this yet,” Tegnell says, diplomatically. “I’m not sure that different strategies in the end will have a huge difference in health; just a huge difference in economy. It might be that, whatever we do, we can postpone the effects of the disease, but we cannot avoid them. So whenever you have to stop these drastic measures you need to go into something that’s going to look more like the Swedish model.”
So far, at least, Swedes are on board with their government’s approach. More than 70 per cent of the population have high level of trust in the public health agency, and about 90 per cent of the population feel they have good information. Tegnell does not always believe Sweden is best — he says he prefers the Beatles to Abba, and beaches to fjords — but he appears quietly confident that Sweden will be proved right over its coronavirus strategy. When we ask whether Sweden might exit from this pandemic first, he says it “sounds like a nice future,” and that his team spent some time this week discussing how soon they could “encourage people to come here and have holidays”.
Anders Tegnell was in conversation with Rachel Sylvester, columnist at The Times
Author and former resident of Sweden
Why has Sweden ploughed such a different furrow to other European countries during the pandemic? The extent of their stance is partly perception and partly reality. Much of Europe has a longstanding fascination with the Swedish model, be that through education, lifestyle or public finance, so its position now has attracted significant attention but has not always been represented accurately. In fact, senior schools and universities remain closed, people work from home, public gatherings of over fifty are banned and the over 70s have to isolate. So it’s not as cavalier as we might suppose, but it is markedly different from our own situation.
Having spent three years living in Stockholm, much of the Swedish approach doesn’t particularly surprise me. This is a country founded on pragmatism, self-sufficiency and humility. So, faced with a crises that set public health and economic fate at loggerheads, Sweden appears to have struck a balance. What’s more, Swedes are spare with their language and social interaction, as well as having a vast land mass and naturally widely spread population. Social distancing is slightly inherent to the way of life. Walking down a main Stockholm street, you do not feel cramped or overwrought with humanity – quite the opposite.
Sweden has not escaped the impact of the virus, though. During the first week of April, 25,230 Swedes registered as unemployed, a larger increase than during the financial crisis of 2008. And its death rate has far exceeded that of Denmark or Norway, with 2,769 deaths from 22,721 confirmed cases, versus 493 from 9,670 cases in Denmark, 208 from 7,847 cases in Norway and 28,734 from 190,584 cases in the UK. The UK tops the table with a 15 per cent death rate from confirmed cases, versus 12 per cent for Sweden, 5 per cent for Denmark and 2.6 per cent for Norway. Economic forecasts abound, but many predict that Sweden will pay as high a price as some countries who enforced a stricter lockdown (as its export dependent economy suffers), whilst others, including JP Morgan, forecast a lesser contraction for Sweden than the rest of Europe. This will play out in the months and perhaps years to come.
Sweden knows it has truly robust employment and benefit systems. Equally, it has one of the best provisioned healthcare systems and longest life expectancy in Europe, not to mention an incredibly fit population. It’s true, also, that the approach of large countries has contrasted with that of small countries. Take New Zealand, which imposed the strictest of lockdowns and completely closed its borders in mid March, resulting in there being no new cases of the virus as of 4th May. Take Austria, which has made a point of learning from other countries and taking a humble approach. There is an inborn arrogance of large countries who think no other country is like them… small countries tend to learn much more from each other. Maybe smaller countries have more margin for manoeuvre, are more nimble, can be truer to themselves.
ANDERS TEGNELL is Sweden’s State Epidemiologist.
ALISON ALLFREY is the author of C is for Covid – The Highs and Lows from A to Z, available to buy now on Amazon.
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Extracts of this article have also been published in The Times.