Covid Lessons from Sweden
Sweden is a country of about 10 million people with one large metropolitan area, Stockholm. The State of New York has about 20 million people, with a large percentage in one large city, New York. Both had severe outbreaks of Covid-19 in the spring of 2020. New York, after its terrible outbreak, is now being hailed as a success story in the fight against this disease, while Sweden is frequently criticized. From press reports in the United States, you would assume New York did a much better job in fighting the pandemic than Sweden.
Let’s look at the situation more carefully:
Sweden had suffered a total of 5,743 official deaths from Covid-19 as of July 31, 2020, which is 568 deaths per million people. This is one of the highest rates in Europe, and a good bit higher than their immediate neighbors Denmark and Norway. It is, however, better than some European countries such as Belgium, the United Kingdom, Spain, and Italy. And it is only one/third the death rate per capita of New York State, which had 1636 deaths per million people in the same period. The State of New Jersey has about a million fewer people than Sweden, but New Jersey has had an even higher death rate than Sweden or New York, at 1743 per million residents.
Importantly, although the policies of New York are being seen as highly effective, approximately 57 people died in New York from Covid-19 the first week of August, while Sweden had a total of only 3 deaths in the same period. Also in New York, after a severe lockdown the infection numbers plummeted, but not as much as they have come down in Sweden. Why, then, is New York being seen positively and Sweden negatively in many press reports?
Basically, it is because Sweden took a less strict approach in dealing with the pandemic than many other countries, and those that used more restrictive measures would like to believe they were right, that they needed to do everything they did. It is time, however, for a thoughtful examination of both the failures and successes in Sweden, in hopes we might come to a better understanding of how best to deal with Covid-19 for the rest of 2020, in 2021, and as we plan for potential pandemics in the future.
As word of this new disease began to be more widely known in late January 2020, and several countries began to lock down or curtail movements and interactions, the leaders in Sweden made a decision to follow a different path, which was recommended by their health experts and scientists. The underlying assumptions were:
1. The world would be dealing with Covid-19 for a long time
2. Locking down for a few weeks would not get rid of the problem
3. Locking down for an extended period would have dramatic negative consequences on all aspects of peoples’ lives
4. Therefore, their goals would be:
A. Find actions that would flatten the curve of rising infections so the medical establishment would not be overwhelmed
B. Limit the spread of the disease as much as possible
C. Do so in a way that could be sustained for a long period of time — as long as Covid-19 was significantly active in the world
D. Develop measures that the people of Sweden would support voluntarily and overwhelmingly, measures they would adopt and continue to follow for at least a year or two
E. Take into account that severe measures would be likely to create a backlash that would undermine any initial efforts at mitigation
F. Educate the people of Sweden quickly and thoroughly about what they needed to do to protect themselves and others
G. Keep as many of their schools, businesses, and normal social venues open as possible so people would not undergo the trauma of more life disruption than was totally necessary
H. Limit activities and close facilities that emerged as primary sources of infection
Following these ideas, they chose not to shut down their country as many others were doing. Rather, they chose to strongly encourage their citizens to voluntarily adopt measures to protect their health, such as wash their hands often, keep a physical distance from people not in their immediate circle of family and friends, venture out less often, and limit gatherings to 50 people or less.
Understanding the importance of going to school, especially for younger students, they kept schools open for everyone under 16 years of age. Most businesses remained open, including restaurants. No masks were required, but some people began to wear them voluntarily.
Many pundits outside of Sweden have said they were choosing herd immunity, but the leaders of Sweden have consistently said this was never their goal. They have consistently said their goal was to flatten the curve so the medical establishment would not be overwhelmed, and then to find a way for their people to live as normally as possible in the midst of a pandemic that would go on for a long time.
Mistakes were made
As the leaders of Sweden have admitted, they made mistakes in their approach.
1. Sweden has an older population than most countries, a significant number in nursing homes, and they had severe outbreaks of Covid-19 in their nursing homes. This led to a higher death toll than many other countries. Almost 50% of their deaths so far have been in the nursing home population. Whether this was the result of their main policy decisions is not clear, since a number of other countries that had extensive lockdowns have also had a high death toll in nursing homes. This was certainly the case in New York. But the leaders of Sweden have said repeatedly that they did not do enough to protect their elderly population when the pandemic began, and recent numbers suggest they have corrected this mistake.
2. They did not begin an extensive testing program as early as several other countries, which delayed their ability to respond to outbreaks. They have now corrected this problem and are doing extensive targeted testing.
3. They did not focus on the problems of crowded housing in immigrant communities, such as the Somalis in Sweden, which led to higher infection and death rates in immigrant communities. Again, this was a problem in many other countries, so it is not clear how much Sweden’s overall policy was the cause of this mistake. And again, the Swedish government began to take significant steps to mitigate this problem, and it is working.
The effects of the mistake with the elderly and infirm on the overall death rate is important to note. Of the 5,743 people who had died in Sweden from Covid-19 as of July 31, their ages were:
90 and over — 1498 (25%)
Under 50–71 (1%)
Thus, 67% of deaths were among those over the age of 80, and another 21% were between 70 and 80 years of age. This means that the total number of people under the age of 70 who have died from Covid in Sweden is 625, or about 20% of total deaths. The number of all deaths of those under 50 is 131, about 4% of the total. Thus, the number of deaths for people under the age of 60 compare favorably with many other countries with lower overall death rates, as well as with many countries that used much more dramatic measures to try to limit the disease. Needless to say, Sweden’s numbers are all dramatically better than those of New York or New Jersey.
Perspectives on the death toll
The Swedish government, following the recommendations of their health scientists, decided on a strategy they believed would save the most lives over the long haul. They concluded this pandemic was going to be a long-term problem, so they searched for a path that did not involve trying to shut down the country, a path that would not disrupt peoples’ lives more than necessary over a sustained period of time.
They specifically said they wanted to avoid shutting down and then having to deal with when to open back up. They saw the dangers of shutting down, trying to open, and then having to shut down again — perhaps going through that cycle over and over. Rather, they tried to find a path that was sustainable for at least a couple of years, and would allow them to gradually adjust rather than going from one extreme to another.
Crucially, they were searching for a path the vast majority of the people of the country would embrace voluntarily for the long term, for they understood that strict lockdowns and regulations ran the risk of rebellions by people who started to feel their lives had been disrupted unnecessarily for too long. Keeping these things in mind, and to put the number of deaths in Sweden from Covid-19 in perspective:
90,000 people die every year in Sweden from all causes (the average each year for the last few years).
This means that by the end of 2020 (assuming current trends continue) Covid-19 will add about 6% to the total number of deaths, bringing that number to about 95,780.
However, since so many deaths from Covid have been among the elderly and infirm, some of those people would likely have died from other causes in 2020 if they had not died from Covid-19. Others in those groups would have died in 2021 and 2022, so the mortality average for those three years will most likely not go up by even 5,780 over those three years. If that turns out to be the case, and current trends continue, Covid-19 will have added less than 2% a year to the total number of deaths in Sweden for those three years. And 67% of those deaths will have been among those over 80 years of age.
Each and every death must be taken very seriously. Yet we are dealing with a worldwide pandemic, so the number of deaths has to be understood in this light. Many, many people around the world are dying, a significant number of whom are dying from starvation caused by the methods used to try to limit the pandemic. As we fight the disease, we have to be mindful of the negative consequences of our actions aimed at suppression. Besides starvation on a grand scale, we are already seeing other diseases being left untreated because of measures enacted to stem Covid-19, as well as increasing suicide, alcohol abuse, drug abuse, and domestic violence. There is no safe path through a pandemic once it begins. Even those countries that locked down immediately and seem to have contained it are dealing with immense problems, one of which is that they cannot remain locked down forever, nor seal themselves off from the rest of the world for years to come without dramatic losses in their economies and way of life. There is no place to hide from a disease that is spreading rapidly all over the world and will do so for years. Today, among as much as 40% of the world’s population — perhaps 3 billion people in Africa, Brazil, several other countries in Latin America, much of India and Pakistan, and on and on — Covid-19 is basically moving through the populations unchecked.
Therefore, we will only know which strategies worked best in dealing with this pandemic after 2 years or more, when we will be better able to see how the disease has played out over time in various countries using different approaches. (A) Will closing off to the rest of the world, as New Zealand has done, be the best long-term path? Can countries that are not isolated islands follow such a plan? And what will happen when New Zealand tries to open up to the rest of the world? (B) Is the authoritarian model of China, imposing great control over all actions and movements of its citizenry the most effective path? Would the people in democracies be willing to accept this approach? And even though this has worked in the short term, as China tries to open its economy to the rest of the world, will it continue to work? © Will the focused and efficiently organized testing and tracing program implemented early on in Germany prove the best path? Will it continue to work as Germany tries to remove restrictions and open up more to the rest of the world? (D) And amidst all these approaches, what can we learn from the significantly different strategy followed by Sweden?
And as of today, August 8, 2020, the Swedish strategy seems to be paying off. Their daily infection rates have plummeted while the infection rates and death rates are beginning to go up in many other countries that shut down and are now trying to reopen. Some of those openings are now being delayed, and some countries are going through the painful process of closing down again. Others that closed down early on, like India, have had to abandon that strategy to a great extent. So far, Sweden has avoided these problems. They have maintained a consistent approach and their infection rate keeps falling as they continue along the same path they have been on, making minor adjustments as they go. As Swedish epidemiology expert Anders Tegnell said recently, Sweden has done as well or better than many countries that are attributing their results to lockdowns, but, “We have managed to do it with substantially less invasive measures.”
And importantly, as mentioned earlier, they now are having on average less than one death every other day in the whole country from Covid-19. If this continues, the overall death rate per capita in Sweden will look much better in the coming months. Since there are so few new deaths occurring in Sweden, while deaths in the rest of the world are still rising, many countries will pass them in deaths per capita in the next few weeks — including the United States as a whole. Significantly, many of the countries that are now passing Sweden employed severe lockdowns, while Sweden did not.
Looking at these results in the larger picture, one of the most important lessons we can take from Sweden is how vital it is for the government of a country to develop a well-thought-out program in response to a pandemic, one that the vast majority of citizens will support. In a democracy, once this is done, the leaders have to go to the people and educate and persuade them, so that most citizens will voluntarily implement the plan. This was perhaps the greatest failure in the United States.
No one approach to this pandemic has emerged as the best so far. Successful countries have used different approaches. The one thing common to all successful countries has been the adoption of a consistent, coordinated approach. And in democracies, for any plan to work it must make sense to most of the people and be effectively presented to them.
The Swedish economy has, of course, been significantly impacted by the crash of the global economy. Many of the Swedish people stopped going out and shopping as often as usual, especially older people. This was exactly what the Swedish government encouraged — they did not make this mandatory like some countries, but they encouraged it. Their plan was specifically put in place with the understanding that locking things down more than absolutely necessary would create major problems.
Also, with regard to the economy, the Swedes have a lot of exports and a great deal of tourism, so they certainly knew that these areas of their economy would suffer. This has been true for most every country in the world, even those that have had very little Covid-19. The Swedish economy will not recover fully until the world economy does so.
But today, there is little question that Sweden’s economy is healthier than many others in Europe, or elsewhere in the world. In the first quarter of 2020, their economy actually rose slightly, while European countries overall had a net loss of about 4% of GDP. In the second quarter, GDP in Sweden fell 8.6%, yet this was much better than the rest of the euro zone, which contracted by 12.1% (and by 11.9% across the broader European Union.) The Spanish economy recorded the sharpest decline among member states, falling 18.5%. In the United States, GDP fell 5% in the 1st quarter of 2020 from the preceding quarter, and another 9.5% below that in the 2nd quarter. Crucially, the U.S. has spent perhaps as much as 4.5 trillion dollars dealing with the pandemic so far (maybe as much as 21% of GDP) with much more in store. (These are rough guesses — we will not know the actual figures for some time.) In contrast, Sweden has committed perhaps half that percentage of GDP, and is in a much stronger position to bear the financial costs, since government finances and debt are in the best condition they have been since the late 1970s.
Overall observations about Sweden’s approach
On the negative side, they had too many deaths in their elderly and infirm populations. But whether this increased loss of life was a result of their overall strategy is not clear, for they made a decision early-on not to use extraordinary measures such as ventilators and long-term intensive care to treat most people in these two categories. Whether this was right or wrong can and should be debated, but it needs to be clearly understood that the higher death toll in Sweden, compared to many other countries, was not primarily caused by their overall approach to the pandemic. Rather, their initial higher death rate resulted from a decision about how extensively to treat those over 80 and those who had other serious complicating conditions.
Another mistake was the failure to start a comprehensive testing program early-on, which likely increased their overall number of deaths. Swedish officials have, in fact, acknowledged this. And they have acknowledged a failure to deal with their immigrate populations as well as they should have.
On the positive side:
They flattened the curve of infections so that the medical system was never close to being overwhelmed.
They did not shut down schools, so they aren’t having to deal with how to open schools in the fall.
They didn’t shut down restaurants, so they aren’t having to deal with that issue.
They didn’t require masks, so they don’t have to decide when people do not have to wear them, and they are not dealing with the revolts many countries are experiencing against mask-wearing.
They didn’t close down most businesses, so they can continue living and working more normally than most other countries, while making minor modifications to their plan.
They have not had the psychological fallout of increasing suicides, loneliness, depression, drug and alcohol abuse, or domestic violence.
They asked for peoples’ voluntary cooperation rather than imposing mandates, so they have not had to deal with rebellious groups flaunting the rules and causing new outbreaks. This is especially important for young people, who feel a need to go to school, have social interactions, meet new people, look for new opportunities, find new relationships. To try to lock down these activities among the young for months on end is a fatal mistake to any plan in a democratic country.
The people of Sweden were not given the message that they should fear each other. Rather, they were encouraged to go on about their lives as normally as possible, while at the same time taking intelligent precautions. Pictures and films of the people of Sweden living fairly normal lives throughout the pandemic present a totally different image than we have seen in most of the world. People seem much more comfortable with each other — smiling, laughing, interacting, living more normal lives than most people in the world today. What might we learn from this?
Dangers of too-strict actions
Covid-19 is a serious, dangerous disease. We must take various intelligent actions to keep it from causing illness and death.
At the same time, we must understand that strict actions to prevent it can and do cause harm themselves. Teaching a child to be careful is critically important, but overdoing it leads to a fearful child who has a hard time participating in life. Marijuana has dangers, but overly strict laws filled prisons in the United States and destroyed many lives. Pain medications can be a blessing when used to relieve pain appropriately, but are a great danger when abused. Automobiles have provided enormous benefits, but they kill and maim many millions each year around the world. Every country has decided that even though they are dangerous, automobiles shouldn’t be banned completely. Rather, each country constantly searches for the best balance between control and freedom. The same principal applies with this pandemic — the goal should be to find the best balance possible between limiting the disease while helping people live full and fulfilling lives.
Looking at the overall picture carefully, we can see the dramatic negative consequences being created around the world by the strict measures implemented to prevent the spread of Covid-19. Considering that few of these negative consequences are happening in Sweden and many fewer would be happening worldwide if every country had followed Sweden’s path makes vivid that most of these negative consequences are being caused by the strict methods employed to limit Covid and not the disease itself.
1. The United Nations World Food Program estimates that 250 million people may face starvation by the end of 2020 as a result of the economic measures taken to limit the spread of Covid-19. Food banks have been overwhelmed even in the United States, the richest country in the world.
2. UNICEF said in a recent report that more than a million children aged 5 or younger will die every six months because of the disruption to medical systems caused in some places by Covid crowding, but in many others simply because people have become afraid to visit medical facilities due to the fear that has been created around the disease.
3. The World Health Organization has warned of a looming mental illness crisis, the result of “the isolation, the fear, the uncertainty, the economic turmoil,” brought on by fear of the disease and actions being taken to limit its spread. As one interviewee in the U.S. put it, “The threat of the virus seems minuscule compared to our mental and physical exhaustion.”
4. Nearly half of Americans report that the coronavirus crisis is affecting their mental health. A federal distress hotline received about 20,000 texts in April compared with 1,790 during the same time last year. “People are really afraid,” Oren Frank, head of an online therapy company observed. “What’s shocking to me is how little leaders are talking about this.”
5. In the United States, parents are postponing children’s health checkups, including shots, putting millions at risk of exposure to preventable deadly diseases. Around the world, tuberculosis usually claims 1.5 million lives each year, almost a million die each year from HIV/Aids, and about 620,000 from malaria. Until this year, we were making progress against each of these diseases. But in 2020, interviews with dozens of public health officials worldwide suggest that: “The lockdowns, particularly across parts of Africa, Asia and Latin America, have raised insurmountable barriers to patients who must travel to obtain diagnoses or drugs.” This will lead to a surge in disease and death in the coming months.
6. In the United States alone, the economic consequences of shutting things down has led to an expenditure of perhaps as much as 4.5 trillion dollars. Much more will eventually be spent. Yet the economy still contracted at a 33% annual rate in the second quarter of 2020. Fifty-five million people have filed for regular unemployment, another 12 million have filed for the special unemployment program, and this doesn’t count the 10–20 million who were not eligible for either. Perhaps half of those jobs had been reinstated by mid-July, but much of that was because almost a trillion dollars a month has been injected into the economy by the government. A lot of this was necessary, but it has saddled our young people with an incredible burden. We must therefore constantly ask ourselves: Which restrictive measures are absolutely necessary?
7. Suicide, depression, drug abuse, anxiety, despair, and domestic violence and abuse have exploded in several countries around the world. Just recently a headline in the U.S read: “Children Vulnerable to Abuse Are Imperiled as Caseworkers Stay Home.” The article went on to say that many investigations of abuse or neglect have been delayed or curtailed during the pandemic, leaving many, many children vulnerable to great harm.
8. Overly strict rules and mandates cause a backlash — people will eventually rebel. Today, all over the world, more and more people, especially young people, are saying, “We followed the rules for months, totally disrupted our lives, and it was all for nothing. We have to go back to living and we will take our chances.” Telling them to keep their lives on hold as they begin to understand that Covid-19 will be around for a long time will not work. The reason it is unwise to impose greater restrictions than necessary is that it leads to more and more people breaking those rules.
9. When I walk through a large grocery store today, I hear people with masks shouting at those without masks. And I hear those without masks yelling at those who have them on. There is a building anger and despair in our country everywhere I turn. I seldom see people look at each other and smile. Rather, they avoid each other, try to stay away from each other. We are becoming more and more afraid of other people. People we don’t know are a threat, even many we do know — and this is causing us to treat each other in ways that are breaking our society apart.
This problem was presented in stark terms by John Feffer at Tomdispatch.com, in an article posted on July 29:
“I don’t trust you. Don’t take it personally. It doesn’t matter whether you’re a friend or a stranger. I don’t care about your identity or your politics, where you work or if you work, whether you wear a mask or carry a gun.
“I don’t trust you because you are, for the time being, a potential carrier of a deadly virus. You don’t have any symptoms? Maybe you’re an asymptomatic superspreader. Show me your negative test results and I’ll still have my doubts. I have no idea what you’ve been up to between taking the test and receiving the results. And can we really trust that the test is accurate?
“Frankly, you shouldn’t trust me for the same reasons. I’m not even sure that I can trust myself. Didn’t I just touch my face at the supermarket …
“I’m learning to live with this mistrust. I’m keeping my distance from other people. I’m wearing my mask. I’m washing my hands. I’m staying far away from bars. I’m not sure, however, that society can live with this.
“Let’s face it: trust makes the world go around. Protests break out when our faith in people or institutions is violated.
“Now, throw a silent, hidden killer into this combustible mix of mistrust, anger, and dismay. It’s enough to tear a country apart, to set neighbor against neighbor and governor against governor, to precipitate a civil war between the masked and the unmasked.
“Such problems only multiply at the global level where mistrust already permeates the system — military conflicts, trade wars, tussles over migration and corruption. [In the past] there’s been enough trust to keep the global economy going, diplomats negotiating, international organizations functioning, and the planet from spinning out of control. But the pandemic may just tip this known world off its axis.”
The danger of infection from Covid-19 is a serious problem. But there is the separate problem of the consequences that actions taken to prevent its spread can cause. Rather than experimenting with the strictest approaches or imposing sweeping mandates to defeat this disease, we must look for the path that can succeed in overcoming it with the least disruptive effect on peoples’ lives, the path that allows each country to function as fully as possible while the effort is underway. Trump’s know-nothing statements and actions have poisoned the waters of trying to find this moderate path, pushing well-meaning people to move too far in the other direction. This in turn has caused more harm. Promises of short-term victory have been disastrous, both on the part of Trump, but also by those who suggested that lockdowns would do the trick.
The reason Sweden is important is that — unconcerned about what Trump says or thinks, and willing to defy those who have pushed for overly strict measures — they have experimented with a path much less disruptive to society and to peoples’ lives. And their approach seems to be working.
Is this path a real possibility for the United States? We should at least be considering very carefully the parts we might adopt here. Sweden made mistakes, and we can learn from their mistakes. Further, what will work in each country will be different from what is working in Sweden. But by carefully examining and thoughtfully considering what is working there, the U.S. and many countries will be better able to find the best path forward for themselves.
My previous essays on the pandemic are on my web site under the heading “During the Time of Covid”:
May you be safe,
May you be well,
May you live a full and meaningful life
In this time of Covid.