COVID-19: the Swedish Model
Sweden’s approach to controlling the COVID19 epidemic is often presented as an independent model and perhaps a laissez faire counter to the hard ‘lockdown’ approach attributed to China, the UK and the USA. However this is to confuse the symptoms with the causes. On closer examination, the Scandinavian country shared much with the neoliberal approaches of the UK and the USA (both of which, in their bewilderment, flipped from one extreme to the other). This was not the mid-20th century social democratic Sweden, famous for its welfare state and egalitarianism, but rather a 21st century Sweden, which had ‘integrated’ the remnants of its social democracy into a corporate driven neoliberalism. Major privatisations and ‘market oriented’ reforms had been carried out in the health sector, affecting primary health care and presented as ‘free choice models’ in which ‘the money follows the patient’” (Dahlgren 2008).
In face of the epidemic Sweden nominally adopted most of the conventional public health aims, such as social distancing and hygiene measures, imposing only limited restrictions such as travel bans and limits on public gatherings. However, unlike the preventive health emphasis of most public health systems, it relied on individual compliance and limited testing. Later the state felt obliged to impose additional measures, such as wider testing and extended travel bans, before public discontent forced an official inquiry into the strategy. After six months Sweden’s death rate (575 per million) was, with that of the UK (610) and the USA (545), amongst the worst on earth, and 5 to 20 times those of its Scandinavian neighbours. Further, by August it was clear that Sweden’s economy had suffered as much damage as that of its neighbours, with an 8.6% slump in the second quarter (Baker 2020).
Comparing Sweden with neighbouring Nordic states (Finland, Norway and Denmark) makes good sense both because they are “culturally, economically, politically and geographically similar” and because they took differing approaches where “15 million people have been assigned to a lockdown, while a further 10 million [in Sweden] have been asked to simply act responsibly” (Franks 2020). Sweden’s neoliberalism helped drive the stress on voluntarism and individual responsibility, with a sub-text of ‘herd immunity’. This is an emphasis which, at the time of writing, was under consideration in the crisis-ridden USA (Abutaleb and Dawsey 2020). Sweden’s second wave of infections may have appeared less dramatic, but that was mainly because its first wave was so large. To properly understand the ‘Swedish model’ we should examine policy and practice in a little detail, before moving to outcomes and criticism.
- Aims, policy and practice
The Swedish government recognised the COVID19 epidemic, adopting conventional themes of social distancing and hygiene to reduce pressure on health systems; but it delayed its reactions and tried to make a virtue out of the themes of uncertainty, voluntarism and individual responsibility. It never had a ‘let it rip’ policy and practice, as some have suggested. Many have observed that “Swede’s were not free to go about their lives as normal” (Duckett and Mackey 2020). There were some early ad hoc government measures: on 11 March public gatherings of more than 500 people were banned, on 14 March the government advised against “non-essential” international travel (on 27 March this became a ban on travel to the EU) along with a number of economic subsidy and social security initiatives (GOS 2020).
In early March Sweden recorded its first infections and first death, but a more considered strategy was not announced until 6 April, when 780 Swedish COVID19 deaths had been recorded (Worldometer 2020). Prime Minister Stefan Löfven announced COVID-19 “as a disease that constitutes a danger to society, opening the possibility of extraordinary communicable disease control measures”. He declared the government’s aim was “to reduce the pace” of the spread of the virus; “to flatten the curve, so that large numbers of people do not become ill at the same time” (GOS 2020: 6 April). Löfven stressed “the right measures at the right time”, suggesting a reactive and not a precautionary approach. He “weighed” measures to reduce the virus spread against “their effects on society and public health in general”, saying these measures would be “reviewed constantly”. An important feature of the government’s approach was that “every person in Sweden needs to take individual responsibility”, while the state mobilised health resources and economic subsidies (GOS 2020: 6 April). This set in train a model which constantly stressed the responsibility of individuals, employers and the community, downplaying the protective role of the state.
Sweden’s chief epidemiologist Anders Tegnall is said to have argued for ‘herd immunity’, where mass infections are supposed to generate immunity amongst the great majority, except those who are stricken down with illness or death. Tegnall denied that this was a government objective. However, email exchanges obtained by Swedish journalists show that he had indeed discussed it in the days after the WHO declared a global pandemic. He wrote to colleagues, “one point would be to keep schools open to reach herd immunity faster”. In response to Finland’s modelling, which suggested that closing schools might reduce COVID19 infections amongst elderly people by 10%, Tegnall responded “10% might be worth it?” (Henley 2020a). Anders Bjorkman, a professor of infectious diseases, said the government “did not want to put it bluntly, but seeking herd immunity was always inherent in the Swedish strategy” (Habib 2020). The actually measured uptake of antibodies was not encouraging. By late May the Public Health Agency of Sweden announced that, in late April, 7.3% of Stockholm residents had developed COVID19 anti-bodies. That was similar to findings in France and Spain, and led the WHO to warn against dependence on herd immunity as a strategy (Habib 2020).
Most science was against the notion of herd immunity as a strategy, unless it were coupled with an effective and safe vaccine. A paper in late July summed it up this way: herd immunity with vaccine could be a “very successful strategy … COVID19 vaccines will be essential in the future for reducing morbidity and mortality and inducing herd immunity” (Filtenborg-Frederiksen, Zhang; Foged and Thakur 2020). In August WHO Health Emergencies Programme Executive Director Michael Ryan warned that reliance on herd immunity was not an answer. He pointed out that, as at August, “we are nowhere close to the levels of immunity required to stop this disease transmitting. We need to focus on what we can do now to stop transmission and not live in hope of herd immunity being our salvation” (ABC News 2020). Academic biologist Sarah Pitt said that people misunderstand herd immunity, and that the possibilities vary depending on the virus. For example, herd immunity to measles cannot be achieved by natural infection, as “not enough people naturally became resistant to produce herd immunity” (Pitt 2020). Hence the ongoing reliance on measles vaccine. Studies of COVID-19 showed that, even in areas where there were large numbers of cases, “less than 10 per cent of the population show evidence of an immune system response from the infection” (Pitt 2020).
Within the framework of a reactive and “individual responsibility” strategy, Swedish policy and practice was adaptive. New measures were rolled out, in an incremental way. On 9 April Health Minister Lena Hallengren and head of the Public Health Agency Johan Carlson announced several protective measures: new powers in the Communicable Diseases Act, restrictions on dispensing medications, a limit on public gatherings of more than 50 persons, visit bans at aged care homes and an expansion in COVID-19 testing (GOS 2020: 9 April). Other measures followed, in reactive fashion: on 16 April the travel ban to the EU was extended; on 12 May there were new measures to strengthen aged care and those with health conditions; on 14 May the EU travel ban became a travel ban for all countries. Yet by mid-April COVID19 deaths in Sweden were “far exceeding the tolls of its nearest neighbours”. In response, Anders Wallensten, the country’s deputy chief epidemiologist, claimed that the number of new cases was starting to decline and he was “cautiously positive” Sweden was approaching its peak (Henley 2020a). His optimism was misplaced. Over the next two months the death toll would quadruple to more than 5,000.
Government and health officials became increasingly defensive. In late April Anders Tegnall asserted that Sweden had “flattened the curve”, a necessary achievement until a vaccine was available. He maintained that closing borders was “ridiculous”, that they could only react to the little that they knew about the virus (as opposed to precautionary and preventive measures), repeating that the government’s voluntarism was “the core” of its strategy. He said individual responsibility was working, pointing out that the winter epidemics of influenza and norovirus (which causes gastroenteritis) had “dropped consistently” as a result of voluntary social distancing, less travel and sanitary measures. He maintained the government had not put lives at risk: “there has been an increase, but it is not traumatic so far” (Paterlini 2020). At that time there were about 2,000 deaths. Throughout, Tegnall kept insisting that face masks were “pointless” (van Leeuwen 2020b). Yet discontent grew over the large numbers dying.
Towards the end of April Minister Hallengren told the WHO that her government had followed the general guidelines of social distancing and stay at home, relying on voluntarism. They had maintained a “flexible” approach while increasing their intensive care facilities (Hallengren 2020a). In late May Hallengren maintained she had never wanted a “full lockdown”, but blamed the deaths in elderly care homes on a “society wide failure”. Using the theme of personal responsibility she attempted to deflect from governmental failures, pointing to relative ‘success’ in compliance through voluntary measures: long distance travel was down 96% during the Easter period and 84% had reported social distancing over April-May. It would be “unreasonable” for the government to assume all responsibility for the deaths, she asserted (Löfgren 2020).
This individual compliance theme was reinforced by a government media release of mid-June: travel within the Stockholm region was down 40% and “more than eight in ten Swedes are keeping a greater distance from others”. Nevertheless, “new restrictions may be issued”, the statement said, which could include bans on visits to old peoples’ homes, bans on gatherings and rules regarding bars and cafes. Even if some restrictions were lifted “this does not mean that life can return to normal”, she said (GOS 2020: 18 June).
By early August Tegnall admitted that spread of the infection to older people was happening far more in Sweden than in the neighbouring countries; but he maintained the official aversion to preventive measures (Holroyd 2020). Once again, prevention was rejected in favour of the supposed need to act on certainties; but there were few certainties. The Public Health Authority claimed it could not act on unknown factors: “since the virus is new, we still do not know enough about which groups are at risk of severe illness”. The government maintained that citizens should individually decide to stay and work at home, to not create large gatherings and to seek assistance if they had COVID19 symptoms (Holroyd 2020). Nevertheless, bans on entry to Sweden were maintained and, in some respects, extended (GOS 2020: 13 August).
A key problem with Swedish understandings and responses was that levels of testing were low; testing was only encouraged for those with symptoms. By late May, according to Our World in Data (one of several sites which compiles information from official sources), Sweden had carried out 23.64 tests per 1,000 people as of 24 May, compared with 31.88 in Finland and 44.75 in Norway (Habib 2020). Some residents with symptoms complained that it was difficult to get tested; and without a test they were not able to receive proper care. Some reported that this lack of testing was reflective of a general attitude that the virus wasn’t a serious threat (Bendix and Baker 2020).
In any event, the government fell short of its goal of 100,000 tests by mid-May. This was in part due to the fact that healthcare was not free until individual patients reached a so-called ‘high cost ceiling’. Further, a medical referral was required and testing was still only encouraged for those with symptoms (The Local 2020a). Tests were increased in early June, hitting a weekly record of 49,200 tests, up from 36,500 the previous week. More infections were detected (Reuters 2020). In June Sweden began to offer free testing, but still only for those showing symptoms; contact tracing of the infected was then carried out (AFP 2020)
By late June the WHO listed Sweden among 11 countries which had “accelerated transmission” which, if left unchecked “will push health systems to the brink once again” (NZ Herald 2020). Over July-August testing rates in Sweden still seemed lower than that of its neighbours, and far less than that of Denmark; though comparisons were difficult as Sweden’s published data on testing was less up to date than that of others (Norrestad 2020).
- Outcomes and criticisms
The outcomes of the Swedish approach can be measured in health and economic terms. For the first six months of the epidemic the health results were very poor. By late July infections and deaths had fallen substantially, to hundreds and several per day, respectively (Our World In Data 2020). However Sweden still had “the 7th highest per-capita death rate in the world … [and] about ten times larger than its Nordic neighbours. Outbreaks spread to aged care facilities and the vulnerable” (Duckett and Mackey 2020). Sweden experienced by far the highest number of COVID19 infections and deaths amongst the Nordic countries, as shown in Table 1 below.
|Table 1: COVID-19 in the Nordic states|
23 Aug 2020
23 Aug 2020
|Source: Worldometer 2020, 23 August|
Even by late March Sweden’s approach was being judged harshly in the medical literature. A Lancet editorial observed that
“many countries are still not following WHO’s clear recommendations on containment (widespread testing, quarantine of cases, contact tracing and social distancing) and have instead implemented haphazard measures .. the initial slow response in countries such as the UK, the USA and Sweden now looks increasingly poorly judged … denial and misplaced optimism … globally many people are afraid, angry, uncertain and without confidence in their national leadership” (The Lancet 2020: 1011).
An important rationale for limiting state quarantine measures was to preserve the Swedish economy, consistent with the neoliberal emphasis on the corporate sector. Many of the early state interventions were subsidies to maintain economic activity. A number of corporate media stories suggested that Sweden’s higher infection rates might help develop ‘herd immunity’ and that Sweden might be “suffering less severe economic trauma than most major European nations” (Birrell 2020). However this was hardly the case, if we compare with its neighbours. By August Sweden had a less serious economic collapse than the EU average, but was faring no better than the other Nordic states (SBC 2020).
An early economic survey of Denmark and Sweden, over March-April, showed that spending dropped strongly in both countries, but almost as much in Sweden (25%) as in Denmark (29%), despite their different quarantine measures (Andersen, Hansen; Johannesen and Sheridan 2020: 13-16). By mid-June the government foreshadowed a 6 per cent fall in GDP for the year (GOS 2020: 18 June) but by July predictions had worsened. Analysts began to point out that Sweden’s economy was “suffering just as badly as their neighbours with heavier lockdowns” (Duckett and Mackey 2020). Official figures showed that Sweden’s GDP fell 8.6% during the second quarter of the year, more than that of Denmark’s 7.4% crash and Finland at minus 3.2% (Baker 2020). Calendar adjusted, compared with Q2 in 2019, Sweden’s GDP decreased by 8.2 percent (SBC 2020). The EU contraction was greater, at 12.1% in the Euro area and 11.9% in the EU (Eurostat 2020). Nevertheless, compared to its immediate region, Sweden’s voluntary social distancing and stay at home measures, combined with travel bans and international isolation, seem to have led to equivalent damage.
The large numbers of infections and deaths shook Swedish public opinion, which had initially backed the government. In a late April survey of 1,600 Swedes, 31% of respondents rated the nation’s response to the outbreak as not forceful enough, while 18% were neutral and 51% considered the response forceful enough. Interestingly, those 50 years or older (and more at risk of the disease) were most supportive of the government while only 40% of 15-29 year olds thought the government response had been sufficient (Wengström 2020). Yet by late June an Ipsos survey showed confidence falling in the government’s management of the epidemic. It fell 11 points to 45%, since April, and backing for the national public health agency had also fallen by 12 points (Henley 2020b). Those satisfied with the government’s response to the pandemic fell to 38%, while the approval rating of Prime Minister Löfven dropped 10 points (Henley 2020b). Ipsos analyst Nicklas Källebring concluded that “the view of authorities’ capabilities has taken a clear negative turn.” The Ipsos poll confirmed an earlier study by Novus pollsters which showed only 45% of voters held a high degree of confidence “in the government’s capacity to handle the crisis”, compared to 63% in April (Henley 2020b).
The Swedish government’s voluntarist, neoliberal approach provoked an ongoing storm of internal as well as external criticism. Even after government officials had admitted failures in protecting older people (Holroyd 2020), one of their key stated aims, some softer critiques argued that more time was needed to assess the approach. This came especially from those concerned to protect the economy. So German-born economist Andreas Ortmann was cautious, recognising by August that Sweden had “one of the worst [death rates] in the world” and that its economic performance “doesn’t seem much better than Denmark’s”. However he noted that Sweden’s deaths had fallen to “close to zero” [Sweden was still averaging a few deaths per day] while many other countries were experiencing a second wave of infections and deaths (Ortmann 2020). Another critique, observing that Sweden had imposed a new round of restrictions in summer pointed out that, after this, “its economy has suffered less than the European average in recent months, but at least as much and possibly more than its Nordic neighbours” (Milne 2020).
Others gave a harsher assessment. In mid-April a group of 22 doctors, virologists and researchers criticised the public health agency in the Dagens Nyheter newspaper, using the conventional public health recommendations. “The approach must be changed radically and quickly … it is necessary to increase social distance. Close schools and restaurants. Everyone who works with the elderly must wear adequate protective equipment. Quarantine the whole family if one member is ill or tests positive” (Henley 2020a).
The Communist Party of Sweden (SKP) accused the government of putting at risk the lives of thousands of workers by not closing down non-essential production in different sectors in the country”. They pointed out that the government had created “support packages of 1,300 billion Swedish Krone (USD 130.16 billion) to big banks and monopolies”, while “even the most basic aid has been denied to the working population.” At the same time special police units had been trained to “deal with protests at government insensitivity” during the epidemic (Peoples Dispatch 2020).
Swedish-Chilean Professor of Epidemiology Dr Marcello Ferrada de Noli said the government’s approach had been a “conclusive disaster”, as official data on infections and deaths testified. He said there were three key failures, an epidemiological failure, an ethical defeat with “thousands of unnecessary deaths” and a huge loss of “international prestige and credibility”, from a state which in the past had a reputation of being a “humanitarian power”. Tegnall’s claims about weakening the virus and developing ‘herd immunity’ were all erroneous. Historical studies of epidemics had demonstrated that the “basic concept of quarantine remains completely valid” and that ‘herd immunity’ for this virus could only be achieved “with the help of an ad-hoc vaccine” (Ferrada de Noli 2020).
Similarly, Dr Lena Einhorn, virologist and prominent critic, refuted claims of ‘herd immunity’, saying of the autumn period, “if Sweden doesn’t change its policy, we won’t see the same thing — because the elderly are better protected — but the numbers will go up”. She argued for mandatory use of face masks in crowded areas and contact tracing for all infected people (Milne 2020).
The poor health and economic outcomes, consistent criticisms and shifts in public opinion, reinforced by parliamentary opposition and partial admissions of failure by the government, led to the 1st July announcement of an official inquiry into the government’s approach to the epidemic. In a fairly relaxed schedule, former judge Mats Melin was asked to deliver an interim report by 30 November 2020, and a final report by 31 October 2021 (GOS 2020: 1 July).
- The model and its consequences
By the time the Swedish parliamentary inquiry began, the government had some new arguments in defence of its approach. The ‘curve’ of new cases and new deaths had begun to flatten. How could this be best explained? Graphs 1 and 2 below, using official data (via OurWorldinData 2020), trace Sweden’s daily new infections and new deaths, between February and August 2020. They show a strong surge in infections from early-March to early-July, and a gradual fall off through July and August.
Graph 1: Daily new COVID19 cases in Sweden, 1 February to 22 August 2020
Graph 2: Daily new COVID19 deaths in Sweden, 1 February to 22 August 2020
Sweden was managing to flatten its curve but many questioned the cost (Fiore 2020). Chief epidemiologist Anders Tegnell announced that “the Swedish strategy is working”, while Norwegian Professor of Immunology Anne Spurkland pointed to social factors including summer and the closure of schools, adding “perhaps Sweden has finally gotten better control over the disastrous spread of the virus in nursing homes”. Almost half of Sweden’s 5,730 deaths were in elderly care homes (Fiore 2020). Tegnell argued that there was “a relationship between the very quick drop of the last few weeks and the increasing immunity in many parts of Sweden” (Milne 2020). But this claim was not backed by antibody tests. Further, by late September, a second wave of infections had appeared and the government was about to impose some additional, short term restrictions (Tegnell 2020).
In mid-July Karin Tegmark Wisell, head microbiologist at Sweden’s Public Health Agency, said most of the population remained vulnerable. According to the agency’s data, about 10% of people in the capital Stockholm, the worst affected area, had developed antibodies, and only 17.6% of the 140,000 who volunteered for free antibody tests gave a positive result (Rolander 2020). That 10% was very close to antibody studies elsewhere (Pitt 2020).
However tests have also discovered the existence of non-specific immunity, where T-cells begin to deal with the virus without specific anti-bodies. Sweden’s Karolinska Institute and Karolinska University Hospital found that “about 30% of people with mild or asymptomatic COVID showed T-cell-mediated immunity to the virus, even though they tested negative for antibodies”. Those involved in the study could not link this phenomenon to Sweden’s decline in cases (Fiore 20202). European studies of immunity and antibodies suggest that “immune response to SARS-CoV-2 involves both cell-mediated immunity and antibody production” but that, given the low levels of both, it is “unlikely that population immunity levels reached by winter 2020-2021 will be sufficient for indirect protection” (ECDC 2020).
Dr Mozhu Ding, epidemiologist at the Karolinska Institute, said the decline in cases is “likely to be a combination of measures taken by individuals, businesses and a widespread information campaign launched by the government” (Fiore 2020). Dr Ding pointed out that, even without a ‘lockdown’ order, “many businesses allowed employees to work from home, and universities are offering distance courses to the students … individuals are also taking personal hygiene more seriously “(Fiore 2020). The generally improved survival rates may also be linked to evolving better treatments.
Underlining the ongoing appeal of Sweden’s ‘model’ to neoliberals Washington, with a seemingly intractable second wave of infections and deaths, was said to be considering a Swedish style ‘herd immunity’ approach (Abutaleb and Dawsey 2020). Meanwhile Sweden’s high rate of infections, like that of the USA, led to travel bans from its neighbours (Ellyatt 2020). Norway required Swedes to quarantine for 10 days when entering Norway, while Denmark also maintained restrictions on Swedes (Fiore 2020).
In summary, the Swedish approach to the COVID19 public health crisis was neither laissez faire nor social democracy, but rather an extended neoliberal model, with an emphasis on voluntarism (in quarantine measures and testing) and ‘user pays’ health care privatisation, delaying state interventions for as long as possible. Travel bans and limits on public gatherings were imposed, but lack of information on the virus (e.g. on the extent of asymptomatic transmission) was used as a pretext to delay state interventions. This contrasted with the more widely accepted precautionary and preventive measures. Sweden showed little if any benefit from this approach and its health outcomes were amongst the worst in the world. That is why, by July 2020, public opinion and opposition politicians forced an official inquiry into the ‘Swedish model’.
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*(Top image: Swedish PM Stefan Lofven. Credit: European Union 2016 – European Parliament)