The Swedish model: a year on, the unique pandemic approach still isn’t paying off

“We need help,” said Bjorn Eriksson, director of healthcare for the Stockholm region, at a recent news conference, per Reuters, noting that 83 patients were in intensive care beds. “That corresponds more or less to all intensive care beds we normally have.”

Despite more months passing and a first wave that many hoped would immunize the country, Sweden’s coronavirus approach doesn’t seem to be paying dividends so far and the situation is close to spiraling out of control, even as the country has one of the best medical systems in the world.

Rather ironically, Sweden ended up in this situation by listening to scientists — or rather, by listening to one scientist in particular: Anders Tegnell, the current state epidemiologist of Sweden. The Swedish constitution prohibits ministerial rule and mandates that the relevant government body (in this case, the Public Health Agency) must initiate action on relevant challenges. It’s very unusual for politicians to ever overrule advice from expert agencies in Sweden.

This put Tegnell in a central situation and made him the de facto czar of the Swedish pandemic response. However, Tegnell’s views are at odds with scientists from other countries. “Sweden is right” and “all the other countries are wrong,” quipped Johan Giescke, Tegnell’s mentor, close confidant, and consultant adviser for the Swedish Public Health Authority

Sweden has not imposed a lockdown, unlike many other countries. Despite some restrictions, Sweden has kept large parts of its society open, counting on people to follow restrictions voluntarily. The Public Health Agency issued recommendations to work from home and avoid unnecessary travel, but they refused to enforce these measures, as was the case elsewhere in the world.

Even if it wanted, Sweden would have had a very hard time enforcing these restrictions. The Swedish Constitution legally protects the freedom of movement for the people and prevents a lockdown in peacetime. But now, the country’s government wants to introduce a temporary pandemic law to grant it increased powers, especially when it comes to enforcing various types of lockdown. Sweden also introduced similar legislation in spring, but the legislation expired without ever being used. Now, however, as cases continue to rise, it seems that they can no longer continue as previously.

At odds with the world

Sweden, a country more used to the ‘Best Countries’ lists, found itself at odds with the rest of the world early on in the pandemic. Sweden seemed to opt for a herd immunity strategy, claiming that its only objective was to avoid the hospitals being overrun. Swedish officials (Tegnell included) then vehemently denied this and said journalists had misunderstood their plan — but email exchanges obtained by Swedish journalists under freedom of information laws showed that Tegnel actually discussed herd immunity as an objective in mid-March. “One point would be to keep schools open to reach herd immunity faster,” Tegnell commented. He also appeared to cynically ask if sacrificing older people would be “acceptable.”

Critics (and there was no shortage of them) pointed out that the approach of letting the disease spread in a “controlled fashion” through the country is not only counterproductive, it’s unethical. After all, every country pondered this, and ultimately decided differently.

Anders Tegnell during the daily press conference outside the Karolinska Institute. Image credits: Frankie Fouganthin.

Achieving herd immunity without vaccines was regarded by many specialists as a huge gamble, and one not likely to pay off. Not only do we still not know how long immunity lasts (if it’s in the order of months, herd immunity is simply not achievable without vaccines), but given how COVID-19 spreads, there’s no way to limit the spread without measures such as face masks and lockdowns. Tegnell questioned the scientific basis for the “stricter” measures taken by other governments but failed to provide solid evidence supporting Sweden’s own approach. As the cases continued to rise in Sweden, not only were face masks not mandated — they were actively discouraged, even in medical settings.

Then, for a moment, it seemed like Sweden’s approach was paying dividends: when the number of cases started to finally drop without a lockdown, some took it as a victory the Swedish approach. But the immunity tests tore the whole idea down. In June, immunity was found just in 6.1% of Swedes. In September, the figure was not different. ‘Sweden’s prized herd immunity is nowhere in sight,’ noted one analyst in the Journal of the Royal Society of Medicine.

Amid a summer which saw Sweden battle with a large number of infections, Tegnell predicted that Sweden was unlikely to see another big wave.

Then, the second wave came.

An even worse second wave

Even if Sweden hasn’t achieved herd immunity, there were hopes that the country would have some significant immunity level that would allow it to avoid the brunt of a second wave. This does not seem to be the case. The Public Health Authority declared — incorrectly — in AprilMay, and July, that Stockholm was on the verge of herd immunity, only to correct itself later on. The country currently has the highest per-capita rate of infection (on a rolling seven-day average), and still one of the highest fatality rates in the world — even as it boasts one of the most competent and well-funded medical systems.

Tegnell himself had to concede that he wasn’t expecting this. Sweden is seeing a record number of cases, and yet again, suffering much more than some of its neighbors.

“We see no signs of immunity in the population that are slowing down the infection right now,” Tegnell commented in November.

The simmering criticism from opposing scientists is starting to boil over, and the politicians who had been supportive of the approach were forced to take a detour. When 22 prominent scientists published an article raising concerns about the country’s approach, they were ridiculed and even insulted by local media. Now, things are starting to change.

“I think that most people in the profession didn’t see such a wave in front of them; they talked about different clusters,” the prime minister, Stefan Löfven, told the Swedish Aftonbladet newspaper on Tuesday.

It’s not just the lack of lockdown measures. A national commission report that analyzed the Swedish response found that the country was slow to protect elderly homes, was slow in implementing measures, and failed to communicate properly — especially regarding the risk of asymptomatic carriers (until recently, Sweden only considered patients with severe symptoms as likely to spread the disease).

While Tegnell’s agency was not responsible for directing the elderly care system and other shortcomings, many still blame the relaxed approach for some of these failures. Many medical workers are also starting to quit, leaving hospitals even more pressured.

Anders Tegnell during the daily press conference outside the Karolinska Institute.

In 2019, the Global Health Security Index of the ‘most prepared’ countries in the world for a pandemic published by the Johns Hopkins Center for Health Security ranked Sweden as 7th overall. If Sweden wasn’t prepared, then almost no one in the world was.

Sweden is abandoning the Swedish model

Denmark, another Scandinavian country where cases have recently been surging, has announced a nationwide lockdown. In Sweden, no such thing has happened — but it’s no longer seeming as impossible as it did a few months ago. Sweden has already announced a set of measures, including allowing high schools to implement distance learning.

Gradually, Sweden seems to be retreating from its no-lockdown stance, as Tegnell and his close collaborators are increasingly pushed to the sidelines, though they still stand by their approach.

“Lifting and closing things is really detrimental to trust and will also have a lot more negative effects than keeping some kind of level of measures all the time,” he told the Observer newspaper. “Opening and closing schools, for example, would be disastrous.”

As of November, Tegnell insisted that it’s “not yet possible” to say which approach is right, but many are starting to see the writing on the wall. Professor David Goldsmith, the lead author of a paper published by the UK’s Journal of the Royal Society of Medicine, told ABC:

“Honestly, there was never a chance of that being a sensible approach,” he said. “Nobody has ever tried to control a pandemic or an epidemic by inducing herd immunity. They deny it now, I know they do, but the evidence is abundantly clear.”

At any rate, it’s obvious that Tegnell and his idea is losing support. Tellingly, King Carl XVI Gustaf made damning remarks during his annual review of the year with the royal family, saying that the relaxed approach has “failed” to save lives. It’s rare for the king to criticize so bluntly, but it’s a strong indication that the country is starting to redefine its approach.

But it’s not happening overnight, and it’s still not clear just how things will happen from now on.

For now, the Public Health Authority still hasn’t recommended the use of masks in public places — making Sweden the only democracy in the world that doesn’t recommend masks.

Rather ironically, Sweden’s approach is also suffering due to how quickly vaccines were developed. Had it taken more time, the Swedish approach would perhaps have been somewhat better in comparison. But with vaccines already on the horizon, allowing the disease to spread so much seems even more unnecessary.

For now restaurants, bars, and coffee shops are still open in Sweden. The Netherlands, with lower infection rates than Sweden, just went into a full lockdown. Germany will close down most of the country, and Denmark is going in full lockdown. Meanwhile, Anders Tegnell called lockdowns in neighboring countries “mad” and “ridiculous,” and Prime Minister Stefan Lofven called on the populace to use their folkvett — a blend of good manners, morality, and common sense that is supposed to be innate to all good Swedes. But these words ring more of national exceptionalism and hope rather than practical ideas.

After all, folkvett can only get you so far.

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