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On October 16, Andrew Ewing, a professor at the University of Gothenburg gave a damning appraisal of Sweden’s response to the Covid-19 pandemic. “So many people have died unnecessarily because of the mistakes we have made,” Ewing told the Swedish newspaper Aftonbladet. With new cases mounting from the second wave – between October 6 and 19, Sweden reported nearly 9,000 new Covid-19 infections – Ewing criticised the continued lack of measures taken by the Folkhälsomyndigheten (FHM), Sweden’s Public Health Agency, to limit the spread of the virus.
Over the next few days, Ewing received a deluge of hate mail from members of the public unhappy with his remarks. “Many here did not like it and I received many threatening emails,” he says.
Ewing is a member of a 200-strong scientific collective in Sweden who call themselves the Vetenskapsforum or Science Forum Covid-19. Since March they have been outspoken critics of Sweden’s unique approach to the pandemic, which has been notably out of sync with the rest of the globe. While most countries enforced lockdowns in the spring, Sweden remained a remarkably free society, a policy which was internationally dubbed ‘the Swedish experiment.’ Bars, shops, restaurants, and other public spaces stayed open, while children up to the age of 16 continued to attend school.
While it has commonly been described as pursuing a herd immunity strategy – something the FHM has never publicly admitted to – Sweden did introduce some rules to try and control the virus spread. In late March, bans on gathering of more than 50 people were introduced, while employees were urged to work from home, and schools were closed to over 16s for three months, along with universities.
Physical distancing was made mandatory in bars, restaurants, and at events, while non-essential travel was discouraged. Data on movement patterns from the telecom company Telia’s mobile network shows that, in Sweden as a whole, travel decreased by more than 20 per cent in response to these restrictions.
Anders Tegnell, Sweden’s state epidemiologist and the architect of the national response, has described the decision to keep society open as a holistic view of public health, aiming to balance the risk of the virus with avoiding the long-term consequences of closing schools and businesses. It is a popular view among many Swedes.
“In one way, I believe the Swedish strategy has been advantageous because of its clear focus to keep society working and keep children at school,” says Jonas Ludvigsson, an epidemiologist at the Karolinska Institute. “Learning is important for future health. And with a crashing economy, there will not only be less money for healthcare, but budget cuts which means there will be less money to help the teenagers with drug problems, single mums with small children. How much would that affect their health in the long term?”
Sweden’s economy has performed better than other nations, although it still shrank 8.6 per cent between April and June, as exports and consumer spending dropped. In contrast, the UK’s economy shrank 20.4 per cent during the same period. However, the Vetenskapsforum argue that protecting the economy through Tegnell’s holistic approach has come at a terrible cost. As of October 21, Sweden stood 15th on the grim global ranking list of Covid-19 deaths per capita, and fifth in Europe, below only Belgium, Italy, Spain, and UK. Its tally of 581 deaths per million people is many times that of Germany, Norway, Denmark and Finland.
The impact has been most severe in the elderly. Statistics show that 89 per cent of Sweden’s 5,929 Covid-19 deaths so far have been over 69. During the first wave, the virus wreaked havoc in nursing homes, where nearly 1,000 people died in a matter of weeks.
Even more worrying, evidence has emerged that many sick elderly patients were effectively automatically denied access to treatment, to avoid hospitals being overwhelmed. One March 17 FHM directive to Stockholm hospitals stated any patients over 80 or with a body mass index above 40 should not be admitted to intensive care, because they were less likely to recover. Other reports describe sick care home residents being administered a palliative cocktail of morphine and midazolam, because the homes were not equipped to administer oxygen, something some doctors have described as ‘active euthanasia.’
“The government didn’t protect the most vulnerable members of society,” says Ewing. “People were triaged out of healthcare and given ‘No Hospital’ notes on their journals, before they got sick. And this was not only for patients who were suspected of having Covid-19. A person who got a urinary tract infection and required hospitalisation, for example for IV antibiotics or fluids, would not get that care either. They received palliative medicine instead.”
As a result, much of the anger that scientists such as Ewing have towards the FHM’s handling of the pandemic is not so much because Sweden kept public places open. After all, there were other nations who did not implement lockdown such as Taiwan, and fared far better than Sweden by implementing rigorous testing, tracing, and quarantines financed by social care packages. In comparison, Taiwan has so far had just 548 cases of Covid-19 (Sweden has had 109,000) and seven deaths.
Instead their anger is because they feel there has been gross negligence in protecting the vulnerable, as well an active evasion of strategies such as face coverings, and quarantines for anyone who might have come in contact with the virus which could have reduced the excess toll. Such measures had already proved to be effective early in the pandemic in countries such as South Korea, which has still only had 453 deaths in total.
For the first eight months of the pandemic, Sweden did not enforce any quarantines for infected households. While evidence pointed to the risk of asymptomatic spreaders, Sweden’s official policy was that those without obvious symptoms are very unlikely to spread the virus. Other nations rushed to procure masks and personal protective equipment for healthcare workers and carers in nursing homes, but Swedish authorities discouraged their use. There have been numerous reports of medical professionals being reprimanded or even dismissed for wearing a mask at work, because it was deemed to spread panic.
“The clinicians among us are still fighting for the right to wear masks when seeing patients, and for extra protective equipment,” says Nele Brusselaers, another member of the Vetenskapsforum. “I know one pneumologist who was fired because she wore a mask. People are afraid to go into hospital, since they know healthcare workers don’t wear masks.”
Some factors were arguably beyond Sweden’s control. Despite having the ideal infrastructure for testing and tracing – the system which has helped South Korea and other Asian countries to suppress the virus so effectively – due to its commonplace digital identity system used to access public services, this was barely utilised due to an inability to source testing equipment. Statistics show that as of May 24, Sweden carried out just 23.64 tests per 1,000 people, one of the lowest rates in Europe. When more tests were finally obtained in the summer, many were of poor quality. In August around 3,700 tests were found to have reported false-positive results.
“Everyone wanted to test more, but there were no tests,” says Ludvigsson. “We did not produce the equipment ourselves, and other nations had banned any exports to keep whatever equipment there was in their own countries. When finally Sweden got hold of test equipment from abroad, the quality was so poor that the tests could not be trusted.”
But despite the comparatively high fatalities, testing failures, and reports of medical negligence in nursing homes, Sweden’s Covid-19 approach still enjoys a relatively high degree of support amongst its citizens. An opinion poll in September, reported that 63 per cent of respondents retained trust in Tegnell’s approach although this was a slight decline from a figure of 69 per cent in April. Even within the scientific community, views remain polarised as to whether it has been successful or not. Members of the Vetenskapsforum have even been reprimanded as ‘troublemakers’ by their own institutions for publicly criticising the high fatality rate, and received threatening emails from the general public.
“Some of us even got death threats, for ‘damaging the reputation of Sweden,’” says Brusselaers.
One of the reasons why many Swedes see their country’s Covid-19 strategy in a favourable light is because the impact of the first wave of the virus was not uniformly spread. The majority of cases and fatalities occurred in the Stockholm urban area, while other cities remained relatively unaffected. The per capita mortality rate in Malmö – Sweden’s third largest city – was lower in May than in the Danish capital of Copenhagen, which had been under lockdown.
This might be down to the lower population density of those cities, and Swedish people taking their own precautions against Covid-19. “Broad segments of the public have taken their own action to help control the virus,” says Peter Kasson, an associate professor at Uppsala University and the University of Virginia. In addition, Sweden’s existing tendencies towards home working – the Swedish Internet Foundation estimated that even before the pandemic, approximately a third of Swedes worked from home on a daily or weekly basis – is likely to have helped.
However with cases steadily rising again in recent weeks from the Covid-19 second wave, with new spikes in cities like Uppsala which had previously avoided the worst of the virus, there are signs that Sweden may be altering its approach more towards those of other European nations. Earlier this week, the FHM announced new recommendations allowing local authorities to instruct citizens to avoid public transport, visiting care home residents, gathering in indoor environments like shops and gyms, and avoid physical contact with those outside their households. Residents of Uppsala are currently being advised to follow these recommendations.
With some noting that these recommendations are very similar to the local lockdowns being implemented in other European countries – although they are still guidelines rather than law – it may seem like the so-called Swedish experiment is over.
However, in the eyes of the Vetenskapsforum scientists more needs to be done if Sweden is to avoid incurring further fatalities amongst the most vulnerable. “Masks should be used especially for everyone working in healthcare and elderly homes,” says Brusselaers.
“Testing capacity has been ramped up the previous months, but there is also still no functional system up and running for contact tracing, so many people do not know if they have been potentially exposed. And there are no efforts to trace back to see where super-spreader events have occurred. Everyone should have the right to healthcare and to be protected. You cannot make decisions that you know may kill thousands of people for the greater good.”
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