Sweden’s top epidemiologist explains his country’s radical pandemic policies
Published in Haaretz: https://www.haaretz.com/world-news/.premium.MAGAZINE-why-sweden-isn-t-forcing-its-citizens-to-stay-home-due-to-the-coronavirus-1.8754251?utm_source=dlvr.it&utm_medium=twitter
STOCKHOLM – The primary schools are operating normally; gatherings of up to 50 people are still permitted; restaurants, shops, cafés and gyms remain open, although there are fewer customers. Most limitations announced by the authorities are no more than recommendations. Anyone displaying the symptoms characteristic of the coronavirus is asked to stay home, but other members of their family are not restricted from going to school or showing up for work.
Public transportation is operating, though people are encouraged to use it only when absolutely necessary, and the borders to most European countries are still open.
Welcome to Sweden, early April 2020 – a country that has adopted a radically different approach to the pandemic from both its neighbors in Scandinavia and on the European continent, and most of the rest of the world, even though the virus has already claimed quite a few victims here (477 deaths as of April 6).
It’s still too early to say whether Stockholm’s policy will turn out to be a success story or a blueprint for disaster. But, when the microbes settle, following the global crisis, Sweden may be able to constitute a kind of control group: Did other countries go too far in the restrictions they have been imposing on their populations? Was the economic catastrophe spawned globally by the crisis really unavoidable? Or will the Swedish case turn out to be an example of governmental complacency that cost human lives unnecessarily?
The body in charge of managing the crisis in Sweden is the National Institute of Public Health. The agency’s 500 experts have the task of monitoring the epidemic’s development, working with the medical services and advising the government and parliament. One of its senior figures, Anders Tegnell, Sweden’s state epidemiologist, has become the country’s best-known face of the crisis, and Sweden’s singular policy has transformed him from an anonymous official into a well-known figure worldwide.
“The truth is that we have a policy similar to that of other countries,” he tells Haaretz. “Like everyone, we are trying to slow down the rate of infection in order to avoid a situation in which too many patients will have recourse to the medical system at the same point of time. The differences derive from a different tradition and from a different culture that prevail in Sweden. We prefer voluntary measures, and there is a high level of trust here between the population and the authorities, so we are able to avoid coercive restrictions.”
Tegnell, 63, has been the country’s chief epidemiologist since 2013. A native of Uppsala, he became a physician in 1985, specialized in infectious diseases, and has held positions in the World Health Organization and in the European Commission. A profile of Tegnell in the newspaper Svenska Dagbladet described him as an “answer machine,” whose phone never stops ringing. Some Swedes consider him a national hero, others see him as a traitor.
The criticism comes from all directions – from some Swedish health-care professionals, local and foreign journalists and of course from the social media. “How many lives are they ready to sacrifice in order to avert the risk of a greater impact on the economy?” Joacim Rocklöv, a professor of epidemiology from the city of Umeå in northern Sweden, was quoted as saying in a recent article in The Guardian.
Britain’s Daily Mail termed Sweden “Europe’s odd man out,” and the German newspaper Die Zeit called the country “an island in Europe” and wondered whether Stockholm was ignoring reality while a carelessly dressed epidemiologist, rather than the government, was the country’s first line of defense against the epidemic.
Indeed, initially Tegnell’s exterior appearance was the subject of many skeptical remarks. By the end of March, things had changed somewhat. Tegnell got a haircut and, like his appearance, the Swedish attitude toward the crisis also became more serious. The National Institute of Public Health developed a strategy, albeit a slightly exceptional and unusual one, the government adopted it, and Tegnell is now at the epicenter of the response to the crisis.
In a phone interview last week, Tegnell answered Haaretz’s questions about the Swedish response to the crisis.
Even given the high level of social trust and personal responsibility in Sweden, there is still the matter of the measures themselves. Don’t you think that, for example, closing schools and refraining from every form of social interaction would be a more effective way to curb the virus?
Tegnell: “Possibly, if it had been possible to do that with a high level of fidelity to the laws, and for a great many months. That is not possible in Sweden.”
As he says, Sweden’s goal, like that of other countries, is to “flatten the curve.” The tactics, however, are a little different. At this stage, they include two central components which are intended to slow down the infection rate. The first is to request of everyone who develops such symptoms as coughing, a sore throat and fever to stay home. The second element is safeguarding the elderly population and high-risk groups. People of 70 and up have been asked to stay home, though they’re allowed to go out for a walk if it doesn’t involve a social encounter.
Beyond that, although kindergartens and primary schools are still open, the universities and high schools have moved to online teaching, and since March 27, gatherings have been restricted to 50 people – 10 percent of the number permitted to congregate at the start of the crisis.
In another new restriction, bars and restaurants are only allowed to serve customers seated at tables (without service at the bar or at stands). In general, entertainment venues, theaters, cinemas and museums are closed. Moreover, no visits are allowed at hospitals or old-age homes (a step that was evidently taken too late, after many of these institutions have already been infected).
Most directives in the country take the form of requests and recommendations. For example, anyone who can, is asked to work from home, and the entire population has been urged to refrain from nonessential trips during the upcoming Easter holiday – but no police officers or mobilephone surveillance are being used to enforce the recommendations.
According to Tegnell, this policy is more likely to be effective than stricter bans imposed by coercive means. Asked whether he is bothered by the fact that Sweden’s elderly population will pay the price if the public does not behave responsibly, Tegnell replies that the principal question is whether rules that are forced on the population create a higher level of obedience than voluntary behavior. “We believe that what we are doing is more sustainable and effective in the long term,” he says.
What is the testing policy in Sweden? How many tests are you doing?
“We are testing medical personnel and everyone who is admitted to a hospital in order to avoid infections there. We are also testing those who are looking after the elderly. At this stage, we are doing about 10,000 tests a week, and that number is growing. In addition, we are carrying out surveys among the general population in order to understand how far the virus is spreading in the community. Those are statistical tests and are not part of the 10,000 or so weekly tests.”
Many people in Sweden are experiencing symptoms of the coronavirus, but they are not being tested, only being asked to stay home. Why aren’t you testing them?
“Partly that is due to a limited ability [to conduct tests], but it’s also because the recommendation would be the same in any case,” by which he means, to stay home.
Are you trying to reach a point of ‘herd immunity’?
“We are not trying to achieve herd immunity, but to slow the virus’ spread. At the same time, the majority of the experts agree that the virus will stop only when widespread immunity is achieved or an effective vaccine is developed. Those are the only means by which to stop the virus. Every other solution is temporary.”
So herd immunity is not the goal of the strategy, but a kind of byproduct that you are hoping to attain?
The issue of herd immunity became a focal point of world interest when the media reported that Britain was basing its policy on the concept at the start of the crisis. According to the reports, the assumption of the British scientists was that it would be impossible to eradicate the virus anytime soon, so the possibility was entertained of allowing most of the population to become infected and thereby to develop immunity in the general population. One of the reasons for adopting that policy, according to various commentators, was concern for the economic consequences of a total lockdown.
Since then, British policy has undergone a complete about-face. Anders Tegnell maintains that it was never Swedish policy to begin with, and that the same holds for the economic aspect.
Are the recommendations of the Swedish National Institute of Public Health being fully adopted by the government, or are economic considerations, including the prevention of mass unemployment or the desire to avert a financial crisis, also influencing the strategy?
“We in the public health agency don’t make economic calculations – our only considerations are for public health. It is true that there are also broader aspects in regard to public health; for example, a decision to close the schools will affect the labor force in the health system [referring to the fact that medical personnel are also parents of children]. But other economic issues are the government’s responsibility. We are working closely with the government, it is basing its decisions on our recommendations, and the dialogue and cooperation are good.”
What about Sweden’s readiness for a scenario of the flooding of the health system with patients? Are there enough ventilators, intensive care beds and is there protective gear for the medical teams?
“There are of course problems of equipment in Sweden, like everywhere else in the world. It’s a constant struggle. In the meantime, nothing is lacking and we are continuing to build up our ability in any event. In terms of intensive care capability, Sweden has already doubled its capacities, and in the Stockholm region, we are on the way to triple and quadruple the ability we had, including a field hospital that is now being set up.”
Tegnell is referring to a field hospital that the Swedish army and the municipal authority just finished building within a convention center in the south of Stockholm. The new hospital will have a total of 600 beds, 30 of them intended for intensive care patients. Another field hospital is being set up next to one of the hospitals in Gothenburg, the country’s second-largest city, in western Sweden. So far, intensive care facilities in the country’s hospitals are strained but not working at full capacity yet.
When do you estimate that the crisis will peak in Sweden?
“We don’t know exactly when the peak will come. The Stockholm region is a week or two ahead of the rest of the country, which is a positive situation, because that way the load is distributed better. The pressure has already begun in Stockholm, and I estimate that it will peak in two-three weeks.”
Some maintain that the Swedish policy can succeed only in Sweden, because of its distinctive characteristics – a country where population density is low, where a high percentage of the citizenry live in one-person households and very few households include people over 70 cohabiting with young people and children. Those are mitigating circumstances which the Swedes hope will work to their advantage.
“The only way to manage this crisis is to face it as a society,” Swedish Prime Minister Stefan Löfven said in a short speech to the nation on March 22, elaborating, “with everyone taking responsibility for themselves, for each other and for our country.”