A Year On, How Coronavirus Changed Sweden

A policy downplaying lockdowns and mask-wearing may have buoyed infection rates and deaths, but Swedes disagree on how the long term will look. How the world we knew has changed – the first in a series.

Published in "Haaretz": https://www.haaretz.com/world-news/.premium.MAGAZINE-coronavirus-year-one-the-way-the-pandemic-has-changed-sweden-1.9511565

Scandiabadet, Malmö, summer 2020. Photo: News Øresund Johan Wessman

David Stavrou

Stockholm, Sweden

 Feb 5, 2021 13:10

STOCKHOLM – Håkan Frändén, 61, lives in Stockholm and normally works as a tour guide, but these aren’t ordinary times and tourists have been a very rare commodity in Sweden since the coronavirus broke out a year ago.

“Of course, the pandemic affected my professional life when the world closed down and the high tourist season ended before it even began,” he says. “In 2020 we had zero tourists and my wife, who’s a tourist guide too, and I lost all our income.”

But Frändén and his wife didn’t give up. She took a course and is now working as a personal trainer and yoga instructor, while Håkan got a part-time job via the national employment agency delivering groceries – plus he receives unemployment benefits for the days he doesn’t work.

.Malmö, 2021. Photo: Maria Eklind

"It’s true this has been a terrible year when it comes to the victims of the pandemic, but personally I had a good year,” he says. “We bought bicycles and made them our main means of transportation, we rediscovered our city – many times with our children and grandchildren – and we had more time for ourselves and our family.”

In the past year, few countries have attracted attention like Sweden. The fact that it didn’t impose lockdowns, didn’t force quarantines, didn’t close schools and didn’t require masks made it the subject of thousands of news reports and commentaries in the world media. Some called Sweden “the world’s control group,” others said it was carrying out “an experiment on people.”

As far as we know, COVID-19 reached Sweden in January 2020, carried by a passenger from Wuhan, China. Still, there’s a suspicion that already the month before people were infected in Sweden, without being traced due to a lack of testing.

Community transmission started in March, after a month earlier many infected people landed on flights from northern Italy, Iran and other countries. Already during the first stage of the pandemic the Swedish authorities were criticized for not assessing the danger and preparing accordingly.

On March 11, the day the World Health Organization declared a global pandemic, the first coronavirus patient died in Stockholm. April saw a significant wave of illness, and by mid-June dozens of infected people were dying every day in Sweden.

Heavy burden on health care

The country’s health care system withstood the heavy burden and didn’t collapse thanks to the great efforts of the medical staff, as well as budgetary and logistics efforts by the government and local authorities. But in nursing homes for the elderly the situation was completely different. A government committee has determined that Sweden failed to protect this population, citing neglect and poor management by the current government and its predecessors.

In the first wave, the Swedish strategy for halting the infection was unique. The authorities simply asked people who developed symptoms and people in risk groups to show responsibility and stay home. Also, everyone was asked to work from home if possible and  forgo unnecessary travel.

Instead of the thorough system of testing, tracing and quarantining established in many countries, the Swedes did coronavirus testing during the first stage only in hospitals and in care for the elderly.

Anders Tegnell, the chief epidemiologist and the person most identified with Sweden’s management of the virus, explained this policy in April in an interview with Haaretz. He said that Sweden had limited testing capacity and that regardless of the test results, the recommendation would be to stay home. The Swedish policy was based on a high level of public trust in the authorities and long-term thinking, he added.

Hagaparkern, north of Stockholm, 2021. Photo: Guillume Baviere

Despite the reliance on public trust, the government and the local authorities, the Swedes took a number of restrictive steps due to the virus. They switched over to online learning at universities and high schools, limited public gatherings to 50 people, prohibited visits to hospitals and nursing homes, and imposed restrictions on serving food in bars and restaurants.

'The long-term social consequences will probably turn out greater in countries that seemed to be succeeding at the beginning'

During the summer the pandemic waned in Sweden and the hospitals’ coronavirus wards emptied out. But this was temporary; in November a more deadly wave began. Once again there were dozens of deaths every day and the hospitals were overburdened. So the authorities tightened the restrictions: They limited gatherings to eight people, banned the sale of alcohol after 8 P.M. and closed movie theaters, museums and libraries.

Still, the overall strategy didn’t change. The country’s leaders continued to rely on public trust and eschewed a general lockdown; they left the schools, restaurants and malls open. Stores and other businesses remained open, but with restrictions on the number of people allowed inside. Also, there was no requirement to wear a mask; Swedes were recommended to wear one only on public transportation at peak hours.

Around the world, people had the impression that while many countries were isolating and suffering a harsh economic blow, in Sweden it was business as usual. But the reality was different. “At first I thought we’d work from home for a month and then return to the office,” says Erik Numan, a 56-year-old art director from Stockholm. “By now, 10 months later, I’ve been in the office for only one day.”

'Even though I work in many fields, everything disappeared and I still can’t plan anything even a year later'

A shopping mall in Stockholm, December 2020. Photo: TT News Agency via Reuters

Numan says he has stopped exercising at a gym, doesn’t visit his parents and rarely meets with friends. Although he says he isn’t very worried about the virus personally, he feels solidarity with others who are likely to become infected and is concerned about the overburdened health care system.

“Nobody checks on me and the police won’t arrest me if I don’t observe the recommendations,” he says. “But I think most Swedes do what’s necessary when there’s a crisis.”

Numan’s 16-year-old daughter contracted the virus, developed mild symptoms and was in quarantine for two weeks. “When she meets girlfriends now they hug as usual, at a time when we adults have completely stopped shaking hands,” Numan says.

Like the Frändéns, Linnéa Sallay, a 60-year-old singer and violinist who lives in Stockholm, saw her professional life racked by the virus. “All the jobs disappeared overnight in mid-March,” she says. “Even though I work in many fields, perform in concerts, guide tours and produce events, everything disappeared and I still can’t plan anything even a year later.”

Sallay notes, however, that the past year has also provided a welcome time-out. She's surviving financially thanks to her savings, she has launched a YouTube channel and is developing her digital skills. She has also spent a lot of time with her family and friends, even if not at restaurants and cafes. And she’s now rehearsing and preparing for digital concerts.

Vaxholm, Sweden, summer of 2020. Photo: Bengt Nyman

Entering the crisis with disadvantages

Sweden has several disadvantages regarding COVID-19. Twenty percent of the population is over 65, it’s cold, its borders are open to other countries, its population is very diverse and it’s not used to emergency situations. But it also had advantages: a universal, quality health care system, stable and well-financed government services, and many single-person households.

Considering its starting conditions a year ago, it’s hard to estimate the real effect of the Swedish policy on illness rates and mortality. Compared to its Nordic neighbors – Finland, Denmark and Norway – Sweden’s mortality has been very high. The country of 10 million people has suffered about 12,000 deaths, with this figure per million people high at 1,444. In Denmark, Finland and Norway the number is 363, 121 and 104, respectively.

It’s not a competition and there’s no point saying who the winner is. It’s far too early and too dangerous to compare week-by-week mortality rates

Swedish Health Minister Lena Hallengren

Swedish Health Minister Lena Hallengren at a press conference in Stockholm in November 2020. Photo: Henrik Montgomery / TT News Agency via Reuters

But compared to many other European countries, including those that imposed lockdowns, closed schools and halted the economy, the mortality rate is modest. In Britain, Spain and Italy, for example, the number of deaths from COVID-19 per million inhabitants is 1,591, 1,254 and 1,473, respectively.

Some experts believe that the shunning of lockdowns has brought Sweden better results in metrics that have yet to be measured such as rates for depression, excessive weight gain, addiction, violence and illnesses from diabetes to heart attacks and strokes. In Sweden you could also hear the claim that the country’s high mortality rate in 2020 stemmed from the low mortality rates from the flu in 2019.

Fiasco at the nursing homes

Swedish Health Minister Lena Hallengren told Haaretz in September that it was too early to judge the Swedish policy because this was a marathon, not a sprint.

“It’s not a competition and there’s no point saying who the winner is,” she said. “It’s far too early and too dangerous to compare week-by-week mortality rates. Different countries were hit differently; they have different structures and relations with their authorities, they test in different ways and have different kinds of data and information. In the long run, we all need well-functioning societies. We should learn what there is to learn from others, point fewer fingers and try to keep up with long-term recommendations.”

Uppsala, Sweden, last month. Photo: Guillaume Baviere

But there’s considerable evidence of failures in Sweden’s handling of the pandemic. The Swedish media has reported on cases where nursing home residents did not see a doctor and were not evacuated to hospitals despite their serious condition. The nursing home staffs were unequipped and not trained at all to deal with a pandemic.

The Public Health Agency of Sweden has been harshly criticized too. Critics say that during the pandemic’s early days, the agency was complacent and didn’t assess the danger correctly. Later, the prime minister himself, Stefan Löfven, said the agency had downplayed the second wave. At various stages, key people in academia and the medical system demanded that the agency make more stringent recommendations to curb the spread of the virus.

Regarding vaccines in Sweden, signs also attest to delays and complications, though here the shortcoming is mainly on the European level. Like many countries, Sweden has bought vaccines as part of an EU transaction, but the supply has been slow, one reason being a hitch in the manufacture and supply of AstraZeneca’s vaccine.

As of now, Sweden has vaccinated 256,978 people with the first dose and 28,279 with the second. That means 3.13 percent of the population over 18 has received one dose and only 0.34 percent two.

Although Swedish politicians in general have backed the government over the past year, other voices have been heard in recent weeks. “We have to respond differently now,” Ebba Busch, the leader of the opposition Christian Democratic Party, told the daily Aftonbladet. “If the government lacks the courage to lead, it should resign.” Nonetheless, the ruling Social Democratic Party is leading in the polls and received 28.5 percent support in a survey last month, a 2-point rise over November.

'I hope we’ll appreciate each other more when all this is over, and I hope we’ll go back to meeting up again. The hell with Zoom'

A nurse vaccinating a nursing home resident in Mjölby, Sweden, in December 2020.Photo: Stefan Jerrevang / TT News Agency via Reuters

“I think we’ve dealt pretty well with the pandemic,” says Frändén, the tour guide. “I wouldn’t want to be anywhere else. But there have been failures too, mainly the spreading of the virus in old age homes. In recent decades there has been unrestrained privatization in our care system, and that’s one reason for the negligence in preparing and training staff.”

Frändén says the virus spread within another marginalized group too. “In 2014 and 2015 Sweden was one of the countries in Europe that opened its doors to the most refugees,” he says.

“As a result, many refugees settled in Stockholm’s suburbs and we saw social phenomena that we didn’t have before – crowded living conditions in large families, large family gatherings including elderly people, and less access to the authorities’ information. Our authorities failed here, and that may be an explanation for the differences in the virus’ spread between Sweden and Denmark, Norway and Finland, which hardly took in any refugees.”

‘Every country has its own conditions’

Sallay, the singer and violinist, also criticizes the authorities’ handling of the pandemic, especially the economic aspect, so she and a colleague launched a protest by the self-employed.

“We, the small independent workers who don’t have employees, have been discriminated against,” she says, noting that large companies in Sweden furloughed employees and received government funding for expenses, while small businesses are only now beginning to receive help.

And indeed, in an interview with TheMarker in June, Swedish Finance Minister Magdalena Andersson said the national priority is to help salaried workers and large companies. During the crisis the Swedish government has invested large sums to buoy employment while providing payments to furloughed workers, compensation and guarantees, while strengthening companies’ liquidity and providing professional training and retraining for the unemployed.

“I think it’s too early to know whether we chose the right path,” says Numan, the art director. “Every country has its own conditions, and the long-term social consequences will probably turn out greater in countries that seemed to be succeeding at the beginning.”

As he puts it, “I hope we’ll appreciate each other more when all this is over, and I hope we’ll go back to meeting up again. The hell with Zoom.”

Why Sweden isn't forcing its citizens to stay home due to the coronavirus

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?

“Yes.”

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.”