Israel is back in lockdown while Swedish COVID-19 mortality rates are plummeting. Here’s the difference

Swedish Health Minister Lena Hallengren tells Haaretz why her country never imposed a full lockdown, and why public trust in the government is a vital component of fighting the coronavirus

Published in "Haaretz": https://www.haaretz.com/israel-news/.premium-israel-s-back-in-lockdown-while-swedish-covid-deaths-are-plummeting-here-s-why-1.9173277

STOCKHOLM – Back in April, many worldwide thought the Swedes had lost their minds. As country after country shuttered its schools, shopping malls and restaurants due to the coronavirus pandemic, Sweden decided to take another approach. 

Despite the Scandinavian country’s death toll reaching a peak of about 100 a day by mid-April, many Swedes were still going about their daily lives, face masks were not recommended and rarely used, young children were still going to school, and no national isolation system was set up for infected but asymptomatic individuals. And though many businesses took a hit – because Sweden relies heavily on its export trade – most remained open and gradually started to rebound. It’s not as if Sweden did nothing at all to combat the virus. High schools and universities switched to online learning, most cultural, entertainment and sports venues closed, and the general population was asked to maintain hygiene and social distancing, avoid traveling wherever possible, and to stay home when symptoms appeared. 

But there was clearly a major difference between the Swedish way and that of the rest of the world. Besides legal restrictions prohibiting gatherings of over 50 people or visitors at hospitals and retirement homes, most were recommendations rather than legal decrees. Fines, police enforcement, mobile phone tracking and curfews were deemed unnecessary. 

Despite this, most Swedes observed social distancing and the infection rate finally began to drop. Last week, Sweden carried out over 140,000 tests, with 1.2 percent coming back positive. The country currently has one of the lowest infection rates in Europe. 

While the curves are clearly flattening, the government isn’t wasting time. After a traumatic spring, it’s doing its best to learn from its initial mistakes by improving testing capabilities and boosting the economy. 

It’s a stark contrast to Israel, which has just become the first country to enter lockdown for a second time. Yet Sweden’s health minister, Lena Hallengren, told Haaretz that it’s not just about having or not having a lockdown.

“It’s true we didn’t have lockdowns [in Sweden], but we did have lots of changes in society – and the most crucial thing is having long-term measures,” she said. “Without a lockdown, restaurants, bars, trains and buses have to be adapted with regulations – legally binding or recommendations. You have to always maintain distance, have signs, information, sanitizing, washing hands: all that has to be in place. We can see that you can’t lock down the virus forever, and you always have to consider the price that society pays.”

Lena Hallengren, Photo: Kristian Pohl/Regeringskansliet

Falling mortality rates

Different countries’ success rates in handling the coronavirus has become something of a “sport” in the past six months, a table reflecting the global “winners” and “losers.” Given its outlier approach, Sweden has come under particularly close scrutiny: initially, it drew harsh criticism and was used as a cautionary tale; now, it’s offered as a slightly more sustainable model than repeatedly going into lockdown. But Hallengren is careful about making any comparisons. 

“We’ve said since the beginning of the pandemic that this is not a sprint, it’s a marathon,” she said. “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. 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 less fingers and try to keep up with long-term recommendations,” she added. 

So far, some 5,800 people in Sweden have died due to COVID-19, mainly as a result of the virus spreading in Sweden’s nursing and care homes in the spring. 

“In the worst week of April, we had 845 new cases of infection in elderly care facilities. Last week we had 17,” Hallengren reported. “Our mortality rates have also fallen radically. We don’t have excess mortality and in August, the rates were below normal [yearly] figures.”

Hallengren also tried to look beyond the headline figure concerning COVID-19 deaths. “One [southern] region in Sweden, Östergötland, recently conducted a study investigating all cases of elderly patients who died infected from the coronavirus,” she said. “In only 15 percent of the cases was it concluded that COVID-19 was the direct cause of death. In 15 percent [of cases], the real reason was another illness or medical condition, and in 70 percent of cases COVID-19 contributed to death due to underlying conditions or the health status of the patient.”

The health minister said her government is analyzing why the coronavirus hit Sweden so badly, especially in comparison to its Nordic neighbors, and is taking long-term measures to tackle possible new local outbreaks. 

Scenarios are being prepared by government authorities and financial resources allocated to address unemployment and support the health care system, as well as those in elderly and mental health care. “The outbreak of COVID-19 is not, and has never been, a narrow health issue for the infected people,” Hallengren said. “It’s a broad issue affecting all parts of society.”

‘Functioning society’

When quizzed on Sweden’s “no lockdown” policy, Hallengren said that although a total lockdown was never imposed, remote work, online studying in high schools and universities, and restrictions on entertainment venues affected the country’s citizens. 

“It was certainly not ‘business as usual’ in Sweden,” she said, rebutting a common claim, “but we needed to have a functioning society. That’s why we made an active decision not to close preschools and elementary schools. If you close schools, how do you enable people to work at the care homes, hospitals, and police and emergency forces? How do you keep the pharmacies, commuter trains and food stores running and open?  

“We decided to lean on experts and the available knowledge at the time,” she explained. “We knew children were not severely affected and not the ones spreading the virus. This was proven by looking at the number of people on sick leave. Teachers working at preschools and schools were not sicker than other groups in society. 

“We need to fight the virus, we need to protect vulnerable groups,” she continued. “But we need to make sure that the measures can be kept for a long time in a functioning society.  

“Swedish people have high confidence in government authorities,” she added, “so with transparency and a lot of quantifying information, we created a strategy based on taking the right measures at the right time and in the right part of Sweden.”

How do you respond to allegations that Sweden sacrificed its older population for the sake of the economy?

“That criticism is unfair and untrue. Of course we never sacrificed anyone. We tried our very best, as I suppose other countries did, to protect lives, to stop the virus spreading in society and to protect the vulnerable groups. 

“The care homes have been an extremely difficult and sad part, but they are very specific – people living there are extremely old, fragile and sick. We created a government commission to find out what happened, who did what and what we can learn from this. 

“In Sweden, care homes are not just facilities for older people; they provide health care. We have 1,700 such homes and about 85,000 people live in them. Fifty percent of them live in these homes for only six months – that’s how old, fragile and multi-diseased their situation is. If you get COVID-19 or even the flu into these homes, it’s a matter of life and death.”

Retirement homes were generally perceived to be the weakest link in Sweden’s coronavirus strategy. But there’s another part of it that others could benefit from: decision-making based on expertise rather than politics. 

“We [political decision-makers] are thinking people and we're responsible for the decisions we make,” Hallengren said, “but our authorities wouldn’t be independent if we’d sometimes decide to follow the experts on disease prevention and disease control, and sometimes not to do so. You don’t have experts and expert agencies just to have them. You have them to listen to, and take what they know into consideration,” she concluded.

What Can Be Learned from the Swedish Coronavirus Case

STOCKHOLM – In the final analysis the Swedes will disappoint everyone. Those who claim that their own government's reaction to the coronavirus pandemic was hysterical, because "in Sweden it's business as usual," have yet to discover how little they knew about business in Sweden. Even those who claim that countries that opted for a lockdown saved numerous lives, as opposed to the Swedes who are dying in the thousands, will discover that the numbers are misleading and confusing.

Published in Haaretz: https://www.haaretz.com/opinion/.premium-what-can-be-learned-from-the-swedish-coronavirus-case-1.8903160

Both groups will be forced to find another source to prove their arguments. Last week, for example, headlines worldwide declared that the Swedes admit their mistake and that their model for dealing with COVID-19 has collapsed. The headlines were incorrect. The Swedish authorities are still adhering to their initial strategy, and the presumed admission of a mistake was a general statement that was taken totally out of context. But Sweden has long since become a punching bag for those justifying the lockdown policy as well as an exemplar for those who oppose it. Meanwhile, in the real world, the situation is more complex.

First it should be noted that it is not business as usual in Sweden – high schools and universities have switched to distance learning, most of the cultural, entertainment and sports venues are closed, and residents were asked to work from home, maintain social distancing and avoid traveling. Although most of the restrictions are only recommendations, it can be proven that most Swedes observe them meticulously,

Despite that, the elementary schools and preschools did not close, no lockdown was imposed and there is no obligation to wear a mask. These are examples of controversial policies, which may turn out to be more damaging than beneficial. It is definitely possible that the Swedish government is wrong, but the claim that it is practicing “human experimentation” could be directed to all the other governments too. In times of coronavirus uncertainty, steps such as isolating asymptomatic patients, prohibiting swimming in the sea and closing places of business are also a gamble. It’s clear to everyone that they all cause social, economic and health-related damage, but it is still unknown if and to what extent these steps limit the spread of the virus.

As is true of every country, Sweden has advantages and disadvantages in dealing with the pandemic. The advantages include: an efficient public sector, a good health care system, a sparse population and a large number of single-person households (about 40 percent of households). And on the other hand, the Swedish population is elderly (about 20 percent are aged 65 and above), the country has open borders and a cold climate, and about one fifth of the population was born outside the country – and therefore has less trust in the authorities and limited access to their directives.

There is therefore a limit to our ability to learn from the terrible figure – about 4,500 dead. Even if we ignore the differences in the way countries count their dead, and complex data such as overall and excess mortality – it is hard to compare young countries with elderly ones, hot countries with cold ones, and open and closed countries. Although Worldometer charts have become a morbid sport of body counts and patriotic wrestling matches, it is doubtful whether we can learn from counting the dead about the degree of effectiveness in a country’s handling of the pandemic, and especially the effectiveness of lockdowns.

Heading the charts are Belgium, Spain, Italy, England and France – countries which imposed a lockdown, and occasionally adopted tough measures to enforce it. They are followed by Sweden, without a lockdown and with a “soft policy.” And then come the rest of the countries, which have various ways of dealing with the problem. There are countries that imposed a lockdown and have a high mortality rate (Belgium), there are countries with a lockdown and a low mortality rate (Israel), countries without a lockdown and a high mortality rate (Sweden) and some without a lockdown and a low mortality rate (Iceland). And of course there are also differences between one city and the next in the same country.

Why then have so many died in Sweden? At this point it seems that the failure is not related to the failure to impose a lockdown. There is no evidence of a significant contribution by schools or shopping centers to the spread of the pandemic. But there is evidence of a different failure – the treatment of the elderly. Although the handling of senior citizens’ homes was problematic all over the world, in Sweden the situation was especially grave. Recently it was revealed that due to power struggles among the authorities, the personnel were not prepared, there was a lack of equipment and the ban on visits was belated.

And yes, although Sweden is a developed welfare state, in the years when the seeds of the failure were sown it suffered from another plague: privatization, cutbacks and reforms in the public sector. Today, as opposed to the situation in the past, senior citizens’ homes in Stockholm lack work slots, equipment and skilled manpower. This is another example of the helplessness of the “invisible hand” when it comes to managing crises and protecting the weak.

Is it true, as has been claimed, that Sweden gave up on its elderly for the sake of the economy? Definitely not. First of all, public health is managed by an independent authority, which is not subject to economic considerations. Second, the Swedish economy is export-oriented. Initial investigations have shown that the blow to Sweden did not differ greatly from that of its neighbors. In Sweden too there was a decline in consumption, growth was harmed and unemployment increased. Even if local businesses remained open, Volvo cannot manufacture vehicles when there is interference in the supply chains and demand plummets, and H&M cannot sell clothing when factories and malls the world over are closed. Not to mention the tourism industry. Policymakers knew that and did not waste time on attempts to prevent the blow, but instead channeled money to reduce the damage it caused.

Even more serious is the claim that the Swedes tried to save the economy by achieving herd immunity, because initial examinations demonstrated that Sweden is very far from that objective. But Sweden has never claimed that it was aiming at herd immunity – on the contrary, it vehemently denied that. The objectives were to flatten the curve of the number of patients and to protect the populations at risk. The first objective was achieved: intensive care beds and ventilators were ready for use at all times – an impressive achievement, because there was no need for a ruinous lockdown. In the case of the second objective, the Swedes themselves admit failure. Those using the example of Sweden would do well to stop looking at the country for proof for their arguments, and to try to think what can be learned from the Swedish case. In the final analysis, this is not a theoretical exercise, it is an essential preparation for the second wave.