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.”

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.