Why is it difficult to measure the success of Sweden’s COVID-19 policy?
As the rest of Europe went into lockdown, Sweden appeared as an outlier in rejecting the measure. What was behind this choice? Is it too soon to conclude if it has been a success?
What is Sweden’s policy?
The typical depiction in British media is that life in Sweden is going on as normal in an effort to establish herd immunity. In reality, only some areas of society remain open as the Swedish government try to flatten the curve. Sweden has banned gatherings larger than 50 people, closed high-schools and universities but left primary and secondary schools, gyms, cafes, restaurants and bars open. The government have stipulated restaurant tables should be set apart, and people must remain seated at bars. Social distancing, isolation when sick, and work from home measures have not been enforced but recommended: left to the public to self-regulate according to their own judgement.
What is behind this choice?
There are several reasons why Sweden did not implement a mandatory lockdown. While the strategy has avoided economic and social consequences that other countries are facing from lockdown, this was not the primary reason for its implementation.
This policy has largely been determined by fundamental constitutional aspects:
By law Swedish politicians cannot tell government agencies what to do. The pandemic response has been led by epidemiologists at the Swedish Public Health Agency (FHM). The epidemiologists have been following their evidence based planning support for an influenza epidemic, published last year, as its best available model for coronavirus. This document states that there is little supporting evidence that harsher measures (lockdown) would be effective for managing an epidemic.
Sweden does not have a provision for a state of emergency to be declared in order to suspend citizen rights. As these fundamental freedoms cannot be restricted, Sweden’s public health measures have been published as ‘recommendations’ which sit between advice and law. The government are able to close specific areas of society (e.g. bars or restaurants) if they do not act in accordance with social distancing recommendations.
Sweden’s policy also takes a longer-term view in measures to limit the spread of the virus. I spoke to Hannes, who lives in Stockholm, who highlighted how Sweden is “trying to establish restrictions which we can maintain, as a vaccine likely won’t be available until next year”. Stefan Lofven, the Swedish Prime Minister, has come out to say “one reason we have supported the FHM policy is that all the measures have to be sustainable over time”. The policy decision is built on the assumption that people would be unwilling to comply with harsher measures (such as lockdown) for as long as is necessary to control the virus.
Sweden also has a socio-political context which makes this policy possible. Shifting the burden of controlling COVID-19 to voluntary-based social distancing, demands that citizens trust that others will also follow this advice (much like the Prisoner’s dilemma). Sweden has some of the highest interpersonal trust in the world. Hannes pointed out how there is “a high level of confidence in the government in Sweden - they know lots of people will listen to their advice so the whole policy is built on a concept of trust”.
Is it a success?
The Swedish government say their strategy appears to be working with people following social distancing advice and many voluntarily self-isolating. In terms of public opinion, Hannes highlighted how “at the start, half of people I knew didn’t seem to like the policy but there has been growing support”. At the end of April, an academic study carried out in Lund found that public opinion was divided as 31% of the 1,600 Swedes surveyed rated the government response as ‘not forceful enough’, 18% responded that they were neutral, whilst 51% were supportive of the response. In terms of health care system service ability, from May 13, pressure was still on the healthcare system but in Stockholm (the most affected region) there is a spare ICU capacity of 30%. In fact public trust in the government and FHM has increased by 20% during the last month.
However, there has been continuing criticism of Sweden’s policy. On March 29, a petition of 2,000 Swedish researchers called for the government to “comply with the World Health Organization's (WHO) recommendations” for a mandatory lockdown for fears that the country would be overwhelmed. Critics point to the significantly higher death rate in comparison to the Nordic countries as evidence that the measures have not been strong enough to control the virus (the UK is included for reference).
A country’s death rate is often used as a comparative measure of the success of their COVID-19 policy. Maintaining a minimal mortality rate and keeping healthcare systems open and capable is typically seen as a sign of a country’s success. However, using cross country comparisons to measure the success of COVID-19 policy has several flaws.
There are differences in how countries document COVID-19 mortality. Until 29 April the UK was not factoring in deaths in care homes. Germany counts COVID-19 deaths only when patients tested as positive, whilst Belgium counts deaths that involve any suspicion of infection from the virus.
Demographics are important. Age structures must be considered when measuring death rate as it is known that older people are much more likely to die of COVID-19. Population density is also important.
Death rate is impacted by comorbidity which varies between country context
Death rates used in comparisons differ in measurement. If death rates are measured by dividing confirmed infections by deaths, then universal testing is the only way to make accurate comparisons. When death rate is compared by deaths divided by total population then the comparison does not consider which stage of the outbreak the country is in.
This last point is important when looking at the success of Sweden’s strategy. Sweden’s policymakers take a long-term view on mortality from COVID-19. Jan Albert, professor at the Karolinska Instituet admits that so far Sweden has had more deaths than its neighbours at least in part because of their softer measures. However she argues that other countries with lockdowns have displaced the number of cases in time if they are to re-open without a vaccine or comprehensive track and trace of the virus. Anders Tengell, the lead epidemiologist in the FHM, thinks that Sweden will be in a better place than countries emerging from lockdown as more people will have developed some kind of immunity to the virus, slowing down the spread of the disease and affecting reproduction rate to prevent a second spike. If Scandinavian countries catch up to Sweden’s death rate when they de-escalate restrictions many argue this would validate Sweden’s approach.
A crisis in the care homes?
Sweden’s Prime Minister has admitted the country has not done enough to protect the elderly. Approximately 50% of Sweden’s death rate originated from its care homes (correct to 14 May), one reason why the rate is so much higher than its Scandinavian neighbours. All visits to care homes in Sweden were banned since March. However, as with many other European countries, care homes were generally advised not to send residents to hospital if they contracted the virus. Lena Einhorn, a virologist and domestic critic of Sweden’s policy also highlighted that the government had failed to account for asymptomatic spread from care workers. Staff have been advised to stay home only if they detect their own symptoms, and unless residents display symptoms it is not mandatory for staff to wear PPE. Furthermore, she attributes the decision not to enforce lockdown as a factor increasing the likelihood that a care worker could become infected outside and bring it into the care home.
Interestingly, the study carried out in Lund found that out of those aged 70 and above who are at elevated risk for COVID, 61% stated that the Swedish response was sufficient compared to 40% of 15-29-year olds. This age gap persists when accounting for other background variables (education) and overall trust in the government.
Going forward - ‘Coronavirus Normal’
It is too early to determine which response to the pandemic was successful and which were not. It is also difficult to define what success is in the case of COVID-19. While death rate is currently used as the main indicator in comparisons, it has its flaws. Going forward, and taking a broader picture of public health, countries in Europe will have to balance economic and social costs of a mandatory lockdown as well as underprioritizing other health conditions when controlling the coronavirus without an available vaccine.