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The Swedish experiment: Who were the guinea pigs?

The Swedish response to the pandemic was described by many as a risky experiment.

“Sweden bucks global trend with experimental virus strategy” – Financial Times, 25/03/2020

Today, one year later, we can evaluate “the experience“.

The beginning

We have all been caught up in the news and images of this new pandemic.

On television and social networks, images of dead people on the streets of China were circulating; images with rows of coffins in Italy that were from 2013, false headlines reporting several dozen children in a serious condition in Portugal (the epidemic had barely begun) or staged whatsapp messages.

Like most, I was led to believe that a tragedy was approaching and that, most probably, only with extreme measures we could mitigate it.

The WHO communication reinforced this perspective. Initial data indicated that 20% of patients would become severe cases requiring hospitalisation and 5% would have to be admitted to intensive care.

As early as March 2020, the WHO indicates a lethality rate (infected) of 3.4% which was a result of virtually everyone developing the disease (99%). It was an extremely slow virus and therefore possible to contain.

Country after country followed the Chinese example, imposing more or less restricted lockdowns. A media avalanche laden with drama, case and death counters, and apocalyptic mathematical models made another kind of response dificult for any government, even when they had the backing of their scientific councils or expert groups (as in the case of the UK or Portugal).

Like the virus, lockdowns have proved to be quite contagious.

If in political terms the consensus was high, in scientific terms it was not, and many scientists had serious doubts, at least until they had more reliable data on the disease.

At a country level, Sweden has incorporated this position.

“The Swedish experience”

I watched some of the first interviews of Tegnell- the Swedish chief epidemiologist. In short, he said that he was going to follow the more conventional procedures because he did not think that the known data justified doing otherwise. He did not rule out the possibility of changing the policy, given new evidence.

Johan Giesecke, one of the epidemiologists responsible for the Swedish response, saidwe and the Swedish government decided early in January that the measures we should take should be evidence-based.”

At the time he said: “if you start looking at the measures that are being taken by different countries very few of them have ‘traces’ of being evidence-based“.

Despite attempts to strengthen the government’s position in the management of the pandemic, and the enormous pressure that they would come under, we can say that the Swedish Institute always remained in charge of the strategy. Some adjustments were made, but that was part of their model. The outlines were very consistent and they didn’t feel the need to change them.

Thus, unlike most countries, the Swedes have not imposed compulsory confinement on the population. This does not mean that they have not taken various measures, mostly in the form of recommendations.

Some of the measures taken at the beginning:

Recommendations:

  • Stay at home in case of even mild symptoms of illness
  • Wash hands frequently with soap and water
  • Keeping your distance to other people
  • Work from home, if possible
  • Avoid funerals, baptisms, parties or weddings
  • Do not travel at peak times, if possible
  • Travel only if necessary
  • People over 70 should avoid social contacts and meeting places as much as possible
  • Recommendation that high schools, universities and colleges adopt e-learning

Restrictions:

  • Public events with more than 50 people;
  • Entry for travel throughout the Schengen area;
  • Clustering in restaurants, cafes and bars;
  • Care homes visits

The main differences were that they did not make it compulsory to “stay at home”, kept schools open until secondary school, did not close most shops and had significantly less restrictions on the concentration of people. Even with few mandatory measures, they still gave strong recommendations.

If we look at the current guidelines we can see that they are surprisingly similar. Especially if we compare them to other countries, where changes have been frequent over time.

If we look at the WHO’s guide to fighting pandemics in use at the time, we see that it was the Swedes who complied most. Most of the measures suggested are in the document. The general confinement of healthy people is not included, not even in the new version.

OMS. Non-pharmaceuticalpublic health measures for mitigating the risk and impact of epidemic and pandemic influenza (p. 3)

Subsequently, most countries made the wearing of masks compulsory in various circumstances. Here too, Sweden has distinguished itself. Not only did they not make it obligatory, but they did not even recommend its use (except in very particular circumstances).  However, they were not alone in this, and other countries such as the Nordic countries took similar positions.

In any case, although the WHO has gone on to recommend their use conditionally for the public, it acknowledges that it is only based on “limited and inconsistent scientific evidence, including for SARS-CoV-2” (p. 8) and that “There is a moderate overall quality of evidence that face masks do not have a substantial effect on transmission of influenza.” (p. 26).

In its guide, the WHO only recommends its use in the community in epidemic/pandemic situations of “high” or “extraordinary” severity.

Forecasts and models

One of the bases of the lockdowns were the mathematical models that estimated the course of the pandemic. Academics, mainly mathematicians, went public with catastrophic predictions that frightened the population and put pressure on politicians to act drastically.

Even some institutions that were more specialised in epidemiology foresaw dantesque scenarios. One of the best known, and one that had a major impact, was the Imperial College.

In its report “Impact of non-pharmaceutical interventions (NPIs) to reduce COVID-19 mortality and health demand” of 16 March 2020, it was stated:

“Perhaps our most significant conclusion is that mitigation is unlikely to be feasible without the emergency capacity limits of the UK and US healthcare systems being exceeded many times over.”

In the most effective mitigation strategy examined, which leads to a single, relatively short epidemic (case isolation, home quarantine and social distancing of the elderly), the peak limits for general ward and ICU beds would be exceeded by at least 8 times under the most optimistic scenario for the intensive care requirements we examined.

Moreover, even if all patients could be treated, we predict there would still be about 250,000 deaths in GB and 1.1-1.2 million in the US.

Sweden was also entitled to its own models. In one of them, researchers from Uppsala University (Sweden) and other institutions based themselves on the Imperial College model and adapted it for Sweden.

At the bottom are the estimates considered by themselves to be “conservative” and which indicated that “with current measures in Sweden they would need at least 40 times the pre-pandemic Swedish intensive care capacity” (page 5).

“Intervention strategies against COVID-19 and their estimated impact on Swedish healthcare capacity”

For deaths they projected, with the approach that was followed by the Swedish authorities, “approximately 96,000 deaths (95% CI 52,000 to 183,000) before July 1, 2020” (p. 17).

“Intervention strategies against COVID-19 and their estimated impact on Swedish healthcare capacity”

Criticism in the press

Although the strategy is radically different from that followed by most countries, very little direct criticism has come from politicians or even the WHO, which has even praised it.

The same cannot be said of the international press. Sweden’s more conventional strategy contradicted the entire media narrative. Moreover, by having high initial infection numbers they became an easy target to demonstrate that not taking more extreme measures would have disastrous results.

From the beginning, the attacks were constant and violent.

News and opinion articles about having changed strategy, being regretful, having a group immunity strategy or the frequent presentation of decontextualised mortality comparisons (without considering, for example, the current population) have become common.

  • “The Swedish COVID-19 Response Is a Disaster. It Shouldn’t Be a Model for the Rest of the World.”-  Time  27/ 07/2020
  • “Sweden is moving away from its no-lockdown strategy and preparing strict new rules amid rising coronavirus cases” – Insider- 18/ 10/ 2020
  • “Sweden, Which Refused Lockdown During COVID First Wave, Imposes Restrictions as Cases Soar” – Newsweek – 19/10/20

Many of these news and opinions were published in leading newspapers and then replicated, usually literally, by the media around the world. Among these newspapers, The Guardian, The New York Times, Financial Times and, more recently, Blomberg stand out.

This negative information avalanche has greatly affected people’s perceptions of Sweden’s performance. As its results turned out to be very different from the predicted disaster, the focus on Sweden plummeted.

https://trends.google.com/trends/explore?cat=45&q=sweden

Only occasional news items appeared, such as when there was an increase in cases or when the King acknowledged some mistakes.

Results

Covid mortality and health services

While death by Covid is not the best indicator for comparison, it is the most widely considered. Sweden appears to have one of the most comprehensive systems of reporting. For example, they consider all deaths occurring within 30 days of a positive test and include deaths occurring in care homes.

Sweden started out as one of the countries most affected by the disease. Among the causes pointed out by Tegnell are the initial large introduction of the virus in the country and the poor results in containing the disease in large care homes in and around Stockholm.

However, over time Sweden has consistently dropped in the mortality rankings for the disease. It is currently 21st among the countries considered in the Worldometer with over one million inhabitants.

Some of the countries with which they were closely compared have plummeted in this unwelcome indicator, such as the Czech Republic (1st) or Portugal (12th).

Regarding forecasts, while the average estimate was 96 000 deaths “before 1 July 2020” Sweden had at that time 5 475.

As for the need for ICU beds being “at least 40-fold greater than the prepandemic capacity if the current strategy is maintained“, with some increase in capacity they have never been exhausted.

It is worth recalling that one of the arguments used against the Swedish strategy was that it has important shortcomings, namely being one of the countries with the lowest overall capacity in terms of beds, and also specifically of ICUs, in Europe.

Ferguson himself, who is responsible for the Imperial College models on which these predictions for Sweden and the UK and US responses were based, said in an interview on 25 April 2020:

“I think we will see their daily deaths increase day by day. It is clearly a decision of the Swedish government whether it wishes to tolerate this.”

In fact, the opposite happened. The numbers started to fall from that moment on. Compared to the UK, which followed a similar policy at the beginning but then opted for several lockdowns, Sweden evolved to lower numbers.

Who seems to have got his predictions right was Johan Giesecke, who had been very surprised that the UK had reversed its initial strategy.

Almost a year ago he said:

“Lockdowns only delay the spread, they don’t stop it. You should compare Sweden with other countries in a year’s time.”

Economy

Despite having felt the negative impact of the pandemic, it was one of the European countries with the lowest recession, well below the European average. This, despite being an exporting country and therefore very dependent on the other economies.

General Mortality

As recognised by the WHO, the best and most reliable indicator is overall mortality. It shows the real impact of the disease, as well as possible side effects of measures to combat it. 

Despite a low mortality year in 2019, with many people vulnerable to this and other diseases, and the high number of deaths associated with Covid, the overall mortality was not very significant.

In an analysis by Oxford University’s Centre for Evidence-Based Medicine, Sweden even comes out as being one of the least affected countries in terms of overall mortality.

Comparison with the neighbours

As their results proved better than those of many countries with which they were compared, their Nordic neighbours became the main benchmark for comparison.

In comparison with their neighbours, they continued to have much higher mortality figures, especially Norway and Finland which have the lowest figures in all of Europe.

However, compared to these two countries, and unlike in the first wave of the pandemic, Sweden has more restrictive measures than them. Even with fewer measures, Norway and Finland still have much lower Covid infections and mortality.

Norwegian authorities have even acknowledged that in the first wave they did not need to confine the population and admit that it was a mistake to close the schools.

Only Denmark has continued to opt for some more restrictive and mandatory measures. It still has significantly lower Covid mortality than Sweden, although not as much as other Nordic countries.

Apart from the possible effect of the measures taken, there are several reasons that may explain the differences between countries: differences in Covid death attribution, population profiles (age, health, immunity, habits) or geography/climate.

In the Swedish case they present some aspects that may have helped to control the pandemic such as: few residents per household, high level of compliance with recommendations or social habits that involve less physical contact.

On the other hand, some points may have made it difficult to control it, such as: the initial size of the epidemic, having care homes with many people or a relatively high concentration in large cities.

Endnotes

Despite all the pressure, criticism and even insults they have suffered, the Swedes have maintained their strategy. This was only possible due to the prestige and, above all, the strong independence, formally and informally, that their health agency possesses.

Rather than reacting to popular perceptions, to which they were likely to get entrapped, they kept to the general strategy based on measures of greater evidence and tradition.

They also distinguished themselves by evaluating at each moment the pros and cons of each measure from a more holistic perspective, avoiding being focused on a single disease.

Thus, they preserved public health (reflected for example in general mortality), ensured the normal education of the youngest, allowed social conviviality and maintained economic activity.

Today we know that although the disease has important challenges, especially for elderly and frail people, it has neither the dangerousness nor the characteristics initially pointed out.

Despite the fact that many of the assumptions about the disease have been proven wrong, many countries continue to implement extreme measures, some unheard of in a democracy, such as: general confinements, limitations on movement, the mandatory use of masks (or even respirators), school closures and many others.

We have seen healthy people forced to stay at home, children unable to play in parks, shopkeepers forced to close down their source of income, public denounses or even in the media of “prevaricating” behaviour, mothers separated from their children at birth due to a positive test.

A climate of constant fear has set in, in which many see in every human contact a mortal danger.

There is no doubt that this pandemic represented an enormous social experiment.

But were the Swedes the guinea pigs?

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