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Europe Versus Coronavirus – Self-Discipline Rather Than Lockdown: The Swedish Strategy

BLOG - 11 May 2020
Key Points
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Sweden was affected by the epidemic at the same time as the rest of Northern Europe. However, in sharp contrast to most European countries and especially its neighbors (Denmark, Norway, and Finland), which have closed their schools and borders as well as imposed national lockdowns, Sweden chose to adopt a more lenient approach. In response to the crisis, the State and communities shared non-mandatory recommendations that the population was strongly encouraged to follow. These recommendations focus on self-discipline, solidarity, and patience.

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Despite a wide acceptance of preventive measures, as well as increased preparedness of the health system and the private sector due to the late arrival of the crisis on Swedish soil, the country saw its Covid-19-related mortality rate increase significantly during the month of April, unlike the rest of Scandinavia.

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According to observers, this unique approach seems to be aimed at achieving herd immunity, although this is not the country’s official position. Swedish immunologists explain that the objective is to limit the progression of the curve, so as to treat the smallest possible number of patients at the same time.

Timeline

  • February 1: The Swedish government describes Covid-19 as "dangerous for Swedish society" and announces its first precautionary measures to reduce the risk of infection.
  • February 4: First case of Covid-19 detected in Sweden in Jönköping, a medium-sized industrial town in the south of the country (on the same day as the first case was detected in Norway).
  • March 6: Sweden exceeds 100 reported cases of Covid-19 between March 5 (86 cases) and March 6 (146 cases). The first two patients are admitted into intensive care.
  • March 11: The government presents its first economic measure to combat the crisis. Along with further economic measures, presented successively on 16, 25, and 30 March and later on April 2 and 14, these aim to reduce the spread of the infection, counter the consequences with regard to employment and businesses, provide opportunities for financial security and compensation for those who have become unemployed, and create the conditions for post-crisis economic recovery.
  • March 12: Gatherings of 500 people or more are banned.
  • March 14: Swedes are urged to refrain from "unnecessary" travels abroad. A telephone hotline is opened on the same day to answer travel-related questions, particularly for Swedish expatriates, as well as more general Covid-19-related inquiries.
  • March 15: More than 1,000 reported Covid-19 infections in the country.
  • March 18: High schools and universities are closed. Schools and kindergartens remain open.
  • March 19: The Swedish borders are closed by decision of the European Commission (first for 30 days, then until 15 May, and finally until 15 June). Moreover, from that day on, only table service is allowed in bars, cafés, restaurants and nightclubs (counter service is common in Sweden).
  • March 20: The Minister of Culture and the spokesperson for the cultural panel within the government announce an additional budgetary effort of SEK 1 billion for 2020 to support museums, theatres and other cultural institutions that are suffering during the crisis.
  • March 22: First official speech by Swedish Prime Minister Stefan Löfven calling for collective solidarity and individual responsibility. He calls on citizens aged 70 and over to stay home and self-isolate.
  • March 29: Gatherings of 50 people or more are banned.
  • March 31: The government announces that more than 36,000 Swedes have been tested and that it will implement a strategy to increase the number of tests throughout the country.
  • April 1: The Minister of Social Affairs and the Director General of the Public Health Authority clarify the government’s official call for individual responsibility until December 31, 2020. The instructions are as follows: stay at home even if you only have a mild cold, wash your hands with soap for at least 20 seconds, respect social distancing as much as possible, avoid peak transport hours, avoid local and family events as well as unnecessary travel, and work from home whenever possible.
  • April 10: More than 10,000 reported Covid-19 infections in the country.
  • April 17: The government asks the National Health Board to initiate an official mission to identify risk groups within the population and to determine the level of urgency per group.
  • April 18: New provisional regulatory measures are implemented with the approval of the Swedish Parliament. These allow stricter provisions to be put in place "in the event that the crisis worsens" (this amendment to the law, announced on April 4, is intended to last 3 months).
  • April 23: Sweden reaches 2,000 Covid-19 deaths.
  • April 24: The number of sick people continues to rise, including in Stockholm. Chief epidemiologist Anders Tegnell explains that "this is certainly not over".

Spread of the virus in Sweden

Sweden appears to follow a similar virus development to Italy, only with a three-week delay. While its infection curve coincided with the rest of Scandinavia’s throughout the month of March, in April the mortality rate started climbing noticeably. On April 27, Sweden recorded 217.24 deaths per million people. It is now among the most affected European countries with the United Kingdom (305.39), France (350.16), Italy (440.67) and Spain (496.99). From this point of view, it stands out from its Nordic neighbors, such as Finland (34.29), Norway (35.6) and Denmark (72.86), in a worrying way.

The very first case of Covid-19 in Sweden this winter was detected in a person returning from Wuhan in China. The following cases contracted the disease during winter sports holidays in resorts in Switzerland and Italy. The capital, Stockholm, quickly became the epicenter of the virus’ spread, which is logical given the city is by far the densest in the country.

The capital, Stockholm, quickly became the epicenter of the virus’ spread, which is logical given the city is by far the densest in the country.

Stockholm's suburbs (Rinkeby-Kista and Spånga-Tensta), which are more vulnerable and even more densely populated, have seen the virus spread massively, with averages up to three times higher than for the rest of the capital. The other densely populated areas (Skåne in the far south and Västra Götaland on the west coast) began to feel the effects of the crisis 15-20 days after Stockholm, with a significant change in the number of infected people. This was due to the movement of Swedes during the Easter holidays.

Responsiveness of the health system and the private sector

With the epidemic reaching Sweden later than Asia or Southern European countries, the country had a short but significant time to respond to the danger. Aware of its main weakness in this crisis (of all OECD countries, it has the lowest number of hospital beds, at 2.4 beds per 1,000 inhabitants), the Swedish health system quickly declared a "crisis situation" for hospitals in the capital. It is worth noting that Sweden is among the most generous countries in the European Union in terms of health spending, after Norway, Germany, and Austria. According to a 2017 study by the OECD and the European Commission, 11% of Swedish GDP is dedicated to the health system, compared to a European average of 9.8%.

In the first few days of April, intensive care capacity more than tripled in the Stockholm area, according to TT, the national news agency. The field hospital in Älvsjö, about ten kilometers from Stockholm, with an additional capacity of 140 patients, quickly opened its doors to lighten the capital’s burden.

With regard to healthcare workers, more than 100,000 of them attended online training sessions on combatting the risk of contagion and raising awareness of the protective measures to be taken. At Karolinska University Hospital in Stockholm, nurses were trained over 3 days to work as intensive care assistants.

Unfortunately, these efforts did not succeed in curbing the excess mortality in April. In Stockholm, the morgues quickly filled up and some refrigerated containers were placed outside hospitals in the heart of the capital. The deceased in Sweden are predominantly elderly, with 87% being over 70 years of age (63% over 80 years of age).

For its part, the private sector played its part from the onset of the crisis. Essity, a Swedish company specializing in hygiene products, has manufactured millions of masks since the beginning of April to support the care system and meet the needs of the Swedish people. In another example, to increase the production of ventilators in the country, medical equipment company Getinge has been "loaned" approximately 50 employees from Scania, a Swedish truck manufacturing company owned by Volkswagen. Furthermore, clothing giant H&M has adapted its production at a factory in China to provide long-sleeved protective gowns for healthcare workers.

Meanwhile, Sweden's four largest cities - Stockholm, Gothenburg, Malmö and Uppsala - have agreed to contribute SEK 125 million to ensure the joint purchase of protective and disinfection equipment for their municipalities and the rest of the country.

"National recommendations" rather than strict measures

Much like the rest of the world, Sweden favors social distancing to effectively combat the spread of the epidemic within the country. In the northern city of Luleå, the social distancing scale of choice is that of a "small moose".

To ensure that this distance is respected, national guidelines must be followed. However, the State declared no national lockdown or other such compulsory measures, with a few exceptions that may seem anecdotal from most other countries’ perspective: gatherings are limited to 50 people, visits to retirement homes are banned, a distance of 2 meters is to be respected in restaurants and parks, and online betting is restricted.

Sweden favors social distancing to effectively combat the spread of the epidemic

These recommendations are made by the government and based on advice of scientists and experts, including Anders Tegnell, the country’s chief epidemiologist, who is invited to news shows almost every night. They are shared with the population through the press, media, and the official government website. Major decisions on the fight against Covid-19 are translated into the languages most spoken by minorities (Polish, Persian, Somali, Finnish, Russian, and Spanish) and posted on the website.

The State and the Public Health Authority also suggested further "preventive measures", to be followed until December 31, 2020. These include staying at home should you show symptoms, washing your hands with soap for at least 20 seconds, respecting social distancing as much as possible and avoiding peak transport hours, avoiding local and family events as well as unnecessary travel, and working from home whenever possible. People aged 70 or over, identified as belonging to the main "at-risk group", are encouraged to self-isolate and stay at home. Municipalities set up systems enabling the purchase of basic necessities for seniors by their neighbors. Primary schools, which have remained open, encourage outdoor teaching and recess as much as possible.

A call for self-discipline and solidarity

Swedes are asked to behave like the "adults" they are, as stated by the Prime Minister in his official speech on March 22. Radio stations throughout the country have been broadcasting factual messages for the past two months: "No need to panic, but better safe than sorry... what if grandma catches it?" or "keep calm... it's going to be okay... it isn’t that different from an ordinary flu, is it?".

As part of these efforts to raise awareness, the government has systematically communicated about the epidemic from both the health and economic perspectives. The Prime Minister has called on every citizen to favor local businesses. The number of hotels and restaurants going out of business has increased by 123% compared to the same period in 2019. Hairdressers, bakeries, cafés, restaurants, and other such businesses have nevertheless remained open all along, provided they comply with the social distancing guidelines (closures have taken place on a case-by-case basis for venues that did not follow these instructions, upon request by citizens), thereby protecting part of the economy. But as Finance Minister Magdalena Andersson pointed out in the New York Times, Sweden is highly dependent on exports and she expects the Swedish economy to drop by 7% this year.

Swedes are asked to behave like the "adults" they are, as stated by the Prime Minister

Overall, the Swedes have respected the instructions they were given, due to the great trust they have in the State. However, a wave of sunny weather around mid-April brought large crowds out to restaurants and parks in Stockholm and Gothenburg.

A long-term strategy

In the eyes of the world, Sweden is considered to be one of the few countries that chose herd immunity from the outset. In reality, there is no evidence to suggest that this is the official strategy adopted by the State. For chief epidemiologist Anders Tegnell, who appreciates the need for herd immunity, the government's primary goal is to limit the number of people with symptoms at the same time in order to avoid overwhelming the system. This slow pace can be successful, provided that recommendations for social distancing are followed and extended over time.

Indeed, while most European countries are working towards the end of their lockdown periods this spring, Sweden has asked its population to "live with" the crisis until at least December. The official stance is thus to think in terms of "months" rather than "weeks". Isabela Lövin, Sweden's Deputy Prime Minister, called the crisis a "marathon". At the same time, Minister for Social Affairs Lena Hallengren and Director General of the Public Health Authority Johan Carlsson said that "this is not the time for looser measures, quite the opposite". The country is aware that it is only at the beginning of the crisis.

Is there a way out of this crisis? The country is relying on a potential Covid-19 vaccine. This comes as no surprise to the Swedes, who have among the highest vaccination rates in the world without even needing mandatory vaccination campaigns. In Sweden, vaccination is seen less as a means of individual protection than as a contribution to the country's common good. It is accepted that the objectives of herd immunity are to be achieved collectively. Only segments of the population need to be vaccinated, with these segments varying from one epidemic to another.

A unique approach. Rightfully, so?

While the country hasn’t been seized by panic, there is obviously a lively nationwide debate regarding the government’s approach to the crisis, as is the case in all democracies. On the one hand, there are intellectuals who are shocked by the choices of other countries throughout the world and cannot imagine a world dictated by prohibitions. This is the consensual position among the Swedish elite. Furthermore, business leaders spoke out during the early days of the crisis to remind everyone of the risks of a closed economy.

On the other hand, some of the country’s researchers and scientists are radically opposed to the Public Health Agency's stance, and feel that they have been wasting precious time. They are looking for domestic media support at all costs (during a debate organized by Dagens Nyheter, a daily newspaper, on April 14, 22 experts referred to Sweden's death figures compared to those of Italy, among other things,) as well as platforms to voice their concerns on an international level (a leading immunologist told The Guardian that "they are leading us to catastrophe").

Is there a way out of this crisis? The country is relying on a potential Covid-19 vaccine. This comes as no surprise to the Swedes.

For its part, the political class has remained astonishingly calm. Even the Sweden Democrats are in line with the overall consensus. Jimmie Åkesson, the leader of this far-right party, did not seize the opportunity to criticize the minority coalition government between the Social Democrats and the Greens. On the contrary, he explains in debates and on social media that protecting the economy and standing together is of the utmost importance. As explained in Politico by Foreign Minister Ann Linde, this support by the Swedish far-right is not an expression of an inclination for libertarianism, but rather a reflection of the fact that the country has managed, in keeping with its history of consensus-reaching, to unite all eight parties represented in Parliament.

Meanwhile, the international community is astounded by Sweden's stance, which is by far a fringe position. A stance which is all the more unexpected, as The Economist points out that, in the 1980s, the country adopted stricter measures overall than its neighbors to combat the spread of AIDS. What explains the adoption of this more lenient strategy for Covid-19?

First, there is the cultural argument brought up by many commentators. The Swedes value their personal space both privately (they don't greet each other with kisses) and publicly. Public transport is rarely crowded. Queues in shops and pharmacies have always followed a ticket-based system. It is worth noting that the Swedes have enough room at their disposal to abide by these customs: indeed, one of Sweden's assets in the face of the pandemic is the low density of its population, which may help to limit the spread of the virus. With 25 people per square kilometer, compared with 120 in France or 206 in Italy, Sweden has one of the lowest population densities in Europe.

If it is indeed a matter of trust, as stated by Cecilia Malmström, a former European Trade Commissioner, during a podcast for the GMF, she also adds that this cultural argument is backed by a crucial legal element: according to Swedish law, the Prime Minister is not authorized to put Stockholm on lockdown.

One of Sweden's assets in the face of the pandemic is the low density of its population, which may help to limit the spread of the virus.

However, this does not mean that the State has not prepared for the worst. Since April 18, and following a vote at the beginning of the month in Parliament, the government is provisionally authorized to prepare stricter legal measures, and has not entirely ruled out a potential implementation of stricter rules, in the event of a significant worsening of the crisis. Should this be the case, these rules would be enforced in collaboration with the Parliament, the Public Health Authority, and the coalition parties.

Conclusion

Sweden hopes to find a way out of the crisis by adopting a long-term strategy. From the very beginning, the government committed to an approach lasting at least until the end of the year, and in the meantime is trying to find solutions to reassure the Swedes. In particular, much is expected of the State with regard to testing. As explained by head of department Karin Tegmark Wisell, the Public Health Authority wants to increase the testing capacity to 100,000 tests per week in the coming weeks. In late April, between 12,000 and 13,000 tests were carried out each week.

Local communities are also looking for ways to make life as easy as possible for the population. For example, in order to avoid problems related to social distancing in public transport, the Skåne Region, in the very south of the country, is launching a new service for users of the local service application to find out the level of congestion on buses and trains by means of sensors in the doors.

However, these are long-term investments. For the time being, Sweden is hurting. While the country is well aware of this, it has chosen to stick to a position that is the total opposite of what the rest of Europe is doing. In particular, it is worth noting that digital tracking solutions, implemented for example in Norway, are not even being considered by the Swedish government. Nevertheless, in order to take into account population movements in the Public Health Authority's daily analyses, the mobile data of Swedes is used as a basis for monitoring. This data is collected by operator Telia from Swedish customers only and is anonymized. From this point of view, science guides the country's strategy.
 
Until a vaccine is developed, the fate of the country will continue to be in the hands of chief epidemiologist Anders Tegnell and his colleagues. With the number of cases continuing to rise, he unsurprisingly stated on April 24 that "this is certainly not over".

 

 

Copyright : Anders WIKLUND / TT NEWS AGENCY / AFP

 

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