Well-Being Prevention & Cures

The problem with holding up Sweden as an example for coronavirus response

by Chia-Yi Hou | Aug. 6, 2020 | Aug. 06, 2020

Story at a glance

  • Sweden, unlike many European and Scandinavian countries, did not enforce a strict lockdown when COVID-19 cases started rising.
  • The Swedish government recommended voluntary social distancing and protective equipment like masks.
  • Schools stayed open for young children, and businesses never fully shut down.
  • Daily deaths in Sweden are now lower, but that does not necessarily mean the country handled the outbreak well.

We still may not fully understand for months whether certain approaches by Sweden’s government were enough for controlling the spread of COVID-19. The facts currently are that the country experienced a lot of deaths during March through June, many at care homes and many of which may have been preventable.

Earlier in the pandemic, Sweden did not go through a strict lockdown like many other countries. Younger children continued to go to school, and businesses and restaurants stayed open at limited capacities. There was a spike in coronavirus cases and deaths, adding up to nearly 82,000 confirmed cases and more than 5,700 deaths. This death rate is among the highest in Europe for its population of about 10 million. Recently, daily deaths in Sweden have dropped down close to zero.

In this context, it might be tempting to think that Sweden had the right idea. The truth is much more complex.

Herd immunity without a vaccine is hard to achieve

Herd immunity is not a strategy for dealing with an epidemic, let alone a pandemic. Herd immunity is something that may be achieved passively through widespread infection or actively through vaccination. But it’s typically not a viable strategy for infectious disease control without a vaccine. You normally would want to achieve herd immunity before an outbreak happens because that’s when it is most useful at stopping a disease from spreading. Although the Swedish government never officially stated that herd immunity was part of their strategy, they talked about achieving greater immunity within their community through exposure.

There’s a lot to indicate that SARS-CoV-2 is a virus that needs to be controlled and not passively waited out. One of the most important factors is that it can be spread by people who are asymptomatic or presymptomatic. People who are asymptomatic never exhibit symptoms, whereas presymptomatic individuals develop symptoms later on but may be spreading the virus before they show symptoms.

In addition, herd immunity as a concept only works if you gain immunity, either from infection or vaccination. With SARS-CoV-2, experts are trying to figure out if people who recover from it have immunity. It’s still unknown whether they have short term immunity for about a year like with other coronaviruses, or any immunity at all. If we cannot achieve immunity for a significant amount of time with a vaccine, it may not be very useful as a tool.

Cherry picking data is dangerous

While it may be tempting to cite standalone statistics to “prove” that Sweden did the right thing, statistics are a tricky thing and you should be informed to get the lay of the land. A few things you would want to know are where the data came from and what might have been left out from the data collection process. Datasets can also be incompatible based on how they were collected, meaning you could not combine the datasets or you would have to do some finagling to combine them. The data could have been collected at different spatial and temporal scales. This also makes them incomparable.

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For example, The New York Times recently reported on data for mask-wearing compliance in different countries, which included survey results from YouGov and Imperial College of London that showed 86 percent of people in Sweden never wear masks. That in and of itself is interesting. However, if you were to try to draw a line from Sweden’s 14 percent mask wearing to its recent zero daily deaths, that would be problematic. These two pieces of information are being taken out of context if discussed together. Do we know if people who died from the coronavirus wore masks? No. If they did not, do we know if their lives could have been saved if they did wear a mask? No. 

There’s no harm in stating a statistic because it’s interesting, but to draw conclusions without understanding the full analysis it came from would be inappropriate.

Masks DO work

On that note, let’s take a moment to appreciate that masks do actually work, at least to some degree. They are not perfectly protective, but neither are the most advanced masks. They offer some protection, which could be enough in everyday settings.

Many experts have used the example of, if you were to go into surgery, you would want your surgeon to be wearing a surgical mask and personal protective equipment (PPE). The point of doing so is to protect the patient who will be deeply exposed during the surgery. It’s a requirement for everyone in the surgery room to mask up, and there are also strict guidelines for air ventilation and washing up before entering. These requirements have saved hundreds if not thousands of lives since being implemented in hospitals.

While it may be obvious that if your organs are exposed you are vulnerable, it’s harder to understand how you could be vulnerable to breathing contaminated air. The probability of infection may be relatively lower, but the risk is still there.

Low mask-wearing compliance and low deaths does not mean masks don’t work. This is a classic example of correlation not causation. It may be a coincidence that there are low numbers of deaths in Sweden, at least currently, and low numbers of people wearing masks. Other factors that could play a part are the population density, how people are mixing with others, and how many contacts they have. If people have reduced how often they mix with others or have a limited number of contacts, the outbreak could naturally taper off because it isn’t encountering new susceptible people.

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Everywhere is an experiment

What we are going through now is like a series of concurrent experiments. The conditions of every country, and even every town or city, is unique because factors like population density and age distribution will be different in each place. Like that old saying, it’s apples and oranges.

And this is not to say that Sweden was wrong. We may not know if anyone was “right” or “wrong” until long after the COVID-19 pandemic has passed, especially as many locations are experiencing new surges in cases after a period of low numbers of new cases. It is likely that Sweden could have dealt with disease spread better early on to prevent more deaths, but the truth is we will never know if doing more would have actually helped. We can only speculate and guess. And if more data becomes available, we can make slightly better guesses.

It’s probably unfair to hold up any country or region as an example for how to deal with the coronavirus. There are so many factors that make each situation different that you wouldn’t be able to replicate the results. Unlike many other infectious diseases, asymptomatic and presymptomatic individuals with SARS-CoV-2 seem to be able to spread the virus.

However, there are general disease control principles that are universal, such as testing, quarantining, contact tracing and PPE. These have been well established in the scientific and medical communities for a long time. It would be a waste if we don’t follow these tried and true concepts.

Some data suggests that Sweden’s number of daily deaths is still higher than its neighbors.

What about the future

Even though the number of cases are trending down in Sweden, the population may be vulnerable to a second wave of infections. There are also some reports that the economy experienced less shrinkage than neighboring countries, but because Sweden’s economy relies heavily on trade the effects of the pandemic may be long reaching. It’s also important to note that it was the worst fall for the economy in its modern history.

There’s recent news in Israel where COVID-19 cases subsided. Schools were reopened and subsequently cases rose again. Part of what may contribute to lower deaths in Sweden is that people may have lowered their social interactions and number of contacts voluntarily without a strict lockdown. Anders Tegnell, Sweden’s state epidemiologist, says that their modeling estimates people have around 30 percent of social interactions compared to before the pandemic, according to BBC.

Whatever your stance is on Sweden’s approach to the coronavirus, the fact remains that many people have lost their lives, and it’s likely that a portion of those deaths were preventable. Some research suggests that doctors in Sweden chose who to admit to the hospitals based on their likelihood of surviving, and that prevented the hospitals from being overloaded; this typically meant older individuals and people in care homes were. These are not choices that anyone wants to make, and we should not allow that to become the norm.

The science is clear about what we need to do to control the pandemic. It’s whether we are willing to do it that is the problem.

For up-to-date information about COVID-19, check the websites of the Centers for Disease Control and Prevention and the World Health Organization. For updated global case counts, check this page maintained by Johns Hopkins University.

You can follow Chia-Yi Hou on Twitter.

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