“One size does not fit all.”
- Frank Zappa, American music producer and musician
“Everything has to do with geography.”
- Judy Martz, former governor of Montana
Just this past week, the U.S. reached the grim milestones of more than four million cases and close to 150,000 deaths from COVID-19. And as it has for many weeks, our country led the world in confirmed cases and deaths. Despite the efforts of the best epidemiologists in the world, much remains unclear about regional differences in the number of cases and infection mortality rates. (In Minnesota, for example, no one to my knowledge has yet explained why the number of cases didn’t spike after the protests that erupted following the murder of George Floyd in May. Nor has anyone figured out why we in Minnesota have significantly more cases than our neighbor Wisconsin.)
I’m sure you’ve been asking, “Why?” and “What’s been learned from other countries and states to help explain these unnerving numbers?” This week’s Germ Gem focuses on the experience of one country that I believe is worth considering—Sweden.
Why Sweden? In the spirit of full disclosure, all four of my grandparents emigrated from Sweden. But this has nothing to do with why Sweden is the focus of this post. Instead, from the very start, Sweden’s approach to fighting COVID-19 has been unique.
In March, when the number of cases of COVID-19 in Europe exceeded those in China, the World Health Organization (WHO) recognized Europe as the epicenter of the pandemic. And the number of COVID-19 cases and deaths in Sweden diverged from the rest of Europe, including its Nordic neighbors (Denmark, Norway, Finland, and Iceland). According to a July 24 report, since the onset of this pandemic, Sweden had the eighth highest number of cases (78,897) and deaths (5,697) in all of Europe, and it led all the Nordic countries substantially in these numbers (corrected for the size of their populations). This same report, however, indicated that the number of cases in Sweden had fallen steadily over the past several weeks and the mortality had plummeted markedly since its peak in April.
What also has distinguished Sweden from the rest of Scandinavia, and for that matter many other countries, is its “no lockdown” approach to the COVID-19 pandemic promoted by the Swedish Public Health Agency. This unique approach allowed businesses, restaurants, gyms, playgrounds, and schools for under 16-year-olds to stay open. Although it hasn’t been a stated goal of the Public Health Agency, underpinning this “hands off” policy is the hypothesis that as the pandemic spreads naturally through Sweden, the level of herd (community) immunity will build faster than it would under lockdown conditions. And, the thinking is that this approach will also better serve the Swedish economy from the more disastrous consequences of a lockdown, while at the same time better preserving the educational system and the mental health of the Swedish people.
The architect of the laissez-faire COVID-19 policy of Sweden is Anders Tegnell, who has gone from an unknown physician and technocrat to a household name in Sweden in a matter of months. While he is beloved by some people, he is intensely disliked by others. For example, he is roundly criticized by other epidemiologists and scientists, both inside and outside Sweden. In a New York Times article on July 7 (“Sweden Has Become the World’s Cautionary Tale”), Peter Goodman suggests that this “unorthodox, open-air experiment has allowed the world to examine what happens when a government allows life to carry-on largely unhindered.” He points to the grim results of more deaths and nearly equal economic damage. (An article from the BBC on July 24, suggests various forecasts predict the Swedish economy will shrink by about 5% this year, which is less than other countries hard hit by COVID-19 such as Italy and the UK but still similar to the rest of Scandinavia.) On the positive side of the economic impact argument, however, is the suggestion made by Karolina Ekholm, Professor of Economics at Stockholm University, “There’s been less disruption for the generation now growing up—in terms of learning. That may produce benefits further down the line when [they start] entering the labour force.”
A study in the first week of July suggested that 30% of Swedes have built up immunity to the coronavirus that causes COVID-19, which some have suggested is one reason for the decline in the number of cases and deaths in recent weeks. The number of daily reported deaths has been in single digits for much of July, in contrast with the peak of the pandemic in April, when more than 100 fatalities were recorded on several dates. Others, however, argue that herd immunity is unlikely to be playing a major role. Mortality in Sweden, like the rest of the world, is largely driven by cases in the elderly. Better hygiene and other routines in elderly care homes may be behind the decline in Sweden’s mortality rate. But some experts have suggested that if community immunity is indeed building up, the “Swedish approach” may be proven right should a second wave occur in Sweden this winter.
What about masks? Most of the world, including the U.S. is masking up (Minnesota’s governor just added our state to the list of 29 other states and the District of Columbia that have instituted or announced statewide orders requiring face coverings in public). In Sweden, however, mask use is minimal in almost all settings, except hospitals. According to Tegnell, “One reason is that the evidence base for using masks in society is still very weak. The other reason is that everything tells us that social distancing is a much better way of controlling this disease than putting masks on people.”
Sweden’s guidelines for voluntary social distancing, including working from home when possible and avoiding public transport have been in place since the outset of the pandemic. Also, there has been a ban on gatherings of more than 50 people, restrictions on visiting long-term care homes, and a shift to table-only service in bars and restaurants.
The jury is still out. When asked in an interview on July 24 whether his (Sweden’s) maverick strategy is a failure or success, Tegnell replied, “A bit of both, but more of the latter.” And in an article in Politico on the same day, “Sweden Split on Coronavirus Immunity,” the author, Charlie Duxbury, comments, “The debate in Sweden illustrates how much is still unknown as the pandemic continues to sweep the globe. Along with how best to measure immunity and herd immunity, key questions also remain about how long immunity lasts and in some quarters, whether it exists at all.” Only time will tell whether the Swedish approach is maverick or mindful.
What should we do here? My personal opinion is that one size may not fit all. The cultural, geographical, and political differences between countries may make one country’s approach to fighting this virus successful there but may not work elsewhere. The approach that the U.S. is taking is based on the recommendations of the U.S. Center for Disease Control and Prevention and the WHO listed below:
· Wear a mask when in public (buildings, restaurants, etc.) and outdoors when physical distancing of at least 6 ft cannot be maintained.
· Avoid enclosed spaces with groups of people, where the virus can linger in the air for long periods of time.
· Get tested if you have cold or flu-like symptoms.
· Stay six feet away from others.
· Cover your coughs and sneezes with your elbow or sleeve, or a tissue and then throw the tissue in the trash and wash your hands afterwards.
· Wash your hands often with soap and water for 20 seconds, especially after going to the bathroom or before eating. If soap and water aren’t readily available, use an alcohol-based hand sanitizer that contains at least 60% alcohol.
· Avoid touching your face – especially your eyes, nose and mouth – with unwashed hands.
I believe these measures are unlikely to do much, if any harm (“first do no harm” or, to use the Latin phrase, “primum non nocere” is a guiding principle in the practice of medicine) and some reflect general good hygiene practices that we should follow even when there isn’t a pandemic. Some things, however, are difficult to assess such as social distancing that takes its toll psychologically as we are unable to socialize with friends and family.
Only time will tell whether Sweden’s approach to the pandemic was more effective than that of its Nordic neighbors or, for that matter, our current approach. When it comes to dealing with COVID-19, we might add “second keep an open mind” or, “secundum habeas semper aperta mentis”…even about Sweden.
