May 1, 2020 -- Sweden has taken a different approach to fighting COVID-19 than most other countries -- and it’s causing a global stir.
Instead of tight lockdowns, Swedish officials have encouraged citizens to use common sense, work from home if possible, and not gather in crowds over 50. Primary schools are open, as are bars and restaurants, with images showing people enjoying drinks and crowding streets.
Their aim, officials have said, is to slow the pace of the virus, so as not to overwhelm the health care system.
But they also want healthy people to keep getting infected, to eventually build “herd immunity,” where so many people have survived an infection that they won’t be vulnerable to it again.
About 80% of people who become sick with COVID-19 will have relatively mild symptoms; some won’t even notice they’re infected.
Theoretically, if enough people could be mildly infected, they would be protected from the virus and not pass it on to others. Outbreaks end when enough people have become infected or protected with vaccines to stop it from spreading. The trick is to infect only people who will have mild infections -- but, of course, no one knows how to do to that.
But there are good reasons, experts say, why nearly every other country on earth has chosen a different path.
And Sweden’s approach might have made sense if the Nordic country had done something to protect its most vulnerable residents, says William Hanage, PhD, an epidemiologist at the Harvard T.H. Chan School of Public Health.
Sweden, which has a population of about 10 million, has avoided overwhelming its health care system so far, says Hanage. But instead of the slow burn among healthy people that the Swedish leadership had wanted, the virus has ripped through the nation’s nursing homes. While outside visitors have been blocked, protections like masks and gloves were not required unless a resident was known to be sick.
As of the end of April, Sweden had reported more than 21,500 confirmed infections and 2,600 deaths, according to data compiled by Johns Hopkins University. That amounts to about 12% of diagnosed people dying of the disease. Among its neighbors, just 210 people have died in Norway -- less than 3% of those diagnosed; 218, or about 4%, in Finland; and 460, or about 5%, in Denmark.
Experts say these fatality rates are expected to fall as officials gain a better picture of how widespread COVID-19 is. While some early data from antibody testing has suggested COVID-19 prevalence may exceed 10%, the World Health Organization says that based on preliminary data, 2% to 3% of the world’s population has developed antibodies.
In the United States, more than 63,000 people have died out of over 1 million reported infections. Both deaths and infections are likely much undercounted, experts say, and that 9% death rate in the U.S. is expected to fall substantially once the true scope of infections can be determined.
In response to a huge public outcry in Sweden and abroad, Anders Tegnell, PhD, an epidemiologist at Sweden’s Public Health Agency, has defended the policy he helped design. He has said he doesn’t think Sweden’s perspective is all that different from the rest of the world’s -- except that it’s based on individual responsibility and voluntary compliance, rather than legal enforcement. Closing borders and schools once an outbreak has arrived doesn’t make sense, he said, and Swedish people respond better to “nudging” than to orders.
Hanage says this approach might have worked if the country had first provided a way to protect its most vulnerable residents. The government might have offered everyone over 70 food and other resources to allow them to stay home, he said. Instead, they were simply advised not to go out.
“Whatever they have done [in Sweden] has been leading to more deaths,” Hanage says. “It does not seem that there were appropriate steps taken to ensure the safety of people in those nursing homes. … If you’re going to have a strategy like that, you need to be thinking about your vulnerable population.”
Hanage also dismisses the idea that Sweden could reach “herd immunity” anytime soon. The expectation is that about 60% of the population will need to be infected to achieve any kind of herd immunity, he says. And no one knows how long immunity to the virus that causes COVID-19 will last once someone is infected. If it lasts less than a year, for example, like its relative the common cold, then someone could be reinfected a year from now -- and even if they don’t fall very ill, they could still pass on the virus.
The Swedish Public Health Authority announced last month that it expected 26% of the population of Stockholm, the country’s largest city, would have been infected by the virus as of May 1. But with a city population of close to 1 million people, it’s not clear how it reached that infection rate with just 21,000 diagnosed infections
The United States should definitely not follow Sweden’s lead, says Tom Frieden, MD, former director of the CDC and president and CEO of Resolve to Save Lives, a global public health initiative.
“If the U.S. were to allow the coronavirus to spread and wait for herd immunity, it’s likely that more than 1 million Americans would die from the infection,” he says via email.
Adrienne Randolph, MD, a senior doctor in critical care medicine at Boston Children’s Hospital, says she sees Sweden as providing scientific evidence to the rest of the world.
“If they want to perform the experiment for everybody, go for it, and see what happens. I’m not going to join in personally,” she says, describing Sweden as often taking a more daredevil stance than other countries.
Sweden’s kind of approach might work in parts of rural America where there are no infections, Randolph says, but “if you try it in the very densely populated areas, you’re going to have a disaster.”
So far, it’s clear that the Swedish people have suffered more so far from COVID-19 than their neighbors, Hanage says, with many more infections and deaths than its neighbors.
But, like everything else with this pandemic, there are still a lot of unknowns. The only way to know for certain whether Sweden’s approach was sensible, he says, will be in hindsight.
“It’s had a worse earlier pandemic than its neighbors,” Hanage says. “But it’s early on in the day, and we’re going to have to look back at this in a few months and see what happens next.”
- A new normal consists of more handwashing, social distancing, and shielding older people and people medically vulnerable to the disease.
- Nursing homes are ground zero for the COVID pandemic and require policies to immediately isolate residents with symptoms and reduce visitors.
- More robust healthcare systems are needed to prepare for a surge, so hospitals don't become overwhelmed.
- Caring for people with chronic conditions will involve telemedicine and increased refills on prescriptions.