How Massachusetts is like Sweden..and Why That Matters

“Does the U.S. really want to be like Sweden?” queries New York Times reporter Thomas Friedman in a recent op-ed. 

News flash: many U.S. states already are. 

As Director of Denver Health Dr. Bill Burman puts it, “Whether intended and communicated as such, I think most of the US is following the Swedish model.”

This may come as a surprise to many because Sweden’s COVID policy has been portrayed in the American press as pretty much non-existent; many articles suggest that most Swedes are still going to work and to school and that businesses haven’t shuttered. But this is not, in fact, the case.  Sweden’s COVID policy emphasizes social distancing, includes a stay at home recommendation, an advisory to work from home if possible and to avoid nonessential travel. It is a policy that, in many ways, looks a lot like that being practiced in many states here in the US, including the state of Massachusetts where I live. 

In Massachusetts, for example, as in Sweden, our COVID policy is an advisory: residents are asked–not ordered– to socially distance and stay home — and to work from home if their work is not essential. Like Sweden, Massachusetts has not set travel restrictions nor has it made that stay at home recommendation either mandatory or enforceable. 

Other states, like Colorado, Washington, and California, have imposed true lockdowns: mandatory stay at home orders that include enforcement measures (fines and jail time for those who fail to obey) and travel restrictions.

 Why does it matter? Because the two contrasting policies appear to lead to very different health outcomes.

Health outcomes of a Stay at Home Advisory vs. Lockdown: Big Differences in Mortality

In Scandinavia, the difference between Sweden’s advisory and the mandatory lockdown practiced by neighboring Norway translates to an increase in total deaths: a tenfold difference in mortality between two countries that have a very similar demographic makeup. And although Sweden has twice the population of Norway, one would therefore expect that it would have twice–not ten times–the number of deaths due to COVID: so for example, 400 deaths instead of nearly 4,000.

In the US, there is also a significant difference in mortality between the states that practiced a strict lockdown (like Colorado, California, and Washington State) and those that have only a health advisory like Massachusetts. 

In Massachusetts, over 5,700 people have died of COVID (death rate: 828/million) to Colorado’s  1,192 (death rate: 207/million) or Washington’s 1,015 (death rate: 133/million)– roughly 4,500 more people than states with similar sized populations that implemented mandatory lockdowns. That is at least a five fold difference in total deaths due to COVID between Massachusetts and Colorado–and likely higher, since Massachusetts, unlike Colorado, has not been counting presumptive COVID deaths. Just a week ago, Massachusetts state officials started to collect data on those presumptively dead of the virus, as Washington, New York, and Colorado already do, but as of the end of  last week those data were not available. 

However, according to CDC, Massachusetts has a documented excess death total that is at least 50% higher than expected compared to prior years–suggesting that mortality due to COVID here is far higher than the official numbers suggest.

Lockdown Vs. Voluntary Strategies–Why They Are Different

The problem with advisories is that they are just that–health advice to the public and not enforceable. So not everyone in Sweden, for instance, or in the parts of the US that have advisories, have paid it much heed. My Swedish physician colleague, Dr. Stefan Larsson, is of the opinion that the recommendation to stay at home and respect social distancing is widely observed there; but news coverage, both in this country and abroad suggest that some are not following the advisory very well; the packed bar scenes in Sweden look a lot like the bar scenes now getting a lot of press in the state of Wisconsin–all of which translates into increased transmission and thus, because of the nature of this virus, to higher mortality.

Success of Lockdown vs. Voluntary Strategies

An astute physician at the Massachusetts Medical Society recently asked when this state would institute a mandatory lockdown: when deaths doubled? When and if a second wave arrived? He noted that deaths in California, where a mandatory lockdown was quickly put in place in the middle of March, were half that of Massachusetts–despite the fact that the population there is many times larger.

Both lockdowns and voluntary advisories will, it is hoped,  eventually translate to success in bringing down the numbers of an epidemic. It is just that results appear to be much more rapid with the more rigorous mandatory lockdown–and the mortality lower. 

But why is the mortality from COVID so much higher in Massachusetts than in Sweden? The reasons reside in the ways the US is not like Scandinavia..

The Big Problem with the US adopting Swedish Policy: the US can’t actually emulate Sweden; so mortality will be–and is currently– much higher here 

While a certain number of the deaths in the US may be due in part to healthcare systems being overwhelmed (think New York City), so far that has not been the case in Massachusetts, nor in Sweden. But we have a higher total death number in Massachusetts than Sweden because we have a population with a  higher percentage of chronic health conditions, limited access to healthcare or bad experience with access that leads to delays in seeking care; and in the case of COVID, all of those factors correlate with higher mortality. Many patients, for race and equity reasons or for lack of available testing, have not received timely care; in addition, medical centers in this country perhaps did not initially recognize how quickly patients with  symptoms of COVID could progress, nor did they have the capacity to observe them in a safe place where care could be quickly ramped up should patients require further support–which  has led to increased mortality

In addition, the public health infrastructure in Scandinavia has offered guidance and consistent policy which has led to broad public support and compliance which has not been the case here in the US. And perhaps most importantly, the U.S. has little in the way of a social safety net.

 For all of these reasons, practicing the Swedish approach to COVID as the US has been doing will have a much higher cost in terms of mortality here than it did there–something we are in fact seeing now. This epidemic is laying bare all of the weaknesses in our healthcare and public health systems. 

Where We Should be Following Sweden (and Norway, Denmark and Iceland): A Stronger Social Safety Net

Dr. Burman points out that even though the US has taken the Swedish approach, ”most of the US is following the Swedish model without the level of social support that exists there.” Those social supports are particularly key when instituting a lockdown. All Scandinavian countries offered their citizens a robust social safety net during the pandemic.

In Sweden,  for example, although Volvo fired much of its staff, the workers received sick leave benefits from the government, according to Dr. Larsson. In Denmark there have been no food lines because its citizens were provided with up to 80% of their current salaries during the pandemic.  A reliable water supply was assured to everyone, unlike households in Michigan, where, according to Dr. Mona Hanna Attisha, a pediatrician in Michigan, thousands there have had their water service cut off  due to inability of residents to pay the water bill.

This is clearly an area that the US could productively emulate the Scandinavian countries: well-nourished citizens who are able to wash hands to protect themselves and their families from infection will protect everyone in a given society. With better social support*, everyone will have a better chance of survival in a pandemic because of the nature of infectious diseases in general and this one in particular.

[*Addendum since the first posting of this article: one reader observes that, although it does not address these local inequities nor the food bank lines not seen since the Great Depression, it is important to note that non-partisan CARES Act has offered an exceptional level of support to Americans who have been left unemployed due to COVID. Although the program was slow to get off the ground, back pay will be provided to those who have had difficulty accessing these funds. According to Raphael Bostic, President of the Federal Reserve Bank of Atlanta, “when very unexpected things happen, everything is possible.”]

Questions for the Future: Immunity

The big unanswered question for the U.S. and Swedish model is: have we engendered greater immunity in our population with the voluntary  “Swedish model” approach –and will that immunity offer some protection and therefore lower mortality down the road in the event of a possible second wave? That is possible. But it’s a gamble, since we don’t know how effective the immunity induced by COVID actually is and how long it lasts: does it last two weeks? Two years? If the former, then when the second wave hits, Sweden and the parts of the US that have been hit hard by the epidemic will be no more protected from the second wave than those that practiced a strict lockdown and whose residents therefore have little immunity.

The duration and efficacy of the immunity engendered by COVID is an area of active study.  So we will have to withhold judgement on the Swedish (and Massachusetts, among other states) approach until the nature of immunity gained by natural infection and its duration is better understood. 

What Will Happen When Voluntary Advisory States Open Back Up vs. Lockdown States

Many US states that have adopted the voluntary approach are now opening up for business. What will happen when states like Massachusetts, which is still seeing over 1,000 new cases a day, opens up? My guess is that we will see a relatively high rate of ongoing infection, with a significant bump in case numbers, including those with severe disease requiring hospitalization, and thus an increase in deaths also.  Much like Sweden, Massachusetts will likely continue to experience a more prolonged plateau of both high case numbers and elevated mortality (note the striking similarities in the pattern of both the Swedish and Massachusetts graphs of daily death numbers; the two are virtually superimposable).

Hopefully, we will not overwhelm our healthcare system when that happens.  

The most important takeaway is: although this trend will seem worrisome to the general public, it  does not mean that social distancing hasn’t worked to stop the virus from spreading–it just means that the curve will flatten more slowly than it did in Norway or Colorado. And the epidemic in Massachusetts may in the end take significantly longer to get under control.

Many pandemic experts are concerned that the US is attempting to open prematurely. This concern was voiced by WHO’s head of emergency preparedness, Dr. Michael Ryan, who espouses a more cautious approach to opening:  “shutting your eyes and trying to drive through this blind is about as silly an equation as I’ve seen. And I’m really concerned that certain countries are setting themselves up for some seriously blind driving over the next few months.”

Detect and Protect

Whether reopening or heading into the second wave–our chief focus should be on preventable deaths: the deaths that will occur where vulnerable populations that live in close proximity and the staff working there are not equipped with proper protective equipment, or provided with the means to distance and isolate if sick. The most important part of reopening is to protect all of the communities where crowding is unavoidable: communities like the nursing homes and assisted livings, the military, low income communities, prisons, homeless shelters. Infectious diseases have a way of inter-linking all communities: and the healthier these communities, the healthier all communities. 

The Swedes, in fact, are very candid about their failure to protect vulnerable populations and are working to rectify it. Sweden is spending over $200 million on protecting elderly patients in particular, which makes sense: in most countries and US states, the elderly account for between 50-65% of deaths; in Sweden, the elderly account for 90% of deaths.  We in the US can model our efforts on theirs–although in this country, the focus should be on protecting all of these vulnerable communities.

Alongside these preventive health strategies, Dr. Burman emphasizes that our other focus must be on “getting testing ramped up” to detect disease, as we continue to treat the sick, quarantine those with mild infection and those exposed, and arrange for “facilities for isolation, social and economic support for people who need to isolate and effective contact tracing.” These will be the best strategies to keep this infection at bay. 

Dr Carina King, an epidemiologist at the Karolinska Institute in Sweden says to remember that these strategies are a choice: that many deaths from COVID are preventable–not inevitable. We are offered informed consent for medical procedures; we should likewise be informed of the known outcomes to strategies to contain epidemics. 

The Economics of Strict Lockdown vs. Health Advisory

The above data suggest that mandatory lockdowns and travel restrictions may lead to lower mortality rates. But rigorous lockdowns may have another advantage: the countries and states that practice them appear able to open their economies more quickly–which may point to a lower economic hit. According to the Financial Times, “Analysts forecast that growth [in Sweden] will contract at a similar rate to rest of Europe. So practicing this strict guidance is not only good public health: it may be better economics.

 Sweden is still in stay at home mode and, like Massachusetts, is still faced with high daily new case and death totals. In contrast, Norway, Denmark and Iceland have all crushed the curve successfully–and this without the use of any special COVID treatment or vaccine–just using the traditional methods that have been used for eons to combat epidemics. In Norway, after a five- week lockdown, schools and businesses are reopening, and that reopening is happening in carefully orchestrated stages. Norway’s reopening started on April 21st; and it has yet to see a significant rise in either COVID cases or deaths.

At this point in the pandemic, that looks a lot like success–something that many of us living in Massachusetts wish were experiencing now.

For those who are interested in more comparisons….a table comparing strategies between US states and countries practicing mandatory lockdowns vs. social distancing

Photo credit: photo by Jonathan Brinkhorst, from Unsplash.com