“No lockdown strategy puts Sweden at odds with Europe,” blares today’s Financial Times headline. “…Norway takes first steps towards reopening,” reads another headline on the same page. The takeaway: Sweden hasn’t taken the proper measures to curb COVID infection, while Norway and Denmark are praised for ‘crushing the curve’ and reopening their societies.
There is no question that Norway and Sweden have taken different approaches to combating SARS-CoV-2, the new virus that launched a global pandemic of COVID nearly five months ago. Since current data point to a much higher mortality rate in Sweden than Norway, it is important to consider how exactly their strategies differ and the implications of those differences. Understanding the outcomes of these policies is particularly critical here in the United State since many of these strategies are being implemented here.
Sweden’s strategy: Health advisory, not a mandatory lockdown
Much has been made of Sweden’s lack of a lockdown to protect its citizens from coronavirus; but according to Swedish physician Dr. Stefan Larsson, the Swedish approach has been mischaracterized: it has been “twisted in the media to polarize and get some headlines,” he says. Dr. Larsson wrote to me that there is a widespread misconception that Swedes are free to work and go out socially:
“We have not had a full lock-down, but everyone who can work from home has been encouraged to do so – and anyone who is an essential worker with symptoms has been asked to stay home at full pay. Compliance has been very good. Elder care centers and hospitals have had no visits since mid- March. Nobody has social dinners with groups of friends, and cinemas, theaters etc have all been closed. In the larger shopping malls, I’d say 1/3 of shops are closed, others very empty, but some stay open for the occasional shopper. Companies in the manufacturing industry are largely closed. I expect maybe 50% of restaurants open, but social distancing is required — two meters between people so typically every second table is open. Just last week, five restaurants in Stockholm were forced to close because they were not compliant with this guidance.“
Dr. Larsson says the photos in the American press that show large gatherings are misleading: “Many of the images in the media are taken with a telephoto lens with a deep focus, so it looks like people are sitting on top of each other…People sit in pairs of two – and most of them 1.5-2 meters apart….”
Different Outcomes in Norway Compared to Sweden: Ten times higher COVID death total in Sweden
The most serious health outcome observed in Sweden is the high death total due to COVID: Sweden has lost over ten times as many people (3,040 as of this writing) as Norway. With a population twice the size of Norway’s and with a very similar demographic make-up, one would have expected Sweden to lose about twice as many as the Norwegians did to the pandemic– or about 430 people (Norway has lost 216 people to COVID as of this writing). At 301 deaths/million, Sweden has one of the highest death rates in Europe. In contrast, Norway’s death rate is 40/million.
Sweden’s total numbers include presumptive COVID deaths as well as confirmed. There do not seem to be unaccounted for excess deaths in Norway at this point; so all deaths there would appear to also include presumptive and certified COVID deaths–thus, it is appropriate to make the comparison.
How to Explain the Difference in Mortality?
Both Norway and Sweden have the ideal medical infrastructure and organization to handle this sort of crisis; and both, unlike Italy and France, have so far successfully met the challenge of COVID, in that their hospitals and ICUs have not been overwhelmed by the epidemic. So why the difference in outcome?
Both Norway and Sweden allowed restaurants that could enforce social distancing between tables to remain open. Norway closed all of its schools, seeing them as a route of asymptomatic transmission; Sweden closed from grade 10 up as well as its universities, on the theory that allowing infection to occur among a group that would be mildly symptomatic would be a good thing and foster so-called herd immunity.
But the key difference between Norway and Sweden’s approach is that in Norway, the lockdown was mandatory, not an advisory. This was also true in Denmark and Iceland–countries whose total deaths have been. like Norway’s, from ten times (Denmark) to 100 times (Iceland) lower than Sweden’s. Norway’s lockdown was also enforceable: failure to keep social distance and failure to self-quarantine if diagnosed with COVID is punishable –and in some cases has been punished–by a fine or even jail time. As in Denmark and Iceland, the lockdown included travel restrictions and border closure.
Sweden’s directive was more like health advice: it was not enforced and it did not include travel restrictions.
Interestingly, a significant difference in total deaths is also seen in the United States between states that have adopted a mandatory lockdowns and those that have only an advisory. In the US, school closure has been almost universal; which may suggest that it is the nature of the lockdown, and not school closure, that may be the stronger predictor of mortality.
Similarities: Failure to Protect Vulnerable Populations
This has been a humbling pandemic, and some mistakes have been made world wide. The most important of these mistakes was the failure to protect vulnerable populations. In China, the most highly affected vulnerable population was initially healthcare workers; in Norway and Sweden, the most hard hit vulnerable population has been the elderly in nursing homes: over 50% of those who have died in this epidemic in both countries lived in what they call elder care centers.
Why did over ten times more people die in Swedish nursing homes than in Norwegian? A number of factors may have been at play. Lack of personal protective equipment (PPE) may have played a role at least initially, in both countries. According to Dr. Larsson, healthcare workers in Sweden were relatively well protected: obtaining personal protective equipment or PPE supplies, he says,“has been challenging, but in most cases hospitals have been OK, partially because a bunch of private companies have stepped in to help manufacture gowns and face masks. Absolut, the Vodka company, changed their manufacturing process to produce alcohol for hand disinfectant.”
But PPE was not initially provided to nursing homes in Sweden and there was little education on how to use it properly: according to Dr. Larsson, “The issue with PPE has been in the elderly care centers – where staff are not trained to use them and access was poor. This is where the Swedish approach has failed.” Dr. Larsson also mentioned that Swedish nursing home workers were more likely to come to work sick, because they are paid hourly.
Perhaps the Norwegian death rate in the nursing home setting was considerably lower for two reasons: first, there are fewer nursing homes overall, since Norwegian policy supports keeping the elderly in their own homes; and second, workers there benefit from a more forgiving sick leave policy. If Norwegian caregivers are sick, they are paid even if they stay home–and therefore would be less likely to bring COVID to work.
Another vulnerable population in Sweden that was not protected was the immigrant population; and this population is much larger in Sweden than in Norway. While immigrants comprise 0.5% of the total population in Sweden, they account for 5% of confirmed cases. Immigrants in Sweden have been disproportionately affected by COVID for two reasons: government advisories were not translated so that immigrant communities were aware of the health risks; and immigrants live in overcrowded communities and generally suffer from poorer overall health.
The Swedish Public in favor of Stronger Policies
Although Americans who cite the Swedish example generally do so as a rationale to take fewer precautions, it is interesting that the vast majority–three quarters –of Swedes who were polled by the Stockholm School of Economics would like to see their government put into place stronger measures to combat COVID, such as temporary curfews, travel bans and more tax relief for small businesses.
Open Questions
Dr. Birgitte Borch, a physician colleague of mine in Denmark, told me, “It will be interesting to see in a year or two which of the strategies worked out best in the end. We should be careful not to make quick judgements; but our different experiences may help shine some light on how we can most successfully deal with pandemics in the future.”
Big questions remain to be answered. What will happen as the countries that enforced strict lockdowns begin to open up, as Norway and Denmark are doing now? Will they see a large second wave of coronavirus infection? Does doing a great job of combating the virus early on imply a greater risk of resurgence later– and perhaps lead to the need to socially distance again, as some researchers in infectious disease modeling have suggested?
In terms of economic impact: is it better to lock down an economy for five weeks and gradually re-mobilize like Norway or adopt a voluntary stay at home policy like Sweden, that leads to a longer plateau of community infection and higher mortality? While it is true that the Swedish policy has enabled its the economy to keep going at a markedly reduced level of functioning, if overall the economy remains on hold longer –which is better? Five weeks of total lockdown, or months of a voluntary stay at home policy? That is a key question.
The greatest unknown–and what will determine, to a large extent, whether one strategy is superior to the other, revolves around the question of immunity.
Misguided or Brilliant?
Sweden’s approach assumes that prior infection leads to herd immunity, meaning that those who are infected will later not be susceptible to reinfection, at least for a period of time. Unlike Norway, Sweden has kept its elementary and grade schools open in the hope that immunity would become widespread in this less vulnerable population. If the strategy works as intended, when the second wave of infection hits, mortality rates will be lower because a certain percentage of the population is immune.
But the efficacy and duration of immunity has not yet been demonstrated in the case of SARS-CoV-2. If immunity only lasts two weeks, that will be much less protective to the population than if it lasts two years. In addition, there is concern that a second encounter with the infection might result in worse disease, as with some other viral infections.
Denmark, Norway and Iceland may indeed experience a second wave and need to lock down again. But it is to be hoped that by buying time and learning more about the virus– if a lock down is necessary again, there will be new knowledge and skills around how to protect those most vulnerable to it, such as immigrant populations and the elderly; and adequate protection for those individuals will already be in place.
In addition, through adequate testing and contact tracing and quarantine, it is hoped that these countries will be able to identify cases and contacts and thus limit infection preemptively. Also, new therapies and vaccines are in the pipeline; hopefully, these therapies will help shorten or prevent the disease by the time the second wave hits, when and if it does hit.
We have much still to learn about SARS-CoV-2. For all countries, this pandemic has been a humbling experience.
Up Next: Some States in the US have adopted COVID policies like Sweden’s and others, like Norway’s. What are the consequences?
Photo credit: photo by Conner Bowe, from Unsplash.com
