The Strange Case of Sweden in the COVID-19 Pandemic

Many countries hit by the pandemic are now exiting or about to exit the period of most stringent isolation measures. Indeed, they estimate they succeeded in controlling contagion. Meanwhile, they avoided the dreaded break down of their health-care system, which could have taken place if hospitals had been overwhelmed.

In Europe, one country stands apart, Sweden. The oft-heard narrative runs as follows: Sweden appears to have decided for a policy of laissez-faire; it recommended but never imposed; it thus has hardly or no exit policy to design and implement, because there is not so much to exit from. Meanwhile, it does fare much better in its handling of the COVID-19, notably in economic terms, while the toll it pays in terms of casualties is far from terrible.

Is this narrative correct? What are the facts? How can we explain the difference between “Sweden and the rest”? Can we already draw lessons from the Swedish case or is it truly too early in the pandemic to do so? Does that mean that all countries who implemented social distanciation and other measures were wrong to do so? Without falling into a caricatural black and white judgement, are there some lessons we could learn from the way Sweden handled this part of the pandemic outbreak? Is it reproductible in time and elsewhere?

These are crucial questions for policy-makers as they are preparing the exit strategy from lockdown and as they need to provide security to their citizens. It could give them further elements to succeed in protecting citizens both from disease and from economic hardship.

These are keys questions for businesses, corporate and financial actors, as they will lobby political authorities for their interests and as they also need to anticipate for the future of their activity.

These are crucial questions for citizens, who need to be able to assess the way their political authorities succeed in their mission of protection of those who are ruled.

This article addresses the way Sweden handled, so far, the COVID-19 pandemic and the “Swedish model” narrative. The aim is to assess in which way the Swedish strategy can be used as a model by others, not to judge the way Swedish authorities handled the COVID-19.

First, the article focuses on the policies and measures Sweden took to face the COVID-19, the rationale for these measures and their actors. Second, it looks at current impacts of these measures, in terms of health and in economic terms. Finally, it wonders about the reality of the idea of an exceptional Swedish model. It looks first, assuming there is a model, to its replicability. Then it questions the very idea of a Swedish model.

Sweden faces the COVID-19

Since the start of the COVID-19, the Public Health Agency of Sweden (Folkhälsomyndigheten) has had the upper hand on all decisions regarding the Swedish answer to the epidemic (Hans Bergstrom, “The Grim Truth About the “Swedish Model”“, Project Syndicate, 17 April 2020). Anders Tegnell, epidemiologist and head of the Department of Public Health Analysis and Data Development of the agency leads the effort (Ibid.).

According to Hans Bergstrom, professor of political science at the University of Gothenburg, Tegnell’s strong and often erroneous convictions paved the way for Sweden strategies (Ibid.). Tegnell did not believe the Chinese outbreak could spread. Then he thought case tracing was a sufficient measure to control the COVID-19, as there was no sign of community transmission inside Sweden (Ibid.). Bergstrom (Ibid,) argues that “between the lines”, Tegnell seeks to progressively achieve herd immunity. Meanwhile, considering that the COVID-19 was there to last, Tegnell thought that policies that could be sustainable over time economically and psychologically had to be implemented (Ibid.).

Indeed, Tegnell interviewed in Nature, confirms this vision:

“This is not a disease that can be stopped or eradicated, at least until a working vaccine is produced. We have to find long-term solutions that keeps the distribution of infections at a decent level. What every country is trying to do is to keep people apart, using the measures we have and the traditions we have to implement those measures. And that’s why we ended up doing slightly different things.

Marta Paterlini, “‘Closing borders is ridiculous’: the epidemiologist behind Sweden’s controversial coronavirus strategy“, Nature, 21 April 2020

Tegnell also stresses that none of the most severe measures implemented elsewhere, such as isolation, are grounded into scientific evidence, and that epidemiologists produced models that were too pessimistic (Paterlini, Ibid.).

As a result, Sweden advised its citizens to practice social distancing and to work from home, but enforced little. Standing at bars is forbidden but restaurants are opened (Emergency Information from Swedish Authorities, “Ban on crowding in restaurants, cafés and bars“, Bekräftad information om coronaviruset, 25 March 2020).

Entry ban applies primarily to foreign citizens attempting to enter Sweden from all countries, except those in the EEA and Switzerland from 17 March 2020 until 15 May, i.e. 30 days (The Swedish Police, Travel to and from Sweden affected until 15 May 2020).

The exemplary Swedish sense of social responsibility and the unique Swedish values are touted as having allowed the policy to be successful. Sweden would be, deep down,

“A model society based on values of social justice and human rationality, with a high level of trust between people and trustworthy authorities. This has its origins from the Social Democrat-introduced concept of “Folkhemmet,” or people’s home, where a welfare state cares for all with the proviso that everyone complies with a communal order.”

Heba Habib, “With science and shared values, Sweden charts own pandemic course“, The Christian Science Monitor, 27 April 2020.

As a result, people are believed to responsibly follow their government’s suggestions, which translates in successful policies. Hence, early April it was estimated that 50% of people worked from home, that usage of public transports had decreased by 50% and that streets in Stockholm were only 30% as busy as before the COVID-19 (“Sweden’s Outlier Response To COVID-19, And Its Results So Far“, PYMNTS.com 16 April 2020)

Thus, until 24 April 2020, Sweden has had a far less constraining policy to control the COVID-19 than its neighbours or than most of the world, as shown in the table below listing the measures Sweden took compared with its Nordic neighbours.

In a 21 April’s interview, Tegnell acknowledged that most of the Swedish deaths came from care houses for elder people and that an investigation in the high number of deaths is needed (Ibid.). Yet, according to him, it is not the COVID-19 strategy that potentially failed here, but the social-care system (Jenny Anderson, “Sweden’s very different approach to Covid-19“, Quartz, 27 April 2020).

Tegnell also does not believe much into asymptomatic contagion, or only at the margin, and decries closing borders, as the contagion now exists within European borders (Paterlini, Ibid.). However, he is also forgetting that Sweden is de facto protected by others’ closing borders and by others’ policies.

As a whole, Tegnell is satisfied with the policy he designed and its results.

However other top Swedish scientists contested this approach and 22 of them published an open letter in the Swedish newspaper Dagens Nyheter: “Public health authorities have failed – now politicians must intervene.” There they highlighted a dangerous failure of public-health authorities as deaths topped 1000. They asked political authorities to intervene and change policies.

On April 15, 2020, the Swedish Parliament indeed “extended their agreement on temporary parliamentary procedure during the COVID-19 outbreak to last until at least April 29, 2020” (Library of Congress, Legal Monitor; Sveriges Riksdag, 15 April 2020).

Yet policies did not change, up until 24-27 April 2020.

Impacts… so far

What are the impacts of the policies Sweden implemented regarding the COVID-19?

Health results

A peak?

On 24 April 2020, there has been 17.567 cases identified and 2.152 deaths (John Hopkins CSSE: Tracking the COVID-19 (ex 2019-nCoV) spread in real-time). On 27 and 28 April, 11:30, there has been respectively 18.926 and 19621 cases identified and 2.274 and 2.355 deaths (Official Swedish data updates), but data for the last 7 days still need to be consolidated (Maddy Savage, “Coronavirus: Has Sweden got its science right?“, BBC News, 25 April 2020). So far hospitals have not been overwhelmed: 1.353 for 27 April, 1388 people for 28 April are in intensive care.

As we monitor the situation after publication of the article, on 4 May 2020, we have 22.721 cases identified and 2.274 and 2.769 deaths (Official Swedish data updates). Interestingly, the figures for 24, 27 and 28 April are now revised and give respectively 18.100, 19.400 and 20.100 cumulative positive cases.

The Public Health Agency of Sweden suggested, first, that, in Stockholm, the epidemic peaked on 17 April 2020 (Reuters, “Swedish health agency says virus has peaked in Stockholm, no easing of restrictions yet“, 21 April 2020). Stockholm represents half of the confirmed cases in Sweden (Ibid.).

Yet, by 27 April 2020, the number of daily cases still rises, with a strong increase between 21 and 24 April, then with lower rises. If the trends continues towards lower increases, then a peak may indeed have been reached.

However as the new updated graph for 4 May 2020 (monitoring after publications) depicts, the revised data show an increase rather than a decrease. Furthermore, 29 April is the day with the highest number of positive cases since the start of the epidemic, i.e. 778 cases, followed by 24 April with 769 cases and 28 April with 750 cases. Thus the idea of a peak for Sweden needs to be questioned, and monitored considering also the variations in data.

Meanwhile, as shown on the graphs below, and considering the uncertainties on data for the last seven days, the number of deaths reported has strongly fallen and the number of people in intensive care units has also fallen.

Thus do we have a peak or not? The reality of a peak is still unclear and only time will tell (John Hopkins data, see also official Swedish data updates). Nonetheless, as we shall see below, the 21 to 24 April period cancelled previous expectations of a peak.

Comparisons

Compared with its neighbours, even considering its larger population, Sweden has fared less well, as shown in the table below. Swedish rates are rather similar to those of the Netherlands, another country that initially had a laissez faire policy.

All the three other Nordic countries, notably Norway, seem to have clearly peaked. The Netherlands has also most probably peaked.

In the case of Sweden, and as we shall further see below, there is ground to worry that Sweden’s peak is not so easy to achieve.

Economic results

Despite rather lax policies compared with most other countries, Sweden also faces economic damages.

Indeed, Sweden also depends on others for its trade and activity. Thus, on 8 April, the economic research unit of BNP Paribas estimated that the country would be hard hit by the major slowdown in global trade, as exports account for 45.6% of Sweden’s GDP.

Yet, some indicators, such as personal spending and unemployment’s increase were also better in Sweden than in Norway (Darren McCaffrey, “Analysis: Is Sweden right in its handling of COVID-19?“, Euronews, 22 April 2020).

Nonetheless, on 24 April 2020, the Swedish finance minister stated that she expected the economy to shrink by 7%, more than she initially thought, and unemployment to reach 11% (Radio Sweden, “More restaurant corona inspections, economy expected to be hit harder, more infections in nursing homes“, 24 April 2020).

So is there really ground for a model? Sweden did not fare as well as its neighbours in terms of protecting the health of its citizens. Yet, it also did not fare worse than, for example, the Netherlands, so far. But again, the Netherlands appears to have peaked. Meanwhile, the economic cost for Sweden is on a par with 14 April IMF forecasts for the Netherlands as the Dutch economy is expected to shrinking by 7.5% in 2020 (DutchNews.nl, “IMF sees Dutch economy shrinking 7.5% this year, unemployment to hit 6.5%” 14 April 2020).

At first glance, and considering that we are still at the start of the pandemic, it is difficult to assess if we have or not a Swedish model. Let us thus now look at a potential replicability of the model, and then at the evolution of the last couple of days.

A Swedish model?

If there is a Swedish model, is it replicable?

First, besides the role the cultural and socio-political values model plays, Sweden was also probably protected from even higher levels of contagion by a low population density, as shown on the comparative graph below, and despite variations according to areas.

Second, Sweden did not have the same global exposure to the world as other nations such as Spain, Italy or France. Indeed, using World Bank statistics, in 2018, Sweden’s main partners, for exports, were Germany, Norway, Finland, Denmark and the United States, and for imports they were Germany, Netherlands, Norway, Denmark and United Kingdom. By comparison, France’s major partners for exports were Germany, the United States, Spain, Italy and Belgium, and for imports they were Germany, China, Italy, Belgium and Spain. Italy’s major partners were for exports Germany, France, the United States, Spain and the United Kingdom and, for imports, Germany, France, China, Netherlands and Spain.

As a whole, Sweden receives far less travellers (tourism includes business trips) than other countries that were more quickly and more intensely hit by the COVID-19, as shown in chart below for Inbound tourism 2018 (UNWTO statistics).

Thus, considering the specificities of Sweden, if there is a model, it can only be replicated in countries that benefit from the same conditions. Meanwhile, these specific factors also point out that rather than only a specifically designed model, we have here particular circumstances, as for every country, or more largely unit of analysis, interacting with a specific strategy.

But is there truly a Swedish model?

Now, we may also wonder if there is truly a Swedish model, considering the 21-24 April 2020 COVID-19 related data.

Towards a change of policies? Not a different model but different dynamics?

The Swedish government also noted the new rise of cases observed between 21 and 24 April (David Nikel, “Sweden Health Chief Admits ‘It’s Not Over’ As Coronavirus Cases Leap“, Forbes, 24 April 2020). The Swedish Public Health Agency acknowledged the increase. As reported by Forbes, Tegnell stated:

“There have been more deaths than expected. It is definitely not over. We see that especially in the small rise in Stockholm again”

David Nikel, “Sweden Health Chief Admits ‘It’s Not Over’ As Coronavirus Cases Leap“, Forbes, 24 April 2020.

The disappointing results would be related to the Easter week-end.

As a result, the Swedish Civil Contingencies Agency warned that people should not relax their responsible approaches (Ibid.). In the meantime the mayor of Stockholm threatened to close restaurants and bars if safe distancing was not respected (ibid.). Some of them were indeed shut by the local food safety board, while Springtime celebrations were cancelled (Radio Sweden, “Stockholm bars shut due to crowding, springtime celebrations cancelled, warning for long-term unemployment“, 27 April 2020).

Thus, when confronted with an unexpected rise of cases, the Swedish authorities have to resort to the same policies as others. They have to reinforce social distanciation rules.

If such rises happen again, then, considering the very recent decisions, it is possible that the authorities will need to continue on the path of more stringent measures.

In that case, Sweden would just follow on the track of other countries. The “model” would actually rather be a longer initial phase, until more stringent measures become necessary.

If the data are improve and then remain good, then Sweden may relax measures again. Thus, if there is a model, it may be one that promotes flexibility.

Timing matters for preparedness

Should COVID-19 cases rise strongly again, Sweden would then risk facing a shortage of intensive care units ICU), as happened elsewhere.

It seems, however, that Sweden is well prepared in terms of ICU capacities. The ICU initial (pre-COVID-19) capacity of Sweden was 526 beds (Joacim Rocklov, “COVID-19 health care demand and mortality in Sweden in response to non-pharmaceutical (NPIs) mitigation and suppression scenarios“, MedRxiv, 7 April 2020).

Rocklov estimated the ICU capacity could be doubled with preparedness, which is what seems to have taken place (Ibid., Anderson, Ibid.).

On 26 and 27 April, COVID-19 patients in ICU would be respectively 558 and 543, thus hovering above the initial number of beds available for all pathologies (Svenska Intensivvårdsregistret). If the capacity has doubled as a result of preparedness, then Sweden is probably able to handle a substantial amount of new cases.

Preparedness in terms of ICU capacities, assuming the doubling of the capacity is correct, could be seen as a successful element of the Swedish model, but it could also have been achieved with less fatalities.

Towards homogenisation?

Now, if the Swedish political authorities were to continue on the path towards more severe restrictions, because they do not succeed in truly achieving a peak, this evolution could take place just when other countries relax their policies.

The countries exiting from severe isolation measures will then fear a return of the epidemic and a second wave. They will most certainly pay a very high attention to the possibility of imported cases, as China does. Thus the Swedish strategy of not believing in travel controls, added to an uncertain peak could threaten to backfire. As a result, the combination of factors could force Sweden to also change its travel policies. This is all the more likely that Sweden did contribute to the general European contagion as early a 7 February 2020, as shown in the fascinating Spanish study tracing the phylogenies of the virus in Europe (Francisco Díez-Fuertes, et al. “Phylodynamics of SARS-CoV-2 transmission in Spain“, bioRxiv, 20 April 2020). True enough, on 7 February most European countries were mocking those fearing a ridiculous small flu-like epidemic. Yet, since then, they appear to have learned.

In that case, the uncertainty of the epidemic curve could play as a disadvantage for Sweden, or, to the least, would force Sweden towards homogenisation. The great political scientist Fred Halliday has shown the imperatives of homogenisation in international relations (Rethinking International Relations, 1994). Further research would be needed here to evaluate if the case of Sweden could give us indications that such dynamics towards homogenisation will be at work in the months and years to come, which is crucial to properly build scenarios.

The model in this case would be different from what was initially expected. It would show the importance of timing, the possible danger of an uncertain epidemic curve as seen by others and a possible tendency towards homogeneity.

Trial by pandemic

If ever the COVID-19 evolution went wrong, and if Sweden had to abandon its touted “cultural” model, then it would be the very belief-system underpinning its socio-political organisation that would be questioned.

Trust in political authorities could be impaired, which would twice hurt the Swedish polity. First, as for any political system, the legitimacy of political authorities would diminish. Second, because trust in the system is so crucial to Sweden values, these very values could be shaken. To measure the difference, imagine a system where the constructed shared historical values led to diffidence towards central political authorities, as in the U.S..

However, this “trial by pandemic” is not exclusively a threat for Sweden. Each and every polity has to face it. How each will handle it, how each will be able to reinvent its system to overcome the threat will most probably deeply change each society and the international system.

It is probably too early in the pandemic to conclude with certainty about the success of the Swedish measures in handling the pandemic. However, looking at the Swedish case helped us understanding better how societies handle the COVID-19 pandemic. It also highlighted that there is no such a thing as a Swedish model that could be an easy recipe to follow by all in our global struggle against the COVID-19.

Further bibliography

Francisco Díez-Fuertes, María Iglesias Caballero, Sara Monzón, Pilar Jiménez, Sarai Varona, Isabel Cuesta, Ángel Zaballos, Michael M Thomson, Mercedes Jiménez, Javier García Pérez, Francisco Pozo, Mayte Pérez-Olmeda, José Alcamí, Inmaculada Casas, “Phylodynamics of SARS-CoV-2 transmission in Spain” bioRxiv 2020.04.20.050039; doi: https://doi.org/10.1101/2020.04.20.050039

Paul W Franks, “Covid 19 coronavirus: Sweden thinks we’re underestimating how many people have had virus“, The New Zealand Herald, 24 April 2020.

Featured image: Kurious (pixabay.com)