The Swedish Response to COVID

The Swedish response has long been considered the polar opposite of the US response. The basis of those responses is “follow the science,” although the science of the Swedes is diametrically opposed to ours. But if we set the science aside, what is far more interesting is the similarity of the criticisms – mirror images despite “inverted” scientific underpinnings.

Could it be that the divisiveness over COVID policies has more to do with human behavior than scientific fact? Considering how Swedish culture and law shaped their response, it becomes clearer that COVID wars are just another skirmish in a larger cultural war. As you read the Swedish criticism of their COVID strategy, consider how they echo the same underlying concerns in the US.

A bit of background

Swedish law guarantees the right of its citizens to move about freely and receive an education; in fact, school attendance is mandatory in Sweden. The Swedish Communicable Disease Act allowed for restrictions of individuals or the quarantining of geographic areas, but the Government did not believe they had a legal basis for lockdowns. “Consequently, the Swedish strategy was based primarily on non-binding “soft law” recommendations, not compulsory nor enforced like in other countries.” This legal framework limited public health choices and served to “legitimize” passive inaction. The legal framework in the US provides far more latitude in public health measures, and the Government, including both the Trump and Biden administrations, implemented binding measures, e.g., travel restrictions and lockdowns.

The Strategy

The Public Health Agency (PHA) is the Swedish equivalent of the CDC and based its decisions on prior pandemic planning. In balancing public health and societal effects, their balance was more on minimizing the “negative effects on society.” The US and the Swedish goal were identical, not overwhelming healthcare resources, flattening, not eliminating the curve. Still, the Swedish “strategy was centered around individual responsibility” – no legal restrictions or fines were implemented in 2020. Ours was more compelled.

“The Government stated that their policy and decisions aim to: (i) limit the spread of infection in the country; (ii) ensure healthcare resources are available; (iii) limit the impact on critical services; (iv) alleviate the impact on people and companies; (v) ease concern, for example by providing information; and (vi) ensure that the right measures are taken at the right time.”

Of course, actions speak louder than words

What was done

Both the US and Sweden set priorities. We set priorities as to which businesses might remain open as “essential services,” and we asked those most at risk to be placed at the front of the line for vaccination. In order not to overwhelm limited intensive care resources, hospitals and health systems implemented placement triage; the most ill receiving the most intensive care.

Sweden, with a population of roughly 10 million, is about the same size as New York City. Sweden has 90 critical care beds; New York City has 760. So triage into critical care, while discussed in the US, was acted upon in Sweden. There are a few reported instances of the disabled in the US being triages away from critical care, but in Sweden, those deprioritized were

“…individuals with comorbidities, body mass index above 40 or over age 80 were not to be admitted to intensive care units, since ‘they were unlikely to recover’”

Ageism is alive and well in Sweden; 20% of nursing home patients were denied individual medical assessment in making these triage decisions which were done “without informing the patient or his/her family or asking permission.”

Despite the images of the Swedes enjoying their social freedom, fed to us by the media, the PHA recommended early on avoiding unnecessary travel or social events, social distancing, and hand washing. Visitors to nursing homes were banned in both the US and Sweden in March 2020.

The Children

Criticism was leveled against CDC guidelines concerning in-person learning, social distancing, and masking. In Sweden, similar charges were leveled, but the script was flipped.

• “The Public Health Agency denied or downgraded the fact that children could be infectious, develop severe disease, or drive the spread of the infection in the population; while their internal emails indicate their aim to use children to spread the infection in society.”
• Schools for those under age 16 remained largely open, as distance or remote learning is not allowed. “No exception was made for children with parents in risk groups or, initially, for children with family members with confirmed COVID-19.” And those parents attempting to keep their children at home were reported to social services and fined.
• Face masks were not allowed, which critics felt was “in conflict with the Parental Code (Föräldrabalken), which states that parents should protect and provide care for their children.”

Early Xenophobia

“President Trump on Wednesday defended his increasingly frequent practice of calling the coronavirus the “Chinese Virus,” ignoring a growing chorus of criticism that it is racist and anti-Chinese.

“It’s not racist at all,” Mr. Trump said, explaining his rationale. “It comes from China, that’s why.”  - NY Times

Here are some of the statements of the PHA that drew concern:

• “The corona infection in the nursing homes may have been spread by staff with poor command of the Swedish language.”
• “We have larger spread because of the larger immigrant population.”
• “Only the foreigners get ill.”
• “Only people looking like tourists wear face masks in public.”

Agents of Change

As in the US, the decisions regarding the pandemic were referred to the PHA and the regions and municipalities. Here are the concerns of the critics:

• Citizens and the public were never fully informed or included in the deeper reasoning behind their decisions.”
• “The assumptions and modeling from the Public Health Agency were not communicated, or they were presented in a methodologically unsound and unscientific manner raising more questions.”
• “Both the Government and the Public Health Agency declined any responsibility for the situation in the elderly homes and referred to the responsibility of the municipalities (responsible for nursing homes) and regions (responsible for equipment, crisis preparedness, and healthcare—especially in elderly care) The care homes and hospitals referred back to the Public Health Agency since that agency provided advice on personal protective equipment and routines to follow.”
• “Because of this sparsity of data, including records of meetings, it appears the strategy was based on the opinions of a very limited number of individuals …This small group of “experts,” with a narrow disciplinary focus, also went beyond their mandate and expertise—for example, commenting on the economic effects—and demanding more power/authority than they were legally allowed to have.”

Information just wants to be “free.”

Critics in both countries pointed to a lack of transparency in data provided to the public creating an “evasive accountability structure.”

• “The number of available ICU beds per region was not publicly available, and regions were unwilling to share information on the spread of the infections to the municipalities.”
• “Many schools did not inform parents or even teachers about confirmed COVID-19 transmission on the premises, nor reported it to official agencies, and urged parents not to tell if their children were infected—since this would “spread fear.”
• “Some municipalities refused to declare the number of deaths in the care homes and there was an attempt to keep the death rates “ covered up” at a regional level.”
• “The underlying models for decision-making from the Public Health Agency and their assumptions were not made public... even expert scientists could not evaluate these and had to rely on press conferences and interviews….”
• “After receiving critique that the Public Health Agency did not consider knowledge or expertise outside the agency, Director General Johan Carlson, announced the members of a newly formed advisory group [including]… six clinicians and scientists with expertise in clinical microbiology, clinical virology and infection control …None of the academic experts that had spoken up publicly with approaches more in line with WHO were invited or selected.”

Push Back

Sweden's largest trade union was pushing back, questioning “the Public Health Agency’s claims that proper face masks or personal protective equipment were not needed when treating COVID-19 infected patients.” Echoes of our teacher’s union and antithetical to the concerns of some of our police and fire unions.

In the US, we saw the rise of America’s Frontline Doctors repurposed to fight the mainstream narrative on COVID-19. In Sweden,  there was the Science Forum COVID-19 with “the declared mission of the association is to save lives and help prevent all forms of suffering during the COVID-19 pandemic by educating the Swedish public about ongoing scientific discussions ….”

And then there were concerns about intellectual independence

• “Sweden’s leading medical research institution in Stockholm, Karolinska Institute …appointed a[n] expert group for the COVID-19 outbreak. Yet, this selected group had clear ties with the Public Health Agency, leading to questionable independence. Hence the Swedish public was led to believe that several experts had separately come to the same conclusion that the unique Swedish strategy was the right.”
• “Several individual academic researchers questioned the Swedish strategy in the social, (inter)national media, and scientific literature. Many have been reprimanded by their superiors, e.g., that they were supposedly not allowed to use their university affiliation, or that they were criticised for undermining the authorities.”
• “Questioning the strategy, even in academic settings, the media, or the Government, was apparently not accepted by the Swedish society and considered disloyal, and critics were discredited as “hobby-epidemiologists” or lacking competence.”

Honest brokers

Many scientists and physicians speaking up in the US and Sweden have limited experience crafting policy; the PHA, like the CDC, was positioned as the arbiter, “trusted to evaluate and interpret prior and new science relevant to guiding the pandemic response.”

• “In practice, the Public Health Agency has primarily acted as an Issue Advocate, reducing the scope of choice available to decision makers, actively discouraging discussion of alternative options, and instead focusing on promoting and justifying their own policy choices. Their narrative at regular press conferences was presented by the national media with little critical questioning (despite regular contradictions), or fact checking.”

Despite very different scientific beliefs, there is a parallelism to the critique of government action in the US and Sweden that is ignored at our peril. This is especially true of polarization between strong supporters of the government position and “those raising critical questions.” Again, I remind you we are talking about very different scientific assumptions. In Sweden, those whose critical questions were belittled were “disillusion in the authorities and healthcare system, [with] and a broken trust in the Welfare State.” Here in the US, you can substitute Deep State. I will end with two particularly salient quotes,

“A one-way trust in “ the authorities” was expected from the entire population. Yet, the authorities did not trust the people enough to be transparent in their communication, strategy, and outcomes.”

“A select group who clearly lacked the multi-disciplinary expertise required to handle all aspects of a pandemic, took on the role as scientists, health officials and political decision-makers—without any opposition or questioning by the political system. Critical questioning, even by internationally renowned scientists and experts, became risky, even dangerous, in a country where conformism was encouraged by the national media.”

Source: Evaluation of science advice during the COVID-19 pandemic in Sweden Humanities and Social Sciences Communications DOI: /10.1057/s41599-022-01097-5