Sweden’s coronavirus suppression strategy was an experiment that few other nations dared champion.
The country’s approach has been more liberal than lockdowns imposed in neighbouring countries or, indeed, around the world.
Instead of mandated curfews and shutdowns, Sweden chose to keep most schools and businesses open throughout the COVID-19 outbreak.
But the model has come under fire, particularly in recent days after email exchanges of the country’s chief epidemiologist at the beginning of the pandemic came to light.
The emails, obtained by Swedish journalists under freedom of information laws, showed that in March, Anders Tegnell appeared to ask whether a higher death rate among older people might be acceptable if it led to faster herd immunity.
“One point would be to keep schools open to reach herd immunity faster,” Dr Tegnell wrote.
He has famously said that although the death rate was too high, “on the whole [Sweden] would go down the same route” if it had its time again.
Sweden’s death rate is among the worst in the world, although it remains lower than some European countries which had imposed much harsher measures, including Italy, Britain and Spain.
More than 5,700 Swedes have died since the start of the year and health authorities have since acknowledged there were clear failings in the preparedness of aged-care homes, just as we’re seeing in Australia.
The Swedish Government has ordered an inquiry into what went wrong in aged-care homes, where thousands died after being exposed to COVID-19.
But cases and deaths have fallen dramatically since a surge in infections earlier this year, professor of infectious disease epidemiology at Stockholm’s Karolinska Institute Joakim Dillner said.
“The reproductive rate of the infection declined drastically as a result of these non-compulsory measures,” he said.
Herd immunity remains contentious within the scientific community
During the pandemic, Sweden has been the pariah in Scandinavia.
Its approach was starkly different from the suppression strategies adopted in Norway, Denmark and Finland.
Yet life in Sweden has still changed for many of its 10 million citizens, prompting immunologists to suggest its strategy can’t be seen as relaxed, just less stringent.
The Swedish Government did put some restrictions in place. Large gatherings were banned and Swedes were asked to avoid non-essential travel, work from home, and to isolate if they were unwell.
And unlike many European countries which first shut up shop and then re-opened for summer, most of Sweden’s measures to curb infections remain the same.
“We’ve had a rather open society, based on recommendations,” Professor Dillner said.
“We’ve not really had draconian measures, but it’s still obvious that it worked.”
But Professor Dillner says within the scientific community there is still “fierce debate” over the strategy that has been adopted.
Prioritised testing of people who are sick, and not widespread screening of healthcare workers, was a mistake in his view.
“There was no screening of the healthcare workers in homes for the elderly, and I think at least in the scientific community, we’re upset about that,” he said.
“We feel that when the WHO said ‘test, test and test again’ — we should have done that.”
Officials were relying on common sense of citizens
Earlier this year, the Swedish Government insisted that its unique approach reflected the nature of the pandemic and the wait for a vaccine, calling it “a marathon not a sprint”.
Sweden’s Prime Minister Stefan Löfven said public health officials were relying on “Folkvett” — the common sense of citizens — to ensure the health system wasn’t overwhelmed.
It was estimated that by rejecting tougher measures, 40 per cent of Stockholm’s population would have achieved herd immunity by May.
Now, some studies suggest that never materialised.
A paper published by the Journal of the Royal Society of Medicine found about 15-20 per cent of the population in the capital had developed antibodies.
Lead author Professor David Goldsmith has been critical of Sweden’s approach.
“I think it was naive, frankly, not to do more at the outset, [but] they would argue that it’s okay and they seem quite pleased with their response,” he said.
“They’ve had a death rate that’s 10 times per million population of the local countries, which really are their best comparison.”
He said antibodies weren’t found in high rates in asymptomatic patients, meaning they’re not likely to be immune.
“I think they’ve got to ask themselves: was that really the right way to go?” Professor Goldsmith said.
“Particularly if there isn’t herd immunity, which I don’t think there will be.”
But Professor Dillner believes there is a “significant spread” in some populations in Stockholm, suggesting his research found about 8-31 per cent of healthcare workers in Stockholm had tested positive in antibody tests.
Did Sweden’s strategy cushion the financial blow?
Sweden’s public health officials insisted their strategy was not focussed on cushioning the economy, but many were watching to see whether its light lockdown would lessen the pandemic’s economic impact there.
Its economy shrank by 8.6 per cent in the April-to-June quarter — the worst performance in decades.
But alongside other Nordic nations, it hasn’t been nearly as hard-hit as larger European economies.
Professor Andreas Ortmann, an expert on experimental and behavioural economics at the University of New South Wales, said it’s far too early to tell if the Swedes’ strategy was a success or a dangerous gamble.
“At this point, simply to look at one measure, which is the death rate, is just completely unscientific and completely misleading,” he told the ABC.
Instead, Professor Ortmann said a longer-term assessment would need to take into account the rate of underemployment, business confidence and the mental health of Sweden’s citizens.
He believes one of Sweden’s strengths is that public confidence in health advice appears to be strong, limiting the risk of fatigue in the long-run.
“The public health authority is quite popular, even now. Two out of three Swedes seem to be not unhappy with what they have been doing,” he said.
“Compliance in Sweden with the recommendations of the public health authority is incredibly high, it’s about 80 per cent.”
Professor Goldsmith agrees, saying that only in years to come will we be able to fairly compare the different approaches adopted by nations around the world.
“Everybody would really love to have the answers to everything and know exactly what to do today,” he said.
“This coronavirus is an impressive adversary, one that we should never underestimate at all.”
As for the short-term, Dr Tegnell recently said that rapid testing and contact tracing will be key to the second stage of Sweden’s attempt to weather the pandemic.
Professor Dillner said many infectious diseases experts are cautiously waiting to see whether Sweden will be properly prepared for a second wave of infections in the European autumn and winter.
“This is the big worry, no-one knows what happens in the future.”