Exponerat

In contrast to many European countries’ tougher, frequently lockdown-focused approaches—including its Scandinavian neighbors—strategy Sweden has centered on individuals accepting responsibility under non-binding suggestions.

1 In the first six months of the pandemic, the government established comprehensive work from home provisions for those who could and remote learning for those over 16s.

The public agreed, and there was little debate about the policy, save for a group of 22 scientists who spoke out about the high number of coronavirus deaths among the elderly, which was significantly higher than that of its Nordic neighbors—131 per million people compared to 55 per million in Denmark and 14 per million in Finland, all of whom had implemented lockdowns.

Tegnell was one among those who insisted that other countries’ lockdowns were excessive. According to Our World in Data, the number of overall cases and deaths in Sweden was low compared to other major European countries—just under 93 000 cases and 6000 deaths by October 1, October 1, 2020, compared to over 118 000 points and 10 000 deaths in Belgium, which has a similar overall population size, or the 606 000 cases and 32 000 deaths seen in France and other larger countries.

However, by the winter of 2020, the second wave of cases with the new alpha type had risen dramatically.

2 The country saw 657 309 positive cases and 12 826 deaths in the six months between October 2020 and March 2021.

The government’s measures were slammed in an 800-page report (the second of its kind) published in October 2021 by the Swedish Corona Commission3—the government-commissioned investigation into the pandemic response—which noted that they were both late and insufficient and called preparedness “non-existent.”

This was followed in November 2021 by a report from the Royal Swedish Academy of Sciences4 proposing the creation of an independent expert unit for future pandemics, claiming that authorities were “inadequately prepared” in terms of knowledge as well as equipment such as face masks and that high mortality during the first two waves of the pandemic was due to “mild and tardy” measures to prevent infection spread.

In his end-of-2020 TV message, Sweden’s King Carl XVI Gustaf called the country’s management of the pandemic a “disaster.” Stefan Lofven, the prime minister, then agreed. “The fact that so many people have perished can’t be seen as anything but a failure,” he remarked.

Anders Vahlne, a virology professor at the Karolinska Institute and one of the scientists who criticized Sweden’s response, told The BMJ that it was shameful that the entire pandemic was in the hands of a few civil servants who acted and reacted slowly, lacked flexibility, and still did not acknowledge that the virus was airborne.

Sweden’s situation remains grave a year later, as the country confronts a second pandemic winter and dangers from both delta and omicron variants, according to specialists The BMJ spoke to.

Going around in circles

The second wave will attack Sweden in the autumn of 2020. Intensive care units (ICUs) in and around Stockholm, the epicenter of the country’s pandemic, were approaching capacity for the first time in December, forcing the government to restore limits. These were expanded in January 2021 to include a recommendation, but not a requirement, to wear masks on public transportation.

The government granted expanded pandemic powers by March 15, 2021, allowing for additional actions over the next 12 months if necessary. Limiting the number of people (one per 10 m2) allowed in gyms, shops, other enterprises, and public spaces like parks and beaches are examples.

The change appeared to be successful. Case numbers began to decline in early June, and limitations were gradually loosened until all were lifted by the end of September. The Swedish Public Health Agency (Folkhälsomyndigheten, FHM) even stopped offering free polymerase chain reaction (PCR) testing to anyone who had already been properly vaccinated on November 1.

Is the healthcare system up to the task?

On the other hand, Persson voiced dissatisfaction with the crowds he sees in public, where few people wear masks. “When all limitations and general recommendations are gone, there is a risk that citizens believe the pandemic is over,” he warns.

Most healthcare workers agreed that such limits should have remained throughout the year. Like the first wave, some argue that schools should have been partially closed.

Because of the high incidence of immunization, Bratt believes the next wave will have fewer mortality. “The truth is that the number of patients in need of intensive care rose during the last week,” he says. With a heavy influx of patients with covid-19, seasonal flu, and other prevalent ailments, it’s the start of a negative trend.”

Vahlne says he’s “very concerned” about the situation in Sweden. “With such a low level of contagion in the summer, we should have started testing and tracing and continued to use basic safeguards, such as masks,” he says.

But, according to Anders Tegnell, scientists are still divided on which techniques are most efficient in preventing virus spread. “This is what we’re still trying to figure out: some measures work in some spots, but trends are hard to spot.”

Pandemic

The national response to the COVID-19 pandemic in Sweden continues to be an outlier in the second wave of the pandemic, with the number of cases and deaths rising at a far faster rate than in Sweden’s Nordic neighbors.

1, 2 On December 20, 2020, the number of COVID-19 deaths in Sweden had surpassed 80003, which is equivalent to 787 deaths per one million inhabitants and is between four and a half and ten times greater than its neighboring countries. 1, 2, 3 This discrepancy across the Nordic nations cannot be explained simply by differences in national cultures, histories, population numbers and densities, immigration patterns, the pathways through which the virus was initially transmitted, or how cases and deaths are reported. Instead, the solutions to this mystery can be found in the Swedish national COVID-19 plan, the assumptions on which it is founded, and the health system’s governance that has made it possible for the strategy to continue without major course corrections.

The Agency for Public Health

The Swedish Public Health Agency, known as Folkhalsomyndigheten (FHM), adopted a de facto herd immunity strategy from the very beginning of the COVID-19 pandemic. As a result, community transmission was allowed to continue somewhat unregulated.

4 Although no obligatory steps were established to reduce crowds on public transportation, in shopping malls, or any other crowded places, a limit of fifty persons was recommended for gatherings5 as of March 29, 2020. This limit will go into effect. The testing for coronavirus, the tracing of contacts, the identifying of sources, and the reporting of findings, as recommended by WHO6, were restricted and inadequate. 7 In our opinion, the national plan does not provide adequate emphasis on the significance of the presymptomatic and asymptomatic transmission of the disease and the information of the virus through aerosols8, nine and the usage of face masks. 9, 10 Recently, face masks were made mandatory in care homes and other healthcare facilities (on November 11, 2020, in Stockholm)11. Face masks will be suggested beginning January 7, 2021: “on public transportation at specified times.” 12 Other gradual interventions are being introduced, such as modifying a prohibition on the sale of alcohol from 2200 h (introduced on November 11, 2020) to 2000 h (beginning on December 24, 2020), which will be implemented on December 24, 2020. 12, 13, suggesting further limits on the number of gatherings and advising individuals to take personal responsibility and remain at home if they are experiencing signs of the illness.

With this gradual approach, the number of COVID-19 deaths in Sweden reached its peak during the first wave at 102 reported deaths (7-day rolling average) on April 21, 20203. This was at a higher level and with a slower decline than in the neighboring Nordic countries, eventually reaching a low at the beginning of September 2020.

1, 3 Instead of preparing for the second wave and changing direction, the government of Sweden decided to relax restrictions at the beginning of October 2020. The number of people allowed to attend public events increased from 50 to 300, and senior citizens aged 70 and older were given permission to get together with family and friends.

Many voices have been voiced that are critical of Sweden’s national response to COVID-19 and its failure to meet its objectives to flatten and shorten the curves of cases, hospitalizations, and deaths. [Case of Viral Infection in Sweden]

4, 15 The Corona Commission (Coronakommissionen), which the Swedish Government created to assess the country’s response to COVID-19, has originally concentrated on the issue among older people. 16 The Corona Commission reached the following conclusion on December 15, 2020: “the overall spread of the virus in the society is the single most important element behind the major outbreaks and the high number of deaths in [elderly] residential care.” 16 In addition to the failure of the COVID-19 strategy, there are other structural issues connected to the organization of senior care in Sweden that has not been resolved.

The recommendations made by the World Health Organization (WHO) to maintain a physical distance, wear a face mask, keep rooms ventilated, avoid crowds, and practice good hand and respiratory hygiene have been validated by an independent review of the evidence17 conducted by the Royal Swedish Academy of Sciences.

18 However, it wasn’t until December 18, 2020, that the government issued directives to begin putting more of these recommendations, such as the use of face masks, into practice. This is because the trend of rapidly rising cases and deaths continues, and intensive-care facilities and healthcare professionals are already at their maximum capacity in many regions of Sweden.