Opinion

Was the Swedish approach to COVID-19 really a mistake?


Horst Herb


1/10/2020 3:16:53 PM

Sweden is often held as an example of how not to tackle coronavirus. But Dr Horst Herb argues this is not entirely accurate in this opinion piece.

Crowded square in Stockholm
The Swedish approach to tackling the pandemic has been severely criticised – but is all of the criticism warranted?

Whenever you question the strong measures governments are using to control the virus, fingers will be pointed at Sweden. This, in the public mind, is a terrible warning – the one developed nation that consciously defied lockdown measures and suffered unacceptable human losses as a result.

But is this entirely true?
 
So far, Sweden has reported 578 COVID-19 deaths per million – around 5890 deaths in total. This seems very high compared to neighbouring Denmark (112), but it is not as high as Belgium (875), the UK (631), Spain (672), or Italy (594) according to Statista data as of 1 October 2020.

One issue with these comparisons is that what counts as a COVID-19 death differs too much between countries to compare directly.

Sweden chose a model that might over-report COVID-19 deaths: they do not require a death certificate stating COVID-19 is the cause of death, but also count all people who die with the virus (including post-mortem testing and all residential aged care facility [RACF] deaths) as COVID-19 deaths by automatically matching the national death registry with test results​.

In principle, an asymptomatic young person stepping out of the testing booth and getting run over by a bus would count as a COVID-19 death.

The Economist has suggested that some countries likely over-report COVID-19 deaths (including Belgium, Sweden and France), while some probably under-report (such as the UK, Italy, Spain and the Netherlands). They compared excess all-cause mortality with reported COVID-19 deaths and noted the discrepancies.

In this analysis, Sweden’s reported COVID-19 deaths account for 101% of their excess mortality, while Italy’s reported deaths account for 64%, and only 12% for Indonesia.

The rationale for ‘flattening the curve’ is to avoid excessive deaths from health systems becoming overwhelmed, as happened in Brazil, Mexico, Northern Italy, Madrid, parts of the National Health Service (NHS) in the UK, and some states in the US. Yet some of these ‘overwhelmed health systems’ can get overwhelmed during influenza peaks. Sweden’s health system, however, is well funded and staffed

Intensive care admissions in Sweden reached their peak between late March and early May, and since then there were only few new admissions. Even during their peak, their health system was never overwhelmed; they still had spare intensive care capacity, though they had to postpone some elective surgical procedures and were close to running out of personal protective equipment (PPE) at one stage.

So what about the big question – mortality? We all heard about their ‘horrendous death toll’.

Surely, with their ‘case rate’ ever rising, the number of deaths would also accumulate.

Not exactly. Let’s have a look at the current data of reported COVID-19 related deaths per day:


Daily COVID-19-related reported deaths in Sweden as of 1 October 2020
 
Like many other European countries, Sweden seemed to have had its peak between early April and late May, and began to approach zero since – despite cases surging in May–June.

Even if we account for a month-long delay between infection and death, we should have seen a big peak of deaths in late June if COVID-19 deaths would follow ‘case rate’ or number of infections. It doesn’t seem so.

What might be helping drive the death rate down is an increasing prevalence of immune response; while Sweden never officially pursued any herd immunity strategy (as opposed to what the press keeps stating), recent research suggests that immunity might be more widespread and lasting than previously assumed.

If we do not trust Sweden’s reporting of COVID-19 deaths, we can look at their overall mortality.

The EUROMOMO project is a sentinel surveillance system for excess mortality – their ‘canary in the coal mine’ for infectious diseases. Their data allows us to compare seasonal excess mortality between participating countries by analysing how far their reported overall deaths deviate from expected seasonal standards. 

And what does it tell us? It shows us that Sweden is faring well when compared to England and Spain, and only doing slightly worse than Switzerland, but much worse than neighbouring Norway or Denmark.

What about keeping the economy going? At first, it was thought that avoiding a government-mandated lockdown would save Sweden from the economic disaster that is following the forced shutdowns in most countries in Europe.

As it turned out, Swedes’ decision to avoid going outside or spending – regardless of government mandate – meant that the expected advantage seems smaller than expected. At the beginning of June, it seemed that Sweden might be doing better than its neighbours economically. But this advantage shrank by July. 

Any economic benefits of Sweden’s more liberal approach will be difficult to determine given their highly export dependent economy, where 46% of GDP hinges on exports. Sweden was well aware of this situation, hence economic protection was not a factor determining the Swedish strategy according to a recent analysis.

Where does this leave us? Sweden’s death rate is higher than some other nations that entered a hard lockdown. But its economy seems not to have been quite as badly affected.

Considering the damage inflicted by lockdown measures, including unemployment, poverty, delayed surgical procedures, delayed cancer diagnosis, neglected chronic disease, social isolation, and increased mental health burden and suicides, the Swedes could still fare better with their policy than more restrictive countries in the long run – while preserving the civil liberties of their citizens.

I do not mean to argue that stricter countermeasures against COVID-19 are futile. I only want to suggest that the most severe interventions could potentially cause more harm than good.

Island nations such as Australia and New Zealand may have postponed their share of deaths, but at the cost of the loss of civil liberties, serious economic damage and major non-COVID health impacts in the long run. I say postponed because both nations are unlikely to avoid them in the long run.

Victoria’s latest lockdown has been estimated to cost the nation at least $3.3 billion, with Federal Treasurer Josh Frydenberg stating it will take several generations of Australians just to pay for the budget blowout so far caused by COVID-19.

All medical interventions (including public health) should balance the benefit versus risk.

In the public mind, Sweden’s efforts to preserve its liberties and economy have failed.

But that overlooks the fact that Sweden did undertake countermeasures – but only evidence-based and ethically defensible approaches, respecting the principles of autonomy, non-maleficence, beneficence, and justice. ​They openly admit where they failed​ to implement them in time, resulting in many avoidable premature deaths in their RACFs, and are adjusting their policies accordingly​.

We began our fight against the pandemic with a dearth of evidence on this major new threat. The knowledge we have gained has been hard-fought.

To write off alternative approaches – and to overlook the major costs that come with lockdowns – is, in my opinion, wrong. We can do better.

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Dr David William De Leacy   1/10/2020 3:55:02 PM

Sweden directly benefited from surrounding nations border lockdown with it because of their COVD19 policy hence their seasonal excess mortality data (EUROMO) must be adjusted accordingly to account for the almost total lack of seasonal influenza and other URTIs primarily effecting the aged in 2020 in that country. A comparative year on year weighted average will be misleading.


Dr Duncan MacWalter   2/10/2020 7:19:03 AM

Why publish this amateur epidemiology piece, giving it the air of medical legitimacy? There is no comment from Swedish doctors which is telling. There is a mistaken belief that an ultra-low covid AU or NZ has a material economic impact, is unsustainable and not one of the 50 vaccines in phase 3 trials won't be successful to reduce severity and death.
There is also no mention of what UK have been calling 'long covid' for the last few months, and thankfully greeting media attention here. The long term morbidity from this virus is significant.

In SEQLD, we had lockdown-lite compared to many other countries. The restrictions are more than bearable. And I thank Victorians for putting up with successful restrictions to get the virus back to ultra-low levels, for all our benefit.


Dr Carolyn Cheng - Ling Ee   2/10/2020 7:19:38 AM

Many of the costs of COVID-19 may persist even when lockdown is lifted. Differentiation between the impact of the global pandemic versus the impact of lockdowns needs to be highlighted. Eg are patients still worried about going to doctors (hence delayed diagnoses) when there are few restrictions? We would have data on this now from different States who have each imposed different restrictions. As for civil liberties, these are restricted all the time for the public good. We can’t drive at the speed we want to; we have to wear a seatbelt; we can’t have 6 beers and then get into a car and drive. Most of the people I know in Melbourne are supportive of the lockdown because they saw it was necessary and is in place to protect them and others. As Victoria heads out of what appears to be a successful lockdown, what is this article trying to say? That it wasn’t needed? What are the alternative solutions - to request that That it causes hardship? (Not new). How is this helpful to Victorians?


Dr Colin Scott Masters   2/10/2020 8:17:20 AM

Thanks for your balanced and interesting insights Horst. The world has learnt a great deal over the last 9 mths about handling a novel Pandemic. Yet we still have a long road ahead off us. It pays to keep analysing the true meaning behind statistics, how they are measured and look at figures beyond just mortality e.g. QALY. Thanks for your contribution


Dr Judith Virag   2/10/2020 9:41:53 AM

Yes, RACGP, why did you publish this opinion? Have we sold out to Rupert?


Dr Ian Mark Light   2/10/2020 11:55:50 AM

More than 5,000 deaths were in aged care homes and in Sweden these are mainly public funded .
It is a high rate of death and a great failure .
Far worse than California per population but far better than New York City .
They are getting more cases now as many young people think they will not get severe disease and it’s risk taking plied with alcohol .
Such behaviour among the youth was not tolerated China -this is one statistic in which the authoritarian stringent policy works .
The Swedes have learnt though and are protecting their aged better than in the beginning .
Winter will unfortunately need a tougher policy .


Dr Meridee Flower   2/10/2020 3:57:01 PM

Hear, hear....
Some people appear very confident they know the best approach to take with this pandemic. How can we be so certain?
Sweden chose a less authoritarian approach allowing for individual autonomy. This is not the same as taking no precautions. Many people isolated, socially distanced and wore masks.
We do not know yet if a vaccine will provide the rescue from this pandemic we are all seeking. I am not opposed to the approach we have taken in Australia and I admire its compassionate intentions. Only with the benefit of hindsight will we know which approach provided the optimal outcome to the majority.


Dr Kylie Fardell   4/10/2020 7:42:42 PM

Thanks for this thoughtful and interesting piece.


Dr Horst Paul Herb   5/10/2020 1:16:05 PM

Re Dr De Leacey's comment about an 'almost total lack of seasonal influenza in Europe' - I would be interested in your information sources, since the official European Union report on seasonal influenza rated it as average activity (https://www.ecdc.europa.eu/en/publications-data/seasonal-influenza-annual-epidemiological-report-2019-2020). It is hard to differentiate cause of death between influenza and covid, since in the elderly cohort both compete for the same vulnerable victims. One could also argue that this civil season left little for the next influenza season to reap.

If you look closer at the Euromomo excess mortality graphs, you will find that most countries with high covid period excess mortality had particularly low excess mortality in the 2 preceding years, supporting the 'dry tinder' hypothesis of covid excess mortality