The Swedish mistake: That's why we die - despite the researchers' warnings
The Swedish corona strategy has both been praised and received stinging criticism. The critics have been called alarmists, while the government and the Public Health Authority have been accused of playing a loud game, which can lead to thousands of unnecessary deaths.
The Express has gone through the criticism of Sweden's corona model and let leading experts respond to any mistakes already made - and list the measures that could save lives in the coming months.
Since the new corona virus gained global spread in February, most of the world has introduced strict precautions with curfews and shutting down of schools, restaurants and shops.
Instead, the Swedish strategy has been based primarily on voluntary and individual responsibility, with calls for the population to wash their hands, keep their distance in the city and work from home to the extent possible.
The Swedish government has both been hailed for refraining from strict but ineffective measures - and accused of exposing the entire population to a life-threatening experiment.
On May 10, 3,252 people in Sweden had been reported dead in covid-19. This is more than in Norway, Denmark, Finland and Iceland together - both in absolute terms and in relation to population.
In Sweden, approximately 32 people per 100,000 inhabitants have died in covid-19.
DEATH PER 100,000 RESIDENTS MAY 11
Number of dead (number of deaths per 100,000 population)
* Source: Compilation from Johns Hopkins University, retrieved Sunday, May 10
Sweden 3 225 (32)
Denmark 529 (9)
Finland 267 (5)
Norway 219 (4)
Iceland 10 (3)
Italy 30 560 (50)
Spain 26 621 (57)
Belgium 8,656 (75)
USA 79 526 (24)
At the same time, there are other countries in Europe that have a significantly higher number of deaths than Sweden, both in absolute terms and in relation to population. For example, Italy, Spain and Belgium.
The United States has by far the most reported deaths in the world - 79,526 on May 10. However, the number of deaths per 100,000 inhabitants is 24 - significantly lower than in Sweden.
When it comes to the number of reported deaths in relation to population, Sweden ranks eighth among all countries in the world, according to statistics from Johns Hopkins University.
So what has gone wrong with the Swedish strategy so far? The Express has spoken with leading experts to find answers to which criticism against the government and the Public Health Authority is actually justified.
QUESTION 1: SHOULD WINTER VACATION TRAVELERS HAVE BEEN PLACED IN MANDATORY QUARANTINE?
The Swedish coronavirus outbreak accelerated after thousands of sports holiday travelers returned home in early March, including from the Italian and Austrian Alps.
On February 8, state epidemiologist Anders Tegnell told TT that alpresor could be implemented as planned:
- When it comes to this type of travel, there is absolutely no need to worry about the corona virus. In the Alps and southern Europe, for example, there is no spread at all.
After the sports holiday, only those returning travelers who showed symptoms of being quarantined were invited. Since then, the World Health Organization (WHO) has announced that even people with very mild or no symptoms can be contagious at all.
There was also quick testimony of people who had been abroad and were showing symptoms, but who were dismissed by the Care Guide in 1177 when they wanted to be tested for covid-19. This is because the guideline of the Public Health Authority at that time was that only people who visited areas with confirmed spread of infection - and who showed symptoms - should be tested.
It would later prove that one of the worst infection cures was in the Austrian Alps, which the Public Health Authority did not classify as a possible coronazon.
Tom Britton, professor of mathematical statistics at Stockholm University, has become known in the corona debate for his calculations on the extent of the spread of infection. If all the sports holiday travelers had been quarantined, he says, today we would see a less widespread spread of infection in Sweden - and fewer deaths.
- Yes, it would have been fewer who had spread the infection in Sweden and then it would have been a slower initial course, says Tom Britton.
He is unsure if it would have affected the total number of deaths in the end.
- What you need not doubt is that there would have been fewer deaths now. But, the future must tell if the countries that have run lockdown will have their deaths later or not at all. We don't know that yet, says Tom Britton.
Björn Olsen, professor of infectious diseases at Uppsala University, was among the first to warn of large-scale spread of the corona virus in Sweden. He is also one of the 22 researchers who criticized the Public Health Authority in a noted article on DN Debate in mid-April.
Björn Olsen has always been convinced that the spread of infection would have been significantly reduced if the sports holiday travelers were quarantined.
- I debated it with Tegnell in February and I said I think they should be quarantined. But he did not even want to admit that the infection was up there in the ski resorts, but he believed that it was only in the lowlands, says Björn Olsen.
Anders Tegnell says that he had received that information from the Italian authorities - how could you know more than he knew?
- Well, because I had talked to Italian doctors about what actually happened.
Björn Olsen believes that the two major pathways into Sweden were the alpine travelers and people who traveled from Iran, where they also received a large outbreak of covid-19 early on.
- When we got the big bang in Iran and the big bang in Italy almost synchronously with each other, then we should have realized that there was something there. Then the flights would be stopped, and those who had flown in would be infected, says Björn Olsen.
If we had quarantined the sports holiday travelers and stopped the Iran flights, would we have had fewer deaths today then?
- I'm convinced of that.
In Ekot's Saturday interview on May 2, Anders Tegnell says he is not sure that the infection was mainly spread to Sweden via returning alpine travelers:
- When we look back now, it is not the Italian travelers that I think we consider to be the great introduction in Sweden. Without it, everything else was traveling then during the sports holiday - we found people who came home with it from the UK, Boston in the USA, Austria who for a long time did not see anything themselves.
QUESTION 2: SHOULD WE HAVE TESTED MORE FASTER?
South Korea has been used as an example of a country that, with the help of advanced infection detection and extensive testing, has been able to keep the spread of infection down. On May 3, the country still had only 256 dead, which corresponds to 0.5 dead per 100,000 inhabitants. In Sweden, the corresponding figure is 64 times higher.
In addition to massive infection detection and testing, South Korea has had a strategy that is more similar to Sweden's than many other countries, with fewer shutdowns of social functions.
After the new corona virus spread outside China, many voices were raised that Sweden should quickly do as South Korea and scale up the test capacity.
In mid-March, the WHO on several occasions called on all countries in the world to test as much as possible - a call that both the government and the Public Health Authority chose to ignore.
On March 14, Anders Tegnell told Aftonbladet that the message from the WHO did not really apply to all countries:
- Countries are in different stages. Sooner or later you get into a phase where you can't find all cases.
At the same time, information from various quarters came about that there were no resources to even be able to test nursing staff, including in Stockholm, where the region made an active decision to prioritize downsizing healthcare personnel, which Aftonbladet revealed.
The moderator, Ulf Kristersson, said in an interview with SvD at the end of March that he had raised the question "at every meeting" about the new corona virus he had hitherto had with the government, without hearing.
When the journal Quarterly on March 24 asked the question of the test capacity to the government, they were referred to the Public Health Authority and the National Board of Social Affairs for that type of decision.
A week later, on March 31, the government nevertheless commissioned the Public Health Authority to sharply scale up Sweden's test capacity.
Had the decision been made earlier, it would have also reduced the spread of infection and fewer deaths at present, according to mathematics professor Tom Britton:
- It is clear that the sooner you discover people who are infected and isolate them, the less the spread of infection.
In a new mathematical study from the German University of Heidelberg, researchers have calculated the probable effects of different corona strategies.
The researchers believe that massive escalation of test capacity, to the extent that it is possible to start testing on a large scale even people who do not show symptoms, is likely to greatly reduce the number of deaths in Germany. This scenario is based on the fact that current restrictions in the country remain and that infected persons are isolated for at least two weeks.
Maria Barbarossa, one of the researchers behind the study, develops the reasoning for Expressen:
- Based on what we've seen here, I think testing is a very important factor. Testing alone does not necessarily lead to fewer deaths, but strategic and more extensive testing in combination with tighter isolation of infected contributes to fewer new cases. So indirect testing can save lives, says Maria Barbarossa.
On April 7, Karin Tegmark Wisell, Head of the Public Health Agency, said in SVT's Agenda that Sweden could test 100,000 people a week "within a few weeks".
However, between April 20 and 26, only 24,000 people were tested - compared to 68,000 in Denmark during the same period.
On May 3, Social Minister Lena Hallengren (S) in Agenda claimed that the test capacity was up to 100,000 a week, but referred to both the Public Health Authority and the municipalities and regions on the question why no more tests are being conducted.
- I think you should be very careful in general in making comparisons and different conclusions, Hallengren answered the question of why other countries managed to test more than Sweden.
On May 8, Hallengren announced at a press conference that testing must increase, and that a coordinator has been appointed to coordinate and accelerate the regions' efforts to expand testing.
QUESTION 3: HOW COULD WE BETTER HAVE PROTECTED THE ELDERLY?
At the end of April, there were confirmed cases of covid-19 in 75 per cent of elderly residents in Stockholm, 50 per cent in Gothenburg and just under 10 per cent in Skåne.
Lena Hallengren has called the dissemination in elderly care "a great failure". Anders Tegnell has also said that they failed to protect the elderly.
Former state epidemiologist Johan Giesecke comments in an interview with British UnHeard spreading the infection among the elderly:
- There we failed. Sweden failed. We were not on our toes enough to protect the elderly. We would have introduced a visitor ban earlier, ”Giesecke says in the interview, and also mentions that many new arrivals work in the elderly care and that there have been problems with getting information to them.
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Johan Giesecke. Photo: Expressen
Neither Anders Tegnell, Lena Hallengren nor Prime Minister Stefan Löfven (S), however, are of the same opinion as Giesecke as to the fact that a ban on visits should be imposed on the elderly residents earlier than March 31, when the decision was made by the government.
Löfven has repeatedly argued that the recommendation previously applied was sufficient, without being able to justify why a ban was needed in the end.
Another widely debated question is whether elderly care staff should have oral protection. In many parts of Europe and the world, mouthguards are mandatory, not only for healthcare professionals, but for all people moving outdoors.
Anders Tegnell and other representatives from the Public Health Authority long argued that oral protection did not reduce the spread of infection, but revised its attitude after new research showed the opposite.
A study from Hong Kong University, published April 2 in the scientific journal Nature Medicine, shows that oral protection can greatly reduce the spread of coronavirus. The study is not done on the new virus sars-CoV-2 but on other types of coronavirus.
Social Minister Lena Hallengren has repeatedly referred to the Public Health Authority when she was asked why the government does not introduce requirements for protective equipment - for example oral protection - in the elderly care.
In Ekot's Saturday interview on May 2, Anders Tegnell was asked if the spread of infection would not be reduced if all elderly people in the elderly care had oral protection:
- I think it is quite dangerous to simplify the problems on the elderly, because there is only this type of simple face protection in place so it will solve everything, it is definitely not that easy. To manage this properly, one must have well-trained staff, they must be properly trained, Tegnell responds.
On May 7, the Public Health Authority also swung at the issue of oral protection in the elderly care. At a press conference, Malin Grape, head of unit health care at the authority, said that oral protection and visors can be used on elderly homes.
- Despite the meager scientific evidence, we see that you can consider adding mouth protection or visor as an extra measure. This is a balance that one has to make locally and according to the conditions one has, says Malin Grape.
At the same time, she warned that use requires caution and good basic hygiene, so that it does not lead to false security and increased spread of infection.
Erik Salaneck is an associate professor of infectious diseases at Uppsala University, an infectious doctor at Uppsala Academic Hospital and responsible for infection control work at the hospital's infection clinic. Just days after the WHO first reported that a new flu-like virus had been discovered in China, he began to prepare routines for managing the virus at the hospital.
Salaneck believes that planning and clear directives on protective equipment in the elderly - he mentions visors, face masks, work jackets, gloves and shoe covers - would have saved many lives. And that it can still do it.
- Yes, 100 percent. No doubt at all. Then you have to add a small passus: protective gear is point one. Point two is training and education. So that you use this right and behave correctly, says Erik Salaneck.
He thinks that the government and the authorities have totally failed to build a readiness for the new corona virus in both health care and the elderly. Several months ago, decisions should have been made on clear guidelines for care situations, training of personnel and the purchase of protective equipment, Salaneck says:
- That's what I think is criminal. We had months to prepare, but the authorities took the trouble to say "this is quiet, this is not coming here". Instead of increasing readiness. I think it's a police case. It is so irresponsible - and it has led to death. It is a drop that I believe they are guilty of. Because it's so terribly simple things that needed to be done, says Erik Salaneck.
QUESTION 4: WHEN WILL WE GET HERD IMMUNITY - AND HOW MANY WILL DIE BEFORE IT IS ACHIEVED?
A crucial difference in different countries' choice of strategy is the view on herd immunity - when the spread of infection decreases because the reproduction number, R, is below 1. R1 means that each infected person infects another person on average.
The proportion of the population that must be immune in order for herd immunity to be achieved depends on people's behavior, says mathematics professor Tom Britton:
- I would say that with our behavior before covid-19 it is about 60-70 percent.
With the Swedes now living with a number of restrictions that limit social contacts, Britton believes that herd immunity is achieved far earlier than that - somewhere around 40-45 percent. Although the restrictions would be lifted, he believes that our behavior will change for some time to come:
- I think, for example, that many will avoid congestion and have better hand hygiene, at least in the next year, says Tom Britton.
Using mathematical models, Britton concluded that about 25 percent of the population in Stockholm should have been infected by the end of April.
- It may vary by five percent up or down, but I would be very surprised if it was more factual.
His conclusion is in good agreement with a report prepared by the Public Health Authority, using a similar method, which predicted that 26 percent of Stockholmers would have been infected on 1 May.
However, neither Britton's nor the Public Health Authority's figures are based primarily on actual immunity tests, but on mathematical models. And other researchers around the world are coming to completely different numbers right now.
Researchers from the London School of Hygiene and Tropical Medicine, for example, have calculated that only 5-10 percent of Stockholm's population should have been infected on May 1. That's what Adam Kucharski, one of the researchers, wrote on Twitter.
In Ekot's Saturday interview on May 2, Anders Tegnell says that the Public Health Authority now believes that between 10 and 20 percent of the population in Stockholm is immune, but that there may be more.
Johan Giesecke, former state epidemiologist and now adviser to both the World Health Organization and the Public Health Authority, has given several different reports on how many in Stockholm he believes have developed immunity.
On April 17, Giesecke tells British UnHeard that antibody tests will soon show that at least 50 percent of both Sweden and the UK have had the corona virus. This would mean an even higher figure for Stockholm, where the Swedish spread of infection has been greatest.
On April 21, Giesecke says in SVT's Morning Study instead that he believes that 500,000-600,000 people in Stockholm may have had covid-19, which is about 30 percent.
On May 3, he participates in Swedish Radio's "Good morning, the world!" and say first:
- A quarter of the population in Stockholm municipality is immune.
Later in the same interview, he comments on the possibility of introducing restrictions that differ across the country, and instead states that "most" in Stockholm had the disease:
- Take the restaurants, in Stockholm you can soon open them, because most people have had it, but you might not do it in Gotland, just to take an example, says Giesecke.
When Expressen seeks Johan Giesecke for an interview, among other things to ask questions about what he bases his assumptions on the proportion of infected, he responds briefly in an email: "Let's drop the subject".
During the course of the study, the research group began to suspect that the corona virus behaves like a so-called "cluster infection", says Björn Olsen:
- Some areas have nothing, you will not find any at all that have antibodies to this virus, they have never encountered it. In some parts of the inner city, for example. But if you go to Rissne, Tensta or Rinkeby, then the picture is suddenly another.
According to Olsen, this is a bad sign if one hopes for herd immunity, as it indicates that the infection is jumping from different "hot spots". Flock immunity must be achieved in the population at large in order for the infection to subside.
Is it even possible to achieve herd immunity, is it not even certain that people are immune for so long?
- Yes, but they probably are. If you look at other coronaviruses, you have immunity, unless this virus is completely wiped out compared to all other coronaviruses we have encountered, then you can have immunity for several years, sometimes tens of years.
Do you think flock immunity is far away in Stockholm?
- Yes, I think so.
