Nexus of Thought: What are your thoughts on the Swedish approach to COVID-19 mitigation?

My overall assessment so far is that the results have been mixed. They are not performing nearly as poorly as their detractors claim they have. However they are not the shining light that others hoped they would be. (Answered on Quora).

One of the problems with digging deeper to answer this question is that there is so much misinformation around the topic. Much of it is unfortunately politically motivated. Here are three common myths that abound. All three have been expressed routinely on Quora.

Myth One - The Swedish Model is predicated on using herd immunity as a way of coping with the COVID-19 pandemic.

Swedish epidemiologists involved in formulating the strategy (such as Anders Tegnell pictured below) were full aware that infected levels of 60–80% are necessary for true herd immunity. This is rarely achieved without a vaccine. It is no easy task. However such thinking was not the main driver for the Swedish approach. The Swedes realized that the mortality profile of the disease skews very heavily toward the aged. Death rates in fact for those below the age of 35 are actually lower than the seasonal flu. So they designed a strategy that would take into account the variation of death rates with age.

This would allow the country to mitigate appropriately without the necessary hit to the economy that has already impacted all of the strong lockdown countries. Their model was one of pragmatic recourse and was/is data driven. A march toward progressive immunity and then ultimately herd immunity was a secondary consideration. It was not the primary focus here. A great deal of the media has elevated this secondary consideration above the primary described above. This seems to be a deliberate misreading.

Here is the over-arching philosophy as outlined on the Swedish government site:

The Government’s policy and decisions aim to:

• Limit the spread of infection in the country
• Ensure health care resources are available
• Limit the impact on critical services
• Alleviate the impact on people and companies
• Ease concern, for example by providing information
• Ensure that the right measures are taken at the right time

Anders Tegnell Sweden’s chief epidemiologist)- Source: Globe and Mail

Myth Two - The Swedish approach ignores the efficacy of social distancing.

The Swedes do not have a nationally or regionally imposed lockdown but the government through its agencies does offer strong recommendations. This includes an active emphasis on social distancing. Elementary schools have remained open but high schools and universities were closed (they are using distance learning protocols). Bars and restaurants are open but have been reorganized to accommodate social distancing parameters. Gatherings of up to 50 people are allowed but they are not encouraged (this was reduced from a number of 500 initially).

Part of the rationale of keeping elementary schools open was to limit the number of health care workers who would have to stay home to take care of their children. Nevertheless the Swedes have encouraged people to stay at home if necessary by increasing from 7 to 21 days paid work leave time (a doctor’s note is required for longer absences) . Social distancing policies have also been placed in the transportation arena that has reduced utilization of public facilities by 50%. Compliance with recommendations on social distancing is very high which is the likely the reason why the disease hasn’t spread so much in Stockholm for example. The Swedes are by nature a cautious people. They tend to listen to government recommendations. In fact it is somewhat of a national joke.

A Swedish park source France24

Myth Three - The Swedish Counterfactual is Failing, Just look at the death rate numbers.

As of May 22nd, 2020 Sweden has a total of 3,925 deaths and 23, 913 active cases (99% mild and 1% critical). On a per capita level its death rate sits at 389 per million. This value is higher than the US (295), Germany (100) and Austria (71) but it is lower than France (433), Italy (539), Spain (612), the UK (536) and Belgium (797). It is slightly higher than the Netherlands (337) and above that of Switzerland (220).

The death rate numbers are not great but compared to several other Western countries Sweden is not performing that badly. If they are failing than what does that say for the strong lockdown countries mentioned above?

Where the negative contrast does arise though is when Sweden is looked at in comparison with the other Nordic countries. Norway (43), Finland (55) and Denmark (97). This is of course a favourite trope of ‘Sweden bashers’ (on both the right and the left) however it needs to be analyzed within a specific context.

Norway and Finland have not been particularly hard hit with COVID-19 to begin with. They were also less impacted by international travel . The Danes have done very well and seem to be following a testing, tracing and isolating methodology that has been the mainstay of the German model.

However it is important to note that roughly fifty percent of Sweden’s deaths have occurred at Elderly Care facilities. These are often large state run facilities that tend to big significantly more heavily populated in Sweden than they are in the country’s Nordic neighbours. It is deaths here that have caused the overall death rate to surge not the absence of a general population lockdown.

Such a factor has to be taken into account for any intra-regional comparison.

Swedish COVID-19 deaths per day. Source: National Board of Health and Welfare (Sweden). There was a slight jump post May 11th largely due to Elder Care death fatalities.

So then what is the chief problem with the Swedish approach?

The challenge with the Swedish approach is that the extended latitude given to interaction among the general population has to be complemented by a vigorous lockdown of the most vulnerable parts of their demographic ie. the elderly. In this respect they have failed miserably. Approximately 50% of Swedish COVID-19 deaths have occurred in elderly care facilities. This spike was likely boosted by its well-intended volunteerism program that unfortunately has had disastrous implications

While care facility deaths has been a truism in most Western countries it has hit Sweden particularly hard when juxtaposed to the overall death rate (by contrast only 25% of UK COVID-19 deaths have taken place in such facilities). Overall Sweden has struggled with protecting its elderly. 88% of deaths involve those over the age of 70.

The government has been addressing this issue with a greater intensity as of late which suggests that the situation should improve.

A further stumbling block in Sweden has been its low level of testing. At 20.8 K per million the country lags behind every other Western European country with the exception of the Netherlands (18.3K). The Danes on the other hand have run over four times the amount of tests per capita.

If Swedes can up the testing rate the key morbidity trackers should make a turn for the better.

What are the benefits of the Swedish approach?

The main benefit of the Swedish policy is that it avoids a great deal of the negativity associated with the hard lockdown methodology. Their economy and national debt will unlikely not taken as big a hit as that of the rest of the Western World. Sweden will also likely see reduced levels of the so-called lockdown pathologies, namely increased suicide rates, domestic violence uptakes and complications resulting from neglect of other medical conditions. All of these factors should not be downplayed. Again they feed into the rationality behind the Swedish approach. In fact if we are considering overall death rates as a metric to compare countries it may make sense to include this mortality in a more extensive analysis.

In addition the Swedes have provided us with important data from their working counter-factual that will help us understand the efficacy of the lockdown. Low infection rates in Stockholm (7–8%) can be looked at as a criticism of a herd immunity approach (which again is not the primary intention of Swedish policy) however it can also give us a better understanding of the R nought for the disease which certainly appears to be much lower than what early doomsayers predicted. This is a hopeful observation.

As it stands we cannot judge the Swedish approach so soon in the pandemic history. The Swedes have mitigated somewhat against a second wave which most hard lockdown countries haven’t. Let us see how this looks a year from now before we rush to judgement. This could all change with a vaccine but if the Swedes have taken a prudent approach to protect other aspects of their socio-economic framework they may still have the last laugh.

Sources

Nexus of Thought

Saturday, May 23, 2020

What are your thoughts on the Swedish approach to COVID-19 mitigation?

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