As Europe comes out of lockdown, what lessons can be learned from Sweden?
As Europe comes out of lockdown, what lessons can be learned from Sweden?
By Catherine Edwards, The Local, May 26, 2020
As countries across Europe ease their coronavirus lockdowns, many may look to Sweden to see how the Scandinavian country has fared without tight restrictions. They could learn both from its failures and from cautious signs of what's working.
At first glance, the popular waterside bar Mälarpaviljongen looks no different from in any other year - groups of people sit eating, talking and laughing on the terrace, some wrapped in blankets against the surprisingly cool May weather.
Then you'll notice the markings on the floor, signs urging patrons to "keep distance", and plexiglass between groups.
Not quite normal, but a lot closer to normal than elsewhere in Europe where bars and cafes have until recently remained shut for weeks.
In Sweden, pubs, restaurants, gyms, shops, hairdressers, and schools for under-16s have all remained open throughout the pandemic, despite the wide spread of coronavirus throughout the country.
Despite death tolls well above the figure in neighbouring countries, hospitals in Sweden have not been pushed to breaking point with 20-30 percent spare capacity in intensive care units - due to huge efforts to double the number of beds early on. In recent weeks the number of patients in critical condition has been falling and Sweden's 'R number' or infection rate is now reportedly below 1.
It might be appealing to make the conclusion that Sweden has managed to keep the epidemic under control, without having to restrict individuals and businesses or pressing pause on the country's whole economy to the same extent as elsewhere in Europe.
But that would be a dangerous conclusion to draw.
If those countries moving out of lockdowns are to learn from the Swedish approach three things are essential: they must understand what's actually been happening in Sweden, which parts of the strategy have and haven't worked (and for whom) and finally the reasons why they either succeeded or failed.
Making comparisons between countries and even within areas of the same countries can be fraught when so many factors play a part, warns Peter Lindgren, Managing Director at the Swedish Institute for Health Economics.
"We have the same measures throughout Sweden and very different infection rates and death rates," he tells The Local.
"The situation is quite severe in Stockholm, but in Skåne (in southern Sweden) the infection rate is similar to Denmark where there is complete lockdown, so there are lots of factors to assess as to whether it's successful as a strategy," he said.
One significant caveat to any assessment of Sweden's strategy is the testing rate, which is among the lowest per capita in Europe and well below the target set by the Public Health Agency.
This has been the subject of criticism within Sweden and made it hard to know exactly how the virus has spread
What Sweden cannot teach others is how to stem the pandemic without a high human cost. With over 3,700 deaths by May 20th the per-capita death toll is far higher than its Nordic neighbours and only behind the UK, France, Italy, Spain and Belgium in Europe. Like in many countries in Europe a large proportion of Sweden's coronavirus-related fatalities occurred in elderly care homes, despite the government imposing a ban on visits.
Protecting these vulnerable elderly is an area where the country's now well-known state epidemiologist Anders Tegnell has admitted failure and says is a source of "deep regret". An investigation has been launched into "serious flaws" in the homes. On this issue any lessons will have to be learned from further afield, for example Hong Kong which has managed to avoid fatalities in care homes.
Can guidelines work without enforcement?
Nevertheless, Sweden's decision not to impose a strict lockdown means countries can learn from its successes and failures as they move to get up and running again, people back to work and the wheels of the economy in motion.
"If we are to reach a new normal, in many ways Sweden represents a future model," Dr. Michael Ryan, Executive Director of the WHO Health Emergencies Programme, has told reporters, while emphasising that the extent of Sweden's success remained to be seen.
"Society may need to adapt for a medium or potentially a longer period of time in which our physical and social relationships with each other will have to be modulated by the presence of the virus [...] so I think there may be lessons to be learned from our colleagues in Sweden."
The guidelines that are at the basis of the Swedish strategy, repeated regularly at near-daily press conferences, are familiar: stay at home with the slightest symptoms, practice good hygiene, keep your distance from others and avoid non-essential travel. So the foundation of the Swedish strategy is something that's happening in most other countries already.
For those at highest risk of serious illness, life in Sweden during coronavirus is similar to any other country: over-70s and others in risk groups are asked to avoid all possible social contact, including trips to the shop and visits with family and friends.
Authorities have repeatedly said the guidelines should be followed at all times. Initially vague appeals to use "common sense" and "act like adults" have gradually changed to specific guidance such as "you can travel no more than two hours from home by car".
Sweden's experience suggests that guidelines can be effective even without specific rules such as limits on the number of people you can meet outside your household or setting specific times for when you can leave your house.
Proof that these guidelines can be effective without the legal enforcement of police stops and steep fines seen in countries like France, Germany and Italy, can be seen in the significant change in public behaviour in Sweden.
The latest surveys by Sweden's Civil Contingencies Agency (MSB) show that 87 percent of respondents report keeping a greater distance from others in places like shops, 66 percent are participating in social activities outside the home to a lesser extent than before the outbreak, and 55 percent were inviting friends to their home to a lesser extent.
This self-reported data is backed up by mobile data showing how people in Sweden have reduced their movement. Telia mobile datashows a reduction in long-distance travel of up to 96 percent over the Easter holiday; the kind of scenario that authorities repeatedly warned, in national and local press conferences as well as through information campaigns, should be avoided.
Mobility data from Google shows that by early May movement in 'retail and recreation' areas had fallen by 16 percent compared to baseline data from January-February, and by 17 percent in transit stations. Those numbers aren't far behind Denmark (-22 and -27 percent) or Norway (-18 and -22 percent), both with far stricter lockdowns.
Peter Lindgren from the Swedish Institute for Health Economics says clear communication with the public has been crucial to ensure guidelines are followed.
"They've been fairly transparent in the reasons for their decision-making, they've been open about what they do and don't know and the uncertainties, such as when it comes to the risk of re-infection," Lindgren said.
State epidemiologist Tegnell told The Local: "It’s a lot of explaining why things should be done and what’s the goal; not to talk so much about how to do things but getting people to understand why you do things so they themselves can see how to do it."
Favourable factors and high trust levels
Sweden benefits from an environment that is naturally less favourable to the spread of diseases, both due to the low population density and the habits of the population.
Sweden has 25.4 inhabitants per square kilometre, based on 2019 data, compared to an EU average of 117.7. Around 40 percent of people live alone. The vast majority of over-70s (95 percent) do not share their home with someone under the age of 40. Compare that to Italy, where 18.9 percent of over 65s have their children living with them.
Sweden is also an outlier when it comes to its high public levels of trust, both in institutions and fellow citizens, something that several of the experts The Local spoke to cited as a factor in the Swedish strategy. MSB's surveys showed high trust for the healthcare sector (80 percent) and Public Health Agency (77 percent), figures which have increased since the start of the outbreak.
"If you have a society where the government is fundamentally mistrusted or a polarised environment where the strategy would get politicised, this may well not work," said the Swedish Institute for Health Economics' Peter Lindgren.
"But in the Swedish parliament, there is very little disagreement – there's some disagreement on the details but everyone is buying in on the general strategy."
Lars Trägårdh, a professor of history and civil society who has studied Swedish individualism and trust said: "If you have mutual trust you don't need harsh measures.
"Harsh measures can only work for short periods, so in the long run we have to depend on people voluntarily following these rules, it's the only way that's sustainable."
Adaptable and reactive
Just as the Swedish response cannot be copy and pasted with an expectation of the same results, nor should we dismiss it as an anomaly or a strategy that was only possible due to the unique Swedish conditions.
Trägårdh says that the stereotype of the individualistic, high-trusting Swede shouldn't be taken too far. People in Sweden aren't necessarily more inclined to follow social distancing, he says, and trust isn't always an advantage.
"It's not that Swedes are asocial, but sociability in Sweden is based on voluntariness. In some cultures you're more forced into community, to live with your parents and so on, and in Sweden the idea is that the welfare state means community is more voluntary," he says. "But the virus doesn't care if you're socialising voluntarily or not. [...] And a risk with high trust that if you make a bad policy choice, they might all march over the cliff together, so to speak."
There are also examples of government efforts having positive results to slow the virus even in parts of Sweden with lower trust levels and higher population density.
Authorities were initially slow to publish the coronavirus guidelines in languages other than Swedish and infection rates rose in immigrant suburbs around Stockholm like Järva.
But after a push in multilingual information campaigns and new measures like opening emergency accommodation for at-risk people living in cramped conditions, the infection rate began to fall. This suggests low trust and cultural barriers weren't the reason for the early high spread as some had claimed. Even in areas with many people in crowded housing and insecure employment, it proved possible to slow the spread of the virus without using laws to confine people to their homes.
And even high-trust Sweden hasn't left everything to chance.
A new law allows the government to take more sweeping measures including the closure of schools, restaurants, and transport hubs without parliamentary approval, something previously not possible under the constitution.
"One big advantage of a somewhat looser framework is that you can allow a bit more flexibility, it's easy to adapt measures at a workplace or business for example, based on local needs rather than having to follow a precise law," says Peter Lindgren.
The Public Health Agency has even said at times that Swedes have taken their advice too strictly and even asked sports training sessions for children to resume because it was "important for children and young people to move around".
One major difference between Sweden and other countries around Europe is that primary schools have remained open. Again the government chose to push new guidelines to reduce spread of infection rather than simply close schools down and force working parents to stay at home.
These measures included staggering class, break and lunch times and spacing out tables and chairs to ensure social distancing.
"Our schools and teachers are working so hard to follow the recommendations and I think they're doing all they can, even though it's sometimes difficult – with kids between six and ten it's harder to maintain social distancing," admitted Maria Olausson from the National Agency for Education.
When deciding to reopen schools, Norway's Public Health Institute used the experience of Sweden, along with Iceland, Taiwan and Singapore – where no clusters of the virus were linked to schools – as an example when it explained its own reasoning.
Restrictions where it matters - and communicating why
In environments considered a high risk for infection, more detailed recommendations and rules apply.
Shops in Sweden have been asked to set up information signs or use audio announcements, mark out distances on the floor, rearrange furniture, and designate a member of staff who is responsible for these measures.
In restaurants and bars, these recommendations are enforced – regional infectious disease physicians carry out inspections to ensure that tables are spaced out, only table service allowed, and crowding is being avoided. Venues which have not followed the measures can be closed temporarily. A new law will give municipalities the power to close restaurants that fail to follow the rules.
Large gatherings have been prohibited with organisers risking fines and when it came to care homes the government banned visits.
State epidemiologist Anders Tegnell said the strategy has been "constantly changing" based on available evidence and the current risks. "When we see restaurants are very crowded, we go in with regulations and when that doesn’t help, we have gone in with inspections and closed them down, so it’s constant adaptation," he told The Local.
Mälarpaviljongen, a waterside bar and restaurant in Stockholm, had not yet opened for the season when the restrictions on restaurants were introduced. "We discussed our plan of action, tried moving furniture around, looked at how to put signs up that people would read," restaurant manager Christofer Kinunnen told The Local.
Those measures included removing 50 percent of the tables, putting plexiglass on benches to divide customers and having doormen to seat customers and manage the flow of guests in the venue.
A key factor in making sure the measures are followed was open dialogue with customers, including on the restaurants' social media channels. This has meant reporting the feedback from inspections and detailing the measures in place.
While the restaurant has successfully passed three inspections, the loss of seating to ensure social distancing has hit hard meaning they, like other restaurants and bars have had to rely on financial support from the government, including adjusted rent.
'All systems in lock-step'
Health economist Lindgren also stressed that the country's strategy depends on cooperation throughout different authorities.
"People need to be able to act in accordance with the recommendations. In Sweden one recommendation is you should stay at home with any symptoms even if they are mild, but for that to work you need a safety net so that you don't have to go to work with symptoms for economic reasons. One change the government made early on was extending the regulations for sick leave so you got paid from day one and didn't need a doctor's certificate," explained Lindgren.
Even with these changes, those on hourly contracts may fall through the gaps – something that has been blamed for the widespread deaths in care homes where a large proportion of staff are not salaried employees.
"You need to make sure all the systems are in lockstep, make sure it's possible for people to act in the intended way without running into problems with other parts of the system," said Lindgren.
The need for extensive financial support for businesses and individuals highlights another warning from Sweden; just because the lack of lockdown doesn't mean the economy is fit and well. Countries easing restrictions and opening schools to allow people to return to work shouldn't expect the economy to burst back into life.
In Sweden one in ten retail stores have lost 80 percent of trade, and Nordic banks SEB and Swedbank do not expect Sweden to benefit financially from its looser restrictions in comparison to its Nordic peers. Staff have been furloughed and unemployment is expected to rise dramatically.
Sweden's Deputy Prime Minister told The Local the economic situation was "very, very tough" and warned that not all companies would survive the crisis.
'Sustainable approach'
The word repeatedly used by Swedish authorities and the Public Health Agency to sell their softer strategy has been "sustainable"; in other words, it's the only way to keep the healthcare system from being overwhelmed and society functioning long-term.
It's a word repeated by the country's Prime Minister Stefan Löfven who said the fight against the virus was a "marathon not a sprint".
State epidemiologist Tegnell has said the strategy is designed to last for months and will help put Sweden in a better position to handle any second wave because the level of collective immunity will be higher in Sweden than in countries where lockdowns were imposed. The World Health Organisation says it is still very unclear whether people who have had the virus are protected against re-infection, or how long any immunity would last.
Sweden's approach has been oversimplified by critics as a "gamble" that may or may not pay off, but authorities in the country have not been relying on guess work and chance to overcome the pandemic.
The strategy has been divisive and mistakes have been made as its failures to increase testing, protect elderly care homes, and communicate with minority and immigrant communities show.
But the approach to voluntary measures provides a combination of warnings and lessons for other countries, who emerge from lockdown with the real fear that a second wave of the virus could put them back to square one.
As the WHO suggests, countries can take lessons and heed warnings from Sweden, but they will need to find their own way forward.
"Every country has to determine the right package of blended measures based on the context," a spokesperson told The Local. "Many factors are important in assessing the context, including population density, geographic spread of the population, living conditions, cultural and social norms and practices, characteristics of vulnerable populations.
"WHO recommends that each country put in place a combination of measures based on a thorough assessment of the evolving situation that looks at real-time surveillance, capacity to identify, isolate, test and treat all patients, and trace and quarantine contacts."
In other words, countries will need to be ready to adapt their strategy based on an ever-changing situation.
This article has been supported by the Solutions Journalism Network, a nonprofit organization dedicated to rigorous and compelling reporting about responses to social problems.
