NIRA OPINION PAPER
No.52 | July 2020

NIRA OPINION PAPER
No.52 | July 2020

Why did Sweden Choose not
to Lock Down?
- Constitutional provisions and national characterare the background factors Yuri Okina

Executive Vice President, Nippon Institute for Research
Advancement / Chairperson, Japan Research Institute

Pereric Högberg

Ambassador of Sweden to Japan

Ayako Miyakawa

Consultant Surgeon, Department of Urology,
Karolinska University Hospital

Sweden has not adopted a mandatory lockdown policy, choosing instead to
adopt a moderate approach to controlling COVID-19 which leaves much to the public’s
discretion. The decision to adopt such a policy was based on the judgment of expertsthat even if a lockdown policy was effective in the short-term, the infection would spreadonce again after it was lifted, and that the government should therefore adopt a policythat the public would be able to tolerate for an extended period. At the same time, it
should be noted that the Swedish Constitution stipulates that the central government
shall not prohibit the movement of citizens, shall respect the autonomy of local
governments, and shall respect the decisions of public authorities such as the Public
Health Agency, which is an expert group. Although there has been considerable
criticism from overseas regarding Sweden’s lack of mandatory measures, the public is
comparatively satisfied with the policy. Historically, Sweden has fostered public trust in
government; in this case the public has cooperated with the government’s policy,
understanding it as a decision based on scientific evidence. In addition, the Swedish
public's attitude of making their own decisions regarding their own actions can bepointed to as one of the reasons for its support of the policy.
In order to enable us to adopt effective measures to protect the health of the
public, it would be valuable to increase our knowledge of policies implemented
throughout the world and to use them as a reference for our own policy decisions. In
doing so, it will be necessary to search for and weigh up the best direction for Japan,
based on a multifaceted study of factors including the countries’ cultures, historicalbackgrounds, social capital, legal systems and medical systems.

Copyright Ⓒ 2020 by Nippon Institute for Research Advancement
This is a translation of a paper originally published in Japanese. NIRA bears full responsibility for the translation
presented here.

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NIRA OPINION PAPER
No.52 | July 2020

Why did Sweden Choose not to Lock Down?
- Constitutional provisions and national character are the background factorsYuri Okina

Executive Vice President, Nippon Institute for Research Advancement (NIRA)
Chairperson, Japan Research Institute

Introduction
Each country has mounted its own unique response to the COVID-19 infection,reflecting factors such as its national character, legal system and medical system. Against
this background, Sweden's unique policies have attracted worldwide attention. What is the
background to Sweden’s moderate response, which allows the public autonomy in making
decisions, and why does Sweden continue to pursue policies which are so different from thoseof other countries?
In order to consider these questions, we interviewed H.E. Pereric Högberg, theAmbassador of Sweden to Japan, and Dr. Ayako Miyakawa, who works as a consultant
surgeon at the Karolinska University Hospital, which is well known as one of Sweden’s core
hospitals, and as an institution that possesses advanced functions. In this paper, I will discuss
the background to measures against infectious diseases in Sweden based on the results ofthese two interviews and the findings of experts in Japan and abroad.

There are a variety of opinions regarding Sweden's COVID-19 response / Some
aspects of Sweden’s response are shared with Japan
Although a state of emergency was declared in Japan between April and May, thenation did not adopt the mandatory lockdown measures put in place in most Westerncountries. While there are many differences between Sweden and Japan, the response
adopted by Sweden is similar to Japan’s in that relevant decisions and actions are left to thediscretion of the public. There are some prohibitions and observances, such as maintaining
social distancing and prohibitions on meetings of more than 50 people and visits to facilities
for the elderly, but these are moderate measures that avoid mandatory lockdown.
There are those who find Sweden's attitude of respecting the autonomy of the people
admirable from an ethical point of view. In addition, from the perspective of maintaining
people's lifestyles, it is predicted that the impact on the economy will be relatively lower thanis the case in the United Kingdom and the eurozone, and this aspect of Sweden’s response has
tended to be positively evaluated.1
This paper was edited by Kozue Sekijima and Ayumi Kitajima of the Nippon Institute for Research Advancement.

Copyright Ⓒ 2020 by Nippon Institute for Research Advancement
This is a translation of a paper originally published in Japanese. NIRA bears full responsibility for the translation
presented here.

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NIRA OPINION PAPER
No.52 | July 2020

On the other hand, in May, U.S. President Donald Trump harshly criticized Sweden’smeasures, stating that the nation was paying heavily for its no-lockdown policy. As of July 20,
the number of deaths in Japan was approximately 1,000, while in Sweden it was over 5,600.
The fact that the mortality rate is higher in Sweden than in other Scandinavian countries has
also drawn criticism.

A structural problem of the nursing-care system is also a factor in the numberof deaths
The reason why the death rate in Sweden is higher than it is in other Scandinavian
countries is, as Dr. Miyakawa points out, because many of the people who have died were
elderly people who were in need of care and lived in care facilities under municipal
administration. A structural problem played a part here, in that clusters occurred because
part-time caregivers continued working when infected because of concern that they mightlose their jobs, and the institutions in which they were working had inadequate infection
prevention measures. Moreover, the underlying cause of the high mortality rate is that anational consensus has been formed that doctors will decide on the necessary treatment forpatients after considering that patient’s prognosis, even in normal times. According to Dr.
Miyakawa, it is up to the doctor to decide whether to treat patients aged 70 or older inintensive care, and this holds true in the case of COVID-19 infection. Given thesecircumstances, it is not necessarily the case that the lack of lockdown is directly linked to thedeath toll.
As this indicates, there are significant divisions in the assessment of Sweden’s
response. The true character of COVID-19 is not necessarily clear, and it is expected to taketime for the disease to converge to an equilibrium. As H.E Pereric Högberg pointed out in
his interview, it is still difficult to make a comprehensive assessment at this point. This
paper will therefore limit itself to introducing the perspectives described above.2

Constitutional provisions that prevented the adoption of lockdown
Some believe that the use of a “herd immunity strategy” lies behind Sweden's decision
not to adopt lockdown regulations. However, the Swedish government has explicitly denied
this. The Swedish government has stressed that the purpose of its measures is to prevent the
spread of infection and the collapse of the system of medical care, as is the case in othercountries. In his interview, H.E Pereric Högberg explained that the government did not apply
lockdown measures because it believed that the disease would require a long-term response
and that this therefore should be a sustainable response that the public and the social system
could tolerate for an extended period.
However, we should also note here that the Swedish Constitution does not allow
restrictions to be placed on citizens’ movements. With regard to the freedom of movement of
Copyright Ⓒ 2020 by Nippon Institute for Research Advancement
This is a translation of a paper originally published in Japanese. NIRA bears full responsibility for the translation
presented here.

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NIRA OPINION PAPER
No.52 | July 2020

the individual, Chapter 2 ("Fundamental rights and freedoms"), Article 8, states that"Everyone shall be protected in their relations with the public institutions against
deprivations of personal liberty. All Swedish citizens shall also in other respects beguaranteed freedom of movement within the Realm and freedom to depart the Realm." As
this indicates, under normal conditions, Swedish nationals are guaranteed full freedom of
movement, both within the nation and across national borders3. It has been pointed out thatthe reason no provisions regarding restrictions on the movement of citizens in times of
emergency are included in the text of the Constitution is that Sweden has not gone to war
since 1814, and there has therefore been no state of emergency for many years (Klamberg(2020)).
The Constitution also gives a strong role to local governments, which is anotherreason why lockdown was not implemented4. Under Sweden's local self-government system,
medical care is administered at the regional level (corresponding to the prefectural level inJapan), while welfare and education services such as nursing care and childcare areadministered at the commune, or municipal, level. Decrees from the central government do
not restrict the autonomy of local governments. We may consider that the central government
did not forcibly close schools because this type of decentralized structure also exists in the
education system. In the field of medical care in Sweden, there are few private hospitals andnumerous public hospitals and this is precisely why hospitals are able to focus on responding
to the COVID-19 outbreak without being overly concerned about profitability. In her interview,Dr. Miyakawa points out that despite the fact that the nation has a regionally decentralized
system, there is cooperation among hospitals throughout the nation as a whole.

Sweden’s reasons for maintaining unique policies that differ from those of othercountries: (1) Establishment of a framework for respecting expert opinions
Sweden’s individual policy response has been criticized even in Sweden. However, it
has been possible for the government to maintain the policy with the support of a relatively
large number of people. Why has this been the case? First, mechanisms that ensure that theviews of experts are respected are guaranteed by the Constitution, and second, there is publictrust in the government.
With regard to point 1, public authorities have been established independently of thecentral government based on the principle of administrative dualism (Jonung (2020)) and theConstitutional provision that insists that the government must respect the autonomy ofpublic authorities and not interfere with them. 5 The stipulations of Chapter 12("Administration"), Article 26, are observed faithfully by the government and politicians. A
public authority called the Public Health Agency, a group of experts whose independence isguaranteed is responsible for directing the nation’s policy response to COVID-19. Sweden has
implemented the policies recommended by experts working in the Public Health Service
without modification.

Copyright Ⓒ 2020 by Nippon Institute for Research Advancement
This is a translation of a paper originally published in Japanese. NIRA bears full responsibility for the translation
presented here.

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NIRA OPINION PAPER
No.52 | July 2020

In an interview in June, Dr. Anders Tegnell, the epidemiologist who is directing
Sweden’s policy measures, indicated that the virus will be with us for a long time, andtemporary lockdowns will not prevent its resurgence and also have negative effects. 7 If
Sweden had a system in which politicians intervened or made final decisions, it might nothave been able to maintain its independent course in the face of the lockdown policies in many
European countries.

Sweden’s reasons for maintaining unique policies that differ from those of othercountries: (2) People's trust in the government and respect for autonomy are
the foundation
The second important point is that the Swedish government has traditionallyadopted a highly transparent, evidence-based and accountable approach to crises, and thatpublic confidence in the government is comparatively high (see the figure on the followingpage). The government adopted a policy of encouraging change in behavior by making
recommendations to the public rather than by imposing mandatory measures; the public
understood these recommendations and voluntarily followed them. During the Swedish
financial crisis in the 1990s, the government aggressively injected public funds into theeconomy in order to bring the crisis under control as early as possible, based on theunderstanding of the public obtained through this approach (Okina, et al (2010)).
With regard to the public's trust in politicians, it has been indicated to the authorthat the facts that in many cases politicians are from the working and lower middle classes
and have been trained as political professionals since their youth, and that the nation has
adopted a system of proportional representation, have provided a foundation for trust8.
As Dr. Miyakawa points out in her interview, we must not ignore the fact that Sweden
is a society that respects the autonomy of individual behavior; for example, while access to
medical care in Sweden is not ideal, there is a consensus that sick people can take time offfrom work and stay home. It is also noteworthy that this national character – respect for thefact that one’s own actions are one’s own decisions – is fostered from childhood in Swedish
education.

Copyright Ⓒ 2020 by Nippon Institute for Research Advancement
This is a translation of a paper originally published in Japanese. NIRA bears full responsibility for the translation
presented here.

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NIRA OPINION PAPER
No.52 | July 2020

Figure : Trust in the central governments of OECD countries (Average for the 2010s)
(%)
80

60

40

20

Gr
ee
ce
Ita
ly
Sp
ai
n
Ch
ile
Ko
re
Un J aite ap
d an
St
at
e
Fr s
an
Es ce
to
ni
O
a
EC
D Isra
-A
ve el
ra
g
Au e
st
r
Un ia
i
Be tedlg …
Au iumst
De ralianm
Ge ark
rm
a
Sw ny
N
e
et d
he en
rla
nd
N
Lu or s
xe w
m ay
bo
ur
g

0

Note) The figures are averages for 2012, 2014, 2016 and 2018.
Source: Formulated by the author based on OECD, Government at a Glance

Need for multifaceted research on responses to COVID-19
As discussed above, legal provisions play a large part in Sweden’s particular response
to COVID-19, but we can also point to the national character (trust of the public in thegovernment and respect for autonomy) as also being a background factor.
In the future, we will be required to be tenacious as we live with COVID-19. In orderto enable us to adopt effective measures to protect the health of the public, it would bevaluable to increase our knowledge of policies implemented throughout the world and to usethem as a reference for our own policy decisions. However, to avoid falling into shortsighted
judgments when we do so, it will be necessary to search for and weigh up the best direction
for Japan, based on a multifaceted study of the countries’ cultures, historical backgrounds,social capital, legal systems and medical systems.

References
Jonung, L. (2020), ‘Sweden's constraint determines its exceptional Covid -19 policy’, VOX EU,
CEPR.
Klamberg, M. (2020), ‘Between normalcy and state of emergency: The Legal framework of
Sweden's coronavirus strategy’, The Local, The Local Europe AB.

Copyright Ⓒ 2020 by Nippon Institute for Research Advancement
This is a translation of a paper originally published in Japanese. NIRA bears full responsibility for the translation
presented here.

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NIRA OPINION PAPER
No.52 | July 2020
Okina, Nishizawa, Yamada, Yumoto (2010), The Scandinavian Model, Nihon Keizai Shimbun
Publishing Co., Ltd.
The Research and Legislative Reference Bureau of the National Diet Library (2012), Collection of
National Constitutions (1): The Swedish Constitution, The National Diet Library
Kanno, N. (2020), ‘The Novel Coronavirus, Sweden's Resolve in the Face of a Protracted Effort,
and the Nation’s Stance of relying on the Reason of its Citizens’, Policy Blog, Japan Center for
Economic Research.
Thomas Cobiliel (2020), ‘Sweden Preserves Epidemiology and Individual Freedom, but COVID -19
Uncertainty Worsens Economic Impact’, NIRA Opinion Paper, No.46, pp. 7 -8.

Yuri Okina

Executive Vice President of the Nippon Institute for Research Advancement
and Chairperson of the Japan Research Institute. Doctor of Economics(Kyoto University). Serves as Chairperson of the Health, Medical andNursing Care Committee of the Growth Strategy Council – Investing for the
Future/Council for Advancing Structural Reform, as a member of the
Financial System Council, and as a member of the Industrial Structure
Council.

Note
1

OECD forecast for real GDP growth in 2020 (June 2020).

In an interview with The Wall Street Journal, one of the experts who leads Sweden's policy
responses, Dr. Anders Tegnell, indicated that it had been reported that the policy of not locking
down was a failure, but that while more could have been done to protect the elderly, he did not
see the policy as having failed.

2

Chapter 2, Article 24 states, “Freedom of assembly and freedom to demonstrate may belimited in the interests of preserving public order and public safety at a meeting or
demonstration, or with regard to the circulation of traffic. These freedoms may otherwise belimited only with regard to the security of the Realm or in order to combat an epidemic.” Thebasis for the restriction on groups of more than 50 people can be found here.

3

Article 2 of Chapter 14, "Local authorities," states that “The local authorities are responsible
for local and regional matters of public interest on the principle of local self-government.”

4

The government consists of the Prime Minister and other Ministers. Public authorities are
independent of the government and ministries, and play the role of providing them withspecialized information and opinion necessary for administration.

5“No public authority, including the Riksdag, or decision-making body of any local authority,
may determine how an administrative authority shall decide in a particular case relating to
the exercise of public authority vis-à-vis an individual or a local authority, or relating to theapplication of law.”

6

7

Published by Bloomberg on June 28, 2020

Professor Hiroaki Watanabe of Ryukoku University, who is well-versed in Swedish politics,
offered many suggestions during the writing of this paper. I would like to take this opportunity
to thank him. The Japanese translation of the Swedish Constitution is published by the
Research and Legislative Reference Bureau of the National Diet Library (2012).

8

Copyright Ⓒ 2020 by Nippon Institute for Research Advancement
This is a translation of a paper originally published in Japanese. NIRA bears full responsibility for the translation
presented here.

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NIRA OPINION PAPER
No.52 | July 2020

Pandemic Responses Rooted in Trust
Pereric Högberg
Ambassador of Sweden to Japan
I would like to reflect on the successes and failures of the Swedish Government’s
response to COVID-19 so far. I want to begin by addressing a common misperception of
Swedish policy, to the effect that it is specifically targeting herd immunity.
It is important to note that the Swedish Government has always had the same goals
as most other countries, which are to limit the spread of the virus in society, and to mitigate
its economic impact. More specifically, the government’s strategy aims to: 1) Limit the spreadof infection in the country and relieve the pressure on the healthcare system; 2) Ensure that
health and medical care resources are available; 3) Limit the impact on critical services(healthcare, police, energy supply, communications, transport and food supply systems, etc.);4) Alleviate the impact on people and businesses; 5) Ease concern by continuously providing
clear and correct information on what measures are being taken and why to all the people
in Sweden; and 6) Implement the right measures at the right time.1

The interview with H.E Pereric Högberg, the Ambassador of Sweden to Japan was conductedby Dr. Yuri Okina, NIRA Executive Vice President / Chairperson of The Japan ResearchInstitute, Ltd., in June, 2020 at the Embassy of Sweden in Tokyo.

This paper was edited by Jonathan Webb.

Copyright Ⓒ 2020 by Nippon Institute for Research Advancement
This is a translation of a paper originally published in Japanese. NIRA bears full responsibility for the translation
presented here.

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NIRA OPINION PAPER
No.52 | July 2020

When Sweden declared a national health emergency in February, its strategy was,from the very beginning, to make sure that the healthcare system could cope while limiting
the infection. The strategy was also to ensure the at-risk groups in society, the sick and elderly,
particularly those over the age of 70, were properly protected.
However, as this is not something that can be overcome in a matter of months, we
believe a long-term approach that minimizes economic and social disruption is equallyimportant. This is one of the main reasons why Sweden never locked down, and never closed
schools. A major factor in the decision not to close schools was labor. In Sweden, housewives
and househusbands are rare, as everyone works. Closing schools would cause enormous social
disruption, including in the area of healthcare, where many nurses are parents. To cope in amanner sustainable over the long-term, then, schools needed to remain open, and this had
nothing to do with herd immunity.
The Swedish government is currently forming a joint commission together with the
opposition party to evaluate its approach so far. The government is confident about its
strategy nonetheless.
Alternatively, one area in which we can identify a clear failure is in Sweden’s
relatively high death rate of over 500 per million inhabitants, whereas in Japan, for example,
that number is only 7.8 (as of July 20)1. The deaths reported have mainly occurred among theelderly. Prime Minister Stefan Löfven has stated that this is a failure of the caring facilities
in not being able to prevent the virus from getting into places like nursing homes, rather than
the government’s strategy itself. This comment does not mean that the government is seeking
to avoid taking responsibility; rather, we couldn’t foresee the problem. The government has
now taken steps to address this problem with a ban on visits to nursing homes that will
hopefully better protect the elderly.
Although there is still work to be done to bring the death rate down, Swedish policy
has generally walked the line between enacting the minimum number of legal restrictions or
recommendations while keeping schools and businesses open and public transportation
running.
Sweden’s response to COVID-19 may be exceptional in the international context. The
approach was decided by the Swedish constitution, which guarantees the freedom of
movement of citizens, making nationwide lockdowns impossible. The Swedish government is
not allowed to declare a state of emergency in peacetime. Furthermore, we have a very
decentralized system, which is also guaranteed by the Constitution. For example, elderly carefacilities and schools are not administered by central government but rather by local
governments, and the central government can only issue recommendations. Additionally, thefunctions of the government and ministries are limited, allowing public agencies and expert
authorities to make policy decisions. To roll out the COVID-19 strategy, the government
listened to the Public Health Agency of Sweden, which is run by epidemiologists, anddecisions regarding the number of people that can gather in public, or the decision to close
elderly care homes, were based on their opinions.

Copyright Ⓒ 2020 by Nippon Institute for Research Advancement
This is a translation of a paper originally published in Japanese. NIRA bears full responsibility for the translation
presented here.

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NIRA OPINION PAPER
No.52 | July 2020

Another key to understanding why Sweden has reacted the way it has is the level oftrust people in Sweden have in government agencies. Swedish society is built on a long historyof trust between the government and the people, something a mandatory lockdown would
undermine. The most effective way to deal with a virus is not to lock down, as you cannotarrest a virus, but to foster the trust of every person living in the society, to encourage themto cooperate with government policy and behave in a way that will limit the spread of thevirus.
This trust wasn’t built in a day; it has developed over the last two centuries of
Swedish history via the peace secured through our neutrality, the push for universal
education in the mid-19th century, the realization of universal suffrage in 1921, and thedevelopment of the welfare state during the 20th century. All of this was the result of abottom-up movement, with the people putting pressure on the government. This has createdan environment in which the government tends to be very in tune with the people, resulting
in the people having a high level of trust in their government, and confidence in public
institutions such as the civil service.
The strength of the Swedish approach can be seen in the healthcare system, where
we were able to avoid a collapse, quickly raise the number of ICU beds to meet the increased
demand, and repurpose existing facilities such as expo centers to alleviate pressure on
hospitals. At the same time, our centralized emergency system successfully coordinatedbetween hospitals ensuring there was never a scenario where ambulances didn’t know where
to go. Patients’ medical records are also available digitally via their Swedish Social Security
Number, allowing for the best possible care.
Examining the Japanese pandemic response from a Swedish perspective, I see many
commonalities. Both emphasized an approach based on trust, voluntary cooperation andpersonal responsibility. An example of this is how after Japan declared a state of emergency,
many businesses voluntarily closed. Another area in which Japan has been doing very well is
its commitment to a multilateral approach. Japan participates in the EU Coronavirus Global
Response Conference, contributes to the GAVI effort to find a vaccine, and has stood firmly
behind the WHO, resisting calls by some countries for retrenchment. From my point of view,
Japan’s response domestically and internationally has been very good.
The one thing I do think has been unfortunate, and honestly a little surprising, is thefact that the Japanese people do not seem particularly happy with their government's
approach. Given how well Japan looks compared to much of the rest of the world, I can’t help
but wonder just what is it that the Japanese people would have liked their government to do.
The pandemic, while tragic, has provided us with a once-in-a-generation opportunity
to forge a new and better normal through digitalization. People are suddenly asking
themselves why they commute 90 minutes a day, why they have to be present physically forwhat could be done over email or video conference. We can build a more environmentally
sustainable society by accelerating the process of digital transformation. I believe Sweden is
uniquely positioned to lead this charge. Even before the pandemic, working from home was

Copyright Ⓒ 2020 by Nippon Institute for Research Advancement
This is a translation of a paper originally published in Japanese. NIRA bears full responsibility for the translation
presented here.

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NIRA OPINION PAPER
No.52 | July 2020

common; medical records were also digitalized, tied to Social Security Numbers and easily
accessible to enable optimization of care. It’s not perfect - sometimes I feel the Swedish tax
authority knows more about me than I do – but it has good consequences, and it is something
to build on.
That said, in the digital age, many people are rightly concerned about their privacy
and the security of their information. However, in an era in which people willingly put muchof their lives on social media and carry smartphones that can track them if inadequately
secured, we must also be rational. This means striking a balance between preventing abuse
and instilling public confidence, while maximizing the opportunities offered by the digitaltransformation.
I believe that as we are still in the middle of the pandemic, it is too early for adefinitive evaluation. However, in closing, Sweden and Japan share an approach to thepandemic rooted in trust in the people and voluntary responsibility. We are united in ourbelief that multilateral cooperation is key to overcoming this crisis. This virus knows noborders and no nations, and thus we must work together to build a better tomorrow.

Pereric Högberg
Ambassador Högberg was appointed Sweden’s ambassador to Japan in fall2019. He has served in positions including as First Secretary of the
Embassy of Sweden in South Africa, Director of the International Division of
the Swedish Arts Council, Director of the Africa Department of the Swedish
Ministry for Foreign Affairs, and as Sweden’s Ambassador to Vietnam.

Note
The interview was held in June, however this paper was revised based on the information
available at the time of publication.

1

Copyright Ⓒ 2020 by Nippon Institute for Research Advancement
This is a translation of a paper originally published in Japanese. NIRA bears full responsibility for the translation
presented here.

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NIRA OPINION PAPER
No.52 | July 2020

Sweden’s Strategy in Response to COVID-19- Observations of a Japanese Physician resident in Sweden
Ayako Miyakawa

Consultant Surgeon, Department of Urology, Karolinska University Hospital

Sweden has decided not to lock down
I work as a consultant surgeon in the Department of Urology at Karolinska
University Hospital. There are arguments for and against the measures that have been taken
to combat the spread of COVID-19 in Sweden, and given that the spread of the disease has
not yet been stopped, it is not clear at this point whether those measures were correct or not.
Nevertheless, I would like to discuss the measures that Sweden has adopted and how theSwedish public felt about them from the perspective of a Japanese doctor working in Sweden.
As of July 20, the death toll from COVID-19 in Sweden (a nation with a populationof approximately 10 million) was more than 5,600, making the mortality rate per 1 million
persons about 550 (for comparison, the mortality rate per million persons in Japan was 7.76).
Anders Tegnell, an epidemiologist who is advising the Swedish government on how to deal
with COVID-19, has repeatedly explained to the public that the pandemic will be a long one,and that policies that the public can tolerate should be implemented until it ends. His
assertion that policy decisions should be made not only on the basis of controlling the numberof infections and deaths, but should also take into consideration the impact on society and theeconomy from a variety of perspectives, seems to me to be reasonable.
Another focus is whether there is a scientific basis for implementing lockdown. Dr.
Tegnell has spent 20 years working with epidemiologists in Europe to combat infectious
diseases. He has indicated that there was a consensus among epidemiologists that lockdown
was meaningless and that a more liberal approach was desirable. He has claimed in aninterview that he was very surprised when European countries chose lockdown despite thisconsensus.

Policy decisions are based on scientific evidence
The reason why the choice of countermeasures against infectious diseases in Sweden
is different from those in other countries is largely because of who directs the policies. Whatis noteworthy about policy in Sweden is that policy decisions are based on scientific evidence;that is, the opinions of experts are respected. The Swedish Constitution also states that it
respects the decisions of public authorities. In other countries, by contrast, politicians makethe final decisions on policy. As a result, when the infection spread and public criticism
increased, politicians were forced to adopt hard-line policies.
Copyright Ⓒ 2020 by Nippon Institute for Research Advancement
This is a translation of a paper originally published in Japanese. NIRA bears full responsibility for the translation
presented here.

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NIRA OPINION PAPER
No.52 | July 2020

In Sweden, public authorities are kept at a distance from the government, andgovernment intervention in individual policy decisions is prohibited1. The stance of politiciansin respecting the opinions of experts from public authorities is consistent in policies otherthan those targeting infectious diseases, and the messages that politicians offer the public
always accord with those of experts. In addition, citizens' interest in politics is generally high;for example, voter turnout in elections is around 90%. The trust of the Swedish public inpolitics and the government has always been high, and it seems to have been relatively easy
for experts to decide on policies with a high degree of freedom and for politicians to respect
and implement them.
It is also the case in Sweden that quite a few researchers are opposed to thegovernment's policy of not implementing lockdown, and discussions regarding this are stillongoing. For example, wearing a mask has not been recommended because it is claimed that
there is no evidence. However, there is some evidence for the effectiveness of masks, and I
personally wonder why the Swedes are not more flexible in this regard.
With regard to the Constitution, as is the case in Japan, the Swedish Constitution
does not give the government the power to enforce lockdown, leaving it up to the people's free
will to observe lockdown measures. This may be related to the fact that Sweden has not goneto war for more than 200 years. It was not necessary for the government to declare a state of
emergency for a long time. However, in March 2020, a law was passed that allows local
governments to order schools to close down in the event that COVID-19 spreads. It could besaid that preparations to close schools have been made at the municipal level.

Employment issues are a factor that explains why the elderly havepredominantly been victims of the virus in Sweden
It is largely the elderly who have fallen victim to COVID-19 in Sweden. This isbecause clusters of infection have occurred in facilities for the elderly. The employment
situation in Swedish nursing care homes for the elderly is a factor in this.
Sweden has seen a decline in the number of elderly people in nursing homes sincethe 1992 Edel Reform 2 . This reform saw the government changing its policy to improve
support for nursing care at home. Today, therefore, it is often the case that only elderly people
with severe conditions necessitating focused care enter nursing facilities.
With the privatization of nursing care facilities, there is a growing need to cut costs.
In addition, workers' rights in Sweden are very strong; once a worker is employed, they cannot
be dismissed unless there is a serious problem. As a result, nursing homes have come to rely
on low-wage part-time workers. The proportion of part-time workers in private nursing homes
is said to be more than 30%. Many part-time workers are immigrants, and their working
conditions are poor. Fearing that their income would be cut off if they were absent from work,some of these employees hid the symptoms of infection with COVID-19 and continued
working, which led to the spread of infection. Sweden also has residential homes for the

Copyright Ⓒ 2020 by Nippon Institute for Research Advancement
This is a translation of a paper originally published in Japanese. NIRA bears full responsibility for the translation
presented here.

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No.52 | July 2020

elderly in addition to private nursing homes of this type, but no clusters of infection have beenreported there.
Other places where clusters have occurred include hospitals in which patients withdementia are hospitalized. In Sweden, it is forbidden to restrain patients with dementia, andthey are therefore able to move freely around the hospital. In some cases, this meant that theinfection spread to doctors and nurses.
However, it is reported that only 30% of elderly patients infected with COVID-19 have
died, with the rest recovering naturally.

A Swedish tendency to take time off from work when sick
After the first case of infection in China was confirmed in February 2020, cases
gradually began to appear in Sweden. Initially, PCR testing was performed on people who
had had contact with infected persons in order to trace the route of infection. At that stage,
PCR testing was not considered particularly urgent. After the week-long “sport break”(Sportlov) holiday in early March, however, the number of people infected with the virus
soared, and it became impossible to trace them. The testing policy was therefore changed, and
PCR testing was limited to seriously ill patients requiring hospitalization. However, since themiddle of May, Sweden’s PCR testing capacity has increased, and PCR testing is conducted
free of charge for anyone who applies. The increase in the number of PCR tests has led to a
sharp increase in infection statistics, and this has intensified resistance to Sweden's policy
responses, but the number of people who have become seriously ill or died has in fact
decreased. Although the number of PCR tests has increased since the second half of June, thenumber of recorded infections is decreasing, and it has therefore been suggested that
Sweden’s heavily-criticized policy response may have been successful.
Sweden’s initial focus on PCR testing is similar to Japan’s response, but it seems that
not as many people in Sweden actually desired PCR tests as they did in Japan.
One reason for this may be differences in the medical system and the work
environment. In Sweden, access to health care is to a certain extent more limited than it is inJapan. For example, in Sweden there is a common perception that influenza is basically adisease that can be cured by resting at home; treatment for the flu is rarely provided, andpharmacies do not readily prescribe drugs for the illness.
Nevertheless, while access to medical care is thus limited to a certain extent, sickpeople can readily take time off work. Even a doctor scheduled to perform an operation canhave another surgeon perform the procedure in their place if their child is sick on the day theoperation is scheduled. If the surgeon is not available, the operation may even be cancelled.
The fact that Swedish society values individual life in this way may have made iteasier for the public to accept the government's message that it would be best to stay at home
without taking a test if one felt ill.

Copyright Ⓒ 2020 by Nippon Institute for Research Advancement
This is a translation of a paper originally published in Japanese. NIRA bears full responsibility for the translation
presented here.

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No.52 | July 2020

Optimization of Healthcare Resources at the National Level
The spread of the COVID-19 infection has been an unprecedented crisis for Sweden,
and the country was not fully prepared at the beginning of the crisis. However, it was able tooptimize the centralization of medical resources.
For example, in Stockholm, the city with the highest number of COVID-19 infections,four hospitals were nominated for the treatment of the highest-priority patients, and otherhospitals were assigned to provide regular care. The government and hospitals moved swiftly,
sending ventilators to designated hospitals, educating doctors and nurses with different
specialties for the treatment of patients in ICUs, and providing training to Scandinavian
Airlines in the support of COVID-infected patients. Protective clothing was temporarily inshort supply; medical personnel were instructed to economize, and it became necessary tosupply hospitals with protective gear that was previously in use in laboratories. Nevertheless,the necessary equipment soon arrived in large quantities from China. We did not experience
any shortage at my hospital.
Another advantage for Sweden is the high proportion of public hospitals. Private
hospitals sometimes hesitate to treat infectious diseases for fear of losing money, but in
Sweden’s case there was no need for hospital officials to take these cost issues into
consideration. In addition, because the destinations for ambulances are decided in advance toa certain extent, it is not the case that patients are unable to find hospitals to accept themand are forced to seek admission to other hospitals.
Another reason for the lack of disruption in Sweden may be the Swedish view of lifeand death. When a person aged 70 or older becomes seriously ill after contracting COVID-19,
doctors have the discretion to decide whether to place the person in the ICU based on acomprehensive assessment of the person's prognosis and ability to tolerate subsequent
rehabilitation. In addition, the wishes of family members do not affect doctors' decisions asstrongly in Sweden as they do in Japan. All human beings die when they are destined to die,and the Swedes seem to accept this fact more readily than the Japanese.

Implications for Japan
Despite the fact that the death rate per population is much higher than it is in Japan,
the Swedish people have a high degree of confidence in their government. While the level of
public confidence in the Public Health Agency (the agency responsible for directing thenation’s measures against the spread of COVID-19), which temporarily exceeded 70%,
dropped to the 60% level in June, the majority of the Swedish public still supports thegovernment's policy measures. Some interesting data suggest that even elderly citizens, who
may be disadvantaged due to the government’s policies, trust the government even more than
younger generations.
There are a variety of differing opinions regarding Sweden's COVID-19 response, but

Copyright Ⓒ 2020 by Nippon Institute for Research Advancement
This is a translation of a paper originally published in Japanese. NIRA bears full responsibility for the translation
presented here.

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No.52 | July 2020

one thing that Japan can learn from it is transparency of information. In Sweden, data fromeach ministry and agency is open to public access. Representatives from each of the nation’s
ministries and agencies hold press conferences on a daily basis to answer questions aboutdata analysis and future plans. The public is able to feel secure about the government's
policies because experts exercise leadership and provide information in an appropriate
fashion.
When I consider Japan’s response to COVID-19 from my perspective in Sweden, my
feeling is that the people on the ground in Japan are working very hard. Medical professionals,
including those in small private hospitals, are doing their best to deal with the problem. The
public has a strong focus on hygiene, and follows the rules that are set for them. It would be
advisable to clarify the division of roles in the medical system, which is tasked withresponding to COVID-19 infections in addition to the provision of normal medical care, toenhance cooperation between hospitals and other medical facilities, and to enable efficient
allocation of medical resources by central leadership.
In Japan, it would be very difficult for a woman like myself, who is also raisingchildren, to work as a physician at the frontline of the COVID-19 response. In conclusion, I
would like to broaden my perspective from the response to COVID-19 and indicate my wish
that Japan would consider the many other positive aspects of Swedish society and become akinder society in which women are able to balance work and child rearing.

References
Izawa, T. (2006), ‘Division of Functions and Connection between Health Care and LongTerm Care for the Elderly in Sweden: Transformation and Current Situation following
the Ädel Reform’, The Review of Comparative Social Security Research (Kaigai Shakai
Hosho Kenkyu), No.156, pp32-44.

Ayako Miyakawa

Dr. Miyakawa is a consultant surgeon in the Department of Urology ofSweden’s Karolinska University Hospital. She graduated from the Keio
University Faculty of Medicine as a Doctor of Medicine. Following terms
as a postdoctoral fellow at the Karolinska Institute and Cambridge
University, and periods of employment with the University of the
Ryukyus and Tokyo Medical University, she moved to Sweden in 2007.
She was licensed as a physician in Sweden in 2008, and qualified as a
specialist in urology in 2009. She has held her current position since 2008.
Dr. Miyakawa was the first female robot-assisted surgeon in the field of
urology in both Japan and Sweden. She is skilled in multiple areas ofsurgery, including laparotomy and robotic surgery. Dr. Miyakawa is also
the mother of two children.

Copyright Ⓒ 2020 by Nippon Institute for Research Advancement
This is a translation of a paper originally published in Japanese. NIRA bears full responsibility for the translation
presented here.

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NIRA OPINION PAPER
No.52 | July 2020

Note
Government Offices of Sweden, "Public agencies and how they are governed"(https://www.government.se/how-sweden-is-governed/public-agencies-and-how-they-aregoverned/)1

Reforms related to the division of medical and nursing care functions and systems ofcooperation between doctors and nurses. Medical services for the elderly and disabled, which
had previously been administered at the province level, were transferred to municipal
administration, enabling them to be centrally managed in each region together with nursing
care services. Following this change, medical personnel such as nurses came under municipal
jurisdiction, while doctors remained under wide-area, province-level jurisdiction. As a result,cooperation between medical care and nursing care has deepened to the level of nurses, but it
is also claimed that the relationship of responsibility between jurisdictions in medical care has
become ambiguous.

2

Copyright Ⓒ 2020 by Nippon Institute for Research Advancement
This is a translation of a paper originally published in Japanese. NIRA bears full responsibility for the translation
presented here.

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