COVID-19 and the Swedish enigma
Authors: Mariam Claeson, Stefan Hanson
Journal: The Lancet (2020)

In the second wave of the COVID-19 pandemic, the Swedish national response continues to be an outlier with cases and deaths increasing more rapidly than in its Nordic neighbours.1Our World in DataCoronavirus pandemic: daily updated research and data.https://ourworldindata.org/grapher/biweekly-covid-deaths?tab=chart&time=2020-02-15..latest&country=DNK~FIN~NOR~SWEDate: 2020Date accessed: December 20, 2020Google Scholar, 2FolkhälsomyndighetenPublic Health Agency of Sweden. Antal fall av covid-19 i Sverige—data till och med föregående dag publiceras varje tisdag-fredag kl.https://experience.arcgis.com/experience/09f821667ce64bf7be6f9f87457ed9aa/page/page_0/Date: 2020Date accessed: December 20, 2020Google Scholar On Dec 20, 2020, COVID-19 deaths in Sweden had reached more than 80003Platz.se. Coronavirus i Sverige.https://platz.se/coronavirus/#jump-to-total-deathsDate: Dec 20, 2020Date accessed: December 20, 2020Google Scholar or 787 deaths per 1 million population, which is 4·5 to ten times higher than its neighbours.1Our World in DataCoronavirus pandemic: daily updated research and data.https://ourworldindata.org/grapher/biweekly-covid-deaths?tab=chart&time=2020-02-15..latest&country=DNK~FIN~NOR~SWEDate: 2020Date accessed: December 20, 2020Google Scholar, 2FolkhälsomyndighetenPublic Health Agency of Sweden. Antal fall av covid-19 i Sverige—data till och med föregående dag publiceras varje tisdag-fredag kl.https://experience.arcgis.com/experience/09f821667ce64bf7be6f9f87457ed9aa/page/page_0/Date: 2020Date accessed: December 20, 2020Google Scholar, 3Platz.se. Coronavirus i Sverige.https://platz.se/coronavirus/#jump-to-total-deathsDate: Dec 20, 2020Date accessed: December 20, 2020Google Scholar This difference between Nordic countries cannot be explained merely by variations in national cultures, histories, population sizes and densities, immigration patterns, the routes by which the virus was first introduced, or how cases and deaths are reported. Instead, the answers to this enigma are to be found in the Swedish national COVID-19 strategy, the assumptions on which it is based, and in the governance of the health system that has enabled the strategy to continue without major course corrections. From the onset of the COVID-19 pandemic, the Public Health Agency, Folkhälsomyndigheten (FHM), embarked on a de-facto herd immunity approach, allowing community transmission to occur relatively unchecked.4Bjorklund K Ewing A The Swedish COVID-19 response is a disaster. It shouldn't be a model for the rest of the world.Time. Oct 14, 2020; https://time.com/5899432/sweden-coronovirus-disaster/Date accessed: December 17, 2020Google Scholar No mandatory measures were taken to limit crowds on public transport, in shopping malls, or in other crowded places, while recommending a limit of 50 people for gatherings5RegeringskanslietSwedish Government. Förbud mot allmänna sammankomster eller offentliga tillställningar med fler än 50 deltagare.https://www.regeringen.se/artiklar/2020/03/forbud-mot-allmanna-sammankomster-eller-offentliga-tillstallningar-med-fler-an-50-deltagare/Date: March 29, 2020Date accessed: December 17, 2020Google Scholar as of March 29, 2020. Coronavirus testing, contact tracing, source identification, and reporting, as recommended by WHO,6WHOContact tracing in the context of COVID-19.https://www.who.int/publications/i/item/contact-tracing-in-the-context-of-covid-19Date: May 10, 2020Date accessed: December 20, 2020Google Scholar were limited and remain inadequate.7Svenska DagbladetCorona virus Sverige. Regioner hinner inte smittspåra i tid.https://www.svd.se/regioner-hinner-inte-smittspara-i-tidDate: Dec 3, 2020Date accessed: December 20, 2020Google Scholar In our view, there is still not sufficient recognition in the national strategy of the importance of presymptomatic and asymptomatic transmission, aerosol transmission,8Folkhälsomyndigheten Public Health Agency of SwedenCOVID-19.https://www.folkhalsomyndigheten.se/the-public-health-agency-of-sweden/communicable-disease-control/covid-19Date: 2020Date accessed: December 16, 2020Google Scholar, 9Jayaweera M Perera H Gunawardana B Manatunge J Transmission of COVID-19 virus by droplets and aerosols: a critical review on the unresolved dichotomy.BMJ. 2020; 370m3223PubMed Google Scholar and use of face masks.9Jayaweera M Perera H Gunawardana B Manatunge J Transmission of COVID-19 virus by droplets and aerosols: a critical review on the unresolved dichotomy.BMJ. 2020; 370m3223PubMed Google Scholar, 10FolkhälsomyndighetenPublic Health Agency of Sweden. General guidelines for the public—a summary.https://www.folkhalsomyndigheten.se/publicerat-material/publikationsarkiv/g/general-guidelines-for-the-public-a-summary/Date: 2020Date accessed: December 16, 2020Google Scholar Recently, face masks were introduced in care homes and health-care facilities (Nov 11, 2020, in Stockholm)11Region StockholmHälso-och sjukvårdsförvaltningen. Rekommendation för personlig skyddsutrustning och source control för att minska risken för smittspridning av covid-19 inom vård och omsorg.https://vardgivarguiden.se/globalassets/kunskapsstod/vardhygien/smittamne-handlingsprogram-och-riktlinjer/skyddsutrustning-enkelsidor/anvandning-av-visir-och-munskydd-i-all-vard-och-omsorg-20-12-11.pdf?fbclid=IwAR1G_J4oQwsmXzDz_-LzWlC_TIxtc8iDxjW4cY8NWWAMUjVL2RrYX1WBu2EDate: Nov 11, 2020Date accessed: December 17, 2020Google Scholar and will be recommended "on public transport at certain times" from Jan 7, 2021.12RegeringskanslietSwedish Government. Ytterligare nationella restriktioner for att hejda smittspridningen.https://www.regeringen.se/artiklar/2020/12/ytterligare-nationella-restriktioner-for-att-hejda-smittspridning/Date: Dec 18, 2020Date accessed: December 20, 2020Google Scholar Other incremental interventions are being introduced, such as changing a ban on the sale of alcohol from 2200 h (introduced on Nov 11, 2020) to 2000 h from Dec 24, 2020,12RegeringskanslietSwedish Government. Ytterligare nationella restriktioner for att hejda smittspridningen.https://www.regeringen.se/artiklar/2020/12/ytterligare-nationella-restriktioner-for-att-hejda-smittspridning/Date: Dec 18, 2020Date accessed: December 20, 2020Google Scholar, 13AftonbladetCorona stoppar alkohol på krogen efter 22.https://www.aftonbladet.se/nyheter/a/0KKPX2/corona-stoppar-alkohol-pa-krogen-efter-22Date: Nov 11, 2020Date accessed: December 15, 2020Google Scholar recommending further limit on the size of gathering, and urging people to take individual responsibility and stay at home when they have symptoms.12RegeringskanslietSwedish Government. Ytterligare nationella restriktioner for att hejda smittspridningen.https://www.regeringen.se/artiklar/2020/12/ytterligare-nationella-restriktioner-for-att-hejda-smittspridning/Date: Dec 18, 2020Date accessed: December 20, 2020Google Scholar With this gradual approach, the number of COVID-19 deaths in Sweden peaked during the first wave at 102 reported deaths (7-day rolling average) on April 21, 2020,3Platz.se. Coronavirus i Sverige.https://platz.se/coronavirus/#jump-to-total-deathsDate: Dec 20, 2020Date accessed: December 20, 2020Google Scholar at a higher level and with slower decline than in the neighbouring Nordic countries, reaching a low in early September, 2020.1Our World in DataCoronavirus pandemic: daily updated research and data.https://ourworldindata.org/grapher/biweekly-covid-deaths?tab=chart&time=2020-02-15..latest&country=DNK~FIN~NOR~SWEDate: 2020Date accessed: December 20, 2020Google Scholar, 3Platz.se. Coronavirus i Sverige.https://platz.se/coronavirus/#jump-to-total-deathsDate: Dec 20, 2020Date accessed: December 20, 2020Google Scholar Rather than anticipating the second wave and change course, the Swedish Government loosened restrictions in early October, 2020, increasing the numbers that could attend public events from 50 to 300 and allowing people older than 70 years to meet with family and friends.14FolkhälsomyndighetenAllmänna råd ändras för personer som är 70 år och äldre.https://www.folkhalsomyndigheten.se/nyheter-och-press/nyhetsarkiv/2020/oktober/viktigt-att-alla-tar-ansvar-nar-allmanna-rad-andras-for-personer-som-ar-70-ar-och-aldre/Date: Oct 22, 2020Date accessed: December 20, 2020Google Scholar Many critical voices have been raised about Sweden's national response to COVID-19 and its failure to achieve its objectives to flatten and shorten the curves of cases, hospitalisations, and deaths.4Bjorklund K Ewing A The Swedish COVID-19 response is a disaster. It shouldn't be a model for the rest of the world.Time. Oct 14, 2020; https://time.com/5899432/sweden-coronovirus-disaster/Date accessed: December 17, 2020Google Scholar, 15Rocklöv J Lundbäck B Larsson E Elgh F Sjödin H Olsen B Sverige bör byta strategi för att bromsa spridningen av coronavirus.Läkartidningen. 2020; 117: FZ7RGoogle Scholar The Corona Commission (Coronakommissionen), appointed by the Swedish Government to review the national COVID-19 response, has focused initially on the situation among older people.16Melin M Ahlbäck Öberg S Enander A et al.The Corona Commission. Elderly care during the pandemic. Ministry of Health and Social Affairs, summary of SOU 2020:80.https://www.government.se/4af26a/contentassets/2b394e1186714875bf29991b4552b374/summary-of-sou-2020_80-elderly-care-during-the-pandemic.pdfDate: Dec 15, 2020Date accessed: December 16, 2020Google Scholar On Dec 15, 2020, the Corona Commission concluded that "the single most important factor behind the major outbreaks and the high number of deaths in [elderly] residential care is the overall spread of the virus in the society".16Melin M Ahlbäck Öberg S Enander A et al.The Corona Commission. Elderly care during the pandemic. Ministry of Health and Social Affairs, summary of SOU 2020:80.https://www.government.se/4af26a/contentassets/2b394e1186714875bf29991b4552b374/summary-of-sou-2020_80-elderly-care-during-the-pandemic.pdfDate: Dec 15, 2020Date accessed: December 16, 2020Google Scholar In addition to the failure of the COVID-19 strategy, there are other unresolved structural factors related to the organisation of the care of older people in Sweden. The Royal Swedish Academy of Sciences' independent review of the available evidence17Royal Swedish Academy of SciencesNy rapport om munskydd och ventilation från Vetenskapsakademiens expertgrupp om Covid-19.https://www.kva.se/sv/pressrum/pressmeddelanden/ny-rapport-om-munskydd-och-ventilation-fran-vetenskapsakademiens-expertgrupp-om-covid-19Date: Nov 19, 2020Date accessed: December 16, 2020Google Scholar validates WHO's recommendations to keep a physical distance, wear a face mask, keep rooms ventilated, avoid crowds, and practise good hand and respiratory hygiene.18WHOCoronavirus (COVID-19) advice to the public.https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-publicDate: 2020Date accessed: December 16, 2020Google Scholar However, not until Dec 18, 2020, did the government give directives to start to translate more of these recommendations into practice including the use of face masks,12RegeringskanslietSwedish Government. Ytterligare nationella restriktioner for att hejda smittspridningen.https://www.regeringen.se/artiklar/2020/12/ytterligare-nationella-restriktioner-for-att-hejda-smittspridning/Date: Dec 18, 2020Date accessed: December 20, 2020Google Scholar as the trajectory of rapidly rising cases and deaths continues and intensive-care facilities and the health-care professionals are stretched to the limits in many regions in Sweden.1Our World in DataCoronavirus pandemic: daily updated research and data.https://ourworldindata.org/grapher/biweekly-covid-deaths?tab=chart&time=2020-02-15..latest&country=DNK~FIN~NOR~SWEDate: 2020Date accessed: December 20, 2020Google Scholar, 19Ström M Fullt på IVA i Stockholm—regionen vädjar om hjälp.Lakartidningen. Dec 9, 2020; https://lakartidningen.se/aktuellt/nyheter/2020/12/nastan-alla-iva-platser-upptagna-i-stockholm/Date accessed: December 16, 2020Google Scholar The ability to work effectively across sectors to minimise the spread of COVID-19 has been further hampered by a decentralised and fragmented system of health and social services, including the care of older people.20Hammarström A Kwiatkowska M Nyman L Hammarström E Felaktig organization grund till tragedin inom äldrevården.Läkartidningen. May 20, 2020; https://lakartidningen.se/opinion/debatt/2020/05/felaktig-organisation-grund-till-tragedin-inom-aldrevarden/Date accessed: December 17, 2020Google Scholar The COVID-19 pandemic has revealed failures in the governance and legal frameworks for health and social services in Sweden, including inadequate multisector coordination, accountability of multiple authorities at different levels (commune, region, and central levels) that share responsibilities, and transparency in policy-making and decision-making processes. Moreover, there has been insufficient participation and engagement of key stakeholders, including informed scientists, civil society, and behaviour change communications expertise. COVID-19 vaccination is expected to start in January, 2021, or possibly sooner.21FolkhälsomyndighetenStart för vaccin mot COVID-19 tidigast Januari 2021.https://www.folkhalsomyndigheten.se/nyheter-och-press/nyhetsarkiv/2020/november/start-for-vaccinationer-mot-covid-19-tidigast-i-januari-2021/Date: Nov 26, 2020Date accessed: December 17, 2020Google Scholar Sweden is likely to be able to implement a strong COVID-19 vaccination programme if it strengthens interagency coordination and decentralised collaboration, provides greater transparency and accountability, including announcing a public national vaccine strategy and monitoring system, and develops an effective communications strategy and plan. Meanwhile, COVID-19 cases continue to increase and too many people are dying unnecessarily in a country without timely concerted actions to interrupt the high transmission and reduce the burden of deaths and illness. We declare no competing interests. The Swedish COVID-19 strategy revisitedIn December, 2020, we wrote about the Swedish response to the COVID-19 pandemic.1 Our hope was that our Comment, together with hundreds of other fact-based articles, would gain the attention of the Swedish Public Health Agency (Folkhälsomyndigheten [FHM]), that they would revisit and change the national strategy that they had designed so that it would be more aligned with global best practice, and that the political decision makers would act on it. They did not. Since then, the FHM has recorded more than 5600 deaths from COVID-19 in Sweden, and cases and deaths continue to rise as we face the third wave without any widespread sense of gravity or urgency. Full-Text PDF