People enjoyed the warm spring weather in Stockholm on April 21, 2020, during the COVID-19 pandemic. Jonathan Nackstrand/AFP via Getty Images
- Sweden has been both praised and vilified for its more relaxed pandemic public health stance during the coronavirus outbreak.
- The country has adopted a strategy that relies on personal responsibility and willful obedience.
- Swedes are asked to stay home when they’re sick with COVID-19, keep their distance while out in public, but otherwise carry on with life as usual, as much as possible.
- The strategy isn’t perfect, and has exacted a deadly toll, but it’s still worth looking at in its entirety, as others consider when, how, and whether to relax their own stay-at-home orders.
In Sweden, bars and restaurants are open to the public, you can go get a haircut, and primary school is in session.
The coronavirus has arrived, but life goes on.
The country has taken a lighter-than-most approach to social distancing for COVID-19, relying on people to monitor themselves for symptoms, stay home when ill, practice good handwashing, and avoid crowds.
You see very few masks on people’s faces in current photos from Stockholm and other Swedish cities.
People had lunch at a restaurant in Stockholm on April 21, 2020, during the COVID-19 pandemic. Jonathan Nackstrand/AFP via Getty Images
It’s a strategy that hasn’t been employed in neighboring Finland or Norway, and it’s one that some Swedish parents (keeping their kids out of school) as well as doctors and scientists (writing open letters of protest to the government) do not agree with at all.
The ruling concept relies on a bedrock of trust between the government and its people, an expectation of willing obedience and a mindset of safety first, coupled with a desire to keep people healthy, both physically, and mentally.
“What every country is trying to do is to keep people apart, using the measures we have and the traditions we have to implement those measures,” the Swedish public health agency’s chief epidemiologist, Anders Tegnell, recently told Nature. “The citizen has the responsibility not to spread a disease.”
If anyone can have success with such a low-enforcement disease-fighting strategy, it may be Sweden. A sparsely-populated country of people who generally agree to follow the rules is certainly a better candidate than most others for this public health experiment.
But even in Sweden, the reality is that COVID-19 is a tough disease to corral, and the relaxed disease-fighting plan doesn’t seem to be going as well as some officials there might’ve hoped.
Sweden is home
to a culture of willing obedience
Sweden is a country of willfully compliant citizens, home of a so-called “consensus culture.” It’s a place that’s birthed some of the world’s safest cars, and most inoffensive furniture. Nearly everyone pays their taxes without prodding, despite the record high rates.
“People trust the government,” American archaeologist and Scandinavian art history professor Nancy Wicker, who’s traveled frequently back and forth between Sweden and the US for nearly four decades, told Business Insider. “It’s definitely part of the culture to follow the rules, or guidelines, and to not be too pushy about it.”
The Swedish prerogative asks citizens to act like adults, and then trusts that, left to their own devices, people will. The Swedish even have a word for this, folkvett. It translates, roughly, to “good manners,” but really means much more, expecting that Swedish people will act appropriately and do the right thing, without being told, or if not, face severe public shame and moral judgement.
In the US, the land of “liberty or death!” and vociferous coronavirus protests, where individualism and independence are prized above all else, it’s hard to imagine the same we’re-a-collective disease-fighting strategy working as well.
A different interpretation
of what ‘a healthy society’ means
Students study at home in Stockholm, as high schools in Sweden are closed due to the coronavirus, March 19, 2020. Jessica Gow/TT News Agency/AFP via Getty Images
The Swedish coronavirus strategy is rooted in a practical, grown-up sense of being in this fight together, and for the long haul.
“People want to get along, and not draw attention to themselves, which is really different than most Americans,” Wicker said.
Swedish actor Alexander Skarsgård once described the mindset at work here, Jantelagen, as “don’t think you’re special,” and it applies to all Swedes (even movie stars and kings).
Indeed, Swedish King Carl Gustaf Folke Hubertus said as much in a recent, rare national address.
“We must act responsibly and selflessly,” he said. “Everyone in our country has this obligation. Each and every one of us. There is still a great deal of uncertainty. But one thing is certain: we will remember these times and look back on them. Did I think about other people? Or did I put myself first? We will have to live with the choices we make today, for a long time to come.”
Sweden’s King Carl XVI Gustaf addressed the nation about the novel coronavirus on Swedish national public television, April 5, 2020. Jonathan Nackstrand/AFP via Getty Images
Sweden places a high importance on the rights of the child, stressing that children need time, space, and friends to play with, and that adults, similarly need go to work, not just to make ends meet and keep the economy chugging along, but to feel a part of the fabric of their society.
The Swedes are also seriously weighing concerns that have been taken as inevitable, if unfortunate, collateral damage in other countries, such as the mental health risks of being stuck inside, rising rates of abuse, and substance use disorders.
“It’s good for people to be outdoors,” Swedish Foreign Minister Ann Linde recently told Politico. “If you’re locked inside there’s risk of depression, domestic violence, alcohol abuse.”
Swedish officials insist they are not sacrificing the elderly and the vulnerable, they are trusting people to be sensible
Nurse Renee Jarvalt puts on her personal protective equipment (PPE) on April 22, 2020 in Stockholm, Sweden. Jonathan Nackstrand/AFP via Getty Images
Other countries, including the UK and the Netherlands, originally toyed with the idea that a tight lockdown would lead to unrest, and that it would be more realistic to go for a looser approach, and to aim for herd immunity.
Both were accused of heartlessness: sacrificing the old and vulnerable to avoid anger over pubs closing. They backpedaled, and issued lockdowns. But Sweden has persevered.
This doesn’t mean that the country is simply comfortable throwing away its elders, or that anything you might’ve seen in a horror flick like Midsommar about old people jumping off cliffs to get rid of themselves, is rooted in reality or history. (“Definitely not, definitely not,” Wicker said.)
Rather, the comparatively lax strategy is about trying to create a sustainable set up that Swedes will respect long-term, leaning on a culture of asking and not telling.
“The health agency in Sweden, we have to remember this, their job is not just simply to deal with contagious diseases, they are concerned with the health of the population as a whole,” Swedish historian Lars Trägårdh told Business Insider. “Whereas in Norway, Finland, Denmark, the politicians have the last word.”
Sweden’s Deputy Prime Minister, Isabella Lovin, told the BBC’s Andrew Marr on Sunday “it’s a great myth that Sweden hasn’t really taken very serious steps” to limit the spread of the virus.
“Every country needs to take its own measures according to its traditions and its systems of governance,” Lovin said, a nod to the fact that Sweden’s public health agency runs independently, so politicians never get to make decisions about Swedish health.
“It’s a real fear that if you have too harsh measures, then they can’t be sustained over time, and you can get a counter-reaction, and people would not respect the voluntary recommendations that will need to be respected for a very long time.”
There are promising signs
Sweden’s ask-don’t-tell approach is working
Hairdresser Abed Khankan cuts the hair of a customer outdoors as a precaution amid the novel coronavirus pandemic on April 17, 2020 in Malmo, Sweden. Johan Nilsson/TT News Agency/AFP via Getty Images
Living in Sweden right now does not mean you can do whatever you want. People are advised to stay home when they feel sick, and then continue to isolate until they’ve been symptom-free for two days. And, for the most part, they do.
There are already promising signs that the ask-not-order strategy is working somewhat well in Sweden, as it has before.
With universal healthcare, Sweden simply “offers” it’s children shots.
With the coronavirus, too, it seems, Swedes are taking their own health seriously, and trying to keep density at the nation’s hospitals (where there aren’t a lot of beds, anyway) low, while at the same time upping their own home hygiene.
“We have data showing that the flu epidemic and the winter norovirus dropped consistently this year, meaning that our social distancing and hand washing is working,” Tegnell said.
COVID-19, however, is not so obedient
Leena Engblom, an SAS flight attendant, training at Sophiahemmet hospital, April 7, 2020 in Stockholm. Jonathan Nackstrand/AFP via Getty Images
Sweden’s COVID-19 game plan is not without it’s issues, though. It’s proving tough to control a raging new virus that is highly contagious, sometimes tricky to spot, and for which there is no population immunity.
Some Swedes have gotten quite sick. More than 2,650 have died. The country’s COVID-19 death rate is 12.3%, roughly triple that of Sweden’s Nordic neighbors, Finland and Norway. The Swedish case-fatality rate also surpasses some of the hardest-hit countries: Spain (11.5%), and the US (5.9%).
Swedish nursing homes, in a country which generally gets good marks for its elder care, have been especially hard-hit during this pandemic, accounting for more than half of the country’s deaths, according to Tegnell. Arguably, some of those infections, and deaths, could have been easily prevented.
“Where I’m working we don’t have face masks at all, and we are working with the most vulnerable people,” one Swedish home care worker, who wanted to remain anonymous, recently told the Guardian. “Everybody’s concerned about it. We are all worried.”
Furloughed airline employees are even being retrained to step in and work at the country’s hospitals and nursing homes.
“We underestimated the issues at care homes,” Tegnell said. “We should have controlled this more thoroughly.”
Trägårdh said that the issue is made even more difficult because most elders in Sweden live at home, meaning nursing homes are reserved for the very oldest, and most fragile patients, already at greatest risk.
“You only really get into these institutions if you are really old and unwell,” he said. “There’s been an underinvestment in elderly care, and that’s a long-term problem.”
The economy has also taken a hit. The Swedish Public Employment Service said on April 20 that 8% of the country is now unemployed, a figure that’s projected to continue to rise, possibly hitting 10% by this summer.
“This is not a strategy that has come without any impact on our economy, or on people’s freedom,” Lovin told the BBC. “We have more than 90,000 people who have been unemployed during these four or five weeks.”
Herd immunity
is on the horizon for Sweden
The Public Health Agency of Sweden is now cautiously applauding its approach, suggesting the worst of the virus’ infectious spread may have already occured in the country’s densest, most populous city.
So far, laboratories have counted 8,200 COVID-19 infections in Stockholm, an infection rate of less than 1%.
But because Swedish health authorities suspect there are approximately 75 unconfirmed COVID-19 cases for each lab-confirmed case, they predict, using mathematical models, that 26% of people, or about 1 in 4 living in Stockholm county, “has or will have had COVID-19” by May, and that, as such, they are not as susceptible to the disease.
That’s still quite a way away from any kind of herd immunity, when enough people are immune to a disease that it cannot make in-roads in the community.
Shoes placed on the stairs to the City hall in Malmo, Sweden on April 24, 2020, in a climate protest titled “Shoe(!)Strike for the climate.” Johan Nilsson/TT News Agency/AFP via Getty Images
“It’s going to take 60% to 70% of the population to be infected and develop immunity, or be vaccinated to slow down transmission in any meaningful way,” Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota, told Business Insider.
Trägårdh said that while herd immunity is not “an explicit policy goal” for Sweden, “you know, it’s there in the mix.”
However, the World Health Organization warns that there’s “not enough evidence” yet to guarantee people who get COVID-19 will be immune from re-infection, stressing that “no study” has yet evaluated the question.
“We expect people that are infected with COVID-19 to develop a response that has some level of protection,” the WHO’s head of emerging diseases Maria Van Kerkhove told reporters at a press conference on Monday. “What we don’t know right now is how strong that protection is, and if that’s seen in everybody that is infected, and for how long that lasts.”
With spring temperatures warming, and the sun shining for more than 15 hours every day in the Swedish capital, there are worrisome signs that go against the government’s rosy projections. Independent estimates show that infection rates are still on the rise, not the decline. It may be time for some more draconian stay-at-home measures right now, even in Sweden, a move officials there say they may consider.
After all, other countries with stricter lockdowns are successfully preventing hundreds of thousands of infections.
Swedish tenor Rickard Soderberg performs during a sing-a-long concert in Malmo, Sweden on April 23, 2020. Johan Nilsson/TT News Agency/AFP via Getty Images
What does Sweden’s gamble mean for the rest of the world, looking on?
While Sweden may provide some inspiration for how to reopen other places with diligence and calm, the country’s high death count shows that it isn’t a perfect coronavirus-fighting model, especially for other countries where fewer people live on their own, citizens are less-than-obedient, and far more crowded public spaces make it difficult to consistently keep a safe distance from others.
“We’ve got to dance with the virus,” George Fu Gao, director of the Chinese Center for Disease Control and Prevention said during a National Academy of Sciences conference last weekend.
“We have to come back, resume the business, resume the social activities.”
In order to be successful at this novel kind of dance, countries need to continue to protect their people from infection, largely by keeping them apart from the sick, until there’s either a treatment, a vaccine, or ideally, both. Complicating matters further, if this coronavirus proves to be anything like the influenza pandemics we’ve seen in the past, we can expect that it’s going to hit hard again, in a devastating second wave of illnesses, perhaps as early as this fall.
“Can we stay locked up for 18 or 20 months?” Osterholm asked, pointing out that even that timeline is highly optimistic for a vaccine.
“We need to have some very painful population discussions about how do we try to get to what might one day be a vaccine, minimizing the number of cases, and particularly seriously ill cases, and those that die, compared to, you know, sustaining our society. I categorically reject the idea that it’s money versus deaths, that’s not what this is about.”
Sweden is already having some of those tough, society-wide discussions, but the US isn’t, largely expecting that more widespread testing and tracing of cases will solve the problem on its own, even as armed protesters rush toward politicians in anger.
“People keep talking about testing their way back into everyday life,” Osterholm said. “That is a part of it, but it’s not the magic bullet people think.”
Ultimately, he says the better question for countries like the US is whether they can achieve a new, well-thought-out, safer way to interact while out and about during the outbreak, with minimum harm, and maximum personal responsibility.
The idea sounds very Swedish, and not very American.
People socialize and enjoy spring, as the COVID 19 outbreak continues, in Stockholm, Sweden, on April 22, 2020. TT News Agency/Anders Wiklund via Reuters
However, there is an opportunity here for other countries to take some inspiration from Sweden’s gamble, while learning from some of the biggest mistakes thus far, by giving more forethought to how to protect some of the most vulnerable populations among us, as we venture back out into the open.
“I think in many ways Sweden represents a future model,” WHO Executive Director of Health Emergencies Mike Ryan said during a press conference on Wednesday. “If we wish to get back to a society in which we don’t have lockdowns, then 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.”
How to emerge from lockdown, without letting cases explode?
There could be conversations about relaxing restrictions for younger people to get back to work and school first, or having sparsely populated areas open up for activities like manufacturing and construction, all the while monitoring those populations for outbreaks of new cases.
The important thing is to talk about all the ways re-opening could look, rather than seeing it as a binary: open, or closed?
“Do we try to bubble-protect the people who have highest risk of serious disease? This is a conversation we need to have right now, and we’re not having it,” Osterholm said.
“It’s almost like we have a light switch, on and off. Either we’ve released society, or we haven’t.”
