Sweden’s Different Response to COVID-19 Based on Mutual Respect and Trust

by Kate Raines

Published May 18, 2020 | Law, International

Story Highlights

• Unlike most other countries, Sweden has not enforced nationwide lockdowns and home quarantines to combat the spread of COVID-19, instead relying on individual citizens to voluntarily follow the government’s suggested guidelines for social distancing to protect the vulnerable.
• So far, both the number of COVID-19 cases and deaths are higher in Sweden than in neighboring Nordic countries, but Swedish authorities have maintained their approach is scientifically sound and are hoping to soon achieve natural herd immunity.
• Some, like Dr. Mike Ryan of the World Health Organization, have praised Sweden’s less restrictive approach, while others have criticized it as putting too many people at risk for infection and fatal complications.

As many countries around the world remain under national lockdown conditions that include widespread home quarantines and closing of schools and businesses in response to the COVID-19 pandemic, Sweden has taken a more relaxed stance to dealing with the new coronavirus.¹ Unlike most countries, including neighboring Norway, Finland and Denmark, Sweden has not closed businesses, primary schools, restaurants, parks or other public gathering places, instead urging citizens to “act responsibly and follow social distancing guidelines.”
Sweden has a population of about 10 million people,² and the population characteristics of Swedish society contributes to the feasibility of the more relaxed guidelines. For example, as many as 40 percent of Swedish households are made up of single adults without children, which automatically builds in a certain level of “social distancing.”³

Strong Government Recommendations for Social Distancing

Sweden has not confined the whole population to home quarantine or closed down its economy. However, it is not really “business as usual” in Sweden either. Government health officials have issued strong recommendations for social distancing to protect those most vulnerable to COVID-19 complications and death and the sick are quarantined, but the guidelines remain voluntary in most cases.
Although the government is poised to impose stricter disease control practices if necessary, Sweden has a long history of respect and trust between the government and the people. Opinion polls show that 48 percent of the population has a high or very high rate of confidence in the trustworthiness of public health officials.
With regard to COVID-19, the Swedish people are generally keeping with their traditional trust in government health officials and the disease control strategies they recommend. The politicians, in turn, are trusting the people to follow the advice given by the government.⁴

Sweden Hopeful It Is Nearing Peak Infection Period and Herd Immunity

Although authorities warn it is too soon to draw any conclusions, they say the numbers suggest that Sweden may be just about over the peak infection period, with a flattening curve both for new cases and for patients admitted to intensive care units. According to Anders Tegnell, chief epidemiologist at Sweden’s Public Health Agency, who is described as the architect of Sweden’s COVID-19 response approach, the latest figures on both number of infections and deaths are starting to stabilize.
In early April, Dr. Tegnell said that COVID-19 would be controlled by “herd immunity or a combination of immunity and vaccination.”⁵ In late April, he and other Swedish public health officials commented that Sweden’s peak transmission period of COVID-19 infections may have occurred around the Easter holiday and that case reports suggest Sweden is currently in a peak infection phase and could achieve herd immunity soon.⁶

What Is Herd Immunity?

Herd immunity is a term that is often used to describe the proportion of people in a population who have been vaccinated, although it is also used to describe the proportion of people in a population who have acquired natural immunity from experiencing and recovering from an infectious disease. According to the Farlex Medical Dictionary, herd immunity is defined as:⁷

The resistance to invasion and spread of an infectious agent in a group or community, based on the resistance to infection of a high proportion of individual members of the group… A measure of the transmission potential of a disease, which corresponds to the number of secondary infections produced by a typical case of an infection in a population that is totally susceptible, and can be quantified by counting the number of secondary cases following the introduction of an infection into a totally susceptible population. Herd immunity occurs when a significant proportion of the population (or the herd) have been vaccinated, and this provides protection for unprotected individuals.

According to the Johns Hopkins Bloomberg School of Public Health, “Depending how contagious an infection is, usually 70% to 90% of a population needs immunity to achieve herd immunity,” and that for COVID-19, “based on early estimates of this virus’s infectiousness, we will likely need at least 70% of the population to be immune to have herd protection.”⁸

Disagreement Among Swedish Health Officials

There has been some pushback from many infectious disease specialists in Sweden, who argue that there are too many unknowns about COVID-19 and it is too contagious and deadly to wait for a large enough proportion of the population to develop herd immunity by experiencing and recovering from the infection. Nele Brusselaers, an associate professor of clinical epidemiology, even questions whether recovering from COVID-19 infection provides any immunity at all. He said, “Herd immunity doesn’t make sense because we don’t know whether or not you can become immune…this is a virus that can kill anybody.”⁹
Dr. Tegnell denies that seeking COVID-19 herd immunity without implementing any type of intervention was ever part of their plan.¹⁰ In an Apr. 28, 2020 interview with USA Today, Dr. Tegnell explained, “We are trying to keep transmission rates at a level that the Stockholm health system can sustain. So far that has worked out. The health system is stressed. They are working very hard. But they have delivered health care to everybody, including those without COVID-19. That is our goal.”¹¹

Higher Mortality in Sweden, Especially in Nursing Home Patients

Sweden has reported a significantly higher number of cases and deaths compared to reports from other Scandinavian countries, particularly among nursing home patients. This fact has led many to question Sweden’s disease control strategy, with Prime Minister Stefan Lofven admitting, “The protection for people in elderly care should have been better… We need to look closer at what has gone wrong.”¹²
As of May 15, 2020, Sweden has reported more COVID-19 cases and related deaths than have been reported by neighboring countries:¹³

•    Sweden:     29,207 cases and 3,646 deaths (population about 10M)
•    Denmark:   10,791 cases and 537 deaths (population about 5.8M)
•    Norway:      8,196 cases and 232 deaths (population about 5.5M)
•    Finland:      6,228 cases and 293 deaths (population about 5.5M)

The COVID-19 case and death numbers for countries are updated daily here.

Strong Guidelines, Voluntary Compliance Define Sweden’s Measured Approach

In a briefing to the World Health Organization (WHO), Sweden’s Minister for Health and Social Affairs Lena Hallengren outlined the nation’s measured approach to the coronavirus pandemic.¹⁴ She explaining that “fundamental characteristics of the Swedish society,” such as its publicly funded universal healthcare system, have allowed the country to be more flexible in its response and allowed the government to quickly change course and impose stricter regulations, if deemed necessary.
The key elements of Sweden’s COViD-19 response plan, as it stands now, echo procedures being followed in other countries, although most disease control measures in Sweden are still voluntary in contrast to involuntary lockdowns implemented in the U.S. and other countries:

• The Swedish government accepts final responsibility for protocols but is following the recommendations of its own expert agencies, as well as those of international powers such as the WHO.
• Top priority is being given to protecting vulnerable groups such as the elderly, which now includes a ban on visitors to nursing homes and strict recommendations limiting social contact for people over age 70, both urging the elderly themselves to stay at home and advising against visiting elders in the community.
• Key tools include recommendations for social distancing and providing incentives for people to stay at home. Pointing to Sweden’s “generous welfare system” that makes it easier for people to stay home if they are sick, Minister of Health Hallengren says both employees and the self-employed are now able to be paid sick leave from the first day and are no longer required to have a doctor’s certificate.
• Public gatherings of more than 50 people have been banned.
• Tools are in place to facilitate social distancing by providing online education for upper secondary schools (high school) and university education.

In concluding her address, Hallengren said:

There is no unique Swedish way of dealing with COVID-19. We share the same goals as other countries, we face the same challenges as other countries and we use similar tools as other countries. We do what we think works best for Sweden in our national circumstances. And we are always prepared to implement stricter measures if necessary.¹⁵

Experts Are Divided in Support of Sweden’s Tactics

Urging everyone to remain calm, Prime Minister Stefan Löfven has asked Swedes to “behave ‘as adults’ and not to spread ‘panic or rumours.’” However criticism of the government’s response to COVID-19 continues. More than 2,000 doctors, scientists and professors signed a petition at the end of March that called on the government to impose far more stringent disease control measures. Professor Cecilia Söderberg-Nauclér, a virus immunology researcher at the Karolinska Institute warned, “We’re not testing enough, we’re not tracking, we’re not isolating enough—we have let the virus loose… They are leading us to catastrophe.”¹⁶
Countering criticism of Sweden’s response to the coronavirus pandemic, Dr. Mike Ryan, Executive Director for Health Emergencies for the WHO, praised the more measured approach Swedish health officials have taken. Dr. Ryan said that Sweden may provide the best model for responding to the COVID-19 pandemic because it is sustainable over the long term, commenting that:¹⁷

If we are to reach a new normal, I think in many ways Sweden represents a future model—if we wish to get back to a society in which we don’t have lockdowns.¹⁸

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