A history of the Swedish covid response

The Swedish response to the covid pandemic has become one of the most talked about topics of the last six months, and there’s a lot of misinformation floating around. Since that’s the case, and since I keep getting asked what the situation on the ground is really like in Sweden, I figured I’d write up a little history, covering the key events from a Swedish perspective, and detailing exactly which restrictions were put in place at what time point, and why.

But first, and perhaps most importantly, why did Sweden decide to follow such an aberrant path?

Actually, to be honest, Sweden could never have done otherwise. The Swedish constitution declares that Swedes have the right to move freely within Sweden, and to leave the country if they so wish. There is a law, the Swedish infectious diseases act, which allows certain limited restrictions to be put in place, but it doesn’t allow for a general lockdown. And the power of the state to enforce restrictions on individuals is heavily limited. That is likely the main reason why the Swedish response to covid-19 has been so much more limited than that seen in other countries.

Do I think Swedish politicians are wiser than politicians in other countries? No, of course not. But while some other governments probably caved under internal pressure from their own media and external pressure from other governments and international organizations, the Swedish government couldn’t have caved even if it had wanted to.

Large parts of Swedish mainstream media have actually been very pro-lockdown from the start, and have been much more in line with foreign media than they have been with the Swedish state. As an example, on March 13th, at the start of the pandemic, Peter Wolodarski, editor of Sweden’s biggest daily broadsheet newspaper, Dagens Nyheter, demanded a lockdown in line with other countries. And tabloids have been full of scare stories. As in every other western country, Swedish media have been feeding people a daily dose of case numbers and death statistics that are never placed in any context. So, while media in most other countries have been marching in lockstep with their national governments, that has not been the case in Sweden.

There is another aspect, and that is that Swedish state agencies are largely free to run themselves, and the ability of the government to interfere on a day to day basis with the decisions made by civil servants is heavily limited. So the Swedish government has only ever had a limited role in the Swedish response. The main decisions have been made by civil servants in the Swedish Public Health Authority, with Anders Tegnell being the prime decision maker, thanks to his role as State Epidemiologist. Maybe the fact that important decisions about how to handle the pandemic have been made by professional epidemiologists rather than by politicians has also played a part in causing Sweden to move in a different direction from most other countries, with measures in large part being driven by scientific evidence rather than by populism.

The Swedish Public Health authority has never admitted that the goal of their chosen strategy is to reach herd immunity. However, from an epidemiological stand point, all strategies depend on reaching herd immunity in one way or another. A vaccination based strategy also builds on getting to herd immunity, it just chooses a different way to reach it. At some point in the relatively near future, every country on Earth will have developed herd immunity to covid, either by letting the disease spread until that point is reached, or by vaccinating enough people to reach that point.

The alternative to a herd immunity strategy is an eradication strategy, which I don’t think any serious person believes is possible. Thus far in human history, only one infectious disease affecting humans has ever been successfully eradicated, and that disease is smallpox. This fact says something about how hard it is to eradicate an infectious pathogen. We’ve been actively trying to eradicate polio for over thirty years, and we’re still not quite there, even though a highly effective vaccine exists and has existed since the 1950’s.

The smallpox eradication program had two big advantages. Firstly, people who have smallpox have very typical symptoms. Secondly, there is no asymptomatic spread. These two facts made it much easier to contain smallpox than is the case with covid, which does spread asymptomatically, and which shares symptoms with many other respiratory viruses.

Anyway, let’s get to what actually happened in Sweden.

On the 24th of January, Sweden had its first confirmed case of covid-19. It occurred in a woman who had recently been to China, and who developed respiratory symptoms shortly after arriving in Sweden. At this point in time, the risk of a pandemic hitting Sweden was determined to be low by the authorities. That changed at the beginning of March, when it became clear that the disease was spreading rapidly in northern Italy, where many Swedes had gone for their “sportlov”, a one week school holiday that occurs at the end of February or beginning of March of every year.

Several people came back to Sweden from Italy infected with covid, and that is when the disease really entered public awareness as something that was happening in Sweden, and not just in other countries. Covid exploded in Sweden in March. On March 6th, the first person was admitted to a Swedish intensive care unit (ICU) with covid. By the end of March, there were 298 people in intensive care being treated for covid.

This explains the Swedish state’s behavior throughout March, as it scrambled to get on top of a disease that was increasing exponentially in the population. Every few days, a new edict or recommendation was issued.

On March 10th, the general public was advised to avoid visiting hospitals or nursing homes unless necessary, and people with respiratory symptoms were urged to stay home if their work involved contact with risk groups.

On March 11th, gatherings of more than 500 people were banned.

On March 14th, the Swedish Foreign Ministry recommended against traveling abroad.

On March 16th, the Public Health Authority urged people aged 70 and over to avoid unnecessary social contacts as far as possible.

On March 17th the Public Health Authority recommended that people work from home as much as possible. On the same day, the government declared that schools for children aged 16 to 19 and universities were required to stop in-person lessons and switch to distance learning.

On March 19th, the government declared that foreign citizens traveling from non-EEA (European Economic Area) countries would not be allowed to enter Sweden for the next 30 days. The government also decided that people taking sick leave would not suffer any salary reduction for the duration of the pandemic (normally in Sweden you only get 80% of your salary when you’re sick), so as to motivate people to stay home if sick.

On March 24th the Public Health Authority required that groups in restaurants, bars and cafés be placed at least one meter away from each other. This decision was enforcible, and some bars and restaurants were temporarily closed down for violating the edict.

On March 25th, the prohibition on more than 500 people gathering in one place was tightened to 50 people.

On March 30th, a formal decision was made banning visits to nursing homes.

The measures that were put in place in March, largely stayed in place unchanged until the autumn. By the end of March, the Swedish response to the covid pandemic had been fully formed, and after March, additional changes were really only minor tweaks.

So, what didn’t happen, that did happen in many other countries? Restaurants, cafés, gyms, hair salons, and shops stayed open. Public transport continued operating. Swedish citizens were free to move around the country throughout the pandemic, and were also free to enter and leave the country at will. As mentioned before, pre-schools and schools for children up to the age of 16 stayed open throughout the pandemic. There were recommendations in place relating to all these things, designed to minimize the risk of spreading infection, but very few formal restrictions that could be enforced by the state, so it was largely up to each individual to decide the extent to which they were going to follow the recommendations.

At no point was there a requirement, or even a recommendation, that people wear face masks in public. Ever since it first became clear that the pandemic was loose in Sweden, staff in hospitals have worn face masks when interacting with people suspected of having covid-19, and since April, staff in care homes for the elderly have also been using face masks.

On June 5th, the WHO announced a recommendation that people wear face masks in public. While most countries followed this recommendation, the Swedish Public Health Authority continued on with its previous recommendation, that face masks be used only in hospitals and care homes for the elderly. The reasoning from the Public Health Authority was that the evidence that face masks have any benefit on a population level is weak.

The goal of the ever growing list of recommendations and restrictions throughout March was to “flatten the curve”. As I mentioned before, the Public Health Authority has never consciously stated that herd immunity is its goal. Rather, there has been a tacit understanding that the pandemic will continue until a significant level of population immunity has been achieved. So, instead of a futile effort to stop the pandemic, it focused on trying to spread out infections over several months. Why? Because throughout March, the rate of hospital admissions was growing exponentially, and no-one knew how long that exponential rise was going to continue for. It was deemed to be of paramount importance to prevent the health care system becoming overwhelmed by too many people seeking help at the same time.

A field hospital was erected inside an exhibition center in a southern Stockholm suburb, with several hundred beds, ready in case the regular hospitals came to be overwhelmed. Another was erected in Gothenburg. The number of ICU beds available in Sweden was doubled over a short period from around 500 to over 1,000. In large part this happened by converting operating theaters in to ICU’s, and staff were taken from surgical departments and moved to intensive care. In order for this to be possible, elective surgeries had to be cancelled or postponed. This allowed many regular hospital wards, for example for post-surgical care, to be converted in to covid wards.

Then, in mid-April, about five weeks after the start of the pandemic, the covid death toll peaked, at 115 deaths per day, and began a slow but steady decline that continued in to September, when deaths per day reached a nadir of one to two. The field hospital in Stockholm never ended up having to treat a single patient. It was closed down quietly in June. The field hospital in Gothenburg was closed in August.

At the peak of the pandemic, in April, over 1,100 people were being treated for covid simultaneously in Stockholm’s hospitals. By September this number had dropped to less than 30. In Sweden as s whole, over 550 People were simultaneously being treated for covid in ICU’s at the end of April. By mid-September, that number had dropped to 12.

As mentioned, the restrictions and recommendations that were put in place in March largely remained unchanged for the next five months. Since it was clear that the infection was declining, and that the health care system wasn’t overwhelmed, additional measures weren’t determined to be required.

At the beginning of the pandemic, visits to Emergency Rooms dropped drastically. Although a large proportion of the people coming in to the Emergency Rooms at the peak had covid, this was compensated for by the fact that many other people weren’t coming in.

I have two thoughts about why this is. The first is that people were afraid of being infected with covid during a visit to the Emergency Room. The second is that there was a wish not to put additional pressure on the health care system at a time when it was believed to be under immense strain. During the peak months, those of us who work in the Emergency Room spent a lot of time sitting around waiting for patients to show up.

I think it’ll probably be a few years before we know the full extent to which people were harmed by this. As an example, the hospital in Uppsala experienced 50% fewer admissions due to cardiac infarctions (“heart attacks”) during the peak period, while the hospitals in Stockholm experienced 40% fewer admissions. We know that people who have a cardiac infarction and don’t get emergency treatment have a significantly increased risk of dying in the immediate future, and also have a greater risk of developing long term complications such as heart failure.

We’re going to finish this discussion by talking about autumn 2020. In the middle of August, when the summer holidays ended, all children went back to school in person, including the 16-19 age group. So did the university students.

Nursing homes were re-opened to visitors from the 1st of October. On the 23rd of October the Public Health Authority announced that it was no longer recommending that people over 70 and members of risk groups avoid social contacts, above and beyond its general recommendations for the rest of the population. The reasoning was that there was increasing evidence that the isolation was harming people’s psychological and physical health, while the spread of the virus was remaining at a low level in the population. It was therefore determined that the harms of isolation were at that point greater than any potential benefit in terms of decreased risk of contracting covid-19.

On the 8th of October, the government removed the 50 person limit on visits to bars, restaurants, and nightclubs. This was however rescinded shortly thereafter, on the 22nd of October, after videos were spread on social media of people partying in crowded night clubs. At the same time, the government announced that it was increasing the limit on the number of people allowed at seated events, such as concerts and sports events, to 300.

Throughout October, there has been a gradual increase in ICU-admissions, from 24 at the start of the month, to 60 at the end of the month. There has also been a much more dramatic increase in cases, from 633 on the 1st of October, to 2,616 on the 29th, the highest number of cases on one day yet, and several times higher than even the highest day during the spring, when almost ten times more people were being treated for covid in ICU’s.

According to the Public Health Authority, the increase seen during October is partly due to a real increase in the number of people being infected, but also largely due to a huge increase in testing compared with the spring. When deaths were peaking in April, Sweden carried out 20,000 PCR tests per week. At the end of October, that had increased to 160,000 PCR tests per week. That is why Sweden had fewer “cases” at the peak of the pandemic in spring, than it does currently.

On the 13th of October the Public Health Authority announced that measures would start to be taken on a local, rather than a national basis. On October 20th, Uppsala became the first region to make use of the option to create stricter local recommendations, following an increase in hospital admissions there. People were recommended to avoid physical contact with those outside their immediate household, and to avoid traveling in public transport.

Uppsala was followed in tightening restrictions on October 27th, when Skåne decided to implement even more severe recommendations. Rather than just avoiding physical contact, people in Skåne have been recommended to avoid all social interaction with people outside their household and immediate circle, and to avoid visiting shops, gyms, and other public indoor environments unless necessary.

On October 29th, Stockholm, Östergötland, and Västergötland implemented similar measures to Uppsala and Malmö, after these regions also saw increases in hospitalizations for covid. And that’s where we stand today.

How do I explain the recent increase in hospitalizations?

I think it’s becoming pretty clear that SARS-CoV-2 is a seasonal virus, just like the four “common cold” coronaviruses. It would be strange if it wasn’t, considering how similar it is to them biologically. And I think that, just as with all other seasonal respiratory viruses, we saw a drop over the summer months, and we are now seeing an increase over the autumn. The pandemic stage of covid is now over, and we have entered the endemic stage.

I don’t think that what we are seeing is a “second wave”. I think we are seeing a seasonal effect. It’s important to keep some perspective. As I explained earlier in this article, cases are a very poor way to determine how active the virus is in the population. In Sweden, the number of tests being carried out is now eight times higher than in the spring. That is why we should instead be looking at hospitalizations, ICU admissions, and deaths.

And those numbers are increasing much more slowly than the number of cases. In the spring, there was an exponential increase in ICU admissions. Now we are seeing a gradual increase, which will almost certainly stop at a much lower level. At the peak in the spring, over 100 people were dying a day of covid in Sweden. Right now, there are three people dying per day of covid. At the same time, there are 250 people dying per day in Sweden of other causes. So covid is currently responsible for 1,2% of deaths in Sweden, but probably gets 99% of the attention. We need to maintain some perspective.

You might also be interested in my article about how deadly covid really is, or my article about how the immune system works, and why this matters in relation to covid.

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Author: Sebastian Rushworth, M.D.

I am a practicing physician in Stockholm, Sweden. My main interests are evidence based medicine, medical ethics, and medical history. I frequently get asked questions by my patients about health, diet, exercise, supplements, and medications. The purpose of this blog is to try to understand what the science says and to translate it in to a format that non-scientists can understand.

72 thoughts on “A history of the Swedish covid response”

  1. Hi Sebastian How are things looking on the ground? Am hearing all kinds of reports that Deaths etc are spiking up, etc

    1. Hi John,
      There has been a slow gradual increase in hospitalizations and deaths over the course of October and November. Seems to be stabilizing now at around 15-20 covid deaths per day, which is a significantly lower level than in spring (when over 100 people were dying per day with covid).

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