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. Thanks for that history. I was not aware of the Swedish constitutional context.

    Was there a reference to positivity rates and how those percentages changed as testing increased in Sweden? Possibly I missed it.

    Thanks.

  2. I’m a child and adolescent psychiatrist from Sweden and I have written about the pandemic both in articles and on Twitter. I’m very impressed by your article and I agree strongly.

  3. Well written and thanks for all the dates during spring, it when so fast that I forgotten some.

    Please add a date to the article, so it can be used months from now.

  4. Yes, that is a very interesting statistic to examine, if available. Is there daily/weekly/monthly data of ICU and hospitalizations due to inluenza from prevoius years?

  5. Thanks. Your factual analysis gives me a perspective I cannot find in any of our media. And I really do not know why it is so.

  6. Dear Sebastian, Fascinating article. I am one of the editors at Reaction, a British news/comment online site – http://www.reaction.life – and would be interested in
    republishing your article. Could you email at the address below please so we can chat ?
    Many thanks,
    Maggie Pagano

  7. Thanks for the numbers. The 2019-20 is exceptionally low. Do the different viruses compete for the same space, so more Covid then less influenza?

    1. I would think so. I think that probably at least partially explains why influenza has so far been unusually absent this year. It’s going to be interesting to see what the influenza numbers for the 2020-2021 season end up being. You can after all only die of one thing, so if a lot of people who would normally die of influenza instead die of covid, then that should be very visible in the statistics.

  8. Hi Sebastian,
    thanks again for a very informative article.
    I am looking forward to reading your article on covid testing.
    I am especially interested in your view of the false positive rate (specificity and FDR) of PCR tests for covid and the way that PCR has been used to test the asymptomatic population for screening purposes, and the rate of false positives in that.

  9. Hi Sebastian, Juana from NZ and The BFD again. May I please have your permission to republish this article on The BFD? I will include links back to your site and give full attribution just as I did the previous two times you allowed me to republish your work.

  10. Dear Sebastian! Thank you for thorough information about the situation in Sweden. Here from Denmark it is truly inspiring to follow the Swedish way. I have a question for you. In many other countries, like Germany, UK, The Netherlands, in India and China e.g. they have great results in treating the virus by homeopathic remedies. I am currently infected the second time (first time in March where I was ill for two months) and second time this week, where I am already out of my bed again, thanks to homeopatic treatment (which I was not aware of in March). I know that doctors in Germany and UK and in the Netherlands are all forced to study homeopathy as part of becoming M.D. or G.P. In Denmark, people taking homeopathic remedies are the laughing stock when you ask people in general and the medical system. How do Sweden look at homeopathic treatment? And is it in anyway included in the medicial school? Thank you so much in advance! Best regards, Karin.

    1. Hi Karin,
      No, homeopathy is not included in medical school education in Sweden. As far as I know, there is no homeopathic treatment that is supported by any scientific evidence. The whole theory behind homeopathy (that medicines have a stronger effect the more dilute they are) is pretty much the opposite of how we know things actually work. From my perspective, homeopathic treatments are just water.

  11. Sebastian, I am an MD in the US. You write very well.

    We know that this disease is virtually like the common cold in younger people. So why has your public health authority restricted the activities of younger people who do not live with or have contact with older or otherwise susceptible people?

    Your state epidemiologist has said that a “herd immunity approach” (whatever that is) is unethical. I find this absurd, akin to calling gravity unethical, and I feel he is really hurting his credibility.

    You have said quite succinctly, as have many others, that herd immunity is inevitable. The only question is which members of the population will comprise the “herd.” A fully representative cross-section including the old and sick, or predominantly young and healthy people. We should be trying to encourage the latter.

    Accordingly, the bars, clubs and other venues where predominantly younger people gather should remain fully open without restriction — we should be doing everything we can to encourage young and healthy people to acquire the disease — or at least not stand in their way.

  12. The media reporting of Sweden and Covid in Australia has been only negative. The recent tightening of rules was reported here as proof that the Swedish approach had been a disaster. We have a national broadcaster, ABC, similar to the UK’s BBC. It interviewed a Swedish epidemiologist in order to get an opinion that Sweden was a disaster. To the interviewer’s horror, she (I forget her name) simply said Sweden was just doing what it had done since March.

    Since March, the ABC has not had one person attempt to present an alternative to our lockdown.

    The Australian Constitution says movement between the States cannot be restricted. We are a Federation of 6 States, similar to the USA. Despite this, all States have restricted movement between each other. Our High Court (similar to the USA Supreme Court) will soon look at this. I am glad your government takes its constitution more seriously that Australia has done this year.

  13. Then, like England & Wales in the first 13 weeks of 2020, it appears normal ‘flu numbers have dropped and partially ‘replaced’ by covid. In their case… Total Respiratory deaths are 2,000 LESS than the 5?year average. – Despite adding covid !

  14. Brian, compared to other nations, our population is politically naive and docile. Never in our past have we needed to overthrow a rotten government. And we have short memories.

  15. Great to understand how Sweden reacted correctly with independency about the epidemiology correct response to the pandemic. And responded in the conventional way about treatment, avoiding early out of hospital intervention with antivirals.

  16. Hi Sebastian.
    We already know there’s a strong correlation between obesity and severe Covid outcomes. We know that obese people have far higher levels of Hyaluronic acid. We know that Hyaluron is the coagulant causing so many of the fatalities.
    It beggars belief that the most of the world has been subjected to long term lockdowns when a national diet program could likely achieved better results in less time, if not only more focused.
    I’d love to see your take on my idea of what would be a far more practical mitigation measure.
    And I’d like to know why no leaders (except perhaps in India) to my knowledge have recommended dietary measures when empirical data strongly suggests it.
    The link is just for correlation.
    https://www.sciencemag.org/news/2020/09/why-covid-19-more-deadly-people-obesity-even-if-theyre-young

    1. Hi Joe,
      Thanks. Yes, a lot could probably have been accomplished in terms of mitigating the harms of covid if there had been more of a focus on improving population health, instead of just single mindedly focusing on restrictions. As you say, obesity is the biggest risk factor outside of age.

  17. Indeed interesting.
    Swedes acted very different to 10 years ago with swine (I thibk) flu.
    I worked with some Swedes in Copenhagen and they were all vaccinated and accused me almost of murder for refusing to vaccinate.

    I believe both countries ended up destroying tons of surplus vaccines but far more so in Denmark

  18. I am from Germany and we have similar constitutional rights compared to Sweden. Still the politicians decided to make use of one article of an infectious disease act (which was written with diseases like cholera or syphilis in mind) to lock down without any parliamental approval. Maybe Germans just like to forbid things. I am interested to see how political scientists will evaluate the different government responses in the future.

    Looking at the numbers the daily deaths are broadly comparable to Sweden but still we lock down…I don’t understand.

  19. Thanks a lot for your highly informative article. I am a retired pediatrician in Germany, and I regard our current situation here just like the posting of thedullchannel does.
    Since March we have been feeded by our newspapers with tendentious information about Covid-associated circumstances in Sweden, so I appreciate your site and informations very much! Just as it was the case when reading the moving report of Eric Bertholds.

    Thanks again.

  20. Thanks for a great article!
    I’m interested to know what the plans might be for a Covid vaccination in Sweden. Do you think it will be mandatory? I believe there was a high take-up of the swine flu vaccine in Sweden and a proportionately high incidence of narcolepsy.

    1. Hi Carrie,
      I know that the Swedish state has pre-ordered a large number of vaccine doses. Whether they’ll end up being used I think depends on how things develop going forwards. Vaccination won’t be mandatory, the Swedish state does not have that kind of power.

  21. If you consider the explosive spread of Covid-19 all over the world, even in countries with lockdowns, it safe to say that in a country like Sweden with a limited lockdown, it will spread more consistantly and without interruptions, which is a good thing because you will reach herd immunity faster, and herd immunity is the only feasible option, as far as I can tell.

    To wait for a safe vaccins which also actually works is a dangerous path to take, giving the time span it take to research, develope, do tests, comparing vaccin-groups with placebo-groups for years, to then evaluate dangerous side effects, and so on and so forth. For comparison, there is no safe vaccin which actually works for SARS1 which came 2003, in other words 17 years ago.

    By looking at Swedens death curve at Statistiska Centralbyrån (SCB), as well as looking at the actual death numbers per day, it’s clear that Sweden had a raise in Mars, peaked in April, went down in May, and then reached the average from previous years at the end of May, which by definition is herd immunity. The Covid-numbers from the EMR in Sweden during the summer confirms this conclusion.
    It seems to me, like there is a great reluctance to confirm Swedens herd immunity, and to admit that our laissez faire approach has been a success, almost like it’s being supressed on purpose by the MSM and the authorities.

    The scaremongering from the last week about an increase in Covid numbers in particular Skane, and with more restrictions, only confirms this further. If you look at (SCB’s) death toll numbers from Skane the last couple of weeks, it’s actually lower than the 5 previous years, other statistics and real number of ICU patients shows the same results. Also, they have tested over 23 000 people the last week just in Skane alone , with very few on the ICU (looks like less than 10), why? What’s the reason behind testing healthy people without symptoms at a rate 1000 times the number of the ones who are really seriously sick?
    On top of that, the normal seasonal cold and flu infection numbers seems to have vanished completely, it’s gone, now everything is Covid-19. Could it be that the real increase is a combination of seasonal Colds, Flu’s and Covids?

    Thanks for your excellent work.

    1. Hi Thomas,
      Thanks for that excellent summary. I think, as you suggest, the increase probably represents a seasonal rise in multiple different viruses, and some of the people in hospitals with covid could easily in fact have something else. After the covid test comes back positive, further investigation usually stops. So it could easily be that the covid test is a false positive and the person actually has influenza or some other virus, but since we don’t do further testing, we don’t know.

  22. I watched this interview with Dr Claus Köhnlein where he discussed the evidence that Doctors actually killed large numbers of covid19 patients with inappropriate use of toxic doses of HCQ in the early stages of the pandemic (essentially indicating that the large death toll was in large part a result of the Doctors intervention not the disease itself).
    https://www.youtube.com/watch?v=-LToSnpz8A4

    I’m also getting the impression from numerous sources that large numbers of patients were killed by Doctors and the inappropriate use of ventilators, when they switched to oxygen therapy rather than going straight to ventialtion the death toll plummeted.

    Would you be so kind as to give me your view on these two issues?

  23. I am no doctor, but I have read a few conflicting stories about this, which should at least be discussed more thoroughly.
    First, I think when Tegnell talks about actively pursuing herd immunity being unethical, he defends primarily his strategy and correctly assumes and stated that consequentially such a h.i. strategy should then mean that people should be encouraged to party and attend mass events.
    He clearly didn’t do that, and one can indeed see why that might be a step too far.
    Secondly, I have read comments by RKjrs CHD and Profs Gatti and Montanari that herd immunity is, in contrast to the various clearly existing immunities (T-cell etc.) also necessary for a successful individual vacvination, a concept that is not based upon any medical evidence.
    It is merely a myth, a theoretical concept, a computer modelled one, done by computer modelers, aka epidimiologists.
    Possibly, as it alone provides the justification for vaccinating all people not at risk of a pathogen or disease as well, invented by them on behalf of the vaccine industry.
    I think this idea merits more discussion, rather than the sofar mostly unquestioned assumption that herd immunity is indeed a medically evidenced fact.
    Gatti for example stated that when he first heard a doctor friend talk about this as being a fact a decade ago, he knew immediately that we’d be in trouble because of that unquestioned assumption one day.

  24. Dr. Rushworth,

    Thank you for this excellent blog.

    I think that you give too much credit to your constitution and the independence of your experts. Here in the U.S. we have constitutional guarantees of the free exercise of religion and the freedom to assemble. Our political authorities ran roughshod over those rights and our courts went along. Our experts are more subject to political control, but that did not matter. Our politicians, almost without exception, let the experts run the show.

    The real difference is that, unlike in most of the world, Sweden’s experts displayed wisdom and good judgement. For that they deserve great credit.

    Sweden’s politicians deserve credit for not panicking and overruling your experts. Your constitution and the independence of your experts probably made it much easier for the politicians.

  25. Thanks for an excellent summary!

    Would it be possible to expand on the “seasonality” since that seems a bit hand-wavy. Lack of sunshine? The cold? Schools open? Moon radiation? Ice hockey? Particles from studded tires? More orange leaves? Active radiators? Julmust?

    1. Haha, I don’t think anyone knows why most respiratory viruses are more active in the colder months. I’ve heard many different hypotheses. Could be due to lower vitamin D levels, or decreased humidity or air temperature harming the respiratory epithelium, or making the immune system less effective, or increasing viral replication.

  26. Reply to thomas, 2 November, 2020 at 03:27

    Yes, Really.

    Trump has overwhelmingly followed the advice of his experts, even while sometimes expressing a contrary opinion himself. His “follow the science” opponents have been unable to enunciate anything they would have done significantly different. Almost all governors have acted in accord with the conventional wisdom.

  27. Thomas. Who are the experts? What if they have contradictory opinions as in every other aspect of medical science? Are the politicians then the one’s who will choose which experts will run the show?

    This disease and our responses to it have an impact far greater than simply strict medical outcomes. Will medical experts take these things into account, or do they even know about them? Should not the people who are being affected by this problem have a voice in how it is managed.

    No. The decisions on how to address this problem belong rightfully in the hands of the politicians, messy as that is, hopefully taking into account advice and recommendations from the scientists, but also considering for the most part the judgement of the public.

  28. Dr. Rushworth. Very informative piece. Thank you. The data from the Bing coronavirus statistics site reports an extremely low Covid 19 death rate in Sweden over the past few months, to be exact 98 deaths since Sept 1 and 4 deaths in the past 7 days. You comment that the current deaths are a bit more, about 3 per day. Is there an explanation for the discrepancy?

    1. Hi,
      The explanation is that there has been a slight rise in deaths during the last few weeks, to an average of about three per day during the last few weeks of October. Data for the last seven days are not reliable since not all deaths have been tallied yet. And I think Bing is probably a bit behind too, I get my statistics from here (the Swedish Public Health Authority’s own site):

      https://experience.arcgis.com/experience/09f821667ce64bf7be6f9f87457ed9aa

  29. Thomas. Who are the experts? What if they have contradictory opinions as in every other aspect of medical science? Are the politicians then the one’s who will choose which experts will run the show?

    This disease and our responses to it have an impact far greater than simply strict medical outcomes. Will medical experts take these things into account, or do they even know about them? Should not the people who are being affected by this problem have a voice in how it is managed.

    No. The decisions on how to address this problem belong rightfully in the hands of the politicians, messy as that is, hopefully taking into account advice and recommendations from the scientists, but also considering for the most part the judgement of the public.

  30. What this crisis has shown, above all else in my opinion, is that most physicians, including the leading medical “experts,” lack intelligence and integrity in many cases. I say this as a US physician who has practiced for thirty years.

    Medical “experts” are just as susceptible to non-scientific influences as anyone else — maybe even more so. We have clearly seen that in the case of the US surgeon general, CDC head, and Dr. Fauci who have advocated positions like masks without any significant evidence whatever for their use, and in fact in the face of contradictory evidence.

    In many of his posts, Sebastian has illuminated the fraud that constitutes much of mainstream medical opinion and recommendations. These recommendations are not based on science, but rather on bribes paid to “thought leaders” and journal editors who agree to promulgate and publish garbage data for a fee. Physicians who got through medical school via memorization rather than the development of a true understanding of statistics or how the body works then obediently regurgitate these positions.

    We have seen for years that pharmaceutical companies, medical device makers, and politicians with nefarious objectives use physicians as tools/pawns to achieve their ends. The “experts” are bought and sold like commodities.

    In the US, physicians opposing the narrative that is endorsed by the mainstream media and the technology companies are silenced. This suggests the illusion of “settled science,” a political phrase that is contradictory on its face. Science is never “settled.”

    US courts have allowed emergencies like civil wars, epidemics, and natural disasters to justify the suspension of our supposedly guaranteed civil liberties. It’s hard to fake a civil war or natural disaster, but politicians have found a way to amplify an epidemic into something it does not even remotely resemble in reality via the authority of fallible and/or dishonest medical “experts.”

    That is the bottom line. And that is why there should NEVER be exceptions to “guaranteed” civil liberties such as freedom of assembly, religious expression, or any of the others.

    When “experts” can be bought and sold, one should not rely on them to discern or promulgate the truth and they certainly should not be used used to justify converting democratic republics to tyrannies.

    This leaves aside the fundamental fact that authorities should not have the power to determine the risk we takes in our lives, whether it is exposure to disease or anything else.

    Hopefully the courts will realize this, but it is not looking good so far.

  31. Would you mind clarifying your thoughts on whether or not Sweden has reached “herd immunity” in light of these increases in “cases”? Does it mean herd immunity has been reached because there are smaller amounts of positivity or does the commonly known coronaviruses also test as positive on these PCR tests? Here in North America skeptics to herd immunity have jumped on this increase in Swedish “cases” as a supposed example of there being no such thing as herd immunity. Thanks for your thoughts.

    1. Hi Christy,
      Good question. I’ve been spending a lot of time thinking about that myself recently. I would say that Sweden has definitely reached a significant amount of population immunity, which is why there has been a much more gradual increase in hospitalizations during October, as compared with the exponential rise seen in March. Whether it has reached the threshold where you would consider there to be herd immunity, is harder to say. I think, to be totally certain that herd immunity has been achieved, you have to see that we’ve reached a steady state from year to year (not from season to season though, since it is to be expected that there will be more cases in autumn than summer), and we really can’t say for certain what the steady state level for covid is until a few years down the line.

  32. Sebastian,
    It is also possible that some of the increased positive tests are reinfections. COVID has been around for about a year now. Herd immunity doesn’t always mean that reinfections won’t occur.

    We know that other viruses, such as rhinovirus and other coronaviruses which cause the common cold, can occur repeatedly in the same person. Immunity remains after initial infections but it can wane, depending on the microorganism involved.

    The good part is that second infections are often much milder because of a degree of acquired immunity that remains, usually due to T cells, and reinfected persons may be less infectious than those with a new infection. I don’t believe we know anything significant about this virus in terms of the length of immunity that is acquired after an initial infection.

    The important metric is the morbidity and deaths from the illness, not the number of positive tests.

  33. Thank you very, very much Mark for sharing your thoughts and your experience. I hope that sooner rather than later the truth will prevail.

  34. Hi Sebastian.
    Once again you enlighten us with your insights and reflections.
    From the beginning I have been studying the measures applied in each country and the development of infections and reported deaths. I did not find any correlation. In fact, I think it may be due to a biased death report, taking the underlying cause of covid 19 as the leading cause of death. In other cases, or countries, I presume that the measures applied as treatment of the disease actually advanced deaths of patients with comorbidities. Anyway, I think that no matter the measures adopted, the disease followed its natural course, even complicated by the quarantine measures themselves even in the healthy population, reducing the natural capacity of immune resistance of individuals due to the stress caused by isolation, by losses of job…

    Can I translate this article into Spanish and publish it under your name?

  35. I don’t think that the sceptics doubt the existence of herd immunity, sadly, only a few do (Gatti, Montanari, CHD). They doubt that the (GBD) strategy of achieving herd immunity through anything but vaccination is ethical– the 3 herd immunity sceptics on the other hand are very much in favour of letting immunities develop through following a GBD like strategy and are very sceptical of vaccinating everyone, which is what herd immunity is all about for the mainstream politicians, professors and drug companies.
    Herd immunity to me seems indeed to be more difficult to achieve (if it existsat all) on a global, continental, national basis etc., if we consider the different regional levels of existing exposure and immunities.
    Sweden seems a perfect example for that, with Stockholm being far along, but Skane not at all, and travel between the two happening unimpeded.

  36. Hi Sebastian, interesting article once again.
    How would you view the situation in Australia? They have just come out of a 112 day lockdown in the state of Victoria, and over the weekend recorded zero new covid cases. Do you think that really a second wave there is still inevitable, and the lockdown has just delayed it?
    I’m in the UK and it seems to me that the sensible way out of this is to achieve some sort of herd immunity while somehow protecting the elderly and vulnerable. Lockdown helps to ease the pressure on the health system but is also just delaying herd immunity.
    Chris

  37. Today it was reported 31 new deaths since Friday. About 8 per day. In an earlier article from august you wrote that you did not think that deaths will pass 6000. Sweden will pass that in a week. Maybe Swden did not have herd immunity in the summer. Maybe it was just summer.

    1. Yes, maybe. That’s what I’ve been trying to figure out these last few weeks, whether the decline was just due to summer or due to herd immunity. However, the much more gradual increase in hospitalizations in October suggests there is at least a significant amount of population immunity now, although maybe not as high as I thought earlier. As an aside, I didn’t say that I didn’t think it would pass 6,000. I said I didn’t think it would pass 7,000.

  38. The Swedish situation is different from the USA in many respects: population, public policy, partisanship, culture, to name only a few.

    Importantly, the Swedish Covid hypothesis and policy were based on science and clearly articulated from the very beginning. That was not the case in the USA. And it is disingenuous to suggest that it was.

    Here is an interesting scientific reference:
    https://www.nature.com/articles/s41562-020-00977-7#author-information

    Note also that the Swedish model was not cited by Republicans until recently and the Barrington report came out in early October. Both provide a convenient justification — after the fact.

    Sweden A+.

  39. Hi Sebastian- interesting article, thanks for your insights. One thing puzzles me somewhat. You purport to be an exponent of evidence based medicine, yet you seem to have presumed that some level of herd immunity has been reached in Sweden. Surely this is pure speculation and not based on hard evidence at all, rather on your own (educated) opinion and anecdotal experience?

    Please don’t get me wrong, I hope you are correct, at least in some way, but is it not a little premature to make this assertion? This is afterall a novel virus, and although it may be related to the more familiar seasonal coronaviruses, this does not mean it will behave exactly the same does it?

    I too watch with interest the statistics across many nations and while the case numbers are taking a leap in many places, including parts of Sweden, I agree that the most important metric to watch is hospitalisations. This is much more important in countries with poorly resourced hospital capacity, where the main threat to overall population morbidity and mortality will be dictated not just by direct illness from sars-cov2, but by the additional pressures on all hospital services, beds and staff due to covid. Here in Northern Ireland we are already at a higher number of hospital inpatient numbers due to covid compared with the Spring; total hospital inpatients are at >100% capacity across the country. Attempts to ringfence normal hospital services have already collapsed with elective procedures, outpatient clinics and cancer operations postponed or cancelled. The numbers of daily deaths attributed to covid19 is back up to the same as April/May. This all started with a rise in positive case numbers mainly in the younger population in September- initially the hospitalisation rates remained negligible but of course the older population do not live in hermetically sealed bubbles so the inevitable has happened. One can only conclude that we definitely do not have herd immunity!

    I will look forward with interest to your further opinions as the situation develops in Sweden.

    1. Thanks for your comments Stuart. I am a strong proponent of evidence based
      medicine. And I believe in following the evidence in general, not just in medicine. I think the evidence at this point strongly suggests that a high level of population immunity has already been reached in Sweden. Evidence isn’t just data from scientific studies. Statistics and anecdote also count as evidence, although of a lower level of quality. Following the evidence doesn’t mean never being wrong. If I turn out to be wrong, I’ll concede that I am.

  40. Thank you. Can we reprint your article in Latvia, as we are just headed into a second lockdown and so many people are desperate for the terrible collateral damage it will involve, whilst the dominant narrative is that lockdown and economic destruction is the only possible solution.

  41. The next weeks will put your “sweden has herd immunity” opinion to the test. So I have to ask you, what death rate/number of deaths must be reached that you withdraw your herd immunity hypothesis?

    1. Hi Erwin,

      Like I’ve written elsewhere, I think I overestimated the level of population immunity that built up during spring. The reason I made this mistake is that the early evidence on covid suggested that it didn’t behave in a seasonal manner, so I underestimated the size of the seasonal effect in pushing down the rate of infection over the course of the summer.

      I think the fact that we’ve seen a much slower rise in hospitalizations over the course of October than we saw in spring shows that there was significant build up of population immunity during spring, but not to the extent I thought back in August and September.

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