COVID-19 and Sweden – an Inside Look

If we are to believe the media, Sweden’s response to the Coronavirus differs from the rest of the world. Certainly, there are no shortages of articles and opinions about Sweden’s approach, spawning much discussion and speculation on its merits or ultimate demise.

Time magazine published an eye-catching title: Sweden’s Relaxed Approach to the Coronavirus Could Already Be Backfiring¹

Euronews was less sensational: Is Sweden’s COVID-19 strategy working?²

President Trump also commented (verbatim):

Now, they talk about Sweden, but Sweden is suffering very gravely. You know that, right? Sweden did that. The herd. They call it the herd. Uh… Sweden’s suffering very, very badly. Uhh, it’s a way of doing it, but, uhh, the, it, it… you know, everybody has been watching everybody else and so far almost every country has done it the way we’ve done it… we’ve chosen to do it. If we didn’t do it that way, we would have lost hundreds of thousands of more people. OK?

So that’s clear…

Employing the typical, understated Swedish style, Sweden’s Chief Epidemiologist (Anders Tengel), replied, “We don’t share his opinion”. Meanwhile Sweden’s Foreign Minister provided his rebuttal, stating that Trump’s comments were “Factually wrong”.

So, what exactly is going on here? What are the facts on the ground? That’s what I wanted to find out. Fortunately, I have some connections.

Swedish Connections

Because my wife is Swedish, we have spent the last 27 Summers in Sweden. How lucky am I, right? We also lived in Stockholm for nearly two years as I completed my MBA at the Stockholm School of Economics. My wife’s entire family lives in Sweden, as do many of our friends and former classmates.

For a more informed view of Sweden’s response to COVID-19, it seemed reasonable to just ask people who live there.³ Is it really that different and, if so, in what ways?

So, I pinged friends and family in Sweden with a short survey to compile a firsthand account of the vibe on the ground. I received answers from three CEO’s, a nurse, a microbiologist, several students, retirees and a handful of others – generally a diverse group of fairly normal people (emphasis on “fairly”). Only half live in Stockholm. One has already had the coronavirus and has fully recovered. In other words, a decent cross-section of the population.

Because I promised everyone anonymity,⁴ I amalgamated their answers. For the most part, responses were consistent across the group. In these cases, I combined answers to eliminate redundant text (to save you the reading, but at the expense of understating the average, consensus opinion). Where there were differences, I kept the text to show variability in perspectives. So, the answers below do not represent a single composite view, but a variety of viewpoints, with most redundancies removed.⁵

NOTE: I have not inserted any of my own opinions into the survey answers. I have simply synthesized the responses.

Also, if you’d like, you can skip down to the Summary at the bottom.

Here we go…

Survey, Responses & Vibe on the Ground

Generally, how restrictive are the social distancing measures in Sweden right now?

Quite restrictive. Basically, the guidelines are:
a) go to work if you’re sure you’re healthy + can’t work from home,
b) be outside but not close to anyone,
c) keep small kids in school to keep hospital care functional,
d) ideally do as little as possible of anything else.

Compared to the rest of Europe, the Swedish social distancing measures are less strict. For example, restaurants can still be open. It’s not forbidden to use public transportation, but a maximum of 50 people are allowed in a public gathering. That’s much less than most other countries, but we do have restrictions.

Restaurants must seat people at least 2 meters apart. There are signs everywhere reminding people to keep at least 1.5 meters apart.

Museums, cinema and other cultural events are cancelled. Shopping malls are still open, but everyone is urged to keep 1.5 meters from each other. Elderly (70+) are urged to keep total isolation and not even shop for food.

Schools and daycare are still open, but universities and high schools have moved to online options. Everyone who can work from home should do so.

Restaurants and hotels are still open, but food may not be served at the bar. Eating is only at seated tables and with distance from other guests.

The mantra is, stay home if you have any symptoms and be careful with the elderly. The idea is to slow the infection rate so hospitals can manage to care for those in need.

We are not allowed to visit the elderly at their homes and no visits allowed in hospitals.

All the bigger events are now closed, and you get fined and jail time if it gets violated.

In school and preschool, the kids are sent home if they have any symptoms. And, they are a lot more focused on washing hands and basic hygiene.

All high schools and universities appear to be studying from home. Every student already had a personal computer, provided by the school. Studies continue, but at a distance.

Within preschool, elementary and middle school students, each parent should keep the child at home with the slightest symptoms. However, my view is that parents continue to leave symptomatic children at school and the staff must contact the custodians every day and ask them to pick up the children. The decision lies with the parents.

General advice to organizations or society activities:

• Mark the distance on the floor where queues can be formed
• Host digital meetings
• Wash your hands
• Limit the number of people in the room at the same time.

These recommendations or restrictions are difficult to define, as there is a wide variation in how each citizen, management or employer perceives the scope of these restrictions.

My life is working a lot like before. I can still go to the store. I go to work, and the kids still go to school. Some stores have lines drawn outside to regulate how many people are inside, so the distancing is made easy.

What is mandated by the government vs what is optional (individual choice)?

According to the existing restrictions, every individual and the whole society has a responsibility to reduce the spread of infection. This means that both the population and organizations in the private and public sector (companies, communities and municipalities) should follow the recommendations of the public health authority (Folkhälsomyndigheten). However, these restrictions may look different in different areas of the Swedish society.

In Sweden, we have “guidelines” from the government. Swedes typically follow government guidelines, so the theory here is that fines/punishment should not be necessary. People are expected to follow, and mostly they do.

Our infectious disease laws cannot force people to stay home. Consequently, there’s not very much mandated. It’s up to each citizen to behave in the way one should.

A lot is voluntary. Cafes/restaurants need to operate with restrictions (for many, this means take-away) or they can be forced to close.

A large part of all the current measures are based on concepts such as exhortation, recommendation and advice, which, in my opinion, becomes difficult for the population to interpret.

Not much is mandated. Some are; universities and high schools (ages 15-19) are closed. Discussions are on-going if the 19 year-olds should go back and complete their final year, to not lose so much (time) in this process. Other mandates include: not to visit elderly care homes, hospitals and generate crowds greater than 50 people.

The government has placed a great responsibility on every employer and municipality, which means there are major differences in how to implement measures. As an example, a high school in Stockholm could choose to keep the school open and a high school in Gävle can have their students home for “distance studies”. Another example is that some companies or employers may choose to run the business as usual, even though the opportunity to work from home exists, while others conduct all day-to-day operations digitally.

How are people actually behaving (going to restaurants, school, shopping, work, etc.) compared to normal?

Schools (except universities and high schools) are open as normal, i.e. kindergarten and elementary schools up until 9th grade. However, many are still staying at home. The theory here is that it is important for the society that schools remain open as closing them would create other problems. Most people are working from home (those who can). In my company, for example, I would say that about 80% are working from home. The rest are in the office. It is voluntary though. Some companies have enforced rules to work from home, but it differs. I would guess that at least 80% of office workers work from home, if not more. People are mostly shopping online, although grocery stores remain open. They have implemented measures to make it easier to keep a distance and also offer free delivery for those 70 years or older. There is a HUGE difference compared to “normal” times, but some shops and restaurants remain open. But it is not a strict quarantine where everybody stays at home all the time.

From what I hear from co-workers and friends, people are especially careful when it comes to at-risk groups. At the same time, I see a more relaxed standpoint among the younger population. From what we can see from the official statistics, the urban areas in Stockholm are hit harder due to bigger family’s living in a smaller living spaces.

People are playing along. Of course, there are exceptions (like all countries), but Stockholm city is empty as people work from home. Ski resorts closed voluntarily ahead of Easter. The subway is empty. We all feel the pressure to create our own lock down.

Not everyone is behaving well, but most are (enough to take the edge of the curve hopefully).

Swedes follow the recommendations to a high degree. Yesterday, we went to the Gränby shopping mall. Only few customers were there, and they were all queuing up with 1.5 meters apart at the cashier.

A large part of the population seems to follow the recommendations and avoid physical stores as well as restaurants. But based on my own experiences, individuals do not keep the recommended distance in the grocery stores and continue to have smaller social gatherings eg. parties. But there still seems to be an integrated picture of the seriousness of the virus, since everyone stays at home and avoids social contacts with even the least cold symptoms.

Is it true that Sweden is taking a “herd immunity” approach to COVID-19, purposely taking more relaxed measures compared to other countries?

Nope.

The public health authority denies that “herd immunity” is the policy.

The government has been saying all along that they are NOT taking the herd immunity strategy. They are saying that they are trying to “flatten the curve” without shutting down everything. They say that a slow increase is the best, but that it is naive to think we will be able to stop the spread. It is a balance between quarantine and flattening the curve. They are openly saying that they are listening to the scientists and that most other countries are taking a “populist” approach by enforcing hard quarantine laws. There is, however, a debate within the country if we are adopting the right strategy, especially as our Nordic neighbors have adopted different strategies, and we usually are quite the same as them. Time will tell if we did the right thing or not, but I would say that a majority of Swedes trust the government strategy.

No, just taking milder measures and closely observing the outcome.

The media here does not refer to it as herd immunity, but yes, this makes a lot of sense. Since I work at the hospital, I have seen and been part of, a lot of changes. As long as the healthcare system can keep up with the inflow of patients, we can ride out the storm.

We all realize it will take a long time to get societal immunity. To say Sweden is taking a more relaxed stance is wrong.

If so, do you think this stance has broad popular support from Swedish citizens?

Yep. There’s polling data to support it.

I am purely guessing, but would say that 70-80% of Swedes support the government strategy.

The current approach has a broad support.

Not many critical voices from the people that I have heard.

I am supportive of the steps taken.

A primary concern that factors into the equation is that the complete closure of schools would take 25-30% of the healthcare staff from the hospital. Given this trade-off, Swedes accept the complexity of the decisions and the measure to keeps schools open.

Based on the articles I read in the media, there is a feeling that the authorities have the situation under control and the majority of the population relies heavily on this authority, despite international criticism.

There is still a high degree of trust of the Government.

Do Swedes generally think the rest of the world is over-reacting?

Not really. We feel fortunate to have a good health care system, reacted early, and fewer-than-most of our population in risk groups. We understand that other countries, particularly those who were taken by surprise/reacted late, now need to act more harshly.

Swedes tend to think that the rest of the world is not necessarily overreacting, but implementing a strategy which would not necessarily work in Sweden. Swedes tend to think people in other countries do not listen to recommendations from their government and hence “need” much stricter rules/laws. Remember, Swedes have always listened and trusted the government and the institutions in all matters. Compare that to Italy, for example, where nobody trusts the government.

Generally, not sure. Personally, yes… though we should take care to protect elderly and those in risk groups and let the rest (that will have only mild symptoms) take on COVID in a reasonable phase for the healthcare system to handle.

Additional comments?

There are no quick fixes and solutions must balance society, business and healthcare providers. The equation is more complex than to simply close schools or not.

Sweden’s measures are having good effects. I think one of the most telling data points is the national health institution’s data on typical airborne diseases. This year, for example, the flu is down a lot. Social distancing is in play.

Sweden’s approach is keeping with our tradition, which is “reason”, i.e. help people understand the underlying reasoning and recommendations and take actions themselves. We’ve done the same with vaccine cures for decades, and programs to avoid over-use of antibiotics.

We may be doing too little. Or too much. No one knows until this is over.

There has been some discussion in the last couple of days about Trump’s comments about Sweden. The picture he paints is not something people recognize living here.

People are very aware that we are adopting a different strategy but so far people are trusting the government (in general) and waiting to see what happens. But things are definitely not “normal” here. We have a lot of restrictions. Some mandated by the government, but also a lot of “self-imposed” restrictions. Swedes are quite good at that.

We can’t know if we are doing the right thing until it is over. Though current statistics/feedback/knowledge gives no urgent signals to change tactics, it seems. We are not worse off than others (not sticking out in the statistics – it is difficult to measure in the same way, of course).

Summary

There are three recurring themes from these responses:

1) Trust of Government & Official Recommendations

If there is one predominant theme from these comments it is this, Swedes trust their government. This comment surfaced a lot precisely because Swedes recognize this is often not the case in other countries. To understand Sweden’s actions to the coronavirus, we must also understand this broad societal notion of trust of government officials and appointed experts.

This position of trust allows the government to make recommendations rather than edicts.

2) Formulating a Balanced View

The second theme is the idea that there must be a balanced view. The country’s leadership and citizens seem to understand the real trade-off and interplay between their recommendations and the potential secondary & tertiary consequences (for example, closing primary schools reduces the pool of available healthcare workers by ~30%). They have modeled the broader social concerns and societal impacts into their decision-making process.

Sweden’s leadership also mention that most other countries, including the United States, will eventually relax restrictions on businesses, schools and social distancing measures while there are still active COVID-19 cases in the population. They must, to avoid complete economic meltdown. In that sense, the only difference seems to be in the timing of how to effectively flatten-the-curve. Sweden maintains their strategy is the correct one, for them, for now, as long as their healthcare system can bear the load. If they see signs of stress on the healthcare system, they reserve the right to implement stricter policies.

In other words, they are not dug in on this position. It’s fluid and based on current data, projections and consideration of the broader social/economic impact.

3) Individual Responsibility to Follow Recommendations Rather Than Mandates

In making recommendations, Swedish officials provide data to citizens and present the rationale behind their thinking. They then leave the implementation largely in the hands of each individual citizen and corporation.

Because of the strong sense of trust in their government (mentioned above), Swedes generally choose to follow the recommendations of their government. Consequently, there are few official government mandates to compel people to follow the rules (with some exceptions noted in the survey answers). It is for this reason that an outsider might look at the actual mandates from the Swedish government and think they are understated compared to the rest of the world.

Final Thoughts

If you have ever lived in Sweden, you know that it is a rule-following society. When you combine a high level of trust in the government with a follow-the-rules based populace, with a fairly homogeneous society and infuse that with an overall cultural attitude that it is each citizen’s responsibility to make decisions that are in the best interest of the broader society, most people implement the stated government guidelines voluntarily.

Americans cultivate a highly individualistic society and therefore have some difficulty understanding the Swedish mindset, which often defaults to doing what is best for the group, rather than the individual.⁶

It is partly for this reason that Sweden’s approach to COVID-19 appears more relaxed. The official mandates are definitely fewer and seemingly more lenient, but the guidelines are very similar. Other than schools being open (up to 8th grade), the actual behavior on the ground does not seem drastically different from the U.S. It is different, but not drastically different.

OK… everyone comment below to add clarifications or to tell me where I got this wrong.

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UPDATE (August 6, 2020)

I spent five weeks in Sweden, returning August 7th. While in Sweden, it was a great break from all the Covid conversation that currently plagues the U.S.

For the most part, Coronavirus isn’t a topic of conversation in Sweden now. People are out shopping, socializing, eating out, playing sports, etc. Much like normal life. No masks. This was so refreshing.

Swedes are the first to admit that it was unfortunate that the nursing homes took a hard hit early on and account for a large number of the deaths shown in their statistics. So, this was a mistake.

However, otherwise, it is my opinion that the herd immunity approach has worked fabulously well there and is a model the rest of us should follow. Many will point to Sweden’s higher death rate per capita to suggest this was not the correct approach. I will counter that, unless an effective vaccine is delivered, the rest of the world will eventually have similar stats as the virus eventually makes its way through societies. For those countries that lock down hard at every outbreak, it might be years before they reach herd immunity, if ever.

We can’t lock down forever.

The good news for the rest of us is this… there is a light at the end of the tunnel. I’ve been there for the past five weeks. Life will return back to normal (or approximately normal).

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FOOTNOTES:

1. April 9, 2020. Source.
2. April 13, 2020. Source.
3. I always prefer to go to the information source when possible.
4. Not that anyone really reads my blog anyway…
5. I know, this was not very scientific, but then, that wasn’t my goal. I was just looking for the vibe, which I try to summarize at the end.
6. I realize this is a drastic oversimplification, but I didn’t want to write a book about this.