Sweden’s Pandemic Experiment

When the coronavirus arrived, the country decided not to implement lockdowns or recommend masks. How has it fared?

Sweden’s head epidemiologist has often said that lockdowns are not supported by science and that the evidence for mask-wearing is “weak.”Photograph by Jonas Gratzer / Getty

- THE NEW YORKER - Apr 6, 2021 -

Mallory Pickett -


On a gloomy afternoon in March, 2020, Angelica Jularbo, a nurse, was in her office at a high school in Stockholm, when one of her students came in complaining of a headache. Jularbo, a mother of four, projects the mixture of sternness and warmth that one expects from a nurse. In the previous month, covid-19 had begun sweeping across Europe, but Swedish schools remained open. As Jularbo bent to take the student’s temperature, the student coughed and then said, “Oh, maybe I should tell you, my partner has been diagnosed with corona.” Jularbo ordered the student to go home immediately. “Don’t go back to class to get your bag,” she said. “We’ll have someone bring it to you.”


Four days later, Jularbo woke with a fever and a splitting headache. “I understand why people who are really sick, or people who are in excruciating pain, say, ‘I just want to die,’ ” she told me. She was so tired that she couldn’t leave her room for several days. One morning, she made tea and sat on the couch, determined to see her children off to school; she woke up to the sounds of them coming home, tea cool on the table. After nine days, the last two symptom-free, she went back to work. But a week later the headache and fever returned. She locked herself in her office to avoid exposing anyone. “I was so, so scared that I had made someone else in the office sick,” she told me.


Jularbo’s illness came at a pivotal time for Sweden. While lockdowns, curfews, and travel bans were being rolled out across the rest of the world, Swedish restaurants, stores, bars, museums, day cares, and elementary schools all remained open. People were encouraged to work from home and to reduce travel, but both were optional. Masks were not recommended and remained rare. Households could mix; until the end of March, even parties of up to five hundred people were allowed. The man behind Sweden’s coronavirus response is Anders Tegnell, the country’s head epidemiologist. Tegnell worked in Zaire during the 1995 Ebola epidemic, and then served as an expert on infectious diseases for the European Union before being hired by the Swedish public-health agency, in 2013.


The Swedish constitution gives government agencies extraordinary independence, so Tegnell and the public-health agency have led much of the coronavirus response, and, constitutionally, the government has little power to impose restrictions. Tegnell, who is sixty-four and tall, with round glasses, has often said that lockdowns are not supported by science and that the evidence for mask-wearing is “weak.” His stance is a startling departure from the scientific consensus, but he maintains that if other countries were led by experts rather than politicians, more nations would have policies like Sweden’s. The world has been left gawking. American liberals were shocked that the country of Greta Thunberg could seem so scientifically backward. Right-wing activists in Minnesota held up signs during anti-lockdown protests reading “Be Like Sweden.” Within the country, Tegnell has become an icon of Swedish exceptionalism, believed to be excessively reasonable, levelheaded, and rational. Supporters praised him for not giving in to political panic. Wearing a mask in Sweden was sometimes seen as a signifier of being anti-science.



Jularbo has many friends and colleagues who contracted covid-19, and her case was severe. But I met her in the “Anders Tegnell Fan Club” on Facebook, which contains a smorgasbord of multimedia tributes: T-shirts bearing his face, a chocolate figurine in his image, a poster with his face glowering above the words “Wash your hands.” “I prefer to have medical experts making the decisions instead of maybe a prime minister who knows, excuse me, shit, about health and medical issues,” Jularbo told me. She’s not the only person in the group who has caught the coronavirus. Staffan Hugemark, a fifty-three-year-old who works at a software company, got sick along with his family after returning from a ski trip in northern Italy. Still, he recently had a falling out with an old friend who disagreed with Sweden’s policies. “People look at Sweden and think that it’s a disaster here, and it’s not,” he said. Viktoria Ellénius, a forty-seven-year-old former aesthetician, got sick early in the pandemic and couldn’t work for weeks, which caused her to lose her skin-care business; she couldn’t get a test, but she thinks she had covid-19. Nevertheless, she believes that Tegnell’s policies saved the country from the costs of a lockdown, including economic damage and widespread depression. “At the beginning, I didn’t like Anders Tegnell,” she said. “But the more I have heard about him, the more time has gone by, the more I love him.”


Jularbo is now working with long-haul covid-19 patients in the rehabilitation unit of a hospital in Eskilstuna, seventy miles west of Stockholm. She suffers from long-term symptoms herself, including lingering fatigue. “I’ve never been tired like this,” she told me. “My alarm goes off, and it’s like, shoot me. I don’t care if my kids get to school on time. I don’t care about anything.” Still, she’s proud of how Sweden’s public-health agency has handled the pandemic. “They’ve been good. They haven’t been running around listening to what everybody else does,” she said. This winter, she messaged me, “I’m more worried about you living in the states. The pandemic is hitting hard.”


Most mornings, my husband, who is Swedish, FaceTimes with his friends or family in Sweden. Early in the pandemic, the calls seemed like windows into ordinary lives, largely uninterrupted. Children had birthday parties and sleepovers. Adults met in restaurants and bars. A friend sent a video of a gym class in Stockholm—twenty people breathing heavily in a windowless room. My father-in-law is in his seventies and has a severe lung condition, which means that if he’s infected with covid-19, it’s more likely to be fatal. But while my husband and I, in California, stayed home, he and my mother-in-law were still going out shopping and seeing friends without wearing masks. They’re not reckless or uninformed people. My father-in-law is a retired engineer who reads the paper every morning, and we almost always agree about politics. Yet every time we suggested that perhaps they should be wearing masks when they went to, say, a bar, we were met with polite skepticism. My father-in-law recently discussed masks with his lung doctor, a senior physician at one of the country’s top hospitals, whose advice was that the only reason one might consider wearing one was because other people would think you were sick and give you more space. This was the philosophy my in-laws adopted. A healthy person “can’t wear a mask in Sweden,” my mother-in-law told me, in October. “People will look at you like you are a very strange person.” The Swedish health agency communicated to the public that there was insufficient evidence that masks prevent transmissions, that they are often used incorrectly, and that they could be used as an excuse not to distance properly, which would be harmful.


Tegnell introduced the country’s light-touch approach to the pandemic in March, as cases were mounting. Internal e-mails obtained by the freelance journalist Emanuel Karlsten show that the government at least considered whether the strategy might lead to more widespread immunity. In an e-mail exchange between Tegnell and the head of the Finnish public-health agency, on March 14th and 15th, Tegnell suggested that keeping the schools open could help the young and healthy develop immunity sooner. His Finnish colleagues noted that their models found that closing schools would decrease the infection rate among the elderly by ten per cent. Tegnell responded, “Ten percent might be worth it?”


However, Sweden seems to have settled on its final strategy primarily through a mix of unorthodox scientific conclusions, pragmatism, and folkvett, a particularly Swedish notion of common sense. No epidemiologists thought that self-isolation should be a long-term solution. “Lockdown is a temporary measure that you do to buy you time,” David Nabarro, a long-time United Nations adviser and one of the World Health Organization’s special envoys on covid-19, told me. But most countries were unable to get the virus under control and decided to leave lockdowns in place until a vaccine became available. This seemed unsustainable to Tegnell. He also shirked masks. A year ago, there were few studies that directly measured the impact of masks on viral-particle emissions and community spread of the virus, and controlled experiments were difficult to conduct, for logistical and ethical reasons. Over the course of the pandemic, evidence supporting masks has piled up. An analysis of mask mandates in German towns found that they may have reduced covid-19 infections by about forty-five per cent. Another study examined U.S. states with mask mandates, and found that the daily growth of infections was two per cent lower in states where a mask mandate had been in place for a few weeks. By April, 2020, the W.H.O., the Centers for Disease Control, and other groups decided that there was enough evidence, and recommended face coverings. The C.D.C. now firmly concludes that “experimental and epidemiological data support community masking to reduce the spread of sars-CoV-2.” Yet Tegnell remained unsatisfied. In April, 2020, he wrote a letter to the European Center for Disease Control urging against a mask recommendation, saying, “The argument for and evidence for an effect of face covering to limit the spread from asymptomatic persons is not clear. . . . The arguments against are at least as convincing.”


As the Swedish strategy garnered attention, Johan Giesecke, Sweden’s former head epidemiologist, told UnHerd, a British YouTube channel, that he expected the infection fatality rate to be “much, much lower” than was being reported in the media at the time. “I think it will be like a severe influenza rate, on the order of 0.1%.” (A study by the Swedish public health-agency later found that the rate was at least six times higher in Stockholm.) He said that the difference between Sweden and other countries’ policies was that “the Swedish government decided early, in January, that the measures we should take against the pandemic should be evidence-based. And when you start looking around at the measures that are being taken now by other countries, you find that very few of them have a shred of evidence.” Tegnell said that he had been in close contact with his counterparts in the United Kingdom, who were planning similarly light restrictions. But cases in the U.K. were increasing rapidly. On March 16th, scientists at Imperial College London published a paper, based on an epidemiological model, predicting that, unless some form of lockdown was imposed, more than five hundred thousand Brits would die from preventable covid-19 infections. A week later, the Prime Minister, Boris Johnson, announced that his government would be closing schools, bars, and restaurants, falling in step with the rest of Europe. “It was slightly frustrating,” Tegnell told me, when I spoke to him, in August. “We were really hoping we could take us through this crisis together.”


Sweden is a country of ten million people, about the size of Los Angeles County, and almost twenty per cent of Swedes live in Stockholm, the largest city. In April, 2020, a widely-circulated pre-print version of a paper by researchers at Uppsala University, adapting the Imperial College model, predicted that, under the Swedish strategy, fifty per cent of susceptible Swedes would be infected within thirty days, resulting in over eighty thousand deaths by July. That spring, the virus began spreading unchecked in Sweden. “It just kept adding up,” Tegnell said. “I mean, you’re always kind of hopeful and think that, O.K., this is something that’s going to pass over.” Soon, the per-capita death toll was among the highest in Europe. Slight modifications were made to the Swedish advice: visitors to nursing homes were banned on March 30th; people were not allowed to gather in groups larger than fifty. Tegnell told me that the death toll weighed on him. “I think this was a big frustration and feeling of failure for us,” he said. But he remained steadfast, often saying, in interviews, “Judge me in a year.”


Tara Twana, a member of the Stockholm County Council, heard about the mounting infections in nursing homes at the beginning of the pandemic and felt grateful that her elderly parents still lived at home. Twana is forty-nine, with long hair that she wears in a blowout. She and her family are Iraqi Kurdish, and her father was one of the leaders in the peshmerga movement for Kurdish independence. The family fled Iraq in 1988 and sought asylum in Sala, Sweden. “The people in Sala were very very kind,” Twana told me. As a child, Twana resented her parents’ activism, which often required that they travel away from home, but, in college, she joined a left-wing political party and began to get involved in local politics. Since joining the county council, she has focussed her efforts on public health and women’s issues.


In the beginning of the pandemic, Twana was “very happy” with Tegnell’s response. “I have a lot of trust in the Swedish government,” Twana said. “Maybe I’m assimilated a lot in the Swedish society.” At the government’s advice, she and her family limited their movement somewhat but never wore masks. Then, at the end of March, Twana’s sixty-seven-year-old mother, Pari, came down with a headache and fever. Twana tried to check her into a hospital to keep her away from her father, Abdulla, who was eighty-three, but doctors told them to stay home. They said that there was no need to wear masks but that they should try to stay apart in the house. They spoke to one another on the telephone from different rooms.


A week later, Abdulla wandered into his bedroom, looking confused, and asked Pari where he was and whether there was a toilet in the house. She called an ambulance, which took him to the hospital, where he tested positive for the coronavirus, with a hundred-and-five-degree fever. Twana’s mother was soon admitted, too, as her symptoms worsened, and husband and wife shared a room. Two days later, Twana’s father’s oxygen levels began dropping. Twana called him on FaceTime to say goodbye. At Christmas, he’d given her a book that he had written, entirely by hand, on Kurdish history in Mesopotamia, and had asked for her feedback. She hadn’t had time to read it, but she lied, telling him that she had liked it. She told me, “He was so happy. I promised I would publish his book.” He died sixteen hours later.


Twana, and some others in Sweden, feel let down by how their government has managed the pandemic. Alexandra Rönnholm, a fifty-four-year-old government employee, lost her husband in January. She wrote to me to say that Tegnell and his colleagues “have acted too late and too little which has led to over 12000 people premature death including my husband. He would have lived without Corona!” Nanaz Fassih, a fifty-two-year-old pediatric nurse, was skeptical of the Swedish response from the beginning; she tried to wear a mask to work in hospitals and clinics, but was told that this was not allowed. (Today, masks are more commonly used in Swedish hospitals.) On December 25th, she lost her eighty-three-year-old father to covid-19. She had often heard the Prime Minister speaking in support of the health ministry’s policies. “He said the strategy is going well,” she told me. “How can he say it is good?” Twana wishes that the government had instituted stricter protections. “That’s a politician’s work, to take information and protect the people in society,” she said. Instead, she said, “Anders Tegnell, he was Prime Minister.” She added, “I still believe in the government. I do. But I’m very, very sad about how they dealt with the issues with the pandemic.”


This summer, case counts began to drop in Sweden. When I spoke to Tegnell at the end of August, he felt that the worst was behind him. Just a few weeks later, he and other international experts had a special audience with Boris Johnson, to give advice on how Sweden had brought numbers down with their light-touch approach. “I think we are reasonably optimistic,” he said. “Our prognosis is, No, we don’t really see a huge second wave coming on.” This did not last. By December, cases and hospitalizations were higher than they’d been since the earliest days of the pandemic. Intensive-care units in Stockholm and Malmö, the country’s third biggest city, were full. “It was just this development we did not want to see,” Björn Eriksson, Stockholm’s director of health and medical care, said during a press conference. Confidence in the public-health agency had fallen from sixty-eight per cent in October, to fifty-two per cent in December. The government appointed an independent commission to investigate the Swedish response to the pandemic, and passed a new law temporarily allowing the state to close businesses as needed.


Tegnell’s prediction of a tapering epidemic curve and quickly-attained immunity never came to pass. Sweden’s per-capita case counts and death rates have been many times higher than any of its Nordic neighbors, all of which imposed lockdowns, travel bans, and limited gatherings early on. Over all in Sweden, thirteen thousand people have died from covid-19. In Norway, which has a population that is half the size of Sweden’s, and where stricter lockdowns were enforced, about seven hundred people have died. It’s likely that some simple policy changes—especially shutting down visitations to nursing homes sooner, and providing more P.P.E. and testing to nursing-home staff—would have saved lives. And the strategy doesn’t seem to have helped the economy much: the Swedish G.D.P. fell by around three per cent, better than the European average, but similar to the drop in other Nordic countries.

Fredrik Elgh, a virologist at Umeå University and one of Tegnell’s former bosses, wishes that Sweden had implemented restrictions like those used by other countries in the region. “Why don’t they go the same route as our neighbors that have been so successful?” he said. “We could have done that, too, if we had followed their path.” The fatalities in the elder homes, which account for about fifty per cent of the covid-19 deaths in Sweden, seem especially needless; if visits to these facilities had been banned sooner, if their workers had been advised to wear masks and get tested frequently, it’s possible that thousands of lives could have been saved. People from both pro- and anti-Tegnell camps believe that this was an unnecessary tragedy. (Tegnell agrees, although he does not think that the responsibility lies solely with the health agency.) “The Swedish strategy aimed at protecting the elderly has failed,” Mats Melin, the country’s former chief justice and the current head of the government-appointed Corona Commission, told me. In December, Sweden’s King, Carl XVI Gustaf, criticized the country’s policies, telling the state broadcaster, “The Swedish people have suffered enormously in difficult conditions,” and adding that, when it came to the strategy that the country employed, “I think we have failed.” Stefan Lofven, the country's Prime Minister, told reporters, “The fact that so many people have died cannot be seen as anything else than a failure.”


But, although the outcome in Sweden was a black spot in Scandinavia, “compared to other countries in Europe, it’s not the worst off,” Patrick Heuveline, a professor of sociology at U.C.L.A. who studies pandemic mortality rates, told me. “It’s not as bad as Italy, Spain, the U.K., and Belgium for example.” Tegnell holds up this statistic when defending his strategy, claiming that sparsely-populated Norway and Finland are the outliers, and that Sweden should be compared to the rest of Europe. Sweden has a larger foreign-born population than other Nordic countries, and its population is more concentrated in urban areas, Tegnell claims. Other experts are skeptical of this argument. “I find no correlation between proportion of foreign-born and Covid death rate,” Heuveline wrote, in an e-mail. “Norway has a higher proportion of foreign-born than Denmark, which has about the same proportion as Italy (about 10%), but Covid-19 mortality is much higher in Italy than in Denmark, and higher in Denmark than in Norway.” Over all, Elgh, Heuveline and other experts argue, Sweden’s population is more similar to the other Nordic countries. Its first infections also came later than in other parts of Europe, giving its government more time to warn its citizens of the virus’ severity. For these reasons, comparisons to the rest of Scandinavia, which are less favorable to Sweden, may be more apt.


Even so, Sweden’s death toll was not as high as some predicted. It will not be easy to tease out the precise reasons for this outcome. In a recent piece for this magazine, Siddhartha Mukherjee noted that, while some countries were ravaged by the pandemic, others had far lower death rates than expected. The reasons for this, he noted, remain an “epidemiological mystery.” It may be, for example, that the Swedish policies appeared more different than they actually were. Small liberties were allowed—restaurants, bars, parties—which made Sweden seem wildly permissive. Lone Simonsen, an epidemiologist at Roskilde University, in Denmark, told me that, in the late spring and early summer, Danes would sometimes take a short trip to Sweden to enjoy a reprieve from lockdown. “If you just went to Malmö, which is right across from Copenhagen here, you would see two completely different societies when we were in lockdown,” she said. But most high schools and universities in Sweden went online. Staying at home was optional rather than mandatory, but mobility data from cell phones show that Swedes did significantly reduce their movement. Simonsen believes that two of Sweden’s simplest restrictions—limiting the sizes of gatherings and regulating visits to nursing homes—did much of the work to limit spread. “Most countries do a bunch of things at the same time, and you really can’t find the effect of the individual ones,” she said. She also points out that Sweden’s restrictions, while relatively relaxed, also remained fairly steady. “They didn’t fluctuate like we did in other countries,” Simonsen said. “We’ve been on a yo-yo diet with covid over here. The numbers went down, we opened up, and then they went up.”


There may also be factors that we’re not yet aware of. “We’ve just got to be humble about what we know and what we don’t know. And we still don’t know a lot,” Howard Forman, a professor of public-health and management at Yale, told me. Protections that seemed important may turn out, after long-term study, to have been less effective than we thought. “If you, one day, come to me and say that masks only reduce spread by fifteen per cent or even ten per cent, I’d be like, O.K., well, that’s within range. It’s not a total shock. And, by the way, I would still say it was worth wearing the masks.” Huevelin added, of the virus’s first wave, “I remember we were given all these reasons why Germany kind of dodged the bullet: they had great hospitals, they had an excess of I.C.U. hospitals, they had redundancies in their hospital system.” But, now, Germany is doing no better than its neighbors, and it’s not clear why. Almost exactly a year from the pandemic’s start, Tegnell said that he believes people should still hold off on judging his policies. “The pandemic is not over,” he said. “Any kind of final review on what’s been good and what’s been bad still awaits us.”


Sweden remains divided on its government’s response to the pandemic. On December 18th, as hospitals were already braced for a post-Christmas surge, Tegnell and the public-health agency finally recommended wearing masks—but only on public transit and only during rush hour. (Tegnell sees distancing as the most important barrier to the virus—“Masking is not a golden bullet,” he said—and only recommends the use of masks where distance cannot be maintained.) Days after this new rule was passed, I asked Tegnell whether he still thought the evidence for masks was “sketchy.” “Yes,” he responded. “Unfortunately, there is not much new evidence in place.” But he told me that he had decided that it was better not to take chances. “Due to the developments we see, we need to use even measures where evidence and effect is low,” he said. Swedes are slowly making masks a part of their pandemic routines. My mother-in-law has bought some masks to wear on buses and trams. She and my father-in-law continue to see a small circle of friends, but they celebrated Christmas alone, seeing their grandchildren only on small screens.


PUBLICAÇÃO ORIGINAL:

https://www.newyorker.com/news/dispatch/swedens-pandemic-experiment


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