- Sweden had one of the most controversial responses to the coronavirus pandemic.
- It kept its country more open than most of its neighbors.
- For some, that was the right approach. But for others, including the elderly population, the trade-off had harsh consequences.
CNBC is looking at how places around the world have tackled Covid-19. By talking to a wide range of experts, as well as everyday citizens, we're taking stock of what's gone well — and what hasn't.
Sweden, the fifth subject of our series, has confirmed more than 76,000 cases and more than 5,500 deaths in a population of 10 million. The country did not go into lockdown, instead issuing recommendations about social distancing and working from home while allowing many schools and businesses to stay open. Sweden's mortality rate per 100,000 is higher than the United States, but it has fared better than the United Kingdom.
Sweden kept its country open relative to its neighbors. Some citizens worked from home, and many bicycled rather than taking public transit. Schools, particularly for younger children, remained open, as did many businesses. Because of the lack of enforcement and feeling of normalcy, some citizens say they didn't feel as stressed and anxious as they might have otherwise.
"There's a mental health aspect to lockdown," said Nils Mattisson, founder of Minut, a home monitoring start-up based in London and Malmo, Sweden. "All the fear can have adverse effects on people's health."
Ramping up ICU beds
Back in the spring, Sweden needed far more intensive care beds to care for a potential flood of Covid-19 patients. According to Dr. Jonathan Ilicki, head of medical operations at health start-up Doktor24, the situation did improve somewhat.
"In a short period of time, we did see a huge increase in ICU beds per capita, particularly in Stockholm," he said. Swedish officials quickly ordered the construction of a field hospital in a convention complex just south of the city center in early April. That hospital closed in June as demand for care eased in the region.
However, there has been some controversy about whether vulnerable elderly patients were provided with these beds when they needed them. Some health-care workers have pointed to a reluctance to admit elderly patients who came down with the virus in their nursing homes.
Daily briefings ... for a while
Sweden's top health authorities provided a daily briefing in the hardest months of the pandemic, which some residents appreciated. But that all changed in late June, when state epidemiologist Anders Tegnell shared that some of the responses were flawed. Updates are now provided just two days a week on Tuesdays and Thursdays. As Bloomberg reports, the briefings had turned into "daily grillings" where Tegnell had to justify his decisions.
Still, citizens say they appreciated the information, particularly when it came from a high-ranking scientist. "It was a source of comfort, and it was helpful and relatively straightforward," said Mattisson.
An engaged and compliant public
Many in Sweden say that public health officials didn't mandate certain behaviors, in part because they didn't need to. Restaurants, bars and salons might have remained open, but they were relatively empty compared with the months before the pandemic. Moreover, many people avoided gathering in large groups, particularly indoors.
"There's a strong trust in Sweden between the government and the people," said Dr. Arvin Yarollahi, the head of the orthopedic department at a hospital group in the country called NU-sjukvarden. Yarollahi said people took the recommendations seriously, even if they weren't enforced.
"I think we had a response that suited our culture," said Fredrik Soder, CEO of a Swedish health-tech company called Health Integrator. "We take the authorities seriously." Soder said that many people chose to work from home if they could feasibly do so, and they took pains to socially distance. Swedish people were also encouraged to refrain from seeing their elderly relatives, who were at high risk for Covid-19.
That said, public health experts feel that the health officials in Sweden could have pushed for more behaviors to suppress infection. That includes wearing masks, or avoiding discretionary travel.
Sweden's economy hasn't been unscathed but its contraction seems to be less dramatic than what other countries are facing. A Capital Economics report from mid-June noted that Sweden's GDP would likely shrink 8%, compared with the harder-hit countries with late lockdowns like the U.K., where the contraction would be closer to 25%. That said, other reports have found that Sweden's economy didn't perform all that differently than its neighbors, including Denmark. Despite less stringent lockdowns, unemployment still rose and consumer spending fell.
That's probably because people did take precautions, despite the relatively mild government-imposed restrictions. "We were told to use our common sense," said Soder. "And that meant a lot less shopping at stores, and a lot more staying at home.
PPE and availability of tests
At the onset of the pandemic, some medical staff have noted that there wasn't sufficient personal protective equipment available to keep them safe. There were also urgent calls, and investigations from local journalists, for more PPE to be provided to those who care for the elderly in nursing homes and other facilities.
Similarly, Sweden struggled to ramp up tests and some residents with symptoms have shared with publications like Business Insider as late as June that they couldn't get tested. Some even went to hospitals, only to be asked to wait hours for a test -- and then be told that they weren't available.
"The speed and scale of distribution of PCR-based testing and screening of health-care workers could have been managed better, faster and more efficiently, especially in elderly care," acknowledged Johannes Schildt, CEO of a Sweden-based health-care start-up called Kry.
Policy around masks
Dr. Cheng Xu, a gastroenterologist in Sweden who treated many elderly patients, recalls honeymooning in Asia in late January and spotting many people wearing masks.
Back in Sweden, Xu hasn't seen most citizens sport a face covering in crowded public spaces. And although he stocked up in the early months, anticipating a potential pandemic, he fears that there's less value in him wearing one if others are neglecting to do so.
"There's an aggregated net positive effect," he said. "We need a more significant percentage wearing them, especially those who have symptoms."
The vulnerable elderly population
Care home deaths have accounted for nearly half of all fatalities in Sweden, even though the country recommended for people to avoid seeing their elderly relatives. One of the problems is that some staff were not provided adequate protective equipment, and may have gone to work despite having symptoms of the virus.
Prime Minister Stefan Lofven admitted in June that the country did not go far enough to protect its most vulnerable, and many public health experts agree.
"Sweden kept many of its schools open and the restrictions were mild, but there were a lot of elderly deaths," said Dr. Andrew Azman, a research associate in infectious disease epidemiology at Johns Hopkins Bloomberg School of Public Health, who is based in Switzerland. "It wasn't one of the better responses overall."
Others say that the outcome has brought to light a deeper need for new policies when it comes to caring for nursing home residents. "The lack of nursing staff has been a problem, and there's also poor wages and poor working conditions," said Yarollahi. "Many things have come to the surface and I'm hoping they can get better."
Lack of tracking and data collection in schools
Sweden made a relatively unique decision in keeping schools open, particularly for younger children. Many countries, including the United States, are weighing opening up schools after the summer holiday -- and are eager to learn from countries like Sweden.
But epidemiologists say there wasn't sufficient data collected about infections among school-age children.
"It's really frustrating that we haven't been able to answer some relatively basic questions on transmission and the role of different interventions," Carina King, an infectious disease epidemiologist at the Karolinska Institute told Science Magazine. King shared that her team had been hampered by "the lack of funding, time, and previous experience of conducting this sort of research."
Achieving herd immunity
With its relatively open strategy, some public health experts have wondered whether it resulted in greater immunity. The vision of so-called herd immunity might be a ways off, recent studies suggest.
"We know that large parts of the population are unprotected, as they haven't been infected," Karin Tegmark Wisell, head of the Public Health Agency's microbiology department, shared with reporters earlier this week. That means there remains a "large susceptibility in the population," she said.
We asked every expert we spoke to for their score out of 10. (1 is the extremely poor and 10 is ideal.) It's an extremely subjective measurement, but the average across all of them was 5.5.
Sweden was one of the most polarizing countries from our series with some rating it as a 10/10 and others giving it as low as a 2/10. Those who have treated Covid-19 patients tended to dole out the lower scores.
"I think Sweden's health officials missed an opportunity to communicate suggested recommendations more clearly," said Azman, who gave Sweden a lower score. "They didn't suggest face mask use, for instance."
"I'd give it good marks for transparency, reassuring communications and finding a mix of restrictions that were sustainable in the long term yet effective in slowing the spread of the virus," said Mattisson, who gave Sweden a 7 overall. "But bad marks for not protecting the care homes, not isolating people who arrived from places like Italy sooner and not being smarter about masks."
Correction: Dr. Arvin Yarollahi is head of the orthopedic department at NU-sjukvarden. An earlier version misspelled his name.