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On Friday February 28, 2020 I was reading the Financial Times’ editorial. The words leapt out of the page at me.
“There is little doubt that decisive action while an epidemic is beginning can at the least slow its onset, to give authorities more time to prepare for levels of infection that might swamp health services, particularly in winter.“
The paper was warning that the western world had just a few days to get it right before it was swamped by the corona pandemic. Yet Sweden seemed to be overcome by inertia. If the Swedish state was not going to act, then at least our family could. We went to the supermarket and bought a dozen cans of pea soup, six litres of milk, lots of oats to make porridge and much other foods, enough to last a couple of weeks if things got bad.
It was particularly concerning to me/us? that Stockholm was at the end of its winter holiday week, and we personally knew of families skiing in northern Italy. We waited for the government to put these people into quarantine on their return, even dreaming that a hotel at Arlanda airport might be dedicated to the tasks. But nothing happened. On Sunday night we had a family meeting to discuss whether our children should go to school the next day. It felt rather dramatic, but the family had practiced crisis preparation on our Australian holidays, given the bushfires all around. We decided that the children would go to school, but they were given clear instructions not to touch anyone and to keep well clear of any peers who coughed.
For the next few weeks, we waited for government action. Would the schools be closed, should Melodifestivalen (the Eurovision song selection) performed in front of tens of thousands be cancelled? When government directives came – they seemed slow, and to be not as tough as expected. Rather than “stay indoors at all cost, or the police will give you trouble”, they sounded ambiguous and open to interpretation – “try not to meet other people, and stay two metres from them”. The debate about schools kept on going. FHM stood firm – they should not be closed. But, by mid-March when we knew many people with corona-like symptoms, we decided to not take risks and pull our children out of their schools anyway.
We watched what was happening elsewhere in Europe, and the US, and it began to dawn on everyone that Sweden had a different approach than most, perhaps all other countries. As owners of Mundus International AB, our business is to advise expatriates on Swedish policies, whatever the subject. Our customers were suddenly keenly interested in Sweden’s public health management, so we were following corona events for both personal and professional reasons. We understood about the separation of powers between the political arm of government and the public authorities. We also agreed in principle with a balanced response between preserving lives and livelihoods. We think that this has made our lives far more tolerable than the hard lockdowns seen elsewhere in Europe, and that Sweden’s economy is probably holding up better because of that.
But the numbers are stark. Sweden has nine times as many deaths as Denmark, and the comparisons with Norway and Finland are much worse. Although when one listens to Anders Tegnell, every response seems to have a good answer for why Sweden has done things differently, we still can’t help feeling that Sweden could, in fact should, have done much better than it did. Perhaps what is almost as bad as getting having had so many deaths is the circular arguments run by the experts which conclude that Sweden took all the right decisions, except for what happened in old-aged homes, where wrong decisions were taken, but those decisions were made twenty to thirty years ago, by people who have mainly retired. That is why the framework introduced in this book can be so helpful. Yes, we must listen to experts, but in a crisis situation, where facts are unclear, we must also use our own heads.
But first some facts, or at least one public version of them;
In mid-June, Johan Carlsson, the Director General at the Public Health Agency (FHM) of Sweden (for international readers, he is Anders Tegnell’s boss) published the Agency’s account of the events during Sweden’s corona pandemic crisis. Here we simplify his version.
- In early January, 2020, FHM became concerned about the novel coronavirus, given events in Wuhan. At this point little was known. Would the virus have a high mortality, and how contagious was it? As the weeks went by it became clearer that the virus had higher infectivity but lower mortality than SARS and MERS. FHM began to prepare.
- The world has learned that there were a variety of corona response practices in place. And then there was the, Swedish model. But this model was not a single decision taken at a point in time. Rather it was adopted incrementally, based upon observations of what was working in other countries. According to Carlsson “our model does not differ much from other countries really.“ FHMs thinking was to look at every decision, and to think how to deliver the best results. The experts thought about whether the greatest results could be achieved by avoiding crowds, or limiting interactions between people. They also looked at what couldn’t be avoided. Carlsson said, “One cannot avoid medical care and staff have to work with the elderly, the whole welfare system must run. You can’t close that. Plus a great deal of other important societies such as goods transport, banks and much more. After that, there wasn’t much left.”
- According to Carlsson, what has separated Sweden from other countries has been how to manage schools. FHM concluded that younger children did not drive the epidemic, and so compulsory schools and preschools should be kept open. He says that this turned out to be a correct assessment, with many other countries deciding children were not spreaders.
- One important question for FHM was how big to allow public gatherings to be. For a few weeks, they settled on 500, but when the pandemic gained momentum, gathering were reduced to 50. But did Sweden lag when it came introducing restrictions? The most blatant example of the challenges to this policy occurred on March 7, when 27,000 people watched the final of the Melodifestivalen, followed by an afterparty at a nightclub. But on this same day, the Norwegian authorities conducted the Holmenkollen ski competition without any public. Sweden could have gotten this timing wrong. But Carlsson argues that the signals FHM saw were that there was not a social spread at that time, and “the big spread” started a few days later. A couple of days later FHM canceled events of more than 50.
- According to Carlsson, the general perception was that the corona virus went to Sweden from Italy, via Swedish skiing travelers. But that picture is wrong. Although many of the skiers did come back infected, Stockholm’s infection control succeeded in tracking down and testing them. But, other groups passed under the radar. FHM has sequenced virus strains, and the evidence points in a different direction. It was probably not Italy that got the only outbreak in Europe. Corona went from China to the United Kingdom, France, the Netherlands and the eastern United States. And from there on into Sweden. When FHM analyses different variants of the virus that are in circulation in Sweden, there is a pattern. FHM concludes that isolation of traveler from Italy largely prevented the infection from getting a foothold via that route.
- But, Swedes are great travelers. Almost a million Swedes returned back to Sweden during February, Italy represented a rather limited part of the infection sources. Swedes travelled to London, Paris, Barcelona and other major cities in Europe, and to New York. It would have been impossible to take samples of all these people from all over the world when they came back to Sweden.
- Carlsson was asked whether he ever thought that Sweden should lockdown society? His response was that although the issue was discussed, FHM was not close to such a proposal.
- Asked whether more should have been legislated and if the Swedish authorities and the government should have been tougher, he responded thatFHM did not share that view. “We do not feel such a great need to demand stricter legislation. We discouraged people from traveling more than in the immediate area, and then people do not do so to any great extent. Our view is that if you get people onboard, the overall community response is better. The actions in Spain, where police cars patrolled the streets and people were fined large sums if they went out the wrong time, felt very far from how we usually handle issues in our country. Trusting citizens is an important part of how the Swedish model works.“ Carlsson doubted whether a lockdown would have reduced mortality significantly. “No matter how many police cars you have, those who work in elderly care must go to work, go back home, shop and more.”
- One distinctive feature of the Swedish system is that the authorities have an independent position, This does not only apply to the corona strategy, it applies to much of how Sweden is administered. While legislation is determined by Parliament, politicians don’t have much say in how it is enacted. So, did Carlson think the collaboration with the government has worked? He said that FHM collaborated primarily with the Ministry of Social Affairs, but also with the Cabinet of Ministers daily for several months. The relationship was “constructive and good”, and the government did not “only passively do what we have said”.
- Another feature of the Swedish system is decentralisation. Although FHM and authorities determine policies centrally, service delivery is performed at a local council (kommun) level. It is very difficult to get everyone going in the same direction. In Carlsson’s view, in Norway, which has a state medical service, it is much easier. You simply decide what to do and then you do it.
- Although FHM worried that there could be difficulties in elderly care, it was a too late to deal with the major structural problems when the pandemic comes. FHM does not handle elderly care, but has a close dialogue with the National Board of Health and Welfare (Socialstyrelsen). It is “problematic that Socialstyrelsen was unable to solve identified structural problems pointed out over thirty years.” Consequently, care staff were not always well trained, or equipped with with sufficient medical/PPE resources.
- Asked if anything might have been gained anything from more testing, Carlsson responded, “It is never wrong to test and we could have caught milder cases, but those who thought they had covid-19 have nevertheless been instructed to stay isolated so I am not so sure it had made such a big difference in itself the epidemic. And you could have tested more in elderly care. That would have been an advantage.”
That, in essence, has been the Swedish public health covid-19 strategy. There are many impressive things to like about it. It’s a system run by experts. The experts were focused on the health results and never said that they were trading off health for economic benefits. The experts were well trained, and say that they received good cooperation from the government. The experts placed a lot of trust in the community, and for good reason – it is a part of Swedish culture to listen to advice from authorities and to act responsibly.
But, despite these strengths, the system did not produce the “decisive action” that the Financial Times had called for on February 28. That made us feel uneasy, and was the reason why we stocked up on pea soup. We acted with both our head and our gut. Most of the time the head was left to rule. Sometimes we let gut feeling take over, when the facts that we witnessed every day were inconsistent with expert advice. The most obvious example of this was we when took our children out of school for five weeks. This decision was made in mid-March, as the number of people in our circle that were infected by covid-19-like symptoms skyrocketed. We reversed the decision when we observed that none of our friends children had gotten sick.
In this book we talk about resilience, by which we mean “the capacity for change in difficult circumstances”. Difficult circumstances feel a good description of the crisis stage of the corona pandemic that we have all just lived through. Many are still living it. The challenge of operating in a crisis is that the solutions are unclear. Sometimes experts have opinions that are helpful to listen to. Sometimes one needs to make a decision on the spot with only one’s own judgement. Overall we believe that our family responded resiliently, although there were times where we felt the strain. Our reason for writing this book, together with Fons is to share experiences, in the hope that this helps to build the resilience of the community, and of countries.