Sweden's renegade COVID-19 policy looks like a disaster — but the country is quietly determined to see it through despite the cost in lives

• Sweden avoided a full lockdown, instead introducing some rules intended to keep people working while protecting the vulnerable and the hospital system.
• But its deaths soared, its expected "herd immunity" outcome failed, and other countries are limiting the movement of people from Sweden when opening borders.
• Now, some Swedes are beginning to question the strategy, and other countries are managing eased lockdowns without a second wave.
• But Sweden says it is playing the long game, and its economy has suffered less than its neighbors.
• As a result, some experts say judgement over whether the strategy was right must wait. But Sweden is now left with a high death toll and worries about future outbreaks.
• Visit Business Insider's homepage for more stories.

In February, the month after the coronavirus was observed in China, and with only 45 cases in Europe, the Swedish government believed the virus would not be a big deal.

Johan Carlsson, the director-general of the Swedish Public Health Agency, then told Radio Sweden: "I think we are very convinced that we could contain this disease. We may get a couple more cases of course but we are not expecting a major outbreak.

"I think we are well prepared," he said.

Later, in April — with Italy seeing almost 1,000 daily deaths — Anders Tegnell, Sweden's chief epidemiologist, told the journal Nature, "closing borders, in my opinion, is ridiculous."

The government's plan centered around long-term goals — the idea countries can't stay in total lockdown forever. The Swedish lockdown was more relaxed. They hoped "herd immunity" would slow down the spread of infections. Initially, most Swedes were on board with the plan.

Those officials were wrong.

In the weeks that followed, the death toll mounted. Sweden's death rate rose to become one of the world's highest, almost equal to that of Italy.

Sweden's domestic consensus is now being tested as countries reopen with eased rules that, ironically, now make them look much like Sweden. Most of them arrived at that point with far fewer deaths.

Other European countries, including Sweden's close neighbours, are increasingly allowing travel between each other.

But many are treating Sweden like a hygiene problem, blocking Swedes from entering or forcing them into quarantine (though those restrictions are gradually loosening).

"Everywhere is reopening now and we're on the same playing field," Prof. Luke O'Neill, an immunologist in Ireland's Trinity College Dublin following Europe's response, said.

"So that initial number of deaths is what counts. And there's a lot more deaths in Sweden."

Officially, Sweden is still backing its plan long-term, and predicting struggles for other countries when reopening.

Many Swedes, however, have doubts.

Public support is slipping

Christina Dahlgren, an architect in Malmö, says she faced backlash when criticizing the strategy on social media.

"I don't share anything on my private Facebook anymore because people tell me to shut up, I should be grateful."

Others felt isolated for questioning consensus.

Dr. Jon Tallinger, a Swedish doctor who left his post to campaign for better elderly treatment during the pandemic,  said when he wore a mask in a shop in May, "people thought I was going to rob the place."

Sweden's government doesn't recommend masks, and foreign residents have fear for their safety while wearing one.

Swedes have generally supported the plan. But support has fallen: a June survey found confidence was at 45%, compared to 56% in April.

Prof. Katrina Eckerberg, a political scientist at Umeå University, described Sweden in May as a "homogenous society" where "people are happy to follow the recommendations."

But in June, she said public trust in the strategy was "diminishing."

Some people have protested the strategy in major cities for weeks, though their group remains small.

Allyson Plumberg, one protester, said: "We demonstrate to show that we are not satisfied with the current Swedish coronavirus strategy."

Sweden's science is under fire

Those unhappy question why Sweden chose such a unique route. Dahlgren said: "Those of us who are critical are in awe. We don't understand: do they know something we don't?"

Experts have similar questions. Some accuse Sweden of dismissing ways the virus works, like spreading between people with no symptoms, and say Sweden risked lives by not treating evidence the same way other countries did.

Sweden says it's using a science-backed approach: making rules based on what we know about the virus.

But those experts highlight how Sweden expected widespread herd immunity, though there was no concrete evidence this could be achieved, and how evidence now shows this doesn't seem possible.

O'Neill said Sweden reacted to available science at the time: "We didn't know how contagious it was. We didn't know asymptomatic spread was a feature, and the Swedes didn't either."

"And other countries decided to be more aggressive. and sadly the more aggressive approach turned out to be the more appropriate one."

Prof. Jan Albert, an infectious diseases expert at Karolinska Instituet, said, while it's too early to weigh the success of Sweden's strategy, "I think that we could have done more very early on and in starting to prepare for more massive spread more rapidly when the first warning signals came."

Not every expert has been as kind.

Olle Kampe, an endocrinologist at the Karolinska Institute, previously told Insider: "We are sacrificing old people and people with diseases."

'A horror show'

Annika Linde, Tegnell's predecessor as chief epidemiologist, told The Local she originally supported the approach.

But by late May, she changed her mind.

"The point is that Sweden made it so explicit from the get-go: we are going to protect our older population. But how can you claim such a thing without taking any measures to speak of?"

Tallinger said that in May, after Sweden's spike in deaths, the country was "like some kind of horror movie."

He said people were unwilling to question the government, even as deaths soared.

"When we wake up in Sweden, the feeling of guilt is going to be so massive that there are only two options: We cover it all up or we admit we were wrong."

Sweden's cases and deaths have dramatically decreased. But experts caution against inferring the strategy was success, pointing to high deaths and lack of widespread immunity, and how Sweden is now cautioning against a second wave, like other countries.

"The deaths rates have fallen but it doesn't change how our strategy has failed. And we don't know when the rates will rise again," Tallinger said.

Sweden's economy isn't saved

Many who fought lockdowns in other countries pointed to Sweden's plan as one that prioritizes the economy.

Its economy now appears to be the least negatively impacted in Europe.

But it hasn't been spared: international tourism and trade are decimated, and social distancing has reduced people's activities.

Sweden's National Institute of Economic Research predicts Sweden's GDP will fall 5.4 % in 2020, after predicting a 1% rise December 2019. It also expects unemployment to rise around three percentage points, to 9.6%, between the end of 2019 and the end of 2021.

Mikael Bask, an Uppsala University economist, said most stores stayed open, but shorter hours and reduced footfall affected income.

He also noted the near-complete absence of tourists.

Stefan Westerberg, the chief economist for Stockholm's Chamber of Commerce, said "Sweden and Stockholm are in a deep recession."

"In a very short period, from mid-March, we experienced a sharp fall in economic activity and a severe increase in unemployment and business bankruptcies."

He said Stockholm is most affected, and warned "the crisis might lead to persistently higher unemployment levels."

He worries tourists may be afraid to visit: "It could be the case that Sweden is asymmetrically affected by many countries' assessment on the assumed risks of traveling to Sweden."

Sweden blames other factors for elderly deaths

Sweden is auditing its crisis preparedness and Prime Minister Stefan Löfven ordered a public inquiry into the decision not to have a lockdown. "We have thousands of dead," he said.

In May, Tegnell expressed doubt over Sweden's response: "If we were to encounter the same illness with the same knowledge that we have today, I think our response would land somewhere in between what Sweden did and what the rest of the world has done."

"Clearly, there is potential for improvement in what we have done in Sweden."

But, overall, he said the plan was still the right one, and Sweden would stick with it.

"We continue to believe the strategy is good but then there are always improvements we can make."

Tegnell was regretful about the "surprise" high death toll, but painted it as an unfortunate factor unrelated to the lack of lockdown because a high proportion of those deaths were in care homes.

Tegnell said it was not clear if a lockdown would protect them, given visitor visitors bans. Some political parties say long-term issues in the care system are what's at fault.

If these other factors are to blame, Sweden's high deaths would be somewhat independent of its lack of lockdown.

Indeed, some other countries with lockdowns have similar elderly death rates.

Richard Nordgren, the Sweden-based Nordic correspondent for Finland's Hufvudstadsbladet newspaper, said he has "spoken to people that have had their relatives die in COVID-19, and obviously they're devastated because of the death, but also they're also not blaming the politicians and the Public Health Authority. "

But, to critics, Sweden's elderly deaths seem callous as the plan meant society took take few steps to protect them. Care homes also reported PPE shortages and not being allowed to give patients oxygen.

Doctors were advised to prioritize patients based on things like age, including guidelines in Stockholm that advised not giving intensive care to patients aged over 80.

O'Neill said lockdowns were designed to stop the virus reaching the vulnerable and elderly in and out of care homes by slowing the spread of infection to those who interact with them.

"Lockdown was justified if only to protect those people in nursing homes," he said.

'Why aren't the hospitals full? Because no one can get there if you're above 80'

Pekka Nuorti, an epidemiology professor at Finland's Tampere University said that, while he is not yet sure if Sweden's response was a mistake or not, "If you have a widespread circulation of the coronavirus in the community, it's very difficult to protect the risk groups."

"The virus could find any little opening to elderly care institutions and to vulnerable populations."

Tallinger said Sweden stopped the health system from being overwhelmed because it sacrificed so many elderly people.

"It's like creating an image that we don't have restrictions and we're doing okay anyway because the hospitals aren't full. But why aren't the hospitals full? Because no one can get there if you're above 80."

"We're choosing to make a make-believe. We're setting it up so the Swedish experiment looks good."

A doctor working in a major Gothenburg hospital, who was not authorized to speak, said the treatment of the elderly became "taboo to talk about," and "a very sensitive topic that everyone is afraid to express their opinion."

Sweden is now providing more funding for more care home staff and to local authorities. It tightened restaurant rules, requiring one meter between customers, and reiterated social distancing guidelines.

The  Public Health Agency is also looking at if it needs to update its guidance after reports of crowding.

Sweden is playing the long game

Many experts say whether Sweden's plan will work depends on the months ahead.

Anders Björkman, a microbiology professor at Karolinska Institutet, said it was "puzzling" that Sweden had performed worse than so much of Europe.

But he said it's not necessarily the plan's fault: "I believe it is not necessarily the strategies but rather their implementation that is the problem." 

Albert said "to some extent, it's too early to really answer because we are, in my view, just at the start of this. And it will not be possible to say something more definitively until maybe a year's time when we'd been through the next winter."

Lina Nordquist, the healthcare policy spokesperson for the Swedish Liberal Party, said the policy's success can only be known with time.

"Most of us are pretty convinced that we won't know for a long time yet what country chose the best strategy. We won't know by looking at the death rates so far, because the pandemic is a marathon. "

"The most important thing is we protect as many lives as possible," including from the effects of things like unemployment and isolation. 

She added: "The people that think our strategy failed, they also don't know, because there's no way we can know that until the pandemic disappears."

Helga Nowotny, the former head of the European Research Council, told Insider: "The jury is still out, but the 'Swedish way' will be intensely scrutinized for some time to come."

Other countries aren't copying Sweden

The most damning evidence against Sweden is its deaths compared to other countries.

O'Neill, like many experts, said comparing Sweden's deaths to countries like the US or the UK is "scientifically unsound," due to their different demographics, culture, and reporting methods.

The key, he said, is to compare Sweden to its neighbours, with similar cultural and political backgrounds.

More than 5,600 people have died there. Its per-capita deaths are five times higher than Denmark, almost 11 times higher than Norway, and more than nine times higher than Finland. All had tighter restrictions.

"The scientific assessment is that clearly Sweden is in a much worse place than, say, Norway or Denmark," O'Neill said.

"I suppose nobody there wants to say they got it wrong, maybe. But compare Sweden and Norway, the facts stare you in the face."

Those countries' success is in line with studies that found lockdowns save lives. One estimated lockdowns saved 3 million lives across Europe.

Krista Kiuru, Finland's social services minister, credited Finland's lockdown and general distancing and hygiene recommendations for its success to Insider: "The restrictive measures imposed and the recommendations issued have been effective in curbing the epidemic and protecting risk groups."

Finland closed schools, banned gatherings of more than 10 people, and stopped in-restaurant dining.

She said Finland, as it eases restrictions, is monitoring the situation daily, with weekly updates to predictions about the outbreak that advise next steps.

Processes are similar in other countries, which, so far, appear to contradict claims their deaths would soar.

And while their eased restrictions mean life looks similar to Sweden, their plans still don't mimic it.

Norway, Denmark and Finland have not seen a national spike, while countries like Germany and Australia have continued testing and locked down regions to stop new outbreaks.

Sweden has not indicated it will do the same, and its testing rate has been below many countries, though its rates are now increasing.

O'Neill said Sweden's plan appears to have been based on the assumption that countries would only do large, strict lockdowns until the pandemic was over.

Instead, he said, countries used lockdowns to buy time to figure out what works and to find new medical treatments.

"The assumption was we'd all end up with the same number of deaths," he said. "That's not the case. There's less deaths everywhere else because of medical advances."

Sweden now has some harsher rules in place than countries with eased lockdowns.

Denmark, for example, now allows gatherings of 100 people — double Sweden's rule.

Nordgren said that, as countries exclude it from travel, "Sweden has become sort of a pariah in Europe."

Sweden might not hold any positive lessons

Sweden wants to avoid negative health outcomes from isolation.

O'Neill said understanding if that worked would only come in time: "That's still a question. But did lockdown do all the harm or not? At the moment, it's not clear."

"Lockdown will come at a price. Maybe Sweden will be slightly vindicated through that. But let's wait and see what those numbers are."

He said the lesson learned was how hard it is to protect the vulnerable.

But Tallinger, the doctor, said Sweden had not put enough rules in place to figure out what ones worked.

"How are you going to sort out what was effective when you did nothing?"

Experts also theorize other countries with other cultures, particularly the US, are likely to have been met with disaster if attempting Sweden's plan.

The months ahead will tell if Sweden's bet on a long-term payoff works. But skeptics say there are no positive lessons.

"If you let the monster loose, people are going to die. We've done the experiment. We know the results. We're not going to learn anything," Tallinger said.

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