Norway and Sweden: Battling Coronavirus in Two Different Worlds

There is no doubt that the coronavirus already has and will continue to put the whole world in a very challenging position. No one knows how to battle the virus nor its implications on the world’s health systems and economies. What is clear, however, is that Sweden is relatively alone in its approach to manage this ongoing crisis, at least in terms of control over the spread of the virus in the population.

Illustration: Indigo Trigg-Hauger. Photo: saamiblog via Flickr

On Sunday March 22, Swedish Prime Minister Stefan Löfven spoke to the nation in a pre-recorded clip for a total of five minutes. For some – the economic sector – those five minutes created a sense of trust in the government, that it is strong and will not let the economy in free fall, that citizens can believe in the expertise of the Swedish public health agency (Folkhälsomyndigheten) follow its’ recommendations, and go on with their lives. For others, those five minutes only brought questions and concerns to the fore.

Individual or collective responsibility?

In Sweden, the public health authority –  free from ministerial rule – recommends life to go on basically as usual; stay home if you are ill; wash your hands;  cover your mouth with your elbow when you cough or sneeze; keep a safe distance from others;  if you can, work from home, and if you do go to the mountains, no after ski partying. These recommendations are at the moment the most liberal among countries who are affected by the virus, and as such they also place heavy emphasis on individuals to act responsibly and follow the recommendations. On Thursday March 26, the Public Health authority commented that they were ‘receiving signals’ that people over 70, one of the risk groups, were not following the recommendations. In consequence, information campaigns towards the risk groups have increased. In order to be able to follow given recommendations, however, individuals must understand what their responsibilities are and why they are responsible for following the recommendations. So far, individuals are trusted, but at the same they are packed in commuter busesn order to get to work because they are asked to do so. That sends mixed signals.

In Norway, on the other hand, comprehensive measures, such as the “Corona law”, were undertaken in order to limit transmission of the virus and not overburden health and care services. Among these measures are closing schools, universities and day cares, a ban on cultural events, closed swimming pools, gyms, and all service provisions that involve physical contact with persons less than two meters away – with an exception for critical health care services, and finally no cabin trip to the mountains, which is a huge deal and has spurred a debate whether it is a human right for Norwegians to go to their cabins. Responsibility to not overburden hospitals and risk putting healthcare workers in difficult ethical dilemmas is placed on the collective, a national dugnad.

In Sweden on the other hand, the public health authority encourages the public to keep gyms and other training venues, youth and children activities and sport events open. A Scandinavian gym chain recently re-opened its centers there, while at the same time keeping the other centers in the Nordic region closed, as instructed by the countries respective Public Health agencies and governments.  The same approach was adopted by a company that owns and runs winter sports facilities in Norway and Sweden. It closed its facilities in Norway but kept them open in Sweden, and alas will continue to do so, despite the hazard of overburdening hospitals in the regions with less resources to handle the influx of broken legs and COVID-19 at the same time.

The logic behind these companies’ decisions is that they are simply following public health agencies’ and governments’ recommendations or rules – blindly.

Inevitably, witnessing the diametrically different approaches to battle the spread of COVID-19 leave the observer with doubt about what the right approach is. And it begs the question: do Swedish authorities have too much trust in the public? Can people really be trusted to act responsibly without the more extreme measures seen in Norway? On the other hand, one can ask if Norwegian government don’t trust its population to follow recommendations and therefore sees the need to implement stricter rules?

Trust in common sense and responsibility

As a Swedish citizen living in Norway, I find this development rather perplexing. The differences in each government’s approach to combat COVID-19 is above all seen in the posts of acquaintances, friends and family on social media in Sweden. I’ve seen social gatherings, parties, game nights and trips to Stockholm, Gothenburg, cabins in the mountains and archipelago – to get some much-needed break from the ‘corona hysteria in the cities’ – girl’s night out, to name a few of the examples. It makes me wonder if Swedes are immune. More critically it makes me question whether the measures millions of people are affected by in other countries are legit. Clearly, Swedes are not immune. In fact, the death rate per million people in Sweden is nearly double that of Norway.

Most people in both countries, however, want to and do trust their governments, above all their respective public health agencies. Support for the governments have increased – as they tend to do in times of crisis. In a recent interview with Dagens Nyheter, foreign minister Ann Linde commented that the level of trust the Swedish public have in its government and public agencies is very high. And, according to the latest government at a glance report from OECD, ‘there is consensus in the academic literature that trust influences the relationship between citizens and the government and has an impact on public policy’.

Thus, the keywords to understand these diametrically different approaches are trust and the Swedish governments belief the common sense – folkvett – of its citizens. Yet, while many people do understand the consequences of their decision to not stay at home and go to the family gathering at grandma’s house with symptoms, alas there are too many who don’t understand that in the end their actions may inflict on doctors and nurses the difficult decision of choosing what life to save – which is a reality in Italy, Spain and now even the U.S.

“It’s a huge experiment. […] We have no idea – it could work out. But it could also go crazily in the wrong direction”.

Starting in mid-March, the Public Health Authority in Sweden and Norway have both commented on the situation almost every day. Journalists in both countries cover their comments meticulously and the Swedish press conferences are screened on Norwegian TV as well. Former Swedish state epidemiologist, Johan Giesecke call the Norwegian measures draconian and unnecessary; ‘We are right while Europe are wrong’ is his message to anyone who want to understand what they are doing, and acting state epidemiologist Anders Tegnell agrees. The public health authority expects people to get seriously ill, and that people will die. But ‘500-2000 people die from the seasonal flu every year’, Johan Giesecke says. The head of analysis at the Swedish public health institute recently commented on international criticism from media and other experts: ‘We do not believe it is possible to keep society closed until a vaccine is developed […] the economy will collapse long before that […] and people will not follow the recommendations.’

Unwilling to risk the economy

The Swedish strategy is based on volunteering, information campaigns and a high level of public trust in the public health agency, and keeping the economy alive. The Norwegian approach on the other hand is based on collective suppression of the virus, but Norway also has the world’s largest financial security – the pension fund. Nevertheless, both the Swedish and Norwegian governments do adhere to advice from various authorities with various expertise and capacities to handle this crisis. Based on the similarities Sweden do share with its Nordic neighbors in terms of levels of education and other and socio-economic factors developed simultaneously during the last century, it is plausible to claim that the countries are not that different, except in crises.

Time will tell. The Swedish approach might be right. Joacim Rocklöv, Professor of epidemiology and Public Health at Umeå Univeristy, emphasizes that we don’t know and that he does “not see why Sweden would be so different from other countries. It’s a huge experiment. […] We have no idea – it could work out. But it could also go crazily in the wrong direction”.

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17 Comments

Sjur Østvold

Interesting aricle. However –
I had expected a discussion on immunization in the article. THe philosophy of the sweedish health administration must clearly be, if not clearly stated, to get as much of the populatuon immune in the shortest time possible. This is of course risky, since it may take too much og a toll on the hospitals. Following their strategy it is most likely that the number of directly related deaths will be much higher than in norway – yearly. However, the population can be expected to be imunized a lot earlier, and no one can guarantee that the number of deaths in Norway over time will be lover. What CAN be forseen, is that Norway will need a much longer time to recover as a nation, economically, socially etc…
It is of course a big moral question here. How can we let so many old and week die, when we have the power to reduce the numbers. Perhaps we should ask ourselves where the line is drawn? THousands die from ordinary flu without any special restrictions beeing enforced. How much more would be tolerated? 10%? 50? 100? 200?
PS: I’m in the vulnerable group myself, at 66 with a chronic heart disease.

Mark

It remains to be seen if “letting the vulnerable die” is an accurate hypothesis.
Getting corona is not an automatic death sentence. Even among the at risk (70 yo myself) its not an automatic death sentence. The droplets are the enemy and we can guard all at risk people against the droplets. A legitimate best intervention is to focus on protecting at risk people.

Bjørn Tore Jakobsen

Its a good blog post, and i’ve as a Norwegian, living in Norway, i’ve contemplated how Sweden and Norway as neighbors can approach this so differently.

Someone stated a while back, that Norway and Denmark’s approach to the virus, is defined by politicians while Sweden’s approach is defined by the experts.
And as i’ve followed both Swedish and Norwegians news over the last weeks, and read the information that published by Norway’s FHI, and swedish Folkhälsomyndigheten (and their daily live streams), this statement seems true to me.

This is especially seems true, since the memo from FHI was published by Aftenposten, where their view on the effectiveness of many measures taken by the politicians in Norway was quite clear.

Johan Carlson, the general manager of Folkhälsomyndigheten said a sensible thing on the press conference on the 20th of march. “We are not only the responsible for limiting the spread of the infection, but are responsible for the totality of swedish health.”
In Norway up until the last few days, this have not even been discussed.

What is known from earlier crisis is that the public health are impacted not only by the epidemic disease.
When people lose their job, suicide rates go up. Children are exposed for more abuse when their parents struggle. Families are torn apart. Divorce rates go up. When old people are not getting visits, or are isolated, or don’t get exercise/physical therapy they die quicker.
All of this have to be weighted against the impact of the actual epidemic disease. And doing this is probably one of the worlds most difficult jobs.
My impression is that sweden take a more holistic view of public health, and attempts to look at the big picture.

As Anders Tegnell stated a while back. “We have to wait a few years before we will know who did this right. But at least we try to do it to the best of our abilities and the knowledge we have at any given time.”

In Norway many politicians in local municipalities are allowed to create their own travel restrictions in violation with the Norwegian constitution, The government block the borders between Sweden and Norway, prohibit the use of cabins, and closes kindergardens and elementary schools without any of these measures based on the expert recommendation from FHI.

Meanwhile in Sweden, Socialstyrelsen are planning for the need to redistribute personnel, equipement and patients between hospitals and regions. And as far as i have heard, no local swedish municipality have closed their borders so other swedes can’t enter, travel trough them, or made rules that violates the swedish constitution.

It will be interesting to follow this difference in handling of this crisis in the coming months and maybe years.
But I’am afraid for what more “draconian” measures we will see from the politician lead Norway, and learn how much the Norwegian constitution is actually worth.

John YSCG

No, most scientists are firmly on the side of lockdown. You are cherry picking scientists.

Joel

Please give a link or proof of that? What is the field of science of the scientists disagreeing with the swedish line? Danish state epidemiologist seemed to agree with Tegnell when Denmark closed it borders? And several European Public health agencies seems to be in line with the swedish one? The difference is how far gone the spread has gone and the actions taken.

Today Norway said they see that curve is going down – Guess what – If I look at the swedish data – The swedish curve is also going down 3/4 we hade 601 new cases, 4/4 we had 357 new cases, 5/4 we hade 294 new cases and 6/4 we hade 84 new cases.This same drop in cases is also seen with the normal influensa – It seems this is the quickest decline in influensa in at least 10 seasons.

And the current death toll in Sweden of Covid-19 is half that of the influence epidemic during the 2017 to 2018 season. And this is by using the same metric.

One of the major contributions to deaths in Sweden seems to be that some people in a couple of elderly care homes had been infected by the virus. So all it needs is that the virus infect three to four elderly care homes in Norway and they will most likely have the same death toll per capita as Sweden. Of course – the Swedish death tolls will most likely increase in the next one of two months due to how deaths are defined. In Sweden the current definition seems to be if an individual dies within 30 days after a lab confirmed an infection(irrelevant of the the cause – so if you have a lab confirmed infection with Corona and then get hit by a car 29 days later – Corona killed you). In Denmark the definition seems to be dies within 30 days after a lab confirmed infection OR 30 days after first symptoms(not sure if Sweden also uses this definition).

My guess is that in the autum – Access for outsiders to the elderly care facilities needs to be blocked earlier and during the summer it is important that these facilities stock up on protective equipment.

Joel

It should be noted that I made and made a mistake and accepted yesterdays statistics as “written in stone”. The latest update shows the following :
New cases 6/4 is currently 336 and deaths is 34. This numbers will increase everyday as the death toll is lagging.

Currently the point still stands – cases and death seems to be going down – the question is if this is just a temporary downturn or if the curve is going down in general.

I will guess that Sweden might end up with around 1000 to 2000 dead.

Pablo

Hi! I live in Buenos Aires, Argentina.
What I do not understand is the different opinion between swedish health professionals and All over the world professionals. What do they know to take such decision? It’s opposite to the most of countries.
We really do not know who’s right and who’s wrong, maybe in fact, taking some of boths could be the best decision.
Who knows?

Sandra

As an American, I find this article fascinating. If the number of deaths in Sweden is twice that of Norway, has an analysis of the age groups been conducted to determine whether those deaths were attributable to flu or Covid-19; were the deaths in more densely populated areas; was there any evidence those deaths in any way resulted from exposure to crowd situations? I should think that the educational system in Sweden would be on a par with Norway, to convince people of the need for distancing, hand washing, etc.
Americans highly value their freedoms, but with this, comes rational thought, analytical thinking, and responsibility for others, rather than the self absorption we are unfortunately witnessing either at present, or in the recent past. We cannot continue to blame others for our reckless behaviors, thinking “It won’t affect me”.
I would hope that while our economy is suffering greatly, the stay at home orders issued in so many States would reduce the cases, over time, thus saving health care workers and emergency personnel the stress of dealing with overwhelming numbers.
Only time will tell whether Sweden or Norway (or many other countries) made the right decisions, but ultimately, it will require a concerted and educated effort to control the current situation.
I shall continue to monitor this site for updates. Thank you.

Joel Jansson

In both Sweden and Norway the majority of cases seems to have been in the regions for the capitals. About half the active cases in Sweden is in the capital region and 303 of 477 deaths are in the this area. The issue seems to be that several patients in nursing homes for elderly got the virus. Most likely due to lack of equipment and no ordered lock down of these(A nation wide lock down was ordered seven days ago – before that there was a recommendation that nursing homes wouldn’t allowed visitors – some municipals had their own bans before that).

I would guess that the Swedish and Norwegian definition of what constitute a death by Covid-19 is the same or similar. In Sweden is seems to be if the individual died within 30 days after a lab had verified an infection – irrelevant of the cause of death. In Denmark it seems that the definition is with in 30 days after a lab has verified an infection OR 30 days after the first symptoms – irrelevant the cause of death.

And to put the deaths in perspective – Currently – using the same metric – we have half the death toll of the flu season 2017 to 2018. That season the flu got epidemic and we got nearly 20 000 lab verified infections compared to around 10 000 to 13 000 in other years. But this is over a 34 week period. The current death toll is during a 6 week period.

Now the question becomes if Norway – during coming autumn/winter is prepared for 34 weeks of measurements to keep the death toll down of the next wave? With an aim of keeping the deaths down to levels lower then what they usually accept with the flu? The average deaths by the flu in Norway between 2008 to 2017 was around 74 with the highest in 2017 with 232 deaths.

Erika Magnusson

Sweden is right!! Time will prove it to the world! But it will be too late, as all other country (specially ordinary people in them) will be economically ruined and all those countries still have many deaths. Stupid World!

Gang Zhang

again I want to give the SARS example.
it would be a huge disaster to take the herd immunity approach with SARS, viruses come and go, viruses mutate and get weaker, cures are invented, vaccines are developed.
The assumption with herd immunity is that the virus will always be around, and always be as deadly, and always be unpreventable by medical means. I’m not sure those assumptions hold in this day and age.
Besides, Taiwan and Singapore are examples of managing it with the shut-out approach, as well as running the society in a semi-normal fashion.

Magnus Flyborg

Except for the massive testing and face masks, Swedens respond to the virus are very similar to South Korea, Singapore and Taiwan.

Gang Zhang

not exactly.
Taiwan and Singapore don’t have wide spread of infection in the first place, they are in a quite different stage, that’s why I think they can be good references for countries like Austria, and Norway, where the spread is somewhat under control.

Sweden is entirely different, it’s still in the expansion stage as of April 7, with record 114 death according to the inaccurate and not up to date Folkhälsomyndigheten.

Taiwan has total 5 death by far, with a population of 2.3 times of Swedish population.
It seems to suggest it’s the wrong time to apply the Taiwan measures in Sweden at this moment.

Gang Zhang

also, Taiwan, Korea and Singapore don’t adopt the herd immunity strategy, on the contrary, they want to have as less people infected as possible.
They did it early. and even now Taiwan has harsher rules than Sweden does. People get fined hugely if they violate the self quarantine regulation, and they get checked by the authority quite often.
They also test a lot of people.

Joel

No – the assumption is most likely that a vaccine will not be ready until earliest spring 2021. This means that a vaccination program can start the earliest in the autumn of 2021 and until then you either need to keep the country in lock down for around 34 weeks OR make sure you have a lower R-value and prepared with stocks and etc and a program similar to Taiwan and Singapore.

Gaspare

Let’s put some number behind these two approaches:
Data for the 7th April
Norway – new cases: 8
– daily death: 13
– total death: 89.
Sweden – new cases: 487 (vs. 8)
– daily death: 114 (vs. 13)
– Total death: 591 (vs.89).

You may argue that Sweden economy may suffer less, but Norwegian are thinking to stay to lift the lockdown measures, while Swedish are considering doing the opposite.

Gaspare

Data for the 8th of April:

Norway – new cases: 0
– daily death: 4
– total death: 93.

Sweden – new cases: 726 (vs. 0)
– daily death: 96 (vs. 4)
– Total death: 687 (vs.89).

Based on this data I conclude that the Swedish political gamble is not paying off…

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