Field hospital constructed outside Östra Sjukhuset in Gothenburg in response to the 2020 COVID-19 pandemic. Photo Helén Sjöland via Wikimedia Commons
Almost two months have passed since my last post about the management of COVID-19 in Norway and Sweden. How outsiders, including myself, see Sweden since has indeed changed a lot. Sweden was recently downgraded on the Standard Ethics Rating (SER) due to flaws in their handling of COVID-19, which allegedly put not only Swedes but also other Europeans at risk. When faced with questions and criticism about the strategy, supporters of the Swedish model have written off critics as expats who don’t understand statistics and communicable diseases, or incompetent scientists. Increasingly the arguments seem more like a culture war – at least on social and traditional media. Specific characteristics such as complacency and exceptionalism, worship of the state epidemiologist Anders Tegnell, and the Swedish public administration model are among the topics that have been meticulously analyzed and discussed. During the last two months, however, a picture of more deep-rooted issues has started to emerge.
Sweden in the Nordic Region and exceptional statistics
As a result of this pandemic, Sweden has the largest number of deaths in the Nordic region. That is a fact that cannot be contested. At least not yet, but there is little to suggest that it will change. While comparing death rates per million, per 100,000 or in absolute numbers might show spurious relationships, and because it is important to consider demographic and regional differences, comparing numbers between countries is indeed a difficult task. Comparisons can however tell us something. The numbers can give us an indication whether the strategy is on the right track or if alterations need to be made in order to prevent as many early deaths as possible. Discrepancies between countries in terms of what counts as a COVID-19 death exists, which indeed has consequences for the total number of deaths reported to authorities in each country. In Sweden, for example, people who die but are not clinically tested are not in the statistics, yet all people who die with – not only of – COVID-19 are reported. There is thus reason to believe that Sweden report higher numbers of deaths related to COVID-19 than countries that only report deaths of COVID-19. Nevertheless, underreporting is certain to be the case almost everywhere, yet I doubt that underreporting of COVID-19 deaths in Norway, Finland and Denmark, when reported, would be in the thousands. Amongst the Nordic countries then, Sweden is worst in class no matter how we interpret the numbers.
As per May 25, the total number of confirmed cases in the Nordics was 61,709 and 5,112 deaths. Sweden reported a total of 3,998, Denmark 562, Norway 235, and Finland 307 deaths. Norway, Denmark and Finland each have approximately half the population Sweden does. By and large, the Nordic countries share the same demographic characteristics, but regions and municipalities within each country experience very different, and often contrasting trends. Yet, the population structure in the combined age group 65 – 80+ years in each country are according to Nordic Council of Ministers demography report in “State of the Nordic Region 2018” largely the same. Given that one of the most common explanations for the discrepancy was due to differences in age distribution, that alone cannot explain why some 75 percent of COVID-19 related deaths in the Nordics happened in Sweden. Moreover, excess mortality rate during April was the highest in 20 years.
It is not a competition; we are just better at this
Explanations are certain to be multifaceted. One of the more common from FoHM and other experts on social- and tradtional media is that data collection and statistics related to COVID-19 in Sweden are more reliable and rigorous. These are comments embedded in a blanket of Swedish exceptionalism that are blatantly thrown at anyone who contest any aspect about the Swedish model. Based on this development, a Swedish news correspondent in Moscow, recently wrote that during this crisis, science and FoHM has become something close to a religion and the state epidemiologist the new Martin Luther. An observation which in itself is interesting since Sweden is the most secular country in the world. Nevertheless, bringing these arguments and the ‘just wait and see, you will get there too’ attitude to the fore won’t help anyone understand how Sweden are just better in understanding and managing COVID-19. An illustrating example is the recent antibody study. At the outset, FoHM expected that 25 percent of the tested population would have antibodies in the end of April. The result was 7,3 percent of the population in the Stockholm region and even lower in the other regions. The state epidemiologist explained the result saying that ‘the (tested) group was likely not representative for the population’. Bottom line is that sceptics and people around the world want to understand and to be certain that this unique approach is not based on a hunch or gut feeling. Besides choosing a unique approach – based on exceptional science – to combat this virus, there are much more deep-seated issues which in conjunction with a more lax approach are likely to explain why COVID-19 has been more fatal in Sweden than in the other Nordic countries.
Care homes and assisted living services
Care homes and assisted living services are pointed out as the Achilles Heel of the Swedish strategy. Thus far some 75 percent of the cases in Sweden were people above 50 years old, of which a majority were above 69 years old at the time of death. Most deaths were related to people in care homes and people with assisted living. Recently, the Swedish National Board of Health and Welfare released statistics on total COVID-19 deaths in nursing homes and homes with assisted living, and how many of these patients were treated at a hospital. It shows that a staggering 90 percent of the elderly who died of – or with – COVID-19 didn’t receive hospital care. This is likely to partly be related to regional and local decisions taken in light of the new guidelines national principles for prioritization in intensive care under extraordinary circumstances which was outlined by the National Board of Health and Welfare in cooperation with ethicists and medical experts in April, as a response to the expected pressure on hospitals and lack of ICU beds. Moreover, de-prioritization of elderly is not only a result of the pandemic. According to Yngve Gustafsson, professor in Geriatrics at Umeå University, it is also a result of structural challenges, and points out that provision of basic health care for elderly, which could have saved lives, has been inadequate since the elderly reform in 1992. The reform removed the responsibility of provision of basic health care for elderly people from the state to municipalities, which has implied a lower level of medical competence, low staffing, lower nursing density, and decreased access to geriatricians in elderly care, which are only some of the issues. In essence, elderly care at the municipal level has ended up discriminating rather than helping them.
When questioned about why, or rather how this happened, responsible ministers in the government and experts at the Public Health Authority (Folkhälsomyndigheten – FoHM) acknowledge that protection of the most vulnerable failed, because – and unsurprising to most – people failed to follow the recommendations. In a recent interview with Swedish Public Radio, state epidemiologist Anders Tegnell said that “We really believed that one would actually protect the elderly”, while also noting that in hindsight there was nothing they could have done (i.e. lockdown) that would have changed the outcome. It is painfully clear, that neither the government nor FoHM are willing to take responsibility. Yet, since the inception of state structures – i.e. since the time citizens started to pay taxes – an essential duty of the state has been to protect its citizens against enemies, such as COVID-19. Instead, responsibility is placed on politicians and civilians at the regional and municipal level and care homes who were expected to- and should have been better prepared for emergencies like this. In turn, when these same politicians and managers at the care homes were questioned about provision of Personal Protective Equipment (PPE) and working conditions by their employees and union representatives – they blamed the health care staff for bringing the virus into the homes. The more structural issues relate to how taking care of the elderly in care homes is not seen as health care per se. Therefore, basic hygiene routines and precautions like those that are mandatory in hospitals are not treated in the same way in care homes– according to the state epidemiologist. He points to Norway and says that ‘the elderly in care homes in Norway in a higher degree treated as patients, and therefore precautions in terms of number of staff, hygiene, among other things are tended more to than in Sweden’.
Health care staff capacity
The third issue is related to health care staff and their capacity to work under crisis conditions which are expected to last somewhere between 6-12 months or more. Many have testified to the physical and ethical stress they endure every day. Swedish public radio reported already in February this year that the ER in one of Stockholm’s central hospitals was filled with patients who hadn’t been looked after for over 24 hours, at the worst moments. At the national level, capacity in hospitals reached 105 percent in January 2020. Since the introduction of New Public Management, every aspect of welfare service has been micromanaged to be as efficient as possible. Staff in hospitals, care homes and assisted living services have for years been pushed to their limits in making the most with limited resources. Thus, at the outset several hospitals had low capacity to not only take in but also attend to patients even at the outset of this pandemic. Although Swedish hospitals, through a coordinated effort managed to almost double the number of ICU beds in just a few weeks, the question remains as to whether there are enough staff to attend to the needs of the patients in intensive care or those with ‘mild’ symptoms such as pneumonia. Moreover, people who had complications from COVID-19 are expected to have a long recovery and rehabilitation period, putting even more pressure on already exhausted resources. Only time will tell for how long we can expect hospital personnel to work under these conditions.
The Question of Responsibility
So far, we don’t know if we are two minutes into the game or closing in on half time. With that in mind, the Swedish administration model, which implies a large degree of regional autonomy and thus also responsibility to protect and be prepared, has proved inadequate to deal with a pandemic that needs a nationally coordinated response in terms of testing, tracing and isolating.
For instance, in the beginning of April both Minster for Health and Social Affairs, Lena Hallengren and the Public Health Authority stated that Sweden was supposed to be able to perform and analyze 100,000 each week mid-May. So far, 209,900 tests have been analyzed since diagnostics started in Sweden, of which 32,700 were analyzed during week 20. Again, regions and municipalities bore the main responsibility to perform and coordinate this effort, which was the case until they realized that 100,000 tests per week was naïve and unrealistic. Thus, a national coordinator was put in place on May 8 to do the job which the regions and municipalities (Sveriges Kommuner och Regioner – SKR) already had done – buying equipment – until the appointment of the coordinator. It is striking that delegation of responsibility has been done so efficiently that no one seems to know who is in fact responsible. It is convenient of course, because if no one knows who, what and when, no one has to take responsibility later. The same can be said when it comes to communication of what we as individuals are responsible for. One recommendation that is reiterated time after time in case of uncertainty in terms of what to do is to ‘take a proper think’ if you really have to do that special thing or go to that other place. Recommendations from FoHM it turns out are not as detailed and straight forward and leave a lot of room for arbitrary interpretations. According to the state epidemiologist, the recommendation to take a proper think is sufficient and clear, because ‘there is a great deal of responsibility left on the individual in the Swedish legislation on communicable diseases’.
Time will tell. While the government in the greatest welfare state on earth give carte blanche to its Public Health Authority, regions and municipalities, the only thing you can do is to take a proper think before doing something that may imply a risk to not only yourself but others as well, and if you do decide to go on; keep a safe distance.