Science’s COVID-19 reporting is supported by the Pulitzer Center and the Heising-Simons Foundation.
On 5 April, Anders Tegnell, chief epidemiologist for the Swedish public health authority, sent an email to the European Centre for Disease Prevention and Control (ECDC) expressing concern about proposed new advice that face masks worn in public could slow the spread of the pandemic coronavirus. “We would like to warn against the publication of this advice,” Tegnell wrote. How much people without symptoms contribute to spread was a “question that remains unanswered,” he wrote, and the advice “would also imply that the spread is airborne, which would seriously harm further communication and trust among the population and health care workers.”
On 8 April, ECDC published its recommendations anyway, in line with an emerging scientific consensus. Although questions remained, “use of face masks in the community could be considered,” it said, “especially when visiting busy, closed spaces.” Tegnell still disagrees. “We have looked very carefully. The evidence is weak,” he told Science. “Countries that have masks are not doing the best right now. It is very dangerous to try to believe that masks are a silver bullet.”
Sweden’s approach to the coronavirus pandemic is out of step with much of the world. The government never ordered a “shutdown” and kept day care centers and primary schools open. While cities worldwide turned into ghost towns, Swedes could be seen chatting in cafés and working out at the gym. The contrast evoked both admiration and alarm in other countries, with journalists and experts debating whether the strategy was brilliant—or whether Tegnell, its main architect, had lost the plot.
The country did not ignore the threat entirely. Although stores and restaurants remained open, many Swedes stayed home, at rates similar to their European neighbors, surveys and mobile phone data suggest. And the government did take some strict measures in late March, including bans on gatherings of more than 50 people and on nursing home visits.
Yet Sweden adopted strikingly different policies from those of other European countries, out of a desire to avoid disrupting daily life—and perhaps the hope that, by paying an immediate price in illness, the country could achieve “herd immunity” and put the pandemic behind it.
Swedish authorities actively discouraged people from wearing face masks, which they said would spread panic, are often worn the wrong way, and can provide a false sense of safety. Some doctors who insisted on wearing a mask at work have been reprimanded or even fired.
Until last month, Sweden’s official policy stated people without obvious symptoms are very unlikely to spread the virus. So instead of being quarantined or asked to stay home, family members, colleagues, and classmates of confirmed cases had to attend school and show up for work, unless they had symptoms themselves. Testing in Sweden still lags behind many other countries, and in many districts infected people are expected to notify their own contacts—in contrast to, say, Germany and Norway, where small armies of contact tracers help track down people who may have been exposed.
The Swedish approach has its fans. Protesters against coronavirus-related restrictions in Berlin in late August waved Swedish flags. In the United States, a prominent member of President Donald Trump’s coronavirus task force, neuroradiologist Scott Atlas, has cited Sweden as a model to follow. The policies also have widespread public support in Sweden, where consensus is prized and criticism of the government is rare.
But within Sweden’s scientific and medical community, a debate about the strategy has simmered and frequently boiled over—in the opinion pages of newspapers, within university departments, and among hospital staff. A group of scientists known as “the 22” has called for tougher measures since April, when it published a blistering critique of the country’s public health authority, the Folkhälsomyndigheten (FoHM). The group, which has grown to include 50 scientists and another 150 supporting members, now calls itself the Vetenskapsforum COVID-19 (Science Forum COVID-19).
It says the price for Sweden’s laissez-faire approach has been too high. The country’s cumulative death rate since the beginning of the pandemic rivals that of the United States, with its shambolic response. And the virus took a shocking toll on the most vulnerable. It had free rein in nursing homes, where nearly 1000 people died in a matter of weeks. Stockholm’s nursing homes ended up losing 7% of their 14,000 residents to the virus. The vast majority were not taken to hospitals. Although infections waned over the summer, scientists worry a new wave will hit in the fall. Cases are rising rapidly in the greater Stockholm area, where almost one-quarter of the Swedish population lives.
The group’s criticism has not been welcomed—indeed, some of the critics say they have been pilloried or reprimanded. “It has been so, so surreal,” says Nele Brusselaers, a member of the Vetenskapsforum and a clinical epidemiologist at the prestigious Karolinska Institute (KI). It is strange, she says, to face backlash “even though we are saying just what researchers internationally are saying. It’s like it’s a different universe.”
Lena Einhorn paid close attention in January to the news of a new virus spreading in Wuhan, China. Einhorn, who has an M.D./Ph.D. in virology and tumor biology, is better known in Sweden as a filmmaker and book author. “But I can still read a scientific paper,” she says. And what she read in The Lancet on 31 January was alarming: A model predicted large outbreaks of the new virus in cities around the world. As far as she could see, nothing was being done in Sweden to get ready for the threat.
Concerned, she wrote an email to Tegnell. “I asked, ‘Have you seen this paper? Isn’t it time we prepare for this?’” Tegnell answered immediately, Einhorn says: “He basically said, ‘Well, we shall see. Everyone is trying to apply complex models to very limited data.’” She wrote back emphasizing how easily the virus seemed to spread, including from people without obvious symptoms, and asked about restricting travel from China. Tegnell noted that the World Health Organization (WHO) opposed such measures, she says, then stopped responding. So Einhorn approached Björn Olsen, a professor of infectious diseases at Uppsala University who was raising the alarm in interviews. “What can we do?” she says she asked Olsen.
In late February, during the school holidays, thousands of families went skiing in the Alps—just as reports surfaced about an outbreak in northern Italy. Many had asked whether they should stay home, but health authorities “kept saying, ‘No, don’t cancel your trip!’” Einhorn says. “It was the middle of that week when the cases in the Italian Alps went boom.” As vacationers returned, many asked whether they should quarantine, but FoHM maintained there was no reason to worry.
When 30,000 music fans gathered in a Stockholm arena on 7 March for the national final of the Eurovision Song Contest, “I’m going bonkers,” Einhorn says. “I can’t sit still.” She reached out to a journalist friend and started to write op-eds. Olsen linked her to “a group of desperate scientists,” she says. “Suddenly I’m in the middle of an email thread of infectious disease specialists, virologists, epidemiologists,” all extremely worried.
On 12 March, as new cases outpaced test capacity, FoHM announced doctors should only test those with severe symptoms, recalls KI immunologist Cecilia Söderberg Nauclér. “I turned to my husband and said, ‘They are letting it loose. We are going to crash the health system. We are going to need 500 ICU [intensive care unit] beds and we have 90 in Stockholm.’” On the same day, Norway closed schools, many businesses, and its borders, mirroring measures across Europe.
On 15 March, Olsen, Nauclér, and five others warned in an opinion piece in the Svenska Dagbladet newspaper that Sweden was just a few weeks behind Italy, where hospitals were already overflowing. Nauclér says she reached Tegnell by phone the next day and told him, “I don’t want to argue with you, but you shouldn’t be doing what you’re doing unless you have data that I don’t know about.” She says they had a good conversation and Tegnell agreed to a meeting, but it never happened.
The next week, Tegnell announced Sweden would try to “flatten the curve” so the health system would not get overwhelmed with cases. The government limited gatherings to a maximum of 500 people, but day care and schools through ninth grade stayed open. (Upper secondary schools and universities went online.) People should work from home if possible, FoHM said, but tests remained very limited, and close contacts of suspected cases were not asked to stay home unless they had symptoms.
Soon, infections surged. By late March, more than 30 COVID-19 patients were being admitted to ICUs every day. By early April, Sweden was recording about 90 deaths from the virus daily—a significant undercount, critics say, because many died without getting tested. Hospitals did not become as overwhelmed as those in northern Italy or New York City, but that was in part because many severely ill patients weren’t hospitalized. A 17 March directive to Stockholm area hospitals stated patients older than 80 or with a body mass index above 40 should not be admitted to intensive care, because they were less likely to recover. Most nursing homes were not equipped to administer oxygen, so many residents instead received morphine to alleviate their suffering. Newspaper reports told stories of people who died after being turned away from emergency rooms because they were deemed too young to suffer serious COVID-19 complications.
On 25 March, as confirmed cases passed 300 per day, about 2000 scientists signed an open letter calling for stricter control measures. It provoked little reaction. But a scathing op-ed, published by the 22 researchers in the newspaper Dagens Nyheter on 14 April, did get noticed. The piece carried the headline “The public health agency has failed. Politicians must intervene.” It noted that from 7 to 9 April, more people per million inhabitants had died in Sweden from COVID-19 than in Italy—and 10 times more than in Finland. FoHM officials “have so far not shown any talent for either predicting or limiting” the epidemic, they wrote.
The response was swift. A cascade of columnists and opinion writers criticized the piece for its tone and said the 22 got their numbers wrong. Tegnell said the authors “were not leaders in their field” and claimed they “cherrypicked” days with the highest death tolls. (The scientists replied they had used ECDC statistics and noted there were even more deaths the next week.) The response to the op-ed was “insane,” says co-author Jan Lötvall, an allergist at the University of Gothenburg. “A colleague emailed me to say [the article] was shameful, and that we should be loyal and follow the tradition of respecting public health workers.”
The frontal attack violated one of Sweden’s strongest cultural norms, the taboo on open disagreement, says Andrew Ewing, an analytical chemist at the University of Gothenburg who moved to Sweden from the United States 13 years ago. If a disagreement does arise, “you can never make it personal,” says Ewing, who was not part of the original 22 but has since joined the Vetenskapsforum.
“When the debate started, harsh words were exchanged,” says Göran Hansson, a cardiac specialist at KI and secretary general of the Royal Swedish Academy of Sciences. But the debate is important, he adds. “Maybe Sweden has too much of a consensus culture. … It’s healthy for science to have discussions. One thing we don’t need in this situation is silencing of views, especially from those with expertise.”
Healthy or not, Brusselaers says she also faced backlash from colleagues and was publicly reprimanded by her department chair for being a “troublemaker” and “a danger to society.” “A colleague told me, ‘We have to stick with [FoHM] and defend it,’” she says. The situation prompted her to return to her native Belgium, where she now has a position at the University of Antwerp, although she is also keeping her group at KI. “I just didn’t expect this reaction in Sweden,” she says. “I never felt like such a foreigner as I did over the past few months.”
Those who challenged the recommendations against face masks faced a similar backlash. Agnieszka Howoruszko, an ophthalmologist at a regional hospital in Landskrona, began to wear a mask in March when she examined patients. “My manager reprimanded me twice,” she says. Howoruszko held her ground. “I said, ‘I’m sorry, if I can’t wear it, I cannot work. Many of my patients are elderly and in high-risk groups.” The manager relented and allowed the clinic’s doctors (but not other staff) to wear masks. “We are the only eye clinic in our province” to take that step, she says.
Dorota Szlosowska, a pulmonologist who had been working at Sundsvall regional hospital, shared an email with Science stating that one of the reasons her contract wasn’t renewed was that “she walked around with a mask,” which the email said made her look unfriendly and made it hard for patients to understand her. Björn Lindström, an ophthalmologist at Falu lasarett, a hospital in central Sweden, says he is the only one in his clinic who wears a mask. In a letter in Dagens Nyheter, Lindström has argued that the failure of health care workers to adopt masks violates Sweden’s patient safety act, meant to prevent patients from being harmed while receiving care.
Harm seems to have occurred. The Falu lasarett announced last week that it had been fighting a COVID-19 outbreak in its cardiac ward for 3 weeks, with 10 patients and 12 staff infected so far. As of 27 September, staff will “use protective visors when working closely with patients,” the hospital said. The Swedish Health and Social Care Inspectorate told Science it is investigating 17 hospital and clinic-based outbreaks. In September, Ryhov community hospital in Jönköping announced 20 patients and 40 staff members had been infected in an outbreak in the hospital’s orthopedic ward in May. Five patients died and one is still hospitalized. (The hospital said it had followed FoHM’s policies.) At least three patients have reportedly died of COVID-19 after being infected at the university hospital in Lund.
FoHM’s decision to keep schools open despite surging cases may also have added to the spread. A report from the agency itself, released in July, compared Sweden with Finland, which closed its schools between March and May, and concluded that “closing of schools had no measurable effect on the number of cases of COVID-19 in children.” But few Swedish children were tested in that period, even if they had COVID-19 symptoms. And the lack of contact tracing means there are no data about whether cases spread in schools or not. When new FoHM guidelines allowed symptomatic children to be tested in June, cases in children shot up—from fewer than 20 per week in late May to more than 100 in the second week of June. (FoHM reversed course in July and returned to recommending that children under 16 not be tested.)
Indirect data suggest children in Sweden were infected far more often than their Finnish counterparts. The FoHM report says 14 Swedish kids were admitted to intensive care with COVID-19, versus one in Finland, which has roughly half as many schoolchildren. In Sweden, at least 70 children have been diagnosed with multisystem inflammatory syndrome, a rare complication of COVID-19, versus fewer than five in Finland.
In the population as a whole, the impact of Sweden’s approach is unmistakable. More than 94,000 people have so far been diagnosed with COVID-19, and at least 5895 have died. The country has seen roughly 590 deaths per million—on par with 591 per million in the United States and 600 in Italy, but many times the 50 per million in Norway, 108 in Denmark, and 113 in Germany.
Another way to measure the pandemic’s impact is to look at “excess deaths,” the difference between the number of people who died this year and average deaths in earlier years. Those curves show Sweden did not suffer as many excess deaths as England and Wales—whose tolls were among Europe’s highest—but many more than Germany and its Nordic neighbors (see graphic, above). Immigrant communities were hit very hard. Between March and September, 111 people from Somalia and 247 from Syria died, compared with 5-year averages of 34 and 93, respectively.
Tegnell has said repeatedly that the Swedish strategy takes a holistic view of public health, aiming to balance the risk of the virus with the damage from countermeasures like closed schools. The goal was to protect the elderly and other high-risk groups while slowing viral spread enough to avoid hospitals being overwhelmed. Protecting the economy was not the aim, he says. (Initial data suggest Sweden’s economy contracted about as much as its immediate neighbors’ as exports and consumer spending dropped.)
Sweden’s light approach is more sustainable than the harsher methods used in other countries, Tegnell also argues. He regrets the death toll in nursing homes, he told Science, and says Sweden should have made it easier financially for caregivers to stay home. “It was a very bad situation for a month,” he says, “but after that it changed completely.” Once strong restrictions were in place, transmission in nursing homes “became lower than in the community.” Tegnell has also said he suspects the number of infections and deaths in other countries will eventually match Sweden’s. Einhorn finds this absurd: “If Norway ever catches up to Sweden in the proportion of people killed by COVID-19,” she says, “I’ll eat my hat.”
Many of Tegnell’s critics say FoHM had an unspoken agenda: to reach herd immunity. Sweden wouldn’t be the only country to consider that strategy: British Prime Minister Boris Johnson toyed with the idea before rejecting it (and contracting COVID-19 himself). Dutch Prime Minister Mark Rutte explicitly said achieving herd immunity would help protect the economy before also abandoning the idea.
Herd immunity is still not well understood, but scientists estimate that in the case of COVID-19, between 40% and 70% of a population would have to be immune to arrest the spread of the virus. Many scientists say reaching that percentage without the help of a vaccine would cause far too many deaths and long-term side effects.
Tegnell has consistently denied that herd immunity is his goal. But emails released in late July after journalists requested them under open records laws show he discussed the idea. In an exchange on 14 and 15 March with the head of Finland’s public health agency, Tegnell speculated that “one point would be to keep schools open to reach herd immunity faster.” When the Finnish colleague said models suggested closing schools would decrease infection rates among the elderly by 10%, Tegnell replied: “Ten percent might be worth it?” (Tegnell says he was only speculating, and the prospect of reaching herd immunity was irrelevant to the decision to keep schools open.)
Tegnell’s thinking appears to have been shaped by his predecessor, Johan Giesecke, an epidemiologist and professor emeritus at KI with whom he exchanged many emails. Giesecke has been a vocal defender of FoHM’s strategy, which he praised in a 5 May article in The Lancet. He said the virus was “an invisible pandemic” in which 98% to 99% of infected people don’t realize they have been infected. “Our most important task is not to stop spread, which is all but futile, but to concentrate on giving the unfortunate victims optimal care,” he wrote. (Giesecke stated he did not have any conflicts of interest, but his correspondence with Tegnell revealed he had been a paid consultant for FoHM since March. Giesecke told Science he sees no conflict.)
Giesecke, a member of WHO’s Strategic and Technical Advisory Group for Infectious Hazards, is still advising a similar approach to governments elsewhere. On 23 September, he told an Irish parliamentary committee that Ireland should aim for “controlled spread” in people under age 60 and “tolerable spread” among those over age 60, though in a later interview he backed off, saying Ireland had to decide policies for itself.
Giesecke and Tegnell believed herd immunity would arrive quickly. In the Lancet article, Giesecke claimed about 21% of residents of Stockholm county had already been infected by the end of April; Tegnell predicted 40% of them would have antibodies by the end of May. When initial studies showed the number was actually about 6% in late May, Tegnell said immunity was hard to measure. FoHM continued to say Swedes had built up immunity, but in September it backtracked, estimating that “just under 12%” of Stockholm residents, and 6% to 8% of the Swedish population as a whole, had antibodies to the virus by mid-June.
If herd immunity is beginning to kick in, it should become visible in Sweden’s case numbers. Cases fell from a record 1698 on 24 June to about 200 per day in early September, and the percentage of positive tests reached a record low of 1.2%. Some speculate that Sweden’s summer traditions may have helped: Hundreds of thousands leave cities and towns for remote cabins in what amounts to 3 months of national social distancing.
At the time, numbers elsewhere in Europe were beginning to soar again, especially among young adults, whereas those in Sweden remained stable. But over the past few weeks, infections in Sweden have started to rise as well. On 25 September, FoHM reported 633 new cases nationwide in 1 day. Stockholm’s rates have nearly tripled in 2 weeks, from 334 in the second week of September to 967 last week. Whether immunity is making a big difference remains to be seen.
The Swedish experiment is coming to an end, as its policies fall in line with those of its neighbors. FoHM officials are “quietly changing their approach,” Einhorn says. The country has boosted test rates; at roughly two tests per 1000 inhabitants per day, Sweden’s testing rate is almost on par with Norway’s—although it is only one-quarter of Denmark’s. The recommendation against testing children between ages 6 and 16 was lifted for a second time in September. (FoHM says this is so children with mild symptoms can return to school more quickly if their test is negative.) Children under 6 are still not tested unless severely ill.
The drop in cases allows Sweden to start to use its contact tracing system, in place for other diseases, for COVID-19, Tegnell says: “Before, we just didn’t have the capacity.” And on 1 October, FoHM announced family members of confirmed cases should stay home for 7 days, even if they don’t have any symptoms—although children through ninth grade should still go to school.
FoHM should go much further, Hansson and a colleague said said in an August opinion piece, for instance by limiting public transport to 50% capacity, recommending masks, and asking travelers from hard-hit regions abroad and all contacts of known cases to quarantine. On 25 September, Hansson announced the Royal Swedish Academy had assembled an expert group to compare the Swedish response with that of other countries and recommend how “researchers can best contribute to future crisis situations.”
FoHM “should have listened more carefully to the scientific community both inside and outside the country,” Hansson says. Still, he predicts the rifts will eventually heal. “I am sure we will continue to argue, but I don’t see permanent damage,” he says. “We’ll move on. We’ll go back to complaining about grants.”
But Ewing worries the fight has left permanent scars. He says at least three more members of the Vetenskapsforum are considering leaving Sweden, as Brusselaers did. And even if it turns out that the country has built up enough immunity to evade a new wave of disease, he says, the price has been too high. “I worry that countries around the world are going to say, ‘We can try what Sweden did.’ But we have killed too many people already.”