(EDITOR’S NOTE: The opinions expressed below are those of the author and not necessarily those of Healthcare Michigan or its publisher.)
By SUSAN ADELMAN, MD
One nation in the developed world stands out for its exceptional approach to the coronavirus pandemic – Sweden. While most Americans were locked down, we looked with jealousy at pictures of Swedes walking on the streets, seemingly unconcerned, living normal lives. How could they do that, and has it worked?
First, it is a myth that the Swedes have had no restrictions, but their rules certainly have been more relaxed than those in most of Europe or in the United States. While their schools remained open for younger children, colleges and universities went online. Businesses and hair salons are open, but people are advised to work from home where possible. Home care and nonessential travel were banned, and so were gatherings of more than 50 people. Restaurants remained open but not bars. Restaurants had to maintain 1.5 meters of separation between tables. Almost all games are closed or must be played without an audience. Concerts and large social activities are closed. Social distancing is voluntary, but the Swedes dutifully stay away from each other. Sweden’s borders are closed to non-EU residents. Internal travel is not limited officially, but people limit it by themselves.
In an interview, a Swedish reporter refers to the “number of confirmed cases,” which seems to imply that their official case count is limited to those who test positive. She also says that there clearly are many more cases than those officially reported. Apropos, sources report that testing now is ramping up in homes “for the elderly,” so we can assume that it was insufficient before. In other words, cases in these homes may have been either undercounted or attributed wrongly to coronavirus.
Sweden also has tightened up. Perhaps because of the high death rate, “the government has moved to limit online gambling in recent days, is closing restaurants that break social distancing rules, and has forbidden family visits to nursing homes.”
Swedish death rates are lower than those of Italy, Spain and France, but other factors may be in play. For one, latter countries have a tradition of warm physical greetings. Italy in particular has an older population, high concentrations of people in multigenerational dwellings and high smoking rates. Northern Italy also has a great deal of commercial exchange with China, especially because of the clothing business, and that is where their epidemic began. Not surprisingly, the cases and death rates of Italy exceed those of Sweden, even with greater social distancing.
England too first tried the herd immunity approach, but ultimately they clamped down, insisting on social distancing because high death rates scared them. Meanwhile, their prime minister and major health policy chiefs became infected.
German death rates are among the lowest in Europe and we do not know why. For one thing, Germans famously follow rules. For another, their early cases were among healthy young skiers coming back from the Italian Alps. Most important, in Germany, testing is so widespread that the denominator is very large. Moreover, in contrast to the United States and many other countries, they report only cases validated by actual test results.
So how well has Sweden’s approach worked? Worldometer listed, as of 4/30/2020, that Sweden had 21,520 coronavirus cases and 2,653 deaths, in a population of 10.3 million. Other Scandinavian countries have very similar healthcare systems and similar demographics, but they immediately instituted social distancing similar to that in the United States. How did they do? Denmark had 9,311 cases and 460 deaths in a population of 5.8 million and Norway had 7,770 cases and 210 deaths among 5.4 million people. Finland had 5,051 cases and 218 deaths in a population of 5.5 million.
Sweden does have twice the population of the other three, but Sweden had a death rate of 22/100,000, while Denmark reported 7; Norway and Finland 4 deaths per 100,000. Put another way, Sweden had 256 deaths per million, out of 2088 cases per million. With their social distancing, Norway reported 39 deaths per million and 1427 cases per million.
Of all the closed cases in Sweden, 72 percent ended with death and 28 percent recovered. In contrast, the United States reports 70 percent recovered and 30 percent deaths, the opposite of Sweden.
We do know that the United States now counts as coronavirus deaths many that only are presumptively due to coronavirus, even if they are not validated by tests. New York instructs their doctors to comply, because “the CDC asked local governments to record “assumed” coronavirus infections on death certificates.” This means that doctors record coronavirus as the cause of death if they just think the patient probably has the virus, even if the patient has one or more conditions that could have been the actual cause of death.” And remember, this started out as an unusually severe flu season. How many of these U.S. deaths actually were from flu is unknown.
In any event, on April 30, the United States reported 1,091,067 cases, and total deaths of 63,657. If we had Sweden’s death rate, there would have been 84,480 deaths in the United States, one-third more.
Granted the Swedish population is one of the oldest in Europe, possibly because they are generally healthier. So, either we should expect more deaths in this group because of their age, or perhaps they should have fewer deaths because of their underlying good health. Only an expert could sort this out. Of note, at least 50 percent of their deaths have been in “the elderly homes.” They attributed this in part to a lack of testing and a lack of adequate PPEs for the staff. Anyway, some of these numbers may be off, as they are in the United States. Some have said that Sweden has approximately 75 unconfirmed cases for each reported case of COVID-19.
The Swedish Public Health Agency has predicted that 26 percent of the Stockholm population would be infected by May 1. The Swedish Minister for Health and Social Affairs denies trying to create herd immunity, but that may be exactly where they are headed.
Some characteristics of the Swedish healthcare system are relevant. All Nordic countries have one-payer health care systems funded through taxes and administered through regional councils. In Sweden, healthcare represented about 11.9 percent GDP in 2015, rather high for Scandinavia. Of importance to this epidemic, care for the elderly is publicly funded, lacking the incentives for good service that private institutions would have. Norway, in contrast, contracts out their long-term care to private providers.
When the Michigan State Medical Society led a group of doctors, lawyers and legislators on a visit to study the Swedish system in 1989, we were told that a committee had just looked into a complaint that workers in a long-term care facility were so anxious to get home that they served the last meal of the day at about 4 pm. The committee managed to make them serve one hour later.
When we were there, we learned that there were some private hospitals, and their excellent service caused them to be much in demand. Otherwise the public system has long had problems with access, long waiting times and doctor shortages. It also has a reputation for steering patients away from doctors where possible. Ideally, they try to limit waiting times to seven days to see a primary care practitioner, 90 days for a specialist, and no more than 90 days for an operation or treatment. Our observation was that the Swedes were remarkably tolerant of these delays and absolutely not litigious. The trial lawyers with us were amazed when they heard stories of seriously delayed care for which, in the United States, they would have sued immediately.
Scandinavians in general are more community conscious than Americans. Sweden is much smaller and always has been more homogeneous than the United States, although large numbers of immigrants from outside of Europe have arrived in recent years. We do not know if that has affected these death rates, but we know that Malmo, a city with a large immigrant community, has only reported 60 cases and no deaths.
Nordics Info explains that not all the Nordic countries are the same . While Denmark, Norway, Sweden and Finland all have one-payer healthcare systems largely financed by taxes, they have carved out varying roles for private payers and they have varying administrative structures. In the very beginning of this pandemic, the other three Scandinavian countries instituted strict social distancing policies, widespread school closures and bans on businesses, later easing them after Easter, but Sweden did not. Why?
Nordics Info says hat Sweden sees itself as the most successful of the Nordic countries, and it has great self-confidence. Swedes also have confidence in their centrally directed economy. In the end though, “Swedes do what they are told.” As an example, “If Danish anecdotes are to be believed, when the Swedish public health authority (Folkhälsomyndigheten) recommends eating five slices of bread per day, then the Swedes eat five slices of bread per day.”
In contrast, Norway and Finland are younger countries and are more democratic. Norway also is known to have the most lawyers. With all their deference to authority, the Swedes like their freedoms, and it might have been difficult to force them to shelter in place. The article points out that, in contrast with Sweden, during World War II Finland learned to act decisively and collectively in the time of crisis. Their reactions come from their military experience, much like that of Israel, a country that has had similarly low mortality from coronavirus. That too has been ascribed to the fact that everyone has been in the military, where once an order is handed down, they salute and obey.
In short, Sweden’s approach works well in Sweden. In the United States., with our loud, outspoken public, a plethora of lawyers and our current lack of confidence in politicians, it would run into a buzzsaw. The Swedes did what they needed to do. We in the United States did what we needed to do to avoid an excess of deaths, which would be blamed on anybody and everybody.