Many Swedish people are happy with their country's unconventional strategy — but the nation has a vocal community of dissenters.
- More than 2,000 experts across Sweden in April urged the country to change its unusual decision not to have an enforced coronavirus lockdown.
- Its per capita death toll in recent days has been the highest in the world, and some of those experts told Business Insider they remained convinced the plan was a historic mistake.
- "This is not an example to follow. I don't want thousands of people around the globe to start dying," one science professor said.
- They say much of Sweden's advice — including on masks, on the risks to children, and on who should self-isolate — is out of step with other countries'.
- They are urging Sweden to test more so it can better understand its outbreak and give information to the rest of the world.
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Sweden's strategy for dealing with the novel coronavirus so far has not included a lockdown.
Instead, the country has allowed people to go to parks, bars, and restaurants and to keep working, while encouraging but largely not enforcing social distancing.
It's a strategy that most in the country appear to support.
But it has sparked alarm among some experts who point to the country's relatively high death toll, the effects on vulnerable groups, and what they say is an approach that ignores much of the best research on COVID-19.
But the letters did not change government policy. Sweden's death toll on a per capita basis is now among the highest in the world and was the highest of any country in the seven days that ended Wednesday.
Business Insider spoke with some of those experts, who said Swedish health officials were not looking closely enough at new research.
They said they hoped no other countries tried to imitate Sweden, which lockdown opponents and some US politicians have held up as an example of a better approach.
Olle Kampe, a professor and senior consultant in endocrinology at the Karolinska Institute in Stockholm, said: "We are sacrificing old people and people with diseases."
"So I don't that it's something that anyone should copy."
Is Sweden gambling on herd immunity?
Sweden has said its strategy is not meant to achieve herd immunity — the point at which so many people are immune to a virus through infection or vaccination that it cannot take hold in a population.
But Anders Tegnell, Sweden's state epidemiologist and the main figure behind the country's plan, has highlighted Sweden's progress toward such a state. He said in late April that up to 20% of people in Stockholm were immune and that this could help guard against a second wave.
Many understood this as a quiet acknowledgment that herd immunity was the strategy. But scientists around the world have warned that there is no guarantee that catching the virus gives permanent immunity — and even if it did, the human cost of reaching that state would be huge.
"They are denying it in practice, but if you look at their actions, they're clearly going for herd immunity — that's why they are keeping schools and everything open," Marcus Carlsson, a mathematician at Lund University, said.
Kampe said Sweden was trying to "reach herd immunity by killing people."
"It's saying that people who are old, or have a disease like obesity, like diabetes, are worth less than the rest of us, so we can just let them die and we get herd immunity," he said.
Kampe said Sweden's radically different approach meant it had a special responsibility to justify itself. "The burden of proof is very strong," he said.
Experts say Sweden's plan ignores science
Kampe said much of Sweden's approach was "not based on facts."
"If you have a virus that's totally new, you know very little about it, why don't you take a step back and say you are trying to infect as few people as possible until we know more?" he said.
"Sweden's strategy is the opposite: Infect as many people, reach herd immunity."
He noted that Sweden did not consider children to be an at-risk group. They are expected to go to school, even if they have preexisting conditions known to increase adults' risk.
Christopher Plumberg, a theoretical physics researcher at Lund University, noted that the stance on children "stands in stark contrast to the United States and the United Kingdom."
Carlsson said the differences showed that Sweden's Public Health Agency had "a strange view on how to do science and research."
"They claim to be more logical while the rest of the world is panicking, claiming to be the voice of rationality."
He described the authority as being "picky about evidence" — insisting on unusually strong levels of proof before taking steps to mitigate the virus, as the rest of the world goes further.
He pointed to how the Public Health Agency had urged people to stay at home only when they show symptoms.
Swedish officials have said it is "still too early to say" how much the virus is spread by those without symptoms.
It is a stark contrast to other public-health bodies, which mostly recommend staying home when possible to mitigate the risk of asymptomatic transmission.
Carlsson said waiting for definitive proof in this case meant waiting too long and risking lives.
"Evidence-based is good science over time, but in emergency response to an unknown virus, you cannot sit and wait for a peer-review process," he said. "Science is very slow."
Sweden's renegade advice
Sweden diverges from the consensus in more ways than its advice on which people should stay home.
Plumberg said Sweden had not "adequately adhered to the European Union precautionary principle," which says lawmakers should act to prevent harm even if they are not yet totally sure it will work.
"More succinctly, the principle cautions: 'Better safe than sorry.'"
Plumberg said he agreed with Tegnell's own statement that Sweden's death toll had been "horrifying."
But he said Sweden should have looked closer at what was happening in other countries.
"To make no decision on condition of 'too little evidence' is already to make a decision," he said. "The virus itself has forced a rapid policy response, and Sweden seems philosophically opposed to making such changes."
Tegnell, the state epidemiologist, responded to the open letters in April by defending the scientific basis for Sweden's policy and calling the figures they cited "inaccurate."
He also said Sweden's death toll was inflated because the virus had spread in nursing homes to a greater extent than in other countries, causing more people to die.
The signatories say Sweden needs to collect more data about its outbreak and to allow an open debate between the Public Health Agency and other scientists.
Flying blind on testing
Sweden is prioritizing its coronavirus tests for healthcare workers who show symptoms and patients already in the hospital.
It then gives priority to police officers and emergency responders. The health agency says people who have cold or flu symptoms "will not be prioritized for testing" but should stay home.
Lena Hallengren, Sweden's health minister, said at the end of March that targeted testing, rather than mass testing of the population, was the right way to go for Sweden.
TheLocal.se, an English-language news service for Sweden, reported that as of May 8, about 1,000 people were being tested in Stockholm a day.
It said the country was hitting around a third of its goal of 100,000 a week.
Sweden's testing rate is at 17.6 per 1,000 people, according to tracking by the website Statista. Norway, its close neighbor, has a rate of 37.9.
Kampe, the science professor, said more testing was necessary to assess Sweden's strategy: "To evaluate this afterwards we have to have data."
"We still don't have data to calculate the projections people are making. It still doesn't exist," he said.
Carlsson said testing was especially important as Sweden's strategy was so different. "Because we chose a different path, we are in a unique position to provide valuable information for the rest of the world," he said.
"If we test a lot, we could provide so much information for the world. And save individual lives."
'Sacrificing' the old and weak
Sweden says its plan is meant to protect the most vulnerable: People over 70 are urged to stay at home, and visitors have been barred from nursing homes.
But about half of Sweden' deaths have taken place in nursing homes, and about 88% of its deaths are people over 70, a figure similar to some of Europe's hardest-hit countries like the UK and France.
Nursing-home workers have reported having to work without access to personal protective equipment.
Some staff members have complained that they do not have permission to give oxygen treatment to patients with the virus and say they have been told not take the patients to hospitals.
People with conditions that make them more vulnerable have also told Business Insider that Sweden's plan has left them frightened as they choose to isolate themselves.
"We are sacrificing old people and people with diseases," Kampe said.
Tegnell denies that Sweden's plan involved sacrificing certain groups. Instead, he said, the high deaths were an unforeseen event, not part of the plan. The health minister, Hallengren, has publicly said Sweden "failed to protect our elderly."
The Public Health Agency has said it started enforcing greater hygiene measures and has seen fewer nursing-home deaths.
But Sweden's death toll — at 3,698 on Tuesday — has soared above its Nordic neighbors that locked down early.
Per capita, its deaths are about four times those in Denmark and eight times those in Norway — countries with similar healthcare systems, political systems, and population densities.
Sweden is also reporting more than 400 new cases a day, compared with about 20 a day in Norway and about 60 a day in Denmark.
'Don't copy us'
Kampe said Sweden too had the ingredients for a low death toll: It is not very densely populated, has a high degree of education, and has low rates of diseases like diabetes and obesity.
Be, he said, "and still there are so many deaths." He continued: "As a physician you don't accept any unnecessary deaths. But we have thousands. If this continues, we will have tens of thousands.
"I don't think that it's something that anyone should copy."
Carlsson said Sweden was at "a very dangerous point in time" as its plan received international attention: "People want a way through without a lockdown," he said.
But he said the strategy would jeopardize lives anywhere it's employed.
"We are not testing," he said. "We are totally in the dark. This is not an example to follow."
So far, it has not indicated that any change is coming.