Sweden was one of few European nations that avoided full-scale pandemic lockdowns. Despite heavy criticism last year, researchers now disagree on the extent to which more restrictions would have led to better overall outcomes.
Sweden imposed some lockdown measures, including varying restrictions on public gatherings, social distancing requirements at bars and restaurants, and temporary high school and university closures. In May 2020, Sweden reported the world’s eighth-highest COVID death rate, according to Our World in Data, a collaboration of University of Oxford researchers and the Global Change Data Lab.
Now, Sweden ranks 46th in terms of COVID mortality, reporting 1,469 deaths per million people. Sweden has significantly more deaths than its Nordic neighbors, Norway (162 per million) and Denmark (460 per million), which both temporarily imposed school closures across all levels and closed workplaces for all but essential workers. But Sweden's mortality rate trails behind European countries like France (1,748), Spain (1,858), the United Kingdom (2,030), and Italy (2,177), which also enacted sweeping school and workplace closures.
David Dowdy, associate professor of epidemiology at the Johns Hopkins Bloomberg School of Public Health, says it’s difficult to say whether Sweden's government should have done more.
This is a really challenging question to disentangle,” he said. “Clearly things could have done better than they were in Sweden, but they could also have been done worse.
TO WHAT EXTENT DOES GOVERNMENT PLAY A ROLE?
Researchers should examine not just policy decisions, but also cultures, Dowdy said.
COVID outcomes could in part depend on whether a culture is more individualistic or more communal, and to what extent a population is accustomed to complying with government mandates. Large outbreaks in places like Peru and Brazil, which saw some of the world’s highest COVID death rates, largely stem from their less “regimented” cultures, he said. In contrast, countries with centralized, authoritarian governments like China, which maintains one of the world’s lowest COVID death rates, have an easier time imposing pandemic restrictions.
The reason that Norway and Finland had such generally favorable outcomes is not just because they had great policies in place, but they also had cultures that were more amenable to following those policies,” Dowdy said.
Some researchers have argued Sweden’s COVID mortality had less to do with lax government policies and more to do with other situational factors, including Stockholm's population size and demographics, the proportion of people in elderly care, and the fact that Sweden experienced a mild flu year in 2019, theoretically making the population more susceptible to COVID-19. Aarhus University economics professor Christian Bjørnskov refers to the latter phenomenon as “dry tinder.”
“What Sweden experienced was a big peak of people who had lived longer than they would normally, and then died during COVID,” Bjørnskov said.
But Dowdy says he doesn’t believe Sweden’s population is that much different from its Nordic neighbors. He says he believes explanations like the “dry tinder” hypothesis were invented “retrospectively.”
“The ‘dry tinder’ hypothesis to me neglects the fact that COVID has been a huge outlier in terms of the amount of mortality that has been experienced across the board,” Dowdy said. “Had you asked anyone before the COVID-19 pandemic and said, ‘We're about to have a pandemic. Do you think that the population of Sweden is at greater risk than Norway, Finland, Denmark because of their lower flu rates of the past year?’... people would say, ‘No, not really.’
In 2019, the Global Health Security Index ranked Sweden seventh in the world in terms of its ability to prevent, detect, and respond to infectious disease outbreaks.
'FOCUSED PROTECTION'
Other researchers say “dry tinder” accounts for “a modest fraction of excess Swedish mortality.” In a paper published this summer in the Scandinavian Journal of Public Health, the researchers conclude elderly Swedish women were more at risk to the virus than Danish women because of “how care and housing for the elderly are organised [sic], coupled with a less successful Swedish strategy of shielding the elderly.”
It is debated whether imposing specific restrictions on the elderly, who experience far higher COVID death rates than younger populations, could alter COVID outcomes. Dowdy says the size and regulation of long-term care facilities could dramatically impact COVID mortality.
This is also why we saw such high levels of mortality early in the pandemic — because people didn’t think to impose specific restrictions or take special care when thinking about those populations that are most vulnerable,” he said.
Imposing special protections on the elderly was a key component of the Great Barrington Declaration, authored last year by epidemiologists from Harvard University, Oxford University, and Stanford University Medical School. The authors advocate for a “focused protection” approach, where vulnerable populations would receive special protection, such as grocery delivery or frequent testing of their nursing home staff, while the rest of society would be allowed to "resume life as normal.”
Dowdy says he agrees that vulnerable groups need special support in preventing infections and outbreaks. But he said protection should go beyond just the vulnerable groups to involve policies like prohibiting large indoor gatherings for people who aren’t masked or vaccinated.
“I don’t think focused protection is all that controversial,” Dowdy said, adding, “We can take focused protection one step further, which is to think about those situations that are going to be the greatest risk for outbreaks, but without saying, therefore, we must lock down society or open society entirely up. I think either of those two extremes are not where we want to be.”
University of Pennsylvania biostatistician Jeffrey Morris pushed back on the Great Barrington Declaration last year in a blog post, suggesting that focused protection might not be so feasible.
Given the known high false negative rate of SARS-CoV-2 tests in asymptomatic individuals who were recently infected (but still contagious), it is not clear whether this strategy will indeed keep the residents safe from the virus, especially if it is allowed to spread unconstrained in the broader society,” Morris wrote. “The high viral levels in the general society increase the risk of it spilling over into the vulnerable populations, even if testing is done, given the high false negative rates.
Dowdy notes that vaccines improved COVID death rates in Sweden. However, Sweden’s death rate had already declined to the 27th highest worldwide by the time its vaccine rollout began in late December 2020. Sixty-seven percent of the Swedish population is fully vaccinated, compared with 53% across Europe.
DO BENEFITS OUTWEIGH THE COSTS?
Dowdy says the real question is whether the societal benefits of lockdowns outweigh their costs.
“Lockdowns work,” Dowdy said. “But, ‘Are they worth it?’ — I think is a question that’s more debatable.”
Other researchers have attempted to answer the question of whether “the cure is worse than the disease," i.e., whether COVID lockdowns caused more harm than the virus itself.
In a paper published this summer in the British Medical Journal, researchers analyzing data from the World Mortality Dataset found no locations, “that experienced both excess mortality and lockdowns concurrently with low numbers of COVID-19 cases.” New Zealand and Australia, for example, both imposed heavy lockdowns and saw relatively few COVID deaths — and ended up with no excess mortality. Meanwhile, the researchers note, countries like Brazil, Sweden, Russia, and parts of the U.S. saw few restrictions and large amounts of excess death.
While it is likely that lockdowns do have negative effects, the fact that there are no locations anywhere in the world where a lockdown without large numbers of COVID-19 cases was associated with large numbers of excess deaths shows quite convincingly that the interventions themselves cannot be worse than large COVID-19 outbreaks, at least in the short term.
Still, other researchers emphasize it's worth considering "other sorts of pain and suffering" caused by lockdowns.
“The end goal is not purely to reduce COVID-related mortality," Dowdy said. "It’s to allow society to be as healthy and as happy as possible. And I don’t know that everyone would say that stringent lockdowns are less harmful to society than substantial death tolls due to COVID.”