US may pay heavy price for being 'an accidental Sweden'

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In early summer, parts of the United States began following a very similar path to that taken by Sweden in dealing with COVID-19, writes STAT News – but one it stumbled onto, not chosen based on science. Now, the next few weeks will show the consequences of being the accidental Sweden.

With the COVID-19 pandemic rampaging across the US in April and 20m people filing for unemployment in that month alone, libertarians thought there was a better way. According to a STAT News report, the Heritage Foundation praised Sweden for “preserving economic freedom”. The Cato Institute said Sweden’s response to COVID-19 “may prove to be superior from a public health perspective”. In early May, Republican Senator Rand Paul said at a committee hearing that the US “ought to look at the Swedish approach.”

The report says Swedish approach was to largely allow businesses to remain open. And at first, it seemed to work, with a death count nowhere near what it was in countries such as Italy, Spain, and the UK. But even as Sweden was being hailed as a model, its cases were steadily rising, and its death rate now exceeds that of the US. Sweden also did not seem to stave off the economic damage it was aiming to avoid.

Sweden’s COVID-19 strategy, adopted in March, emerged from the country’s top epidemiologist and other leaders’ evaluation of what little science about transmission there was at the time, factoring in economic considerations, and making a considered – albeit controversial – decision to stop well short of the full shutdown that other countries in western Europe (and many US states) adopted.

The report says in early summer, parts of the US began following a very similar path – but one it has stumbled onto, not chosen based on science. Now, the next few weeks will show the consequences of being the accidental Sweden. “In some ways you could say we’re doing Sweden, but unintentionally” and, crucially, without the guardrails that kept that country’s case count from exploding, said physician David Rubin, director of PolicyLab at Childrens Hospital of Philadelphia (CHOP), whose COVID-19 model shows the epidemic resurging through early August almost everywhere in the US but New England.

In addition to places like Arizona, Texas, and Florida that have been hammered since June, the report says the latest run of the CHOP model identifies Las Vegas, Los Angeles, northern California, Kansas City, Missouri, Tulsa, Oklahoma, Greenville, South Carolina, and Atlanta, Georgia as poised for widespread transmission. And there are early signs that the virus is moving up busy travel routes, spreading north to Baltimore, Philadelphia, and all of Ohio’s major cities.

By “doing Sweden,” the report says Rubin and other experts mean the US’ pullback from social distancing that dates from May, when states began lifting stay-at-home orders and other policies aimed at reducing viral transmission. The effect has had many of the failed aspects of Sweden’s approach, but with none of the steps that kept that country from being a total disaster.

Sweden never imposed a total shutdown of non-essential businesses. It closed universities and banned gatherings of more than 50 people, including sports events, and discouraged domestic travel. But most bars, restaurants, schools, salons, and stores were allowed to remain open, with largely voluntary social distancing. “If Spain and Italy got hit by an early COVID-19 tsunami,” said Peter Kasson of the University of Virginia School of Medicine and Sweden’s Uppsala University, “Sweden said, ‘let’s go swimming.’”

The report says many of its citizens, however, didn’t jump into the deep end. For one thing, “a lot of Swedes went well beyond the official recommendations for social distancing, individually taking the kinds of actions that in other countries were mandated,” said Kasson, co-author of a recent study of Sweden’s strategy. “A lot of people self-isolated at home, and companies promoted working from home even though it wasn’t mandated. That shows that individual decisions that reduce (viral transmission) can have a substantial effect on national outcomes.”

Among those individual decisions: 58% of Swedes didn’t meet friends, and 74% stayed home during their spare time. Sweden also issued its distancing recommendations early. Imposing less restrictive policies right away can be more effective at slowing transmission and preventing cases than stricter measures later in an outbreak.

In contrast, if Swedes had done everything they were allowed to do (especially since face coverings were never required nationally), such as shop and socialise at the same levels they had pre-pandemic, “it would likely have led to runaway infection,” Kasson said. But “Sweden is a place with a very strong embrace of government authority.” When that authority said keep gatherings small, Swedes “took individual actions that went beyond the mandated measures,” he said.

Sweden is 18th in the world in COVID-19 cases per million people, with 7,524 as of last week. That’s better than the US (10,626), but much worse than European countries that imposed shutdowns. Sweden is seventh in deaths per million people (with 549; the US is ninth, with 419), though the UK, Spain, and Italy are worse, possibly because of older populations, denser cities, and more imported cases early on.

But a death rate nearly 12 times Norway’s is hardly reason for celebration. (In fairness, however, there is evidence that one reason for Sweden’s high death toll is that when elderly people contracted COVID-19, they did not receive aggressive treatment, Kasson found; if they had, about one-third might have survived.)

STAT News reports that because factors that kept Sweden’s numbers from being even more dire are largely absent in much of the US, there is growing concern that this country will blow past Sweden’s death rate and exceed its case rate even further. Some states, especially in the South, began easing restrictions in late April. But many people seemed to take “bars and restaurants can reopen with capacity limits” as “back to normal!” An entrenched culture of “don’t tell me what to do” just about ensured the opposite of Swedes’ placing greater restrictions on themselves than the government did. And that’s what happened.

In early-reopening Tennessee, 20- and 30-somethings packed Nashville clubs, skin-to-skin with scores of strangers (and few face coverings). That pattern repeated from pool parties at Lake of the Ozarks to bar openings, such as one in Michigan blamed for more than 100 cases.

Call it “individualism, cultural libertarianism, atomism, selfishness, lack of social trust, suspicion of authority,” The Week columnist Damon Linker writes, “it amounts to a refusal on the part of lots of Americans to think in terms of … what’s best for the community, of the common or public good. Each of us thinks we know what’s best for ourselves. We resent being told what to do.”

The report says the White House’s coronavirus task force, led by Vice President Mike Pence, is now stressing that individual decisions to distance, wear masks, and practice good hygiene can reduce transmission, even as the Trump administration has not rolled out new strategies to address the skyrocketing case numbers in parts of the country.

Sweden’s light-handed restrictions, Kasson said, produced results similar to those in countries with stricter policies because so much of the population was willing to voluntarily self-isolate. In the US, even though phased re-openings have been accompanied by pleas from experts (but not necessarily state or local officials, at least initially) to social distance and wear face coverings, many people have said, nah.

After Memorial Day, social interactions in the US began creeping up to half or more of what they had been during the period of the strictest mandates. “By the beginning of April, people were already tiring of stay-at-home and were increasing their movement,” said epidemiologist Jeffrey Shaman of the Mailman School of Public Health at Columbia University, “so it actually predates the loosening of restrictions that began at the end of April.”

Indeed, the report says cellphone data show that, after a month of increases in social distancing, as of 24 April, 48 states saw a drop, researchers at the University of Maryland found. Many Americans had said, enough.

Also missing from the US: strong national policy, as Sweden has. Instead, each state and many cities were left to devise their own plans for the initial shutdowns and, especially, re-openings. Although there was federal guidance on what would be safe to do when, based on measures such as case counts and hospital capacity, many states ignored them. Social distancing varied enormously, the Maryland data show: In early May, its index of social distancing ranged from the 50s (on a scale from 0 to 100, with 100 being maximum distancing) in New York, New Jersey, and Massachusetts to the 30s or less in many Southern states.

As a result, risky decisions made in, say, Florida and Texas have started to bleed into surrounding states, the report says. “We can see the virus moving along travel corridors,” said CHOP’s Rubin. “Even though the number of cases is still low, you can see it in the R,” the number of new cases each earlier case is causing.

Sweden’s COVID-19 messaging was also much clearer than that in the US. “An important factor in shaping people’s behavior is how governments talk,” said epidemiologist Jennifer Nuzzo of the Johns Hopkins Centre for Health Security. “If you talk about COVID-19 as a hoax, you can be pretty much assured that you’ll be on a path to a rapid acceleration of cases and deaths.”

In the US, Pence has highlighted the fact that a larger percentage of new cases in states like Florida and Texas are occurring in younger people. But, the report says, if the virus is spreading in one population, it won’t be contained there. As cases rise among younger people, experts expect more transmission to reach older people. That is what happened in Sweden, driving up the country’s mortality rate. Probably because workers brought the virus into care homes for the elderly, COVID-19 raced through such facilities, which have accounted for about half of all deaths in Sweden; people over 70 accounted for some 90% of deaths.

Anders Bjorkman, an infectious disease expert at Stockholm’s Karolinska Institute, pointed to another problem that has plagued both the Swedish and US response: a slow rollout of diagnostic testing. Both countries effectively limited testing initially to people who were really sick, which he called “a clear mistake.” Even now in the US, as demand has soared along with cases, some people are still unable to get tested or have to wait more than a week for results. That makes it harder for people to know if they should isolate themselves and tell their contacts to stay home as well.

And, STAT News reports, if an unstated goal of Sweden’s approach was to get closer to herd immunity, it does not appear to have been realised. Serology studies looking at how many Swedes have contracted the coronavirus — and who are then, scientists hope, protected from another infection for some amount of time — have ranged from about 6% to 14% in the Stockholm area (though some Swedish scientists say they believe the figure is higher than that based on different signals of immunity). That leaves the country far short of the 60% or so that experts say will slow down transmission.

“I was surprised they didn’t recalibrate” as the serology findings came out, said University of Florida biostatistician Natalie Dean. “My concern with Sweden is that they’re going to muddle along at this level and it’s not going to go down, for longer than the models say.”

The report says in the US, states outside the Northeast have started to pause their re-openings and, in some cases, re-imposed some restrictions in an attempt to gain a handle over the spiralling outbreaks. But the effects of the US’ version of Sweden are becoming alarmingly clear.

In the CHOP model, current hot spots such as Miami and Houston get worse over the next few weeks. San Francisco and New Orleans surge, as do suburbs of Kansas City, Missouri, and Chicago. Philadelphia and New York City also see an increase in cases.
“We’ve lost control at this point,” said CHOP’s Rubin. “Unless we go back to the very early phase of our re-opening, and do it quickly, the fall could be catastrophic.”

Background: The COVID-19 pandemic has spread globally, causing extensive illness and mortality. In advance of effective antiviral therapies, countries have applied different public-health strategies to control spread and manage healthcare need. Sweden has taken a unique approach of not implementing strict closures, instead urging personal responsibility. We analyze the results of this and other potential strategies for pandemic control in Sweden.
Methods: We implemented individual-based modeling of COVID-19 spread in Sweden using population, employment, and household data. Epidemiological parameters for COVID-19 were validated on a limited date range; where substantial uncertainties remained, multiple parameters were tested. The effects of different public-health strategies were tested over a 160-day period, analyzed for their effects on ICU demand and death rate, and compared to Swedish data for April 2020.
Results: Swedish mortality rates fall intermediate between European countries that quickly imposed stringent public-health controls and countries that acted later. Models most closely reproducing reported mortality data suggest large portions of the population voluntarily self-isolate. Swedish ICU utilization rates remained lower than predicted, but a large fraction of deaths occurred in non-ICU patients. This suggests that patient prognosis was considered in ICU admission, reducing healthcare load at a cost of decreased survival in patients not admitted.
Conclusions: The Swedish COVID-19 strategy has thus far yielded a striking result: mild mandates overlaid with voluntary measures can achieve results highly similar to late-onset stringent mandates. However, this policy causes more healthcare demand and mortality than early stringent control and depends on continued public will.

Shina CL Kamerlin, Peter M Kasson


STAT News report


Clinical Infectious Diseases abstract

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