Coronavirus: Inside Sweden's unique and controversial approach to Covid-19

They're images that seem alien these days – people dining out at restaurants, lazing in parks surrounded by others, going to work and dropping their kids at school, or chatting in shops.

Since the coronavirus pandemic forced almost every country on the planet to bring a rapid end to many elements of everyday life, these kinds of once-normal activities have been largely impossible.

But one nation remains the stark outlier, adopting a unique and controversial approach to dealing with the public health crisis.

It hasn't banned anything. Instead, Sweden is simply asking citizens to be responsible and safe, and is counting on them to do the right thing.

Apart from encouraging people to keep two metres away from others and work from home if possible, it's business as usual in the European nation.

Sweden has 22,300 confirmed cases of coronavirus and the death toll stands at 2679.
The country had processed close to 120,000 tests as at April 26, about 16 per cent of which had come back positive.

Despite that heavy loss, significantly higher than its Scandinavian neighbours, some are heralding the approach as something of a success – and a potential roadmap for the rest of the world.

As the rest of Europe – and indeed the world – began locking down as coronavirus spread in February and March, Sweden's health authorities decided on a vastly different approach.

Its neighbours watched on in horror and surprise.

Across the border in Finland, the government declared a state of emergency in mid-March, shutting down schools and ordering the closure of restaurants, bars and cafes.

It was a few days after Denmark made a similar decision, closing its borders and instituting a number of bans on socialisation.

People gather in a park in Stockholm, Sweden. Photo / AP

At the same time, Norway closed its schools, childcare centres and universities and told businesses where people were in close proximity, like hairdressers and cafes, to shut.

Defending Sweden's approach, chief epidemiologist Dr Anders Tegnell earlier this month said a lockdown like that was viewed as unsustainable.

"Locking people up at home won't work in the longer term," Tegnell said. "Sooner or later people are going to go out anyway."

In an interview with The Times, he repeated his belief that a short and sharp lockdown would only delay the inevitable – a high number of cases and potentially a high number of deaths.

"Even the most optimistic people seem to say that if we have a vaccine available in the next 18 months we are going to be very lucky," he told the newspaper.

"To keep schools closed until we have a vaccine in place, I would say that will not be possible because then you are going to see a big damage to a cohort of children in your country."

Sweden's approach hasn't been without controversy and fierce debate. Far from it.

In late March, some 2000 researchers from around the country signed a petition demanding the government "immediately take steps to comply with the World Health Organisation's recommendations".

"The measures should aim to severely limit contact between people in society and to greatly increase the capacity to test people for Covid-19 infection," the group wrote.

A group of 22 professors also wrote an article raising serious concerns about the strategy and warning it could lead to preventable deaths and chronic lung illnesses.

Anders Vahlne, a professor in clinical virology, is worried that Swedes don't appreciate how infectious coronavirus is and that it can spread via asymptomatic people.

"Even if you don't sneeze or cough, you still breathe," he told EuroNews.

"All data indicate that this virus spreads through the inhaling of aerosol particles, which stay infectious in the air for more than 16 hours."

In contrast to those experts, it seems Swedes themselves are comfortable, with the ruling Social Democratic Party seeing its opinion poll results rise for the second month in a row. Prime Minister Stefan Lofven's handling of the pandemic is attributed with growing support for the government.

Tegnell believes it's only a matter of time before other nations that reacted swiftly and strongly, essentially bringing an end to normal life and halting their economies, will have to backtrack.

And it's at that stage when Sweden could shine a light on a possible path forward.

THE 'H' WORD

Sweden's model of dealing with coronavirus can be simply described as planning and hoping for herd immunity.

Herd immunity should theoretically occur when a significant proportion of the population has contracted Covid-19 and recovered from it, therefore unable to get it again, if that indeed is possible.

The science isn't yet settled, but Tegnell is hopeful.

"I think that is the only thing that is going to slow this down when we have a considerable proportion of the population in most countries who are immune to the disease, because these diseases are not stopped by anything else really if you don't have a vaccine."

Paul Franks, a professor of genetic epidemiology at Lund University, is one of those who believe Sweden could provide a guide for the rest of the world in the coming phases of the epidemic.

Until there's a vaccine, there will inevitably be new waves of coronavirus outbreaks – unless enough people have been infected to achieve herd immunity, Franks said.

But that assumes those who have already contracted Covid-19 retain enough antibodies to protect them, and that the virus doesn't mutate into a distinct new strain.

In any case, herd immunity would require about 60 per cent of a population to be infected and recover, according to estimates, Franks said.

"Sweden, which is encouraging social distancing but has not fully locked down, could guide the world," Franks wrote in The Conversation. "Here, the authorities claim the country is rapidly approaching herd immunity (levels)."

That looming milestone won't come without significant cost.

Sweden's mortality rate is in the 10 highest in the world and significantly greater than its neighbours Norway, Denmark and Finland.

"The high mortality rate in Sweden we can see is very closely linked to our elderly homes in Sweden," Tegnell said.

"That has happened far less in Norway and Finland.

"We have looked at the death rates very closely and we are trying to work out why because there was already a ban on visiting care homes.

People gather for a drink at an outdoor bar in Stockholm, Sweden. Photo / AP

"But in the homes in Sweden they are really old and really sick and need constant care.

"They need people coming there and the lockdown can't stop that."

It could be that achieving herd immunity and getting coronavirus under control in Sweden is at the expense of the deaths of those most vulnerable in the community.

Professor Marylouise McLaws, an epidemiologist with the Healthcare Infection and Infectious Diseases Control unit at the University of New South Wales, said the herd immunity approach came at a "high price".

"Sweden has unfortunately chosen 'herd immunity' at a high price, with 2500 deaths and a very large number of active cases who, without stringent quarantine of cases and contacts, have the potential to continue rather than flatten the curve," McLaws told news.com.au.

"Of great concern is the future impact for our ability as a global neighbourhood to open our borders with a 'herd immunity' approach that fuels the pandemic and may potentially causes a boomerang of seasonality around the world."

MILESTONE IMMINENT

This week, Sweden's Public Health Agency forecast that one-third of people in the capital of Stockholm will have been infected by coronavirus by early next month.

That's the equivalent of 200,000 people and significantly higher than the official number of cases confirmed across the whole country.

It's because the agency believes there are some 75 unconfirmed cases for every confirmed case.

And it's confident the peak of infection has passed.

"We believe we passed the peak of the transmission a week ago," Tegnell told the BBC.

"It will definitely affect the reproduction rate and slow down the spread."

There are some early signs that he could be right.

A study from New Zealand researchers this week examined the reproduction rates in several countries and compared it with their individual pandemic response plans.

Hassan Vally, an associate professor at La Trobe University, examined the research and said Sweden's Reff – or effective reproduction rate of infection – has dipped below one.

A member of the medical staff in protective gear takes a swab for a Covid-19 test at a test facility in a tent outside Skane University Hospital in Lund, Sweden. Photo / AP

"A Reff of less than one means each infected person spreads the virus to less than one other person, on average," Vally explained.

"By keeping Reff below one, the number of new infections will fall and the virus will ultimately disappear from the community."

Sweden's "markedly relaxed" approach has been contentious, he said, and the number of cases and deaths there is much higher than elsewhere in Scandinavia.

"But Reff indicates that the curve is flattening."

SHOULD OTHERS FOLLOW SUIT?

Franks said Sweden's modelling provided reasons to be cautiously optimistic about the coming weeks and months.

"If the simulations conducted in Sweden are correct, and post-infection immunity is achieved in most people, we should soon expect infections and deaths in Stockholm to drop substantially in the coming weeks," Franks said.

But Erik Wengström, a professor of economics at Lund University, isn't convinced such an approach would work everywhere for one big reason – trust.

Put simply, the level of trust people have in government, politicians, agencies and their fellow citizens is extremely high in Sweden.

"Since Sweden has among the highest levels of trust in the world, the strong relationship between trust and approval of the strategy might suggest its approach would be less successful elsewhere," Wengström wrote in an article for The Conversation.

A sign on a tree saying 'Avoid congestion' at the popular Hellasgarden recreational area in the outskirts of Stockholm, Sweden. Photo / AP

"There is a clear risk that in countries characterised by lower levels of trust, the perception of a more voluntary-based approach will be less favourable.

"In addition, a crucial part of Sweden's policy is to get people to voluntarily follow recommendations from authorities. And if people do not trust others to comply, they are less likely to comply themselves."

More than trust, McLaws described Sweden's approach to controlling coronavirus as "unsuccessful".

"To date Sweden's approach has resulted in over 20,000 cases, of whom 83 per cent are still active cases who have the capacity to contribute to the transmission of further cases. 479 cases are serious or critical and nearly 2500 deaths have been reported.

"I would described their approach to control as unsuccessful.

"Their curve suggests they have several waves or surges in cases. For anyone to describe their epidemic curve as showing early signs of flattening is an optimistic interpretation."

And Vally said the New Zealand research showed that, Sweden aside, one approach overwhelmingly seemed to be the most successful.

"Individually, (the country's results) each tell their own story. Together, they have one clear message: places that moved quickly to implement strict interventions brought the coronavirus under control much more effectively, with less death and disease.

"And our final example, Singapore, adds an important coda – the situation can change rapidly, and there is no room for complacency."