The Sabbatsbergsbyn nursing home in Stockholm struggled to control the spread of the coronavirus. Photo / Felix Odell, The New York Times
Decades of budget-cutting and market reforms laid the ground for a wave of death in Swedish nursing homes.
In the popular imagination, Sweden does not seem like the sort of country prone to accepting the mass death of grandparents to conserve resources in a pandemic.
Swedes pay some of the highest taxes on Earth in exchange for extensive government services, including state-furnished health care and education, plus generous cash assistance for those who lose jobs. When a child is born, the parents receive 480 days of parental leave to use between them.
Yet among the nearly 6,000 people whose deaths have been linked to the coronavirus in Sweden, 2,694, or more than 45 per cent, had been among the country's most vulnerable citizens: those living in nursing homes.
That tragedy is in part the story of how Sweden has, over decades, gradually yet relentlessly downgraded its famously generous social safety net.
Since a financial crisis in the early 1990s, Sweden has slashed taxes and diminished government services. It has handed responsibility for the care of older people — mostly living at home — to strapped municipal governments, while opening up nursing homes to for-profit businesses. They have delivered cost savings by relying on part-time and temporary workers, who typically lack formal training in medicine and elder care.
This is how the nursing staff at the Sabbatsbergsbyn nursing home in the centre of Stockholm found itself grappling with an impossible situation.
It was the middle of March, and several of the 106 residents, most of them suffering dementia, were already displaying symptoms of Covid-19. The staff had to be dedicated to individual wards while rigorously avoiding entering others to prevent transmission. But when the team presented this plan to the supervisors, they dismissed it, citing meagre staffing, said one nurse, who spoke on the condition on anonymity, citing concerns about potential legal action.
The facility was owned and operated by Sweden's largest for-profit operator of nursing homes, Attendo, whose stock trades on the Nasdaq Stockholm exchange. Last year, the company tallied revenue in excess of US$1.3 billion.
On weekends and during night shifts, the nurse was frequently the only one on duty. The rest of the staff lacked proper protective gear, said the nurse and a care aide, who spoke on condition of anonymity for fear of being fired. Management had given them basic cardboard masks — "the kind house painters wear," the nurse said — while instructing them to use the same ones for days in a row. Some used plastic file folders and string to make their own visors.
By the time the nurse quit in May, at least 20 residents were dead, she said.
"The way we had to work went against everything we learned in school regarding disease control," the nurse said. "I felt ashamed because I knew that we were spreaders."
The lowest-wage workers — who are paid hourly and lack the protection of contracts — continued showing up for shifts even after falling ill because government-furnished sick pay did not cover all of their lost wages, the care aide said.
"This is an undervalued part of the labor market," said Marta Szebehely, an expert in elder care at Stockholm University. "Some care workers are badly paid, badly trained and have really bad employment conditions. And they were supposed to stop a transmission that nobody knew anything about, and without much support."
Vulnerability in another area was central to the devastation: Over the last two decades, Sweden has substantially reduced its hospital capacity. During the worst of the initial outbreak, elderly people in nursing homes were denied access to hospitals for fear of overwhelming them.
When nursing home residents displayed Covid symptoms, guidelines in force in Stockholm in the initial phase of the pandemic encouraged physicians to prescribe palliative care — forgoing efforts to save lives in favor of keeping people comfortable in their final days — without examining patients or conducting blood or urine tests, said Dr. Yngve Gustafson, a professor of geriatrics at Umea University. He said that practice amounted to active physician-assisted suicide, which is illegal in Sweden.
"As a physician," Gustafson said, "I feel ashamed that there are physicians who haven't done an individual assessment before they decide whether or not the patient should die."
In the United States, some 40 per cent of total coronavirus deaths have been linked to nursing homes, according to a New York Times database. In Britain, Covid has been directly blamed in more than 15,000 nursing home deaths, according to government data.
But these are countries characterized by extreme levels of economic inequality. An estimated 45,000 Americans die every year for lack of health care, according to one report. Britons endured a decade of punishing austerity that battered the national health system.
Sweden is supposed to be immune to such dangers. Yet this country of only 10 million people has been ravaged by the coronavirus, with per capita death rates nearly as high as the United States, Britain and Spain, according to World Health Organization data.
One element appears to have substantially increased the risks: Sweden's decision to avoid the lockdowns imposed in much of the rest of Europe as a means of limiting the virus. Although the government recommended social distancing, and many people worked from home, it kept schools open along with shops, restaurants and nightclubs. It did not require that people wear masks.
"There's been more society transmission, and it's been more difficult to hinder it from entering the care homes," said Joacim Rocklov, an epidemiologist at Umea University. "The most precious time that we lost, our mistake, was in the beginning."
Those who operate private nursing homes in Sweden assert that residents have been the victims of the government's failure to limit the spread of the virus.
"It's the total transmission in society, that's the key," said Martin Tivéus, chief executive of Attendo, the company that owns the Sabbatsbergsbyn home in Stockholm.
Investigations by Swedish media have concluded that private nursing homes suffered lower death rates than their public counterparts. But experts say private and public homes are governed by the same decisive force: Municipalities handle elderly care, and taxpayers have been inclined to pay less.
For decades aggressive public spending was the rule in Sweden, rendering joblessness a rarity. By the beginning of the 1990s, a sense had taken hold that the state had overdone it. It was subsidising industries that were not internationally competitive. Wages were rising faster than productivity, yielding inflation.
In 1992, Sweden's central bank lifted interest rates as high as 75 per cent to choke off inflation while preventing a plunge in the national currency, the krona. The next year, amid a tightening of credit, Sweden's unemployment rate surged above 8 per cent. The economy contracted, depleting municipal tax revenues.
This played out just as the policy sphere became infused with the thinking of economists like Milton Friedman, whose neoliberal principles placed faith in shrinking the state and lowering taxes as a source of dynamism.
From the middle of the 1990s through 2013, Sweden dropped its top income tax rate to 57 per cent from 84 per cent while eliminating levies on property, wealth and inheritance. The net effect was a reduction in government revenue equivalent to 7 per cent of national economic output.
Under a 1992 law, Swedish elder care shifted from a reliance on nursing homes to an emphasis on home care. Part of the alteration was philosophical. Policymakers embraced the idea that older people would better enjoy their last years in their own homes, rather than in institutional settings.
But the shift was also driven by budget imperatives.
As a share of its economy, Sweden spends 3.2 per cent a year on long-term care for the elderly, according to the Organization for Economic Cooperation and Development, compared with 0.5 per cent in the United States and 1.4 per cent in Britain. Only the Netherlands and Norway spend more.
But that expenditure is now spread across a population with greater needs. With home care the rule, nursing homes are reserved for older people suffering from complex ailments.
Attendo said it had enough protective gear to satisfy Swedish guidelines and more than public nursing homes had but not enough to manage the pandemic. When the company realized it needed more, it confronted a global shortage.
"It took five or six weeks to get the volumes outside of China," said Tivéus, the Attendo chief executive.
The shortages at Swedish nursing homes underscore the extent to which budget math has taken precedence over social welfare, say those who have watched the refashioning.
"What this pandemic has done is demonstrate a number of system errors that have gone under the radar for years," said Olle Lundberg, secretary-general of Forte, a health research council that is part of the Swedish Ministry of Health and Social Affairs. "We totally rely on the global production chain and just-in-time delivery. The syringes we need today should be delivered in the morning. There is no safety margin. It may be very economically efficient in one way, but it's very vulnerable."
Mia Grane was unaware of the systemic issues when she moved her parents into the Sabbatsbergsbyn home in the summer of 2018.
In their younger days, her mother had been an Olympic swimmer. Now she was descending into Alzheimer's. Her father used a wheelchair.
The home sat in the center of Stockholm, a 15-minute bike ride from her apartment, with lovely gardens that were used for midsummer parties.
"It was a perfect place," said Grane, 51. "They felt at home."
But her confidence evaporated as the pandemic spread. When she asked the nursing home staff how it planned to manage the danger, it reassured her that everything was fine.
"I thought, 'If this virus gets into this place,'" she said, "'a lot of people are going to die.'"
A week later, she read in a local newspaper that a prominent Swedish musician had died. He had lived in the same ward as her parents. She called the home and was told that her father was suffering cold symptoms. A test showed that he had contracted Covid.
Grane urged the staff to transfer her father to the hospital. It told her that no one was making that journey, she said.
Nursing homes lack advanced medical equipment like ventilators, and hospitals were effectively off-limits to nursing home residents.
"We knew that Sweden had fewer intensive care beds per inhabitants than Italy," said Dr. Michael Broomé, a physician at an intensive care unit in Stockholm. "We had to think twice about whether to put elderly people with other conditions on ventilators."
This forced the nursing home to administer comfort care, easing the pain with opioids as death approached.
Grane's father died April 2. "He was all alone," she said.
She begged the staff to save her mother — "the most important person in my life." But she wasn't eating. A week later, her mother died, too.
Grane struggles to make sense of it — the staff not having proper masks, the hospital deemed off-limits, the lack of concern about the nature of the threat.
"For me, it's clear that they wanted to save costs," she said. "In the end, it's the money that talks."
Written by: Peter S. Goodman and Erik Augustin Palm
Photographs by: Felix Odell and Elisabeth Ubbe
© 2020 THE NEW YORK TIMES
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