Posted on Apr 22, 2020, 2 p.m.
Ander Tegnell the epidemiologist behind the country’s controversial strategy recently had an interview with Nature to explain the “trust based” approach to tackling the COVID-19 outbreak, the following is an excerpt of that interview:
Much of the world has imposed severe restrictions on public life in recent months to try and slow the spread of this virus, among them there is one country standing out from the crowd: Sweden. In this country there is no lock down or strict social distancing policies. Rather this country has imposed a voluntary trust based measure that advises those who are older or with existing conditions to avoid social contact; it recommends people work from home, wash their hands regularly, and people should avoid non-essential travel.
Another more glaring difference is that in Sweden the borders and schools for children under the age of 16 remain open, as do many businesses including bars and restaurants. Their unique approach is gaining attention from critics among whom 22 scientists wrote an article in the newspaper Dagens Nyheter that public health authorities are failing and they urged politicians to step in an impose stricter measures pointing to a high number of deaths in elder care homes and the overall fatality rate which is the highest reported of the Nordic neighbours.
Ander Tegnell is an epidemiologist at the Public Health Agency in Sweden and is the architect behind their strategy who suggests that it is overstated how unique their approach is, as they too are aiming to flatten the curve to slow down the spread as much as possible as to not collapse the healthcare system.
Tegnell says this is not a disease that can be stopped or eradicated, as such there needs to be long term solutions that keep the distribution of infections at a decent level. Every country is trying to keep people apart by using the same measures and traditions, and this is one of the reasons they ended up doing things slightly different.
The laws on communicable diseases are mostly based on voluntary measures in Sweden, falling on an individual’s own responsibility, clearly stating that each citizen has the responsibility to not spread a disease. In Sweden using their present laws there is not much legal possibility to close down cities, a quarantine can be contemplated for people or small areas such as a hotel or a school but they legally are not able to lock down an entire geographical area.
In his view closing borders, lock downs and close downs have nothing to do with historical scientific basis, when they were investigating European countries to examine published analysis of the effects of these measures almost none were found. Thus in his opinion closing borders is ridiculous because COVID-19 is in every country now, and they have more concerns about movements inside of Sweden. In order to be effective those measures needed to be implemented immediately to be effective, as once it has spread it is too late.
In Sweden as a society they are more into nudging and continuously reminding people to use safety measures, working to improve measures as they are seen to need to be adjusted day to day, and there is no need to close everything down completely because it would be counterproductive.
Every morning the Swedish Public Health Agency meets to review and update decisions and adjust recommendations as needed according to data collection and analysis, talking to regional authorities twice a week.
Currently the big debate is regarding elder care homes where the country is registering a very unfortunate outbreak of the coronavirus which largely accounts for Sweden’s higher death rate as compared to the Nordic neighbors. To better understand which recommendations are not being followed and why not investigations are ongoing to make adjustments to try and correct the situation.
Although the country is being criticized for being too relaxed and possibly putting citizen lives at risk Tegnell does not believe there is that risk. Public health officials have released a detailed model on a region by region basis that comes to less pessimistic conclusions than that of other researchers in terms of hospitalizations and deaths per thousand infections. While there has been an increase in cases it is not traumatic so far, he says adding that the country is currently in a phase where there will be more cases during the next few weeks, just as every country either has or will experience, and nowhere in Europe has the spread been able to be slowed down considerably.
According to Tegnell the science does not support closing down schools at this point. In an epidemic to get an effect you have to shut things such as schools down early, and we are now close to the top of the curve so closing down schools would be meaningless at this point. It makes more sense along with being more instrumental for psychiatric and physical health that the younger generation remains active.
While there is a possibility asymptomatics are contagious, the amount of spread is mostly likely small compared to those showing symptoms as in the normal distribution of a bell curve asymptomatics sit at the margin whereas the majority of the curve is accountable to symptomatics which are the ones we really need to stop, says Tegnell.
Tegnell says that it is too early to know if their approach will be successful. Every country needs to reach herd immunity in one way or another, and Sweden is going to reach it in a different way. Some argue that keeping people in quarantine will limit their exposure and hault developing natural immunity needed to develop herd immunity. Just as the common cold or flu we once had no immunity, and many people died, which is the same as with this virus. Herd immunity is when a high proportion of the population becomes immune to an infection which largely limits the spread to those who are not immune, and quarantine undermines this process. According to Tegnell there are enough signals to show that we can think about herd immunity for this virus, how long it will last is unknown, but there is a definite immune response.
Tegnell believes that they underestimated the issues that would arise at elder care homes, and how the measures would or in this case would not be applied, and they should have controlled this more thoroughly in these communities.
Thus far he is satisfied with this strategy, and most of the problems the country is facing at the moment are not because of the disease, rather because the recommended measures in some environments have not been applied properly such as the deaths among older people which is a huge problem they are trying to fight hard against.
Looking at pandemics there are far worse scenarios than this one, Tegnell has data showing that the flu epidemic and winter norovirus dropped consistently this year which means that the social distancing and hand washing recommendations are working. Tracking models show that the movements in Swedes has fallen dramatically, and the voluntary strategy is having a real effect, adds Tegnell.
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