Pandemics are unpredictable and it is too soon to say, argues Richard Smith

Sweden stood alone in Europe in not opting for a severe lockdown when cases of covid-19 began to rise in the spring. As a result, the New York Times called Sweden “a pariah state,” and Sweden has had higher death rates than most countries in Europe, although lower than Britain. But, as I write this on 20 September 2020, the difference in the number of cases in Sweden and most of the rest of Europe is striking. Most countries in Europe have a rapid rise in cases, whereas Sweden does not. Spain, which had one of the most severe lockdowns, has one of the steepest increases.

The reason for the difference may well be that Sweden has more immune people, probably mostly younger people. But another possible explanation is that Swedes have followed the rules more dutifully than in other countries—perhaps because they trust the public health officials, understand what they have to do and why, and have avoided the stop-go confusion that besets Britain and other countries.

We knew from the beginning of the pandemic that it was likely to last years and that most of us had no immunity. We would either catch the infection or try to avoid it by minimising our contact with others. Eventually either enough of us would have caught the disease to generate the much-maligned herd immunity or many of us would be vaccinated. Either way it was going to be a long haul, and years of minimising contacts would mean no work, schools, or fun.

Sweden could behave differently from other countries because public health officials not politicians decide how to respond to the pandemic. It’s very hard for politicians to do things differently from other countries. Putting health officials rather than politicians in charge sounds like the creation of an iatrocracy and frighteningly anti-democratic, but the decision to do it this way was reached through democratic means.

In an interview in the Financial Times, Anders Tegnell, the chief public health official in Sweden, describes the thinking of him and his colleagues:  “At the outset we talked very much about sustainability, and I think that’s something we managed to keep to. And also be a bit resistant to quick fixes…We see a disease that we’re going to have to handle for a long time…” Tegnell describes a lockdown as “using a hammer to kill a fly.” You need “a strategy that can work for years if need be, rather than constant chopping and changing as seen in the rest of Europe.”

Crucially to my mind, Tegnell and his team thought about “public health in the broadest sense,” recognising the importance of education, work, and meeting with friends for health. “We are not just working with communicable diseases, we are working with public health as a whole.”

Sweden has concentrated its efforts against the virus on places where it’s most likely to be spread—places of entertainment where many people gather. Those places have strict rules on social distancing. Tegnell is unconvinced by the value of face masks, and they are not much seen in Sweden. Face masks are “more of a statement than actually a measure…Face masks are an easy solution, and I’m deeply distrustful of easy solutions to complex problems.” I’m also wary of simple solutions to complex problems, but I can understand why easy solutions and quick fixes are attractive to politicians.

The same thinking makes Tegnell cautious about the “silver bullet” of a vaccine. The idea that “once vaccine is here we can go back and live as we have always done…[is] “a dangerous message…because it’s not going to be that easy.”

David Nabarro from the World Health Organisation emphasises that the people not governments hold the key to responding to covid-19. We need to follow simple rules, and I can see why people in Sweden might be much more able and willing to follow the rules than people in other European countries. Most people in Europe must have heard the messages about these rules, but in Britain they are mixed with lots of conflicting messages. The stop-start messages from the British government are confusing, and many people don’t understand why they should follow the rules. Worse they don’t trust the government, and in Britain you don’t have to go far to see people breaking the rules. People may wonder why they have to follow the rules if others aren’t.

Sweden has avoided the stop-start messages, and the Swedish government is more trusted than the British one. Plus importantly Sweden has emphasised that the pandemic will last a long time (avoiding things like British politicians saying it might be over by Christmas), and it has not asked Swedes to make such extreme changes, meaning surely that it’s easier to sustain the changes in behaviour.

When the FT journalist spoke to Tegnell in the spring he said that “it would be in the autumn when it became more apparent how successful each country had been.” As Britain looks close to going into another national lockdown, some are arguing that Sweden seems to have adopted a better strategy. But all judgements must be provisional as pandemics are unpredictable, and Tegnell does expect local spikes in cases.

Richard Smith was the editor of The BMJ until 2004.