“The measures enjoined were far from Draconian and one had the feeling that many concessions had been made in a desire not to alarm the public” (The Plague, Albert Camus, 1947)
Why is it that Sweden, which was first to introduce mandatory use of seatbelts in cars, seems to be the last country to recommend face masks to prevent community transmission of COVID-19 spread? Sweden has been a champion for evidence-driven public health. Even when the weight of evidence has been questionable, national authorities have opted for precautionary measures in the name of health and wellbeing of its citizens, such as maintaining a state monopoly on alcohol sales.
A lot has been written about the Swedish response to COVID-19, often with a mix of surprise and disappointment in light of the contrast between Sweden’s public health reputation and its failure to implement an effective national strategy. Within Sweden, criticism of the public health authority’s handling of the pandemic has often been met by vague responses, and the country has missed out on an open, transparent and factual debate about these life and death questions.
Although countries often lack standard case definitions and criteria for deaths attributed to COVID-19 in their analyses, it is beyond doubt that Sweden, with a population of about 10 million, has had a comparatively high number of deaths, now reaching six thousand. Many of these could have been prevented if Sweden had started earlier with more aggressive testing and contact tracing, if social distancing had not been simply a recommendation without any enforcement, if face masks had been added to the toolbox of other partially effective instruments and if efforts had focused on the elderly and most vulnerable.
Sweden has still not introduced the use of face masks in the general population in combination with other preventive interventions as recommended by WHO. Even in situations where social distancing has proven challenging, such as on public transportation or in shopping malls, these were not implemented – arguing that it is too difficult and ineffective. However, the combination of social distancing and wearing a face mask, even if each is only partially effective, when combined with frequent hand disinfection, is more effective than the sum of the parts. We may accept the early hypotheses of the Swedish Folkhälsomyndigheten (public health authority) and its bold policies based on what was known at the beginning of the pandemic. But not now, when more is known about asymptomatic spread, acquired protection, herd immunity, the value of face masks and the challenges of sustaining other behaviour change interventions, an effective preventive strategy aimed at elimination of community transmission can and should be enacted. These lessons learned should change the course of the national COVID-19 strategy in Sweden and elsewhere where cases, hospitalizations and deaths are on the rise again.
We often hear that Sweden “has a good national strategy, but care of the elderly is not working”. This is an odd conclusion since an effective pandemic control strategy would aim to immediately identify and protect the most vulnerable in the population and to reduce risky practices. People of all ages and segments of society should be covered by a national COVID-19 strategy.
In Sweden, a paradoxical strategy was introduced in the spring of 2020: the elderly could not meet their family members even when they were dying in nursing homes, but they would be cared for by health providers and caregivers without mandatory protective equipment who were not tested for COVID-19 status. A frequent response in defence of the Swedish failure to prevent transmission and excess mortality among the elderly is that the care of the elderly is decentralized. However, we would expect a nation with a decentralised and fragmented health care system without clear lines of accountability, to focus on strengthening multi-sectoral collaboration at decentralized levels. If that does not work, as in the case with the Swedish social and health care system, then a higher central authority should step in and coordinate the response when faced with a national threat to the health of the public.
A coherent communications strategy is also key to an effective national response. The spokesperson for the Swedish public health authority often sends similar messages and signals to the general public to that of the current US administration. “You have to have ice in your stomach, we test more and that’s why we see more cases, facemasks have only symbolic value” sounds very similar to “don’t let it dominate your life, take it easy, facemasks are a hoax, we test more that’s why we see more cases”.
We vaccinate all to protect a few. We use seatbelts when driving even if they are not 100% protective but, the combination with other safety precautions (like not driving under the influence of alcohol and using infant car seats) amplifies their impact. It is unclear why the Swedish national health authority does not apply the same preventive principles to COVID-19, but has a blind side for facemasks which, if used by many, protect the few, often the most vulnerable ? Where is the classic Swedish solidarity and fact-based public health response? Is it possible that there is an element of national pride and prestige in how it is handling COVID-19?
What Sweden must do now is open up for a wider, more critical and fact-based debate about the national strategy and to correct course as new evidence and learning emerge. Second, establish a centralised authority for preparedness and response with a mandate to bridge the decentralised and fragmented sectors with responsibilities for health and social services, which the government can mobilize when faced with a national health threat, and third, combine interventions to reduce spread and deaths, like facemasks, social distancing and handwashing. Those are the lessons from the exemplars across the world that have managed reduce or eliminate community transmission of the virus, keeping cases, hospitalizations and deaths across the life-course to a minimum.
About the author:
Mariam Claeson is the former director of the Global Financing Facility for women and children, at the World Bank, is a public health specialist who has worked for many years in global health and International development.
The author declares no competing interests
Handling Editor: Soumyadeep Bhaumik