“Judge me in a year,” said Swedish public health boss, Dr Anders Tegnell, in July 2020.

The Covid-19 crisis was still in its infancy, but the Nordic nation normally lauded for its social safety net had already emerged as a global pandemic pariah.

Its light-touch approach, which kept open schools, workplaces and cafés and encouraged Swedes to make their own decisions about staying home and social distancing, was presented as the antithesis to New Zealand’s hardline elimination strategy.

Lockdowns would not work, said strategy supporter and former Swedish state epidemiologist Johan Giesecke. They only postponed the inevitable cases and deaths. And keeping the virus out indefinitely would be unachievable.

“I think it’s impossible in a Western democracy. You could do it in China, you can’t do it in New Zealand,” he told Radio New Zealand in May 2020.

New Zealand’s experience – and the success of other countries that eliminated Covid-19 – clearly showed lockdowns were both possible and effective.

https://ourworldindata.org/covid-deaths

But 18 months later, Sweden no longer seems such a global outlier.

It currently has lower case and death numbers than its Scandinavian neighbours and its overall pandemic death toll, per million residents, is lower than the United Kingdom’s.

So was the Swedish experiment a stunning success, or a reckless failure?

What was Sweden’s strategy, again?

Here’s an awkward thing. Giesecke – one of the most public defenders of the Swedish strategy – and Kiwi epidemiologist and architect of New Zealand’s elimination strategy, Michael Baker, are friends.

When Baker did a six-month sabbatical in Stockholm, Giesecke was his host. When Giesecke visited New Zealand, he lectured alongside Baker in Auckland.

But on Covid containment, their views were poles apart.

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Remember herd immunity – the idea that if enough of the population are immune, either from infection or vaccination, the virus will run into so many roadblocks to infection it will eventually die out.

That was the basis of the Swedish strategy. In the early days of the original Wuhan virus strain, scientists estimated if 60-70 per cent of people were immune, that would be enough to achieve herd immunity.

In an April 2020 Good Morning Britain panel moderated by Piers Morgan, in which Baker also appeared, Giesecke made the bold statement that Stockholm would reach herd immunity in mid-May.

That’s where Sweden went wrong, Baker says. Its strategy was based on flawed assumptions.

“The Covid-19 pandemic didn’t behave as expected. Initially, people thought it would behave like influenza. That you’d get a wave of infection that would sweep across the globe, people would get exposed and most would develop immunity and some would die. But most wouldn’t and that would be the end of the pandemic.”

Take New Zealand’s 1918 ‘flu pandemic wave, for example. The wave quickly infected large numbers and killed almost 1 per cent of the population. But in two months, it was gone.

But Covid-19 wasn’t like that. And Sweden never hit herd immunity. So more than 15,000 people died as the virus continued to spread.

In that RNZ interview, Giesecke conceded their strategy had failed to protect the old and vulnerable. But he remained convinced that Sweden’s disturbing initial death toll would not look so bad once other countries lifted their lockdowns and let the virus in.

“You’re pushing your cases and your deaths into the future. They are not disappearing.”

He told Good Morning Britain: “I think we should wait a year in comparing deaths in different countries... In the end, I think they will be about the same in each country.”

Morgan asked if he could be wrong. “Everything is a possibility. But it is highly unlikely,” he replied.

https://ourworldindata.org/covid-cases

How is Sweden doing now?

Giesecke was partly right.

East Anglia University professor of health protection Paul Hunter faced off against Tegnell in an April 2020 debate, defending lockdowns.

But he notes Sweden currently has lower case numbers than its Scandinavian neighbours, despite slightly lower vaccination rates and more relaxed control measures.

“Sweden is in a good position now and that will be down to high population levels of immunity due to vaccine, but more importantly – relative to its neighbours – high levels of prior infection.”

Some studies suggest immunity gained from infection is more effective than vaccination at preventing re-infection, so having had lots of cases should make Sweden more resilient to outbreaks.

But that immunity came at a high price, Hunter says.

“You could say that Sweden bought its current good place by allowing very many more of its people to die last year. About seven times as many Swedes died as Norwegians per head of population and three times as many as the Danish. I don’t think that is a record that Sweden can be remotely proud of.”

Clearly, vaccination has changed everything. Had vaccines not been effective, or not been developed at breakneck speed, the different approaches might have come out in the wash.

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But as it was, lockdown countries loosened restrictions into a very different environment – one in which most people were protected by vaccination. Even way back in May 2020, Giesecke conceded that New Zealand’s strategy could be the best option if it could keep the virus out until vaccines became available.

Melbourne-based Kiwi epidemiology professor Tony Blakely says with hindsight, Sweden did get some benefit by letting the virus spread when the easier-to-control original strain was dominant.

But even if he’d known last year that 2021 would deliver the doubly-infectious Delta variant, he would still have opted for an elimination strategy.

Blakely’s modelling of the health and economic impacts of elimination, tight suppression and loose suppression (the Swedish approach) found elimination came out tops.

“We definitely want to have done elimination till we got vaccinated, so it’s easier to do, but it does mean that we have to go through our bumpy stuff now.”

What we can learn from Sweden, though, is that as long as you have people who refuse to be vaccinated, you will need natural infection to plug the immunity gaps, Blakely says.

“At some stage we need to really learn to live with this virus. Not look at it from across the dancefloor, but actually go and dance with the damn thing... They probably let the virus run a bit too much initially, but in a year’s time or two years’ time, we may actually decide that the Swedish approach wasn’t a bad one.”

Baker says Sweden’s strategy is now fairly mainstream, but vaccination changes the maths.

“We are seeing all high-income countries gradually converging on a similar approach, which is essentially highly vaccinated, with some social and public health measures retained.

“But in year two you have got vaccines, so it’s quite a different situation. With or without a more infectious variant, the outcomes are just completely different.”

But here’s a confounding statistic – Britain’s cumulative death toll is 2145 per million, while Sweden’s is 1494 per million.

Britain started out with a Sweden-style herd immunity strategy, but changed tack after an Imperial College report predicted that it could result in 510,000 deaths, sparking panic and outrage.

That eroded trust in the government, Baker says.

“Because the UK flip-flopped on its strategy, they did get much worse outcomes, I think.”

 

How does Hunter explain Britain’s higher death toll?

“You cannot compare Sweden with the UK – entirely different country, different lifestyle, different demographics and different economic inequality, all of which will have a big impact on mortality from any disease.”

Is it even useful to compare countries?

We’ve seen it time and again throughout the pandemic – Ireland is great; Ireland is having a ‘mare; Be like Singapore; Singapore is swamped. So is it meaningless to compare countries?

Blakely wouldn’t go that far, but does advise caution. There are two problems – the first is Hunter’s point, that two countries can have very different characteristics, which affect how the pandemic plays out.

Sweden, for example, has low population density and one of the world’s highest proportions of people living alone. Given Delta tends to infect everyone in a household, that could have a huge impact.

An August 2021 comparison of different countries’ approaches to the first pandemic wave estimated death rates in Britain would have doubled had they adopted the Swedish policy, while Swedish deaths would have more than halved if they’d used the British or Danish strategies.

The second problem is that the outcome of outbreaks can turn on the smallest things, including whether the virus reaches the areas where it can spread quickly, Blakely says. In Melbourne, that was aged care. In Singapore, it was migrant worker dorms. In New Zealand, it was gangs and marginalised communities.

“The vast majority of the time, what I did four weeks ago at 3.10 in the afternoon has no consequence on humanity. But if I happen to have gone into a rest home and kicked it off, then that one action of mine has a major impact.

“Cross-national comparisons are useful, but people have placed too much reliance on them, because they think that if exactly what happened in Sweden happened in New Zealand, then the outcome would be exactly the same. Well, you can't get exactly the same circumstances, and you've also got things like seasonality, you've got different social structures between places. So things can play out differently.”

As a predictive tool, country comparisons need to sit alongside modelling and theory, Blakely says.

“What happens in the real world in Sweden is essentially like just one run of a time machine in a model that does it thousands of times, to see what could have happened.”

Baker says comparing countries is useful, but cautions against getting too hung up on any one measure. Cumulative deaths only tell part of the story. Measuring years of life lost is better, as it takes into account age at death.

Research analysing life expectancy changes in 37 countries put Sweden in the middle of the pack, with a 0.75 year loss, well behind the two-year losses of Russia and the United States. In Taiwan and New Zealand life expectancy actually increased, because lockdowns also kept out other fatal illnesses.

But you have to also consider the economic and human rights impacts of restricting people’s freedoms, Baker says. So far, elimination has performed best on all those measures, but that might not have been a feasible option for countries with porous borders.

“What measures would you say would define success, overall? I think that will be quite a big discussion topic... In the end, it’s partly about how societies value the choices these governments are making. And inevitably, there are quite complex tradeoffs.”

Giesecke declined an interview request for this story. But he is not yet about to admit he was wrong.

“Far too early to evaluate and compare. Lead tables still changing by the week. The pandemic is still on,” he says.