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The Sweden no-lockdown model is bad. It's bad!

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Last night Trevor Noah blankly accepted a Swedish health official’s defense of a policy that let hundreds of elderly Swedes die. The official was state epidemiologist Dr. Anders Tegnell, who masterminded Sweden’s “do what you want” response to the coronavirus: senior high schools have been closed and large gatherings have been banned, but the country has otherwise allowed daily life to carry on as normal, with people encouraged rather than required to stay home and avoid nonessential travel.

Public opinion in Sweden largely favors this approach, though it has led to a death toll—2,679 as of May 4—nearly three times the combined death toll of Norway, Denmark, and Finland, which took more restrictive measures. A high proportion of those deaths has been in elder care homes: 630 of 1,406 COVID-related deaths in Stockholm, for instance, were in such facilities.

Noah, to his credit, asked Tegnell whether he considers Sweden’s approach “successful” in spite of the death toll. Tegnell basically said yes, though he couched it in a string of euphemisms about Sweden’s “holistic” approach to the virus, one that weighs not only the adverse health effects of dying from COVID-19, but also the adverse health effects of staying home from school and work. He also took pains to tie the high death rate to elder care homes, separating them rhetorically from the rest of Swedish society:

I think we're trying to look at it holistically. And I'm not saying we were successful in all different ways. I mean, our death toll is really something we worry a lot about. And it's very much related to elderly people's homes, who have proven to be extremely susceptible to this disease. And we know that there's a number of things, quality-wise, that needs to be addressed in those, and we are addressing them. We have a lot of agencies involved, and we're seeing some improvement. But our death toll has very much to do with that.

In other aspects, many of the things have worked, I think, reasonably well. And I think the good thing is that we've been able to keep schools open. Keeping schools open is very important for children and children's health. We know that for sure. We have been able to keep a lot of people working. And we know that losing your work is very dangerous to your health. So we've been trying to take a slightly more holistic approach to this than maybe some other countries have done.

It would not be hyperbolic to say this boils down to “things are going well, even though we let hundreds of old people die.” It is true that the coronavirus has more severe effects on elderly people, but outbreaks in elder care homes are not a foregone conclusion, and they are certainly not counterbalanced by “children staying to school.” They are the result of bureaucratic and policy failures, such as understaffing that results in high patient-to-caregiver ratios; shortages of personal protective equipment, medicine, and tests; failures to isolate patients with COVID-19; and a lack of clear, accurate guidance from authorities. These are more or less what happened in Sweden:

The [government public health] agency’s advice to those managing and working at nursing homes, like its policy towards coronavirus in general, has been based on its judgment that the “spread from those without symptoms is responsible for a very limited share” of those who get infected.

Its advice to the care workers and nurses looking after older people such as Bondesson’s 69-year-old mother is that they should not wear protective masks or use other protective equipment unless they are dealing with a resident in the home they have reason to suspect is infected.

Otherwise the central protective measure in place is that staff should stay home if they detect any symptoms in themselves.

“Where I’m working we don’t have face masks at all, and we are working with the most vulnerable people of all,” said one care home worker, who wanted to remain anonymous. “We don’t have hand sanitiser, just soap. That’s it. Everybody’s concerned about it. We are all worried.”

“The worst thing is that it is us, the staff, who are taking the infection in to the elderly,” complained one nurse to Swedish public broadcaster SVT. “It’s unbelievable that more of them haven’t been infected. It’s a scandal.”

What is even more galling about the Swedish approach is its stated goal: a level of public immunity that slows the spread of the disease. This is grounded in a belief that people who develop antibodies will not be reinfected. But as public health experts around the world have said again and again, there is no basis for this belief: we have no idea yet whether antibodies provide immunity from reinfection, many antibody tests are inaccurate, and even a low percentage of “immunity” would leave high-risk groups unprotected. From a critique of the Swedish model in the New York Times yesterday:

The results have been mixed. Sweden has the highest fatalities and case count per capita in Scandinavia, but is lower than some of its neighbors to the south. Economic disruption has been significant but not as debilitating as other countries. In the capital, Stockholm, the nation’s top infectious disease official recently estimated that approximately 25 percent of the population has developed antibodies.

It is too early to tell whether the approach has worked. Stockholm isn’t all of Sweden. And 25 percent of its population with antibodies is not cause for an immunity celebration. We don’t know if that percentage is accurate because the data isn’t available, the antibody tests still appear to be of uncertain accuracy, and we don’t even know what a positive antibody test means. There is some optimism that most people who are infected will have some temporary immunity. But if immunity is short-lived and only present in some individuals, that already uncertain 25 percent becomes even less compelling. We also still don’t know what total population percentage would be necessary to reach the herd immunity goal. It could be as high as 80 percent of the population.

So we have to be very skeptical of anyone basing near-term policy decisions on some baseless idea of immunity. Noah, again to his credit, did offer some skepticism; frustratingly, he also let Tegnell get away with obvious bullshit.

NOAH: There have been reports coming out saying that there will be herd immunity achieved, I think, in Stockholm at least, over the coming weeks. What does herd immunity mean for you? And what are you hoping herd immunity will achieve for Sweden?

TEGNELL: I think complete herd immunity, we're not sure any country will ever achieve, because that means that the disease goes away, and I don't really see this disease going away. But even some immunity in the population, like the 20%, 25% that we are reaching now, will have a great effect on the speed of the spread. So with that and the measures we have in place, and with immunity going up, I think there is a possibility that we can ease down on some of the restrictions, otherwise, that we have, so that we, by the immunity level of the population, can have such a slow spread of the disease, that society can start work more or less normally again. I mean, some portion will always be at risk. Elderly people will most likely always be at risk for this kind of disease. But many things we can then ease up a bit on.

NOAH: If somebody said to you, "Dr. Tegnell, you know, your numbers, we understand your methodology, we understand everything you're trying to do, but having triple the death rate of countries like Norway and Denmark means that, you know, you've put some lives above other lives." Do you think that's that's a decision epidemiologists slash governments need to make? Is it an easy decision to make? 'Cause I don't think anybody has the right answer in this regard. But I would like to know, like, how you got—how you and your team got to that place, where you said, "You know what, it's worth the risk. We want kids to be in schools, we want people to still be working, and we understand that that might lead us to have a higher death toll initially."

TEGNELL: No, I don't think—we never really calculated with higher death toll, initially. I must say, that's not right. I mean, we calculated more people being sick, but the death toll really came as a surprise to us. We really felt that our elderly homes would be much better at keeping the disease outside of them… Not that Sweden is the only country with this problem. I mean, many countries in Europe have a problem with elderly homes, which it's very difficult to keep the disease away from that. And even if we're doing our best, it's obviously not enough. So, we are not putting anybody's life above anybody else's life. That's not the way we are working. We are really trying to keep the public health as good as possible in this troublesome time.

NOAH: That's really interesting, 'cause that's not how it's being reported in many places. No, I'm glad you said that. It's interesting to hear it from somebody in Sweden who's part of this directly.

We are not putting anybody’s life above anybody else’s life. We just didn’t consider that it might be bad to leave our elderly citizens to the whims of a virus that does.

I’m glad Noah led Tegnell into this corner. He’s right—it’s interesting to hear someone who sounds nice and credible make a bunch of impossible promises, admit his own catastrophic failures, then brush aside preventable deaths. But Noah should have drilled deeper. Why did Tegnell feel elder care homes would be better equipped? Did his agencies do anything to equip them in advance? If “doing our best” isn’t enough to prevent those fatalities, does that mean they are just built into the model? Why is that a justifiable cost of society returning “more or less” to normal?

It’s monstrous! It’s just plain monstrous to suggest life can go on while scores of your most vulnerable citizens are dying. A competent interviewer might acknowledge this, but Noah’s line of devil’s-advocate questioning goes no further. From the above he proceeds to ask Tegnell how Sweden’s model might work in the US, as though it’s even working in Sweden. This is a ghoulish moral calculus to normalize on a comedy news show that’s extremely popular among young Americans. It’s not just Swedish nursing homes ravaged by the coronavirus; more than 4,800 nursing home residents have died of COVID-19 in New York alone, and that number is likely an underestimate. Last month Gothamist spoke to elder care workers so horrified by their facilities’ conditions that they quit after their first shift. They described patients with gaping bedsores from days of neglect. They described administrators telling them to lie on official records when they couldn’t find a patient’s medication—to note that the patient refused it, not that it was out of stock. They described systemic isolation failures, with workers treating COVID-19 patients sharing elevators with everyone else. They described patients rotting and dying in their beds.

The Swedish model asks us to separate these people from our idea of a functioning society—or rather, to continue separating them, to reverse engineer a nauseating scandal into an unfortunate cost of business. Given the grim news that we are headed towards a daily death toll of 3,000, it is crucial for people like Trevor Noah to condemn policies that leave people to rot and die, not to ask how we might apply them best. I understand that he likes to play the neutral party, asking his interview subjects what they would say to this or that critique, how they might feel about this or that hypothetical. But we are in a moral crisis, now, and there’s an old saying about those who maintain neutrality in times of moral crisis. I’d like to add my own saying to the canon: “Make people feel bad about the people they let die.”


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