Hedvig Gröndal
There has not been a general lockdown in Sweden due the corona pandemic, in stark contrast to many other European countries. In Sweden, primary schools and day care centres for children have remained open and so have shops and restaurants. There are no curfews, and most measures aimed at hindering the spread of infection are not enforced legally, but voluntarily. In short, the policy states that the public is strongly advised to self-isolate when showing symptoms that could be Covid-19, and persons over the age of 70 are told to avoid social contact altogether. People are also generally advised to perform social distancing. Universities and secondary schools practice distance teaching instead of teaching on campus. Restaurants are only allowed to have seated guests and crowds over 50 people are prohibited.
Within and outside of Sweden, the Swedish corona strategy has stirred up reactions from researchers, politicians and news media: ranging from harsh criticism to interest and support. Here I discuss the Swedish corona strategy from a sociology of science perspective. I argue that characteristic of the Swedish strategy is how it emphasized not only short term, but also long term risks, and that it draws on cooperation not only with humans, but also with the corona virus itself. As such, the strategy has parallels to Swedish work against antimicrobial resistance.
In international media the Swedish corona strategy has been described in terms of an “experiment” on the Swedish population, as “naive” , and as prioritizing economy over human lives. The strategy has been strongly criticized within Sweden too, both from researchers and influential opinion-makers. The critics stress that the death toll in Sweden is much higher than in the neighboring countries: Denmark, Norway and Finland – which have implemented full lockdowns. Researchers have – often referencing the famous Imperial College report and such like – claimed that the Swedish Public Health Agency has ignored scientific evidence and largely underestimated the epidemic. It will very soon spiral beyond control, they say, wrecking the health care system with enormous death tolls as a consequence. Thus, researchers and others have argued that Sweden, should enforce a lockdown akin to the rest of Europe in order to stop the spread of infection.
The Swedish Public Health Agency – the expert agency responsible for the strategy – and its defenders, argues that the Swedish corona strategy is evidence-based and effective. They claim that various measures implemented in other countries – school closures and border closure, for example, are mainly the result of politicians wanting to boast strength, not of scientific evidence. While critics within Sweden have voiced that the epidemic should be “stopped”, the Swedish Public Health Agency has (since public spread was confirmed in Sweden in the middle of March) argued that this is not a realistic scenario.
The agency instead pursues the goal of slowing down the spread of infection to a manageable rate for the health care institutions and to direct the spread to the healthy, away from the most vulnerable. The concept of herd immunity is not described as a strategy per se, but as the inevitable outcome of the epidemic. Immunity in the population is described as something that, hopefully, will reduce the consequences when a plausible second or third wave of the epidemic occurs. A lockdown might, according the Swedish state epidemiologist, possibly reduce the death tolls in the short term, but in the long run all countries will probably have to go through the epidemic before any vaccine will be available. This, he argues, makes it problematic to compare death tolls between countries at this point in time. Moreover, he describes the removal of lockdowns as possibly causing dangerous spikes in the spread of infection.
Additionally, the Swedish Public Health Agency argues that lockdowns in general, and school closure in particular, might have more negative effects on public health – especially for unprivileged children – than the corona virus itself. Johan Carlson, the director general of the agency has argued that locking down democratic countries and “locking up” populations should be considered the real experiments, and are most likely not a sustainable strategy. The Public Health Agency moreover describes the voluntary rationale of implementing disease prevention as the established manner of working successfully in a Swedish setting – referring among other things to the Swedish child vaccination programme which is voluntary and has a very high coverage.
So, how can we understand the Swedish strategy? Is it true that while other countries are ruled by politicians who steamroll expert advice, Sweden’s strategy is more knowledge based? Probably not. However, the opposite – that Sweden is not acting in a knowledge based manner – is also likely false. No single policy – and no corona strategy – is given by scientific knowledge, or evidence, alone (cf. Jasanoff 2004). This is due to several things: Scientific knowledge tends to be characterized by uncertainties, even tensions – especially regarding new phenomena such as the corona virus. For example, representatives of the Swedish Public Health Agency have criticized the Imperial College Report while being – seemingly – more attentive to other studies and forms of knowledge.
The production of policy always requires decisions about how to handle scientific uncertainties and tensions: Which knowledge is more robust, and – maybe even more importantly – which knowledge is useful? The policy making process also involves decisions about how different values and risks should be managed and balanced. For example – what is most critical: the risk constituted by corona virus today, the risk during a likely second virus outbreak, or the long term risks created by lockdowns? Moreover, policy makers need to consider what is actually practically doable (Knaggård 2014), for example: what kind of restrictions are people likely to follow, and for how long? These decisions are, of course, context dependent. It is therefore entirely expected that corona strategies differ between countries – it is more surprising to see how much the responses, at least up to this point, have been so similar.
The Swedish corona strategy is the product of a number of factors. As a sociological researcher into policy for antibiotic use, I find two related aspects of the Swedish strategy especially interesting: First, how the strategy not only accounts for the risks related to the corona virus now, but also accounts for more long term risks – both directly related to the corona virus in a second or third wave, and related to lockdowns. Here there are similarities to how antibiotic use and antimicrobial resistance have been managed in Sweden. Policy for prudent use of antibiotics due to the risk of antimicrobial resistance also emphasize accounting for not only the risk here and now, but future risk as well. Sometimes there are tensions between these forms of risk. In Swedish public health policy, antimicrobial resistance and antibiotic use is a highly prioritized matter.
More specifically, the importance of antimicrobial resistance – and thus long term risks – is a well established priority in the Swedish disease control organization (Gröndal 2018a). This state of affairs appears to have been successful – the use of antibiotics is very low in Sweden in an international perspective. Second, I argue that the Swedish strategy draws on managing the corona virus through acceptance of, and even cooperation with, the virus. The virus is not described with war metaphors, but as something that we will most likely continue to live alongside. Through directing the virus to those whose immune systems who will most likely manage it, the infection becomes part of the solution and maybe even a means to protect the vulnerable. Thus, in this sense, the Public Health Agency tries to cooperate not only with its population (through voluntary policy), but also with the virus itself (Hinchliffe and Ward 2014). Also here there are similarities with how policy for reducing the use of antibiotics in Sweden – for example the national guidelines for managing throat infection – draws on flexible relations to, and a kind of cooperation with pathogens (Gröndal 2018b)
We don’t know how this will end. Defenders of the Swedish strategy claim that the strategy is working since the curve has been flattening out, and the death tolls are lower than various countries utilizing lockdowns – Italy, Spain, United Kingdom, Belgium etc. The health care system is still operating (however burdened). During the last few weeks studies suggest that a large fraction of the population in Stockholm – the part of Sweden most impacted by the spread of the virus – has already had the infection, something that, according to The Public Health Agency, has likely already slowed down the spread of infection. Moreover, the agency believes that herd immunity might be reached in the Stockholm region by the end of May. On the other hand, it is uncertain how long immunity will last. In addition, the virus has spread in several homes for the elderly, which is a failure of directing the virus from the most vulnerable. Considering the complexity and the time horizons involved, however, the evaluations of the strategy and the varying forms of success and failure will not be a straight forward matter.
References:
Gröndal, H. (2018a). The Emergence of Antimicrobial Resistance as a Public Matter of Concern: A Swedish History of a “Transformative Event”. Science in context, 31(4), 477-500.
Gröndal, H. (2018b). Harmless, friendly and lethal: antibiotic misuse in relation to the unpredictable bacterium Group A streptococcus. Sociology of health & illness, 40(7), 1127-1141.
Hinchliffe, S., & Ward, K. J. (2014). Geographies of folded life: How immunity reframes biosecurity. Geoforum, 53, 136-144.
Jasanoff, S. (Ed.). (2004). States of knowledge: the co-production of science and the social order. Routledge.
Knaggård, Å. (2014). What do policy-makers do with scientific uncertainty? The incremental character of Swedish climate change policy-making. Policy Studies, 35(1), 22-39.
Hedvig Gröndal holds a PhD in Sociology and is currently employed as a post doc at the Swedish University for Agricultural Sciences where she researches antibiotic use in livestock.