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Second Look at Sweden’s Response to COVID-19
It’s not too late to learn from Sweden‘s management of the COVID-19 pandemic. As the first phase winds down and the results can be tallied, it is clear that Sweden is in an enviable position both economically and medically.
Rather than relying on speculative models to justify draconian policies, Sweden’s public health officials noted the lack of evidence that social isolation mandates could reduce COVID-19 deaths over the full course of the virus. Plainly put, you can change the timing of the damage but you can’t make the virus go away.
So Sweden pursued a policy of targeted precautions rather than the shotgun approach adopted in the US. Only the most vulnerable were isolated. There was no lockdown. Businesses stayed open. Students attended school. Patients continued to receive non-COVID medical care.
So what happened? Swedish hospitals never suffered the crush of ICU patients predicted by our experts if we were to adopt such “reckless“ policies as they did. It turns out that shutting down the economy and practically imprisoning the young and healthy weren’t necessary to flatten the curve.
Sweden recently reported 265 deaths per million population, less than many of its locked down European neighbors, but slightly more than the 204 reported at that time in the US, (where multiple reports of overcounting are emerging).
Sweden has a more elderly population than the US and didn’t initially do a good job of protecting nursing homes. As a result, 90% of Sweden’s deaths were over 70 years old, half were over 86, just one percent were under 50. Age adjusted, Sweden‘s case rates and death rates are comparable to ours, maybe better.
That’s where the similarities end. Sweden, because they didn’t isolate their non-vulnerable population, is positioned to achieve herd immunity possibly as early as this month. We are facing a probable “second wave“ sweeping through our non-immune, formerly quarantined population as we return to normalcy.
Unlike pretty much everywhere else, Sweden isn’t facing the tough choices of when and how to end social isolation. They don’t have to select who goes free and whose civil liberties to violate.
Moreover, Sweden’s economy suffered nothing like the crippling damage inflicted on ours. Their recovery will be much quicker and easier. There will be no deluge of the “deaths of despair” that accompany economic catastrophes. They won’t have to cope with a new mountain of government debt.
It’s easy to second-guess now, although many of Dr. Fauci‘s worst recommendations were first-guessed at the time. What’s done is done. But there’s no excuse for missing the boat again, now that the outcomes of the contrasting strategies can be seen.
Unfortunately, many experts are choosing to nitpick Sweden’s success, seeing it is an affront. So we still have governors like Cuomo and Newsom claiming that, based on Fauci’s advice, they can’t end the lockdown until it is “safe“ and we know there will be no increase in cases.
But we know now that’s not necessary or even possible. We were told we were at war with the virus and our main weapon, for now, was isolation. But viruses can’t be eliminated by permanently denying them hosts. At some point life has to go on.
Only immunity can provide protection. In the absence of a vaccine, that means herd immunity, accepting that the virus will run its course, while protecting those likely to perish from it.
Another lesson is that experts should be consulted but not in charge, Particularly when opining from models, rather than controlled experiments or experience, they’re often wrong. Moreover, they’re not qualified to determine whether following their advice is worth the economic and social costs. That’s a decision we all share.
Finally, we should have learned by now that government taking over our lives and throwing gobs of money at the problem doesn’t work. Rather than shutdowns and subsidies, we should have relied more on the personal decisions of informed citizens.
Because of our extreme risk aversion, we conducted a massive novel experiment, the first-ever attempt to defeat a viral epidemic by isolating millions of well people and shuttering business activity. We have squandered trillions. It’s time to move on.
Published in Economics, Healthcare
R0 is one of those things that doesn’t change. It is a constant for a disease. Rt, however does change as a function of time and takes into account various interventions.
For example, a disease with an R0 of 2-3.8 cannot achieve that result if the population has an immunity greater than 51% or greater. The Rt could be a max of 3.8 at the start but would decrease over time to result in less than 2.0
Belarus is a low trust country. SInce I don’t have faith in their crime statistics, I also don’t have faith in their public health statistics.
South Korea has been remarkably transparent, so I trust their data.
The rest of the world (excluding Singapore, Western Europe, and other more transparent countries), I have zero faith in their numbers.
Sort of. It depends on whether superspreading is due more to the individual superspreader or to a certain set of environmental settings.
If superspreading is primarily caused by a small subset of infected people with ridiculously high viral loads, it would probably be very difficult to identify them in advance.
But if superspreading is caused by people with normal infections who end up in situations that promote transmission to dozens of people in a short amount of time, we could intervene to prohibit/alter those situations. I’m sure by now most people have heard the stories of a single person infecting twenty or more others in a bar, a long (and loud) bus ride, or a choir practice (interestingly, there are very few reports of transmission on airline flights so far). There certainly seems to be a trend of lots of people tightly packed in an indoor spaces with lots of loud talking/singing.
You’re assuming that all of the countries you mention did an equally good job of testing their populations. We know for a fact that isn’t true.
I think you’re falling for the illusion that Germany, France, Italy, etc. have all detected a similar percentage of their total cases. But Germany has tested a higher percentage of its population than most other countries from day one. It seems likely that Germany may have “only” been missing about 1/2 to 3/4 of its total cases, whereas Italy, Spain, etc. have been missing 90% or more – this was recently suggested for Spain by the largest antibody test in the world to date. Once you adjust for differences in percentage of cases missed, the fatality rates start to even out.
Even then, Germany’s rate will likely be somewhat lower than the hardest-hit countries. I wouldn’t necessarily attribute this to doing a “better job” of protecting the elderly – we’ve actually had fewer restrictions in place than neighboring countries, and we have the same pattern of about half of all deaths being in nursing homes. I think the explanation is likely more that keeping overall transmission down is the most effective way of “protecting” nursing homes, simply because the virus shows up at fewer of their doorsteps.
Germany does have a pretty large army of contact tracers. They started recruiting college students whose college classes got cancelled back in March.
On the other hand, one reason German contact tracing has been successful without some omnipresent shadow security force is precisely because they’ve managed to keep case numbers manageable from day one.
There’s a positive feedback loop to starting contract tracing early: by interrupting the growth in transmission before it reaches the spiraling-out-of-control phase, you naturally keep the number of people who need to be traced within manageable limits. Conversely, once the virus starts really spreading like crazy, no amount of contact tracing will ever help. Germany has managed to stay on the good side of that inflection point from day one.
That was one of the major arguments against re-opening by the public health experts a few weeks ago: they said once the virus started spreading again, our contact tracers soon wouldn’t be able to keep up, and we’d find ourselves in an Italy or Spain scenario. Luckily, sanity prevailed and we’re on track to be more “open” than Sweden within a week without explosive growth.
I think that’s the bigger question right now: why hasn’t the virus exploded in all of the countries that re-opened over the past month? My guess is that warmer temperatures and the “light-touch” social distancing still in place are playing a major role.
Dogs. We need sniffer dogs.
Now that we have confirmed reports that people can pass the virus to their pet minks, I call for a sentinel mink in each house.
Dead mink at home = Quarantine for you.
Just to add a little more detail to a few previous points for any nerds still reading.
Looking just at the static number of tests/million is pretty useless. As @ryanm has pointed out a few times, simple rote testing isn’t always useful.
One big difference in testing between, say, Germany and the UK is that Germany front-loaded much of its testing before its epidemic really got going. That provided two benefits: 1) there was enough excess capacity (relative to cases) to detect lots of presymptomatic/asymptomatic cases before they could transmit to others. This is where judicious contact tracing came in handy. 2) it gave everyone a heads-up about where the virus had already landed, which led to many municipalities imposing Sweden-style light-touch social distancing at a point in time when it was most effective.
Contrast that with the UK: they didn’t ramp up their testing capacity until the virus was already widespread. As a result, they had to focus on testing people showing up to the hospital with Covid symptoms. The added value of testing is very limited in that scenario: when doctors are already 95% certain that a patient has Covid, a positive test result doesn’t change the way that patient gets treated.
Another interesting point: Germany is presently only using about half of its testing capacity. We have capacity for 900,000 tests/week, but are only registering about 500-1,000 new cases/day. So another reason why our test numbers are equivalent to, say, the UK is because we haven’t been testing much for the last two weeks, whereas they have been testing furiously just to play catch-up.
Bottom line: when testing is used simply as a rear-guard maneuver, as in the UK or Spain, having large numbers of tests really doesn’t impact the outcome much. Intense testing before the transmission inflection point combined with contact tracing/isolation almost certainly made a big difference in Germany.
To add a little more detail here as well:
Germany’s elderly have indeed been less sheltered than in almost any other western European country, including Sweden, France, or Spain.
For example, in many of those countries the elderly were prohibited from leaving their houses at all. Here, they were been a constant presence in supermarkets and on the streets all through the lockdown. And while Germany doesn’t have as many multigenerational households as, say, Spain and Italy, we also don’t have separate neighborhoods or residential complexes for the elderly, so they’re definitely not naturally isolated from younger generations.
Also consider that Sweden is still prohibiting nursing homes from receiving any outside visitors, whereas family members have been allowed to visit relatives in nursing homes in Germany for quite some time now – and despite that, our rate of elderly/nursing home deaths has been lower than Sweden’s.
Policies regarding which nursing home patients get sent to hospitals or when they get sent back from hospitals to their facilities are usually decided on a local level in Germany so it’s hard to compare those policies with other countries.
Either way, though, Germany has generally taken considerably fewer active steps to protect its elderly than the countries with higher death rates.
I’m semi-serious. There are trainers working on this. Dogs have been trained to detect certain cancers and other diseases. If they could be trained to detect COVID-19 carriers, they could be used at the entrances to malls and other places where crowds congregate.
Now, if they get infected and it affects their CNS the way it does ours — lost sense of smell — that would pretty much defeat the purpose, sadly. But, I’d like to see some trainers and their dogs allowed onto the hospital wards where they’re treating WuFlu patients to find out how this might work.
Interesting point!
A paralell scenario happened in my wife’s hospital in the U.S. At first, tests were hard to come by and they couldn’t get enough of them, especially because many test kits were re-routed to New York City who were being swamped with cases. Many people with Wu Flu symptoms were not tested and told by their doctors just to remain at home and wait this thing out. About a month ago, the test kits were becoming more numerous and the referred patients less numerous, finally causing a surplus of test kits. Hers and other hospitals have recently been testing more healthcare workers and in-patients, who had not been tested previously, and they are stockpiling the other excess kits so they can use them in upcoming studies on the virus.
This is a fascinating story that I have not seen mentioned anywhere in the Press or in discussions on Covid. Perhaps we should be examining Germany’s practices more than Sweden’s?!
You sure know how to think outside the box! Perhaps you’re on to something.
Not my original thought. I saw a headline go by. Someone is working on this.
I think there are important lessons to learn from both.
But I don’t think US states should try to emulate either. Most US states don’t bear much if any resemblance to either Germany or Sweden (or South Korea) in terms of demographics, density, lifestyle, health infrastructure, and so forth. What worked in another country may or may not work in any given US state, but the optimal solution is probably a different one in each state.
That’s why I find the premise of the original post here (“hey, look at what that country we usually ridicule is doing! Let’s do that”) or some of the comments attempting to argue that German health authorities don’t actually understand their own success to be ridiculous exercises. Just because a certain strategy worked in a different country doesn’t automatically mean every (or any) US state has to adopt it.
It frustrates me to hear how many US states seem to be either going for the gold-plated contact tracing scheme (and thereby keeping lockdowns in place indefinitely until they are in place) or bumbling backwards into re-opening without any meaningful plan at all. I know there are a few exceptions (like Texas, Arizona, maybe Utah and Florida?). But there are now a large number of tools available in the anti-Covid toolshed that states could be using to craft unique solutions that fit their own situation. That’s why I’m dismayed when an expert like the OP here just blindly points to another country and says “let’s copy them!”.