The Swedish COVID-19 strategy revisited

In December, 2020, we wrote about the Swedish response to the COVID-19 pandemic.¹ Our hope was that our Comment, together with hundreds of other fact-based articles, would gain the attention of the Swedish Public Health Agency (Folkhälsomyndigheten [FHM]), that they would revisit and change the national strategy that they had designed so that it would be more aligned with global best practice, and that the political decision makers would act on it. They did not. Since then, the FHM has recorded more than 5600 deaths from COVID-19 in Sweden, and cases and deaths continue to rise as we face the third wave without any widespread sense of gravity or urgency.

The debate among critics of the Swedish national approach to the pandemic has been consistent since March, 2020: be strategic, test and trace more, follow the growing evidence base and recommend the use of face masks, and enforce regulations about physical distancing and ventilation, especially in schools if they are open. Some critics have advocated for more government-led legal interventions such as reinforcing quarantine or lockdown. It has been a call for timely implementation of basic principles of pandemic prevention and control to contain the spread and flatten the curves of hospitalisations, deaths, and chronic illness.

Instead of following evolving evidence, the FHM has doubled down and defended its approach without reconsidering the assumptions on which the failed national approach is based. It has downplayed the roles of asymptomatic spread, aerosol transmission, children as potential source of infection, and the use of face masks. It has maintained an approach that mainly builds on recommendations to take voluntary actions, guided (in our view) more by public opinion than by sound public health policy. The media has played a crucial role in this pandemic response, mostly lacking in investigative journalism and failing to question or hold the public health agency accountable, with some exceptions.² Dagens Nyheter, a major newspaper, recently exposed³ Sweden's large inequities in COVID-19 deaths across income, education, and origin of birth—data that should have informed the national strategy from its inception.

As of April 16, 2021, more than 13 700 people have died from COVID-19 in Sweden. The country has one of the highest infection rates in western Europe according to Our World in Data COVID-19 statistics, with 606 new infections per million per day, while its neighbours Denmark, Finland, and Norway reported 115, 62, and 112 new infections per million per day, respectively (April 15, 2021). New and more infective and deadly variants have taken over, and by April 15, 2021, the UK SARS-Cov-2 variant was supected to have caused 75–100% of all new cases in all regions. This indicates more rapid spread, more deaths, and that more young people will be affected, with intensive care units already at full capacity in some regions.⁴

While other countries are closing down in response to this new surge in cases, Sweden is opening up—high schools were opened on April 1, 2021. To continue on the same trajectory in the face of current trends, without timely action by agency and government leadership, raises concerns about governance and accountability, and ultimately about fundamental ethics and values.

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We declare no competing interests.