Sweden’s chief epidemiologist challenged a wide array of public health practices — from wearing masks in public to keeping young children home from school — that countries are using in the fight against COVID-19, in an interview with the International Center for Journalists (ICFJ) Friday.

Dr. Anders Tegnell also cast doubt on the likely availability of new therapies and vaccines in the near future. From the outset of the pandemic, Sweden, under Tegnell’s leadership, has embraced a herd immunity approach to managing the outbreak. Sweden’s controversial public health policies have encouraged personal responsibility for physical distancing and other measures, offering recommendations to citizens without imposing strict emergency orders.

“The Swedish model is showing you can get very far by voluntary measures," Tegnell said, in a webinar moderated by ICFJ President Joyce Barnathan. The conversation was sponsored by ICFJ’s Global Health Crisis Forum in partnership with the Embassy of Sweden in Washington.

Other nearby countries, such as Finland, may have lower transmission rates than Sweden, but Tegnell said it will be difficult to keep those rates down when daily life returns to normal - and 99 percent of the population is still susceptible to the disease. Meanwhile, Sweden’s approach has already led to about 25 percent immunity among its population. 

In Sweden, early detection of the novel coronavirus in the population made the less-harsh restrictions feasible. “We were very much alert, so we saw cases very early on,” he said. By the time many countries knew there were positive cases in their populations, the number of those cases were already spreading at a rate that would soon overwhelm hospitals. “This was probably due to limited testing in other places,” he said.

Here are key quotes from the conversation:

How Sweden chose its approach to managing the pandemic

“I think we started out using the methods that we always use in public health. Having sort of a conversation with the public, putting a lot of trust in the public and giving a little responsibility to the individuals, which is exactly what our communicable disease laws are telling us to do. And by following the pattern. Doing this, we could keep the number of cases down, and we could keep our health services working.”

"We did a number of smaller things…. We also looked at the restaurants, which we knew from Italy and Austria and other places were places of great transmission. And we tried to minimize the transmission in those places. So in general, we said we don't want to lock down the whole thing. We want to sort of close down and minimize the transmission in areas where we know that is a high risk of transmission.”

On why Sweden’s death toll has been higher than that of neighboring countries

“We found that the big explanation behind it was really a lot of deaths in our elderly homes. And these are elderly homes in Sweden, which are not just for any kind of older people, these are suffering people who are really ill and very old,” he said. “And unfortunately, we had a big introduction to those homes, especially in the Stockholm area. And that accounts for more than 50 percent of all the deaths that we experienced in Sweden.”

On outbreaks in Sweden’s nursing homes

“I think we have known for a long time that the quality of care in those facilities has not always been up to standard, especially in the area of hygiene procedures. And there has been a number of investigations telling us that, no, the level is not high enough. And we also know that we get spread of antibiotic resistance, and so on, in those facilities. So they were known to be a weak part.”

“The number of cases in those [nursing homes] are slowly coming down, especially in the Stockholm area. And the actual death toll is falling slowly, but falling.”

On whether shutting down an economy saves lives

“We are now getting results from several countries showing that our Nordic neighbors, maybe 1 to 2 percent of the population are now immune, while the estimate for Sweden is around 25 percent. So of course, we are much further into this epidemic, and much closer to having a level of immunity in the population. That would help us very clearly to keep a low number of cases every day while having a very open society,” he said. “If this translates into death tolls exactly remains to be seen.”

On whether Swedish hospitals were overwhelmed

“The national board of health and welfare who takes care of this, they say that there has been no time during this pandemic in Sweden where we have had less than 20 percent of the beds free. And then beds are really beds, they are beds with staff, facilities, everything in place.”

On the focus of Sweden’s approach to managing the pandemic

Our goal has always been to keep the level of spread down low enough for our health system and for society as a whole to keep on functioning at a good level. And I think we have managed to do that in Sweden with, of course, the very sad exception of the high death toll we have,” he said. “We also know that eventually we would get help from the immunity in the population to keep the level of spread down. And in the long term, only a level of immunity in the population will keep the spread down to a reasonable level until we have a vaccine, which is going to be quite far off.”

On whether contracting COVID-19 provides immunity

“Normally you measure immunity by the number of antibodies you can find in the blood. The level of antibodies among different cases seems to vary a lot. So it's going to be a bit tricky on the individual level to estimate if somebody is immune,” he said. 

“On the other hand, it is quite certain that immunity does exist. And I think there is a lot of proof of that,” he said. “I mean, for all the cases we have had in Sweden, there has not been one single person who had this disease twice. And we have a very strict identification system. So there is no way we would miss a person who had it twice.” 

“I haven't heard any reports from any countries where there has been a certified case who has actually had this twice. There's been rumors about it. But in the end, they have been disclaimed. So I think that's not the problem. The problem is to say if an individual will be immune so that you can tell this person, you will never have this disease. And that's where we still don't know because we don't have long enough observation [periods], because we are not quite ready yet to say what level of antibodies is protective. And maybe there are other parts of the immune system that provide protection that antibodies would not do. And for how long this immunity would last. [Our] virologists said at least three to six months. They would say it's a minimum, but nobody knows because we haven't observed this for very long yet.”

“We think that the now-slowed decline of the number of cases in Stockholm is due to the level of immunity in the population because we do see a drop of cases and we haven't really changed any measures for the last four or five weeks,” he said. “If anything, there is a slight sign that adhering to social distancing and so on is maybe a little bit less now than it used to be a few weeks back. So the one reason we can see for this slow decline of cases, is really that there must be enough immune people in the population to keep the spread down a bit.”

On countries that issued stay-at-home orders, then plan to gradually open

“I think these countries are thinking about the same thing that they want to have a slow spread of the disease. And I think the lockdown, at least in some countries, is due to a very rapid increase of cases. And then these sort of softer measures [such as those Sweden is using] might not have stopped that,” he said. Now, “maybe a level of softer measures can keep the level of new cases down.”

On using testing and contract tracing to make decisions about opening economies 

“If this thing about testing a lot, contact tracing and so on would really make this possible, that remains to be seen. I mean, we're talking about a huge undertaking in a country like Denmark,” with its population of four million. “They are going to employ 18,000 people just to do the tracking. And that does not account for all the testing personnel and so on, so this is a huge investment by society to do something. Really, I'm not quite sure about how well it's going to work because [COVID-19] is a tricky disease.”

On why Sweden has not recommended that its citizens wear cotton masks in public (as many other countries have): 

“I think for two reasons. The first reason is that the science behind this is not very strong. I think everybody I talked to points back to one study from Hong Kong, a very theoretical study where they've studied how droplets pass through, mostly some droplets containing different kinds of viruses, not COVID-19, but similar kinds of virus. It might be true, but it's one small study. It's never shown that it's going to work out in public.”

“In Sweden, one of our strong policies has been if you feel the least bit sick in the morning, stay home. And we are afraid that if we start introducing masks, people will, instead of staying home, put on the mask and go to work, go out and shop and so on. And that will definitely be a lot more spread around those people than people staying home and isolating themselves.”

“Our government has made it possible to stay home for the first time because you get your sick pay from the first day from the government. So there is no financial incentive to go away to work. You can safely stay home and you keep on getting the same kind of money.” 

On Sweden’s decision to move to distance learning for secondary and college students

“The reason why we said that high schools and universities should go to distance learning is twofold. One, that we know that distance learning works quite well in that context. It's used quite a lot of universities and to a certain extent already in high schools. So they will still get their education and thus the system will still work. But on the other hand, they traveled quite a lot, especially in universities, but also in high schools. You tend to sometimes travel quite long distances between your home and a high school.”

On whether children are 'super spreaders' of the virus

“There is no such evidence whatsoever [that children are spreading the virus at high levels]. We see extremely few cases among children. Among the 15,000-16,000 [COVID-19] cases in Sweden, only 200 were among people less than 20 years of age. So we don't see much disease in those age groups.”

“And then people say, ‘OK, children still have the disease but don't get very sick.’ Children do have the virus now and then. But there is very little evidence that this spreads the virus from children to adults.”

The International Center for Journalists (ICFJ) is connecting journalists with health experts and newsroom leaders through a webinar series on COVID-19. The series is part of our ICFJ Global Health Crisis Reporting Forum — a project with our International Journalists’ Network (IJNet).

Homepage image by Frankie Fouganthin.