In just a few short months Anders Tegnell, architect of Sweden’s unique response to the Covid-19 pandemic, has gone from unknown physician and technocrat to a household celebrity in Sweden and in countries around the world. He is beloved by some (people have even had tattoos made with his face) and intensely disliked by others. Today he is suntanned and relaxed, having just returned from his summer holiday, and wearing an open-necked polo shirt.
After all these months, does he now think that his strategy is a failure or a success? A bit of both, he says quickly, but emphasises more of the latter:
“I think to a great extent it’s been a success. We are now seeing rapidly falling cases, we have continuously had healthcare that has been working, there have been free beds at any given time, never any crowding in the hospitals, we have been able to keep schools open which we think is extremely important, and society fairly open — while still having social distancing in place in a way that means that the spread of the disease has been limited.
The failure has of course been the death toll … that has been very much related to the long-term care facilities in Sweden. Now that has improved, we see a lot less cases in those facilities.”
Mortality is hardly an afterthought — so why is Sweden’s mortality rate so high? At around 550 per million of population, it sits just under the UK and Italy but far above neighbouring Norway and Denmark. Dr Tegnell offers a collection of reasons: with its larger migrant populations and dense urban areas, Sweden is actually more similar to the Netherlands and the UK than it is to other Scandinavian countries; he believes the Swedish counting system for deaths has been more stringent than elsewhere; also, countries are at different points in the epidemic cycle so it is too early to compare totals.
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The one thing he doesn’t mention in this list is that Sweden, uniquely in Europe, did not impose a mandatory lockdown at any point. Is he really claiming that this is not even a factor?
“I am not sure that it is easy to say that lockdown would make the difference … in many ways we have had a very stringent lockdown in Sweden. We have cut down on movement in society quite a lot: we have compared how much we travel in Scandinavian countries, and the decrease in travel is the same in Sweden as in neighbouring countries … In many ways the voluntary measures we put in place in Sweden have been just as effective as complete lockdowns in other countries. So I don’t think complete lockdown is the way to go for all countries … the rapidly declining cases we see in Sweden right now is another indication that you can get the number of cases down quite a lot in a country without having a complete lockdown.”
I ask again: is he claiming that lockdowns make no difference?
“We don’t know. It would have made maybe some difference, we don’t know. But on the other hand we know that lockdowns also have big other effects on public health. We know that closing schools has a great effect on children’s health in the short and the long term. We know that people being out of work also produces a lot of problems in the public health area. So we also have to look at what are the negative effect of lockdowns, and that has not been done very much so far.”
Tegnell points out the huge differences between different areas in Sweden — parts of the South that have had much lower Covid-19 than Copenhagen just over the water while Stockholm has had it much worse, despite the same lockdown policy nationwide. This he puts down to the volume of original introduction of the disease due to international travel:
“There seems to be a close connection to how many people introduced the disease at the same time… The spring holidays in Sweden are spread over four different weeks depending on different geographical regions. Unfortunately Stockholm happened to have its spring holiday just when there was an enormous spread of Covid-19 in Europe … so a lot of Swedes living in the Stockholm area came back with the disease. And that started an epidemic on a level that was much higher than the start of the epidemic in the South of Sweden, or in Finland or in Norway. Currently that’s to me the most likely theory – that if you have a massive introduction, it’s going to be a disease that is very, very hard to control.” Stockholm, in other words, was more like London or New York than Oslo or Helsinki in terms of introduction of the virus.
He believes strongly that eradication — the zero-tolerance approach that is increasingly winning the day in the UK and US — is not a viable option.
“I don’t think that this is a disease that we can eradicate – not with the methods that we have right now. It might be a disease that in the long term we can eradicate with a vaccine, but I’m not even sure about that. If you look at comparable diseases like the flu and other respiratory viruses we are not even close to eradicating them despite the fact that we have a vaccine. I personally believe that this is a disease we are going to have to learn to live with.”
Many people feel that Anders Tegnell’s approach has been overly laissez-faire and that even now, he should be introducing more draconian measures. A model this week from his Health Agency suggested as many as 3000 additional deaths may be seen in Sweden in the next year — shouldn’t he do more to stop that happening?
He insists that those projections are only models, and that he hopes and expects to achieve a much better result. But he is also mindful of whether these draconian measures may do more harm than good:
“Of course we are trying to keep the mortality rates as low as possible, but at the same time we have to look at the draconian measures you are talking about. Are they going to produce even more deaths by other means than the disease itself? Somehow we need to have the discussion of what we are actually trying to achieve. Is it better for public health as a whole? Or is it trying to suppress Covid-19 as much as possible? Because getting rid of it I don’t think is going to happen: it happened for a short time in New Zealand and maybe Iceland and those kind of countries might be able to keep it away, but with the global world we have today, keeping a disease like this away has never been possible in the past and it would be even more surprising if it were possible in the future.”
One type of intervention that does not appear to have adverse effects is encouraging, or mandating, the use of masks. This has become an intensely political issue in the US and more recently in the UK. In Sweden mask use is minimal in almost all settings. Why is he not even recommending use of masks?
“One reason is that the evidence base for using masks in society is still very weak. Even if more and more countries are now enforcing them in different ways … we haven’t seen any new evidence coming up, which is a little bit surprising. The other reason is that everything tells us that keeping social distance is a much better way of controlling this disease than putting masks on people. We are worried (and we get at least tales from other countries) that people put on masks and then they believe they can go around in society being close to each other, even going around in society being sick. And that, in our view, would definitely produce higher spread than we have right now.”
The emphasis on spread of the virus to the exclusion of everything else Dr Tegnell believes is misguided, as the number of cases is less and less correlated to the number of deaths.
“Deaths are not so closely connected to the amount of cases you have in a country. There are so many other things that influence the amount of deaths you have. What part of the population gets hit? Is it the elderly people? How well can you protect people in your long-term facilities? How well does your healthcare system continue to function? How can we improve the treatment in ICUs? All of these things have been changing a lot in the past few months… Those things will influence mortality a lot more, I think, than the actual spread of the disease.”
His belief is that, in the final account, the Infection Fatality Rate will be similar to the flu: “somewhere between 0.1% and 0.5% of people getting infected, maybe … And that is not radically different to what we see with the yearly flu.”
On the controversial question of immunity, he suggests that a larger percentage of the population in Sweden is already immune than antibody studies suggest.
“There are a number of small studies already that show that of people who had been diagnosed with Covid-19 with PCR, not all of them develop antibodies. On the other hand we have quite a lot of evidence that falling ill with Covid-19 twice seems to be extremely rare… Obviously there is also quite a big part of the population that has other kinds of immunity and T Cell immunity is the one that is most likely.
“What we see right now is a rapid fall in the number of cases, and of course some kind of immunity has to be involved in that as nothing else has changed. That means that immunity affects the R value quite a lot in Sweden today.”
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Does that mean that Sweden will be better placed to limit second waves and future flare ups than countries that have had minimal infection levels so far?
“I think it’s likely that those kinds of outbreaks will be easier to limit in Sweden because there is immunity in the population. All our experience with measles and other diseases shows that … we know that with large immunity in the population it is much easier to control the outbreaks than if you don’t have immunity in the population.
“There is now a number of countries in Europe that have a fairly low level of spread for a very long time, which is very unusual with a disease that seems to be so contagious, and where there is so little immunity in the population. If that is really a sustainable way for the disease to exist we will wait and see — I think the fall will show if it is possible or not.”
The eyes of the world have been on him for the past few months. How would he like to be judged, and when?
“It is better to have a more complete discussion around this in say 12 months, after next summer, then I think we can more fairly judge what has been good in some countries and bad in other countries.”
He has promised to talk to us again at that time. 23rd July 2021 – it’s in the diary.