The Nordic divide on coronavirus: Which country has the right strategy?

The Nordic divide on coronavirus: Which country has the right strategy?
The Øresund Bridge. Photo: Niels Christian Vilmann/Ritzau Scanpix
Looking at the front pages of some news sites in Norway and Denmark, it almost seems as if they are willing the coronavirus outbreak in Sweden to worsen. Will the coming weeks prove Denmark and Norway were right to impose tougher restrictions on the country?
“21 dead in Stockholm”, read Monday's headline in Norway's VG. “The number of corona deaths in Sweden rises to 146,” runs the headline in Norway's NRK newswire. “146 people infected with coronavirus in Sweden are dead,” ran Tuesday's story from Denmark's Ritzau newswire.
 
When the British medical journal The Lancet on Tuesday described Sweden's “slow response” as looking “increasingly poorly judged”, it was the main story on VG's homepage. 
 
Two weeks after the Norway and Denmark shut schools and kindergartens and asked all but essential workers to stay home, the media in the two countries is watching Sweden's hospital admissions and coronavirus death tally almost as closely as their own, ready for signs of a spike to justify their own lockdowns. 
 
So far, there has been little conclusive. 
 
Norway tops the three countries in terms of the number of confirmed cases per million inhabitants with 810, followed by Denmark with 441, and Sweden with 331. 
 
But this reflects the fact that Norway has tested 87,191 people, while Denmark has tested just 21,378. Sweden's most recent testing figure, from 25 March, was 24,500.
 
On deaths per million inhabitants, Sweden is currently fractionally ahead with 14 per million compared to Denmark's 13 per million, with Norway way behind on just 6, according to the Worldometers website. 
 
But the way deaths are rising in Sweden does look more dramatic, according to data from the European CDC put together by Our World in Data. 
 
 
Danish and Norwegian politicians have now begun claiming that the lockdown measures have been successful.  
 
“Over the past week, the number of admissions has risen slightly more slowly than the week before, and without the explosion in the numbers that we have seen in other countries,” Danish Prime Minister Mette Frederiksen said on Monday, as she announced plans to reopen Denmark. 
 
“There is still uncertainty. But figures for hospital admissions may indicate that it is going the right way. Time will tell if the measures are working well enough,” Norwegian Prime Minister Erna Solberg told a news conference on Tuesday. 
 
Kåre Mølbak from the Danish infectious diseases agency SSI, told the press conference that he believed Denmark's actions had reduced the average number of people each infected person infects in the country from 2.6 to 1.4. 
 
“The infection rate in Denmark has been more or less halved. This is a gladdening development. The epidemic is by no means over, but it has been better brought under control than anywhere else in Europe,” he said.
 
The SSI compared hospital admissions in Denmark against those seen in northern Italy. 
 
 
 
Bjørn Guldvog, the Director-General of the Norwegian Directorate of Health, said on Wednesday that he believed Norway is “well on the way to succeeding” in bringing coronavirus under control, with the infection rate now “moving down towards one”. 
 
On Tuesday, both Norway and Denmark reported small reductions in the number of people hospitalised with the virus, although the number rose again on Wednesday. 
 
Some health officials in Sweden have also expressed confidence in their country's strategy, despite growing international criticism. 
 
Stockholm region's health director Björn Eriksson told Swedish radio: “Up until now the health care system has been one step ahead of the virus”, but he warned “the storm was growing”.

 
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Bjørn Guldvog, Director General of the Norwegian Directorate of Health, Swedish state epidemiologist Anders Tegnelll, and Søren Brostrøm, Director General of the Danish Health Authority.
 
Allan Randrup Thomsen, a professor of virology at the University of Copenhagen, in an interview with Denmark's Ekstra Bladet newspaper on “Why Sweden is not locking down”, argued the difference between the countries policies was “purely ideological”. 
 
“I believe that they've based their strategy on the notion that they're just going to ride through the epidemic,” he said. 
 
Unlike Frederiksen, he said it was still too early to tell if Denmark's lockdown was working, but he said he believed Sweden would pay a price. 
 
“Sweden is getting a greater spread of coronavirus. They do not have this dampening, which we have worked hard for at home, and so I fear that they will not be able to handle the peak of the epidemic, which everything points to us succeeding in,” he said.  
 
“I fear they're going to experience a greater number of hospital admissions and deaths.” 
 
In an interview with The Local, Sweden's state epidemiologist Anders Tegnell argued that the tough actions taken by the authorities in Denmark and Norway were not based on scientific evidence. 
 
“I think it's political,” he said. “You saw that the head of the Sundhetsstyrelsen [Danish Health Authority] actually went out and said that these are not the measures they had been recommending. 
 
“If it's an overreaction, or if it's an adequate reaction, we will not know until afterwards.” 
 
Just as the Danish Health Authority advised against closing borders and was overruled by the country's politicians, the
Norwegian Institute of Public health last Monday called for kindergartens and schools to be partially reopened, but was overruled. 
 
Tegnell said that in his weekly online meeting with his counterparts in Denmark, Norway and Finland, his approach was respected. 
 
“I'm not going to name any names, but I do get a lot of support,” he said.  “We meet with the Nordic countries once a week and discuss where we are, and where we're going and so on.
 
“Nobody is sure who is right anymore. But I think a lot of my colleagues like that we can have an open and technical debate about it, which seems to be more difficult in some of the other countries where the political level has already taken a decision and taken it very quickly.” 
 
With pressure already growing in Norway for schools to open, Finland already partially reversing its closures, and Danish Prime Minister Mette Frederiksen on Monday announcing plans to start gradually winding down the lockdown after Easter, Tegnell's argument that Sweden has saved the most restrictive measures for when they are most needed may carry more weight in a few weeks' time. 
 
“These are measures that you can only keep up for a very limited amount of time, so it's much better to save them until you really need them. If you do it too early, then people get tired of them,” he told The Local. 
 
Nonetheless, Tegnell conceded that he expected pressure on Sweden's hospitals to start to grow, with the field hospitals built in conference centres outside most Swedish cities almost certain to be necessary. 
 
“Yes, I think that's quite possible, for some weeks. That's what our projections say will be needed.” 
 
But he said all countries' projections were uncertain. 
 
“Nobody knows. We are all guessing,” he said.  “My hope, if you put it that way, is that we keep on like this. Like we are going now. We have some 200 cases a day. We are probably going get more of the disease in different parts of Sweden, but it's all going to be on a level that's manageable for health care. And we keep on doing that… for weeks.” 
 
“That's probably asking for too much, but that's my hope. The worrying part is if it takes off and really produces a lot of cases, especially a lot of cases among the elderly. Because that really would be the worst-case scenario. If we get a big spread in a number of elderly homes and hospitals, and both elderly and health staff start getting sick.” 
 
He said that the big unknown was the extent to which populations are building immunity to the virus, and what would happen in areas of China, South Korea, or Hong Kong, where lockdowns had successfully contained the virus' spread. 
 
“We don't even know the level of immunity in China. And of course, that would be very, very good to know, for all of us. If we know that China has sort of reached, quote, 'immunity level', that tells the Swedish something about how we should move forward.” 
 
“If the level of immunity in China is only a few percent, then we have a completely different scenario in front of us.” 
 
It is possible, even likely, that over the next few weeks the number of  hospital admissions in Sweden will start to rise much more rapidly than in Denmark and Norway.
 
If Sweden's health system is overwhelmed, then Denmark and Norway will feel their tougher policies were justified. 
 
But the real test of Sweden's strategy will come later, when Denmark and Norway start to lift their lockdowns.
 
Can they return to normal without the infection flaring up again? Will they be hit by a second wave this winter? Will any additional deaths Sweden sees over this Easter be the price it pays for having fewer over the coming years? 
 
“This is not a disease that you get rid of. And if you don't get rid of it, what are you waiting for?” Tegnell said. “You can either wait for some kind of immunity to develop in your population, or you can wait for a vaccine. And the vaccine is, most likely, at least a year away.” 
 
Tegnell said he suspects that public policies put in place will anyway turn out to have had less impact on the virus than most think. 
 
“I wouldn't be too surprised if it ended up about the same way for all of us, irrespective of what we're doing,” he said. “I'm not so sure that what we're doing is affecting the spread very much. But we will see.” 
 
 
 
 

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  1. We now have Dr. Fauci’s estimates for the likely death rate in the US: 100-240,000 if social distancing / lock down is maintained across all states vs up to 2.2 M if nothing is done. We have similar estimates for the UK. It would be interesting to understand how the FHM sees this issue. I have looked around but have not been able to find estimates from the FHM for the likely death rate in Sweden. These are surely estimates they have made and the public should know about them. If they are reluctant to release such estimates, the public should understand why.

    Another issue that I haven’t quite got my head around, is to what extent herd immunization plays a role in the Swedish approach? Articles are starting to appear globally focusing on the next phase of the epidemic. That is, once we have gotten through the first peak in hospitalization / fatalities, then what will be the strategy? Clearly governments around the world will not let the global economy come to a complete standstill, and communities will open up again and people will go back to work. The question mark is to what extent the general population will be immune at that point in time? One argument for a less stringent policy now is that it will lead to greater general immunization earlier on in the process and reduce the likelihood of a second extreme peak once things open up again.

    It would be interesting to understand the FHM’s views on this. On the cynical side, I have seen comments from the public suggesting that if immunization is part of the FHM’s strategy (ie., be less stringent on socialization upfront to allow for more immunization), then they are experimenting with people’s lives. On the other hand, perhaps when faced with impossible decisions regarding life or death, immunization is indeed a factor the FHM should consider upfront; perhaps it makes more sense in the long run. Clearly the world will look very different after the first round of this terrible epidemic. But what will it look like on the second round: 60% of the population immunized, or 10%? The latter is a disaster and the global economy will have to go on life support more permanently.

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