Science’s COVID-19 reporting is supported by the Pulitzer Center and the Heising-Simons Foundation.
On 5 April, Anders Tegnell, chief epidemiologist for the Swedish public health authority, sent an email to the European Centre for Disease Prevention and Control (ECDC) expressing concern about proposed new advice that face masks worn in public could slow the spread of the pandemic coronavirus. “We would like to warn against the publication of this advice,” Tegnell wrote. How much people without symptoms contribute to spread was a “question that remains unanswered,” he wrote, and the advice “would also imply that the spread is airborne, which would seriously harm further communication and trust among the population and health care workers.”
On 8 April, ECDC published its recommendations anyway, in line with an emerging scientific consensus. Although questions remained, “use of face masks in the community could be considered,” it said, “especially when visiting busy, closed spaces.” Tegnell still disagrees. “We have looked very carefully. The evidence is weak,” he told Science. “Countries that have masks are not doing the best right now. It is very dangerous to try to believe that masks are a silver bullet.”
Sweden’s approach to the coronavirus pandemic is out of step with much of the world. The government never ordered a “shutdown” and kept day care centers and primary schools open. While cities worldwide turned into ghost towns, Swedes could be seen chatting in caf s and working out at the gym. The contrast evoked both admiration and alarm in other countries, with journalists and experts debating whether the strategy was brilliant—or whether Tegnell, its main architect, had lost the plot.
The country did not ignore the threat entirely. Although stores and restaurants remained open, many Swedes stayed home, at rates similar to their European neighbors, surveys and mobile phone data suggest. And the government did take some strict measures in late March, including bans on gatherings of more than 50 people and on nursing home visits.
Yet Sweden adopted strikingly different policies from those of other European countries, out of a desire to avoid disrupting daily life—and perhaps the hope that, by paying an immediate price in illness, the country could achieve “herd immunity” and put the pandemic behind it.
Swedish authorities actively discouraged people from wearing face masks, which they said would spread panic, are often worn the wrong way, and can provide a false sense of safety. Some doctors who insisted on wearing a mask at work have been reprimanded or even fired.
Until last month, Sweden’s official policy stated people without obvious symptoms are very unlikely to spread the virus. So instead of being quarantined or asked to stay home, family members, colleagues, and classmates of confirmed cases had to attend school and show up for work, unless they had symptoms themselves. Testing in Sweden still lags behind many other countries, and in many districts infected people are expected to notify their own contacts—in contrast to, say, Germany and Norway, where small armies of contact tracers help track down people who may have been exposed.
The Swedish approach has its fans. Protesters against coronavirus-related restrictions in Berlin in late August waved Swedish flags. In the United States, a prominent member of President Donald Trump’s coronavirus task force, neuroradiologist Scott Atlas, has cited Sweden as a model to follow. The policies also have widespread public support in Sweden, where consensus is prized and criticism of the government is rare.
But within Sweden’s scientific and medical community, a debate about the strategy has simmered and frequently boiled over—in the opinion pages of newspapers, within university departments, and among hospital staff. A group of scientists known as “the 22” has called for tougher measures since April, when it published a blistering critique of the country’s public health authority, the Folkh?lsomyndigheten (FoHM). The group, which has grown to include 50 scientists and another 150 supporting members, now calls itself the Vetenskapsforum COVID-19 (Science Forum COVID-19).
It says the price for Sweden’s laissez-faire approach has been too high. The country’s cumulative death rate since the beginning of the pandemic rivals that of the United States, with its shambolic response. And the virus took a shocking toll on the most vulnerable. It had free rein in nursing homes, where nearly 1000 people died in a matter of weeks. Stockholm’s nursing homes ended up losing 7% of their 14,000 residents to the virus. The vast majority were not taken to hospitals. Although infections waned over the summer, scientists worry a new wave will hit in the fall. Cases are rising rapidly in the greater Stockholm area, where almost one-quarter of the Swedish population lives.
The group’s criticism has not been welcomed—indeed, some of the critics say they have been pilloried or reprimanded. “It has been so, so surreal,” says Nele Brusselaers, a member of the Vetenskapsforum and a clinical epidemiologist at the prestigious Karolinska Institute (KI). It is strange, she says, to face backlash “even though we are saying just what researchers internationally are saying. It’s like it’s a different universe.”
Lena Einhorn paid close attention in January to the news of a new virus spreading in Wuhan, China. Einhorn, who has an M.D./Ph.D. in virology and tumor biology, is better known in Sweden as a filmmaker and book author. “But I can still read a scientific paper,” she says. And what she read in The Lancet on 31 January was alarming: A model predicted large outbreaks of the new virus in cities around the world. As far as she could see, nothing was being done in Sweden to get ready for the threat.
Concerned, she wrote an email to Tegnell. “I asked, ‘Have you seen this paper? Isn’t it time we prepare for this?’” Tegnell answered immediately, Einhorn says: “He basically said, ‘Well, we shall see. Everyone is trying to apply complex models to very limited data.’” She wrote back emphasizing how easily the virus seemed to spread, including from people without obvious symptoms, and asked about restricting travel from China. Tegnell noted that the World Health Organization (WHO) opposed such measures, she says, then stopped responding. So Einhorn approached Bj?rn Olsen, a professor of infectious diseases at Uppsala University who was raising the alarm in interviews. “What can we do?” she says she asked Olsen.
In late February, during the school holidays, thousands of families went skiing in the Alps—just as reports surfaced about an outbreak in northern Italy. Many had asked whether they should stay home, but health authorities “kept saying, ‘No, don’t cancel your trip!’” Einhorn says. “It was the middle of that week when the cases in the Italian Alps went boom.” As vacationers returned, many asked whether they should quarantine, but FoHM maintained there was no reason to worry.
When 30,000 music fans gathered in a Stockholm arena on 7 March for the national final of the Eurovision Song Contest, “I’m going bonkers,” Einhorn says. “I can’t sit still.” She reached out to a journalist friend and started to write op-eds. Olsen linked her to “a group of desperate scientists,” she says. “Suddenly I’m in the middle of an email thread of infectious disease specialists, virologists, epidemiologists,” all extremely worried.
On 12 March, as new cases outpaced test capacity, FoHM announced doctors should only test those with severe symptoms, recalls KI immunologist Cecilia S?derberg Naucl r. “I turned to my husband and said, ‘They are letting it loose. We are going to crash the health system. We are going to need 500 ICU [intensive care unit] beds and we have 90 in Stockholm.’” On the same day, Norway closed schools, many businesses, and its borders, mirroring measures across Europe.
On 15 March, Olsen, Naucl r, and five others warned in an opinion piece in the Svenska Dagbladet newspaper that Sweden was just a few weeks behind Italy, where hospitals were already overflowing. Naucl r says she reached Tegnell by phone the next day and told him, “I don’t want to argue with you, but you shouldn’t be doing what you’re doing unless you have data that I don’t know about.” She says they had a good conversation and Tegnell agreed to a meeting, but it never happened.
The next week, Tegnell announced Sweden would try to “flatten the curve” so the health system would not get overwhelmed with cases. The government limited gatherings to a maximum of 500 people, but day care and schools through ninth grade stayed open. (Upper secondary schools and universities went online.) People should work from home if possible, FoHM said, but tests remained very limited, and close contacts of suspected cases were not asked to stay home unless they had symptoms.