Sweden’s lockdown paradox
Policymakers shouldn't focus on differences in restrictions but on common causes of death.
Phillip W. Magness is a senior research fellow at the American Institute for Economic Research.
For the past two months, journalists and commentators have made a cottage industry out of comparisons between the respective COVID-19 mitigation strategies of Sweden and Norway. The two Scandinavian neighbors adopted contrasting approaches to the pandemic, with Norway imposing a lockdown similar to most other European countries and Sweden opting for a lighter-touch strategy based on voluntary social distancing and the attainment of herd immunity.
The point of such comparisons usually entails citing Norway’s relatively low COVID-19 mortality rate (44 deaths per million people as of writing) as a vindication of the lockdown approach, whereas Sweden’s higher toll (442 deaths per million) allegedly illustrates the failure of shirking international political trends.
Sweden’s mortality rate, of course, is comparable to or better than several other European countries with heavy-handed lockdowns including France, Italy, Spain, the United Kingdom and Belgium. Yet its geographical neighbor serves as the most common point of contrast to indict the country for bucking the shelter-in-place convention.
Let’s consider another comparison — one that has largely escaped the attention of experts and armchair epidemiologists alike. With 820 COVID-19 deaths per million residents, Belgium is currently the most severely afflicted nation on earth on a per capita basis.
Belgium also has one of the most severe and longest-lasting COVID-19 response policies in Europe. The Belgian government first issued warnings against travel to coronavirus-infected regions in early February, moved to cancel large events and gatherings on March 10, imposed wide-scale restaurant and school closures on March 13, imposed shelter-in-place for nonessential activities on March 17, and shut its borders to nonessential travel on March 20.
Emerging statistical patterns show that acute outbreaks in care facilities account for as many as half of all COVID-related deaths in several European countries
Belgium’s restrictions were among the most severe in the region, prohibiting the sale of non-food and nonessential items in stores and restricting grocery shopping to one person per family. These containment measures have only relaxed in the last few weeks as part of a heavily regulated reopening process.
As a point of contrast, consider how the pandemic has played out in Belgium’s low country neighbor, the Netherlands. Like Sweden and Norway, Belgium and the Netherlands share a common geography and closely intertwined history. The Netherlands controlled a sizable portion of Belgium’s current territory prior to the latter’s independence in 1830, and Flemish, a Dutch dialect, remains the largest language group in Belgium today. The Netherlands and Belgium also rank eighth and ninth respectively in population density among European states, displaying relatively similar distributions around their main urban centers.
Compared with the Belgians, the Dutch have weathered the crisis relatively well. At 348 deaths per million, the Netherlands has experienced less than half of its neighbor’s mortality rate. The country also adopted a shorter and milder pandemic mitigation strategy, including initially pursuing a “herd immunity” strategy similar to Sweden. The Dutch government switched to stricter lockdowns on March 23, placing it about a week behind Belgium.
Although its policies included canceling large events and shuttering schools and dine-in restaurants, the government’s “intelligent lockdown” policy allowed most clothing retailers, toy stores and most other businesses to remain open, provided that they followed social-distancing guidelines.
Based on the same line of reasoning that routinely proclaims Sweden’s light-touch approach a failure by way of comparison with Norway, one might just as easily conclude the opposite about Belgium and the Netherlands, that the former’s lockdown strategy is a failure.
The truth however is that neither comparison sheds much light on the real challenges in tackling the coronavirus crisis. Whether one uses Norway to condemn Sweden’s light-touch approach and vindicate the lockdowns, or the Netherlands to decry Belgium’s heavy-handed restrictions, they amount to little more than cherry-picked comparisons designed to highlight or deprecate a specific policy approach — often for purely political reasons.
Instead, policymakers should pay closer attention to an area of the COVID-19 response where most countries have clearly failed.
Despite taking dramatically different approaches over the decision to lockdown, Sweden and Belgium have both seen their nursing home populations ravaged by the disease. Indeed, a similar story has played out in most other European nations.
Although the data quality varies (Belgium’s government, for example, claims that its atypically high death rates reflect a more comprehensive approach to recording fatalities in nursing homes), emerging statistical patterns show that acute outbreaks in care facilities account for as many as half of all COVID-related deaths in several European countries.
All the more astounding, this clear pattern of nursing home outbreaks appears to be largely unaccounted for in one of the leading epidemiology models that governments relied upon to impose the lockdown strategy. The push for COVID-19 shelter-in-place policies stems from a set of models that purport to predict the transmission of a disease based on the level of social interactions that occur under different policy scenarios.
Examples include the now-famous Imperial College London model of the U.K. and its adaptations to other countries (including Sweden), all of which operate on the premise that restricting social movement will curtail the transmission of a viral disease.
But while models of this type propose a suite of policy options, including lockdowns, school closures, event cancelations and social-distancing mandates, they offer little advice when it comes to acute outbreaks in nursing homes and similar facilities. Indeed, as the Imperial College team acknowledged in its original 2006 model, “lack of data prevent us from reliably modelling transmission in the important contexts of residential institutions (for example, care homes, prisons) and health care settings.”
The nursing home situation presents policymakers with a set of uncomfortable facts, because it cuts across almost all European countries, irrespective of the severity of their social and economic restrictions. A key factor in COVID-19’s deadliness may therefore have very little to do with society-wide countermeasures such as lockdowns and everything to do with particular locations and settings that increase “super-spreader” transmission risks.
Rather than waste time arguing about the differences in lockdown policies, which seem to have variable effectiveness, at best, policymakers should focus on common challenges like the acute vulnerability of nursing homes. It’s efforts in these areas that are likely to save the greatest number of lives as the pandemic continues.