“Maybe better to let the nature take its course […] frankly I’m a bit concerned about Sweden*”

The words belong to Mika Salminen, Director Department for Health Security, THL, Finnish Institute for Health and Welfare, when asked about what Sweden seemed to base its strategy on by staying open (*personal opinion). It was March 25 and Finland was about to announce a lockdown of its capital Helsinki and Province of Uusimaa, whereas Sweden was yet to close its elderly care units for visits, a measure Finland had taken on March 16. On the same day during the Swedish press conference, Anders Tegnell, chief epidemiologist at FHM, Folkhälsomyndigheten, Swedish Public Health Agency, had said that the situation in Sweden was stable.

Finland had confirmed its first case on January 29, two days prior to Sweden. By March 25, Sweden had already outnumbered Finland, and now counted for 34 times higher death rate (103 vs 3), more than twice as many confirmed cases (2,711 vs 1,133), almost ten times more ICU patients (207 vs 22), and a total of 1,459 hospitalizations compared to Finland’s 62. Just ten days earlier it had reported 5 deaths.

It was then, ten days earlier on March 15, when Tegnell had told on national TV that Sweden’s primary goal was to protect the elderly, unlike Italy that had failed to do so because it had taken them too long to realize what was happening. A comment on par with statements made by [choose from the smorgasbord of the current White House administration’s press secretaries, former or current]. In fact, Tegnell’s continuous bashing of Italy led its ambassador to Sweden, Mario Cospito, to issue a statement on May 27 in response to his slandering. Why it took Sweden until March 30 to close its elderly care units for visits after mid-March decision with regions to move from tracing to stop the virus to mitigate the effects, is beyond one’s grasp if the primary goal was to protect the elderly.

And then, a month later, the onslaught of Sweden’s elderly was a fact; a total of 1,646 people had died without their loved ones by their side, 1,025 were fighting for their lives in ICUs, and the country of 10,3 million people saw one of its deadliest Easters with 461 COVID-19 related deaths (April 9-13). Investigations by media have detailed how elderly peoples’ chance to receive ICU care during Easter dropped dramatically from earlier 50 per cent to as low as 11 per cent on April 21. Disturbing records show that 34 per cent of all COVID-19 patients die alone without any other person present in the room, not even healthcare personnel. That’s 1,910 people and counting (Deaths July 17: 5,619).

The excess death rate went up 27 per cent from previous year between March 16 and May 5, translating into staggering 3,300 people. According to investigation conducted by IVO, Health and Social Care Inspectorate, of Sweden’s all 1,700 elderly care units, 30 per cent of excess deaths and nearly half of all COVID-19 deaths had taken place in them.

As people ages 70 and older make 89 per cent of all the Swedish COVID-19 deaths, but only 24 per cent of ICU patients, there has been several reports where doctors in many elderly care units have ordered palliative care over the phone without personal visit or individual diagnose, thus leaving the elderly in the hands of the nature to take its course, oftentimes without oxygen support, something the investigation also confirms. 5,000 elderly had lost their lives by July 17. How many of them had seen a doctor or had someone to hold their hand, we don’t know.

Almost a third of all 290 municipalities don’t provide sufficient COVID-19 care for their elderly, and 40 municipalities count for 70 per cent of all the deaths. 40 per cent of those municipalities reported insufficient capacity for care and individual diagnose by a doctor, while remaining 250 reported 33 per cent insufficient capacity. Making matters worse: 70 per cent of the 82,200 residents have either early, moderate, or severe form of dementia, which makes it nearly impossible for them to apply social distancing and hygiene instructions, leaving them unable to protect themselves in any way. (Dementia is classified as an endemic disease in Sweden between 130,000 and 150,000 cases.)

Several municipalities have been found to cover up COVID-19 spread in their elderly care units, and probably one of the most disturbing comments I’ve heard was made by Kristina Holmberg, director elderly care management at Sigtuna municipality. She referred to patient confidentiality as a reason to not disclose the virus spread and merely noted, without any visible remorse, that it’s voluntary to live in an elderly care unit, therefore would relatives feel worried or wished to guarantee the health and wellbeing of their loved ones, they could always take them home. Cold. She is also responsible for purchasing false and dangerous protective masks used in hospitals and elderly care without testing them or informing the personnel. Paraphrasing: “We took what was available at the time.” A person so dead inside even Cruella de Vil would be embarrassed to know her. How she still has her job is a mystery to me.

It gets worse: The instructions to deny individual diagnose by a doctor often came from municipal and regional authorities. One horrifying account of a Finnish nurse working in various elderly care units in region Stockholm confirms the practice as routine and what can only be described as an active death aid. COVID-19 patients are denied oxygen and medication, and are instead ordered a cocktail of morphine and midazolam to further slow down breathing. In many cases the doctors in charge have refused to speak with the patients’ relatives both prior and after a decision for palliative care was made.

Yet, perhaps the most troubling aspect of these findings is, that on June 1 when the daily death rate had hit a plateau of average 50, Tegnell suggested that ICU availability was the best indicator to measure infection rates and the virus spread. Unsurprisingly, available ICU capacity is also the easiest indicator to manipulate using triage as a way to deny a patient by referencing individual’s prognosis to survive intensive care. Several hospitals have been reported to have used this praxis to deny ICU care for elderly COVID-19 patients despite available capacity “in case a younger patient would need care within next few days”. All ICUs in region Stockholm are now under further investigation by IVO for their practices.

Furthermore, it was revealed that region Stockholm, where 50 per cent of all deaths have occurred in elderly care units, had already on March 20 implemented general CFS (clinical frailty scale) based patient prioritization regarding hospitalizations in order to avoid emergency mode. The scale was set to level 5 “Mildly Frail” and higher, which meant that elderly who in their daily lives need help with such benign things as medication, transportation, or finances, would be denied any hospital care. That basically translates into all elderly care residents.

Socialstyrelsen, National Board of Health and Welfare, did comment the high mortality rates, downplaying them by saying that they don’t differ much from a regular flu season, which in worst case means that Sweden’s elderly are routinely receiving active death aid instead of treatment for preventable outcomes. A scenario so dark that it makes increasingly hard not to draw parallels to certain Nazi Germany activities and medical procedures during the Second World War.

Here’s how dire my view of the Swedish COVID-19 response had become just after 10 weeks of following the developments: When reading a French study “Acute Cerebral Stroke with Multiple Infarctions and COVID-19” (May 26, 2020) on two patients, an 84-year-old man with a history of diabetes, hypertension, and coronary heart disease who had sought care for respiratory symptoms, and a 74-year-old man with a history of multiple cardiovascular diseases who had sought care for influenza-like illness, I was struck by my initial reaction, because it had nothing to do with the conclusions of the study itself, as interesting as they were, but the fact that I thought this could have never taken place in Sweden. It seemed unreal that people of such high age and several underlying illnesses could have been admitted to hospital care.

If all that hasn’t already left you disturbed, numb, and gasping for air, with or without COVID-19 symptoms, wait for it: The excess death rate among ethnic minorities from Syria, Somalia, and Iraq ages 40-64 is at startling 220 per cent. Considering that 25 per cent of Sweden’s population have migrant background, one can’t simply dismiss the morbidly high rate with unfortunate circumstances such as frequent travelling as Tegnell prefers to explain it with.

FOI, Swedish Defence Research Agency, highlights this in its first analysis, “Perspective on the Pandemic”, of the Swedish COVID-19 response from a civil defence perspective, stating that despite comprehensive national health statistics and December 2019 report published by FHM itself on communication during a pandemic, information on other languages was available first in early April, and only after doctors had warned that residents in socially vulnerable areas were over-represented in death statistics. That’s two months after the first COVID-19 press conference on March 6.

Sadly, all the warning signs that everything was not going to be fine with Sweden were in plain sight from the very beginning. FHM held its very first COVID-19 press conference crammed like sardines as if they were about to take a selfie, and on March 23 when rest of the Europe had already closed its doors, they were still standing uncomfortably close while passing around one, presumably highly contagious, mic among the press like it was a championship trophy. That also marks the day the term hot mic got a whole new meaning. These are scenes and behaviour one might expect to hear in the news from Florida, but certainly not from leading experts in infectious diseases and responsible for Sweden’s COVID-19 strategy during an ongoing global pandemic.

(To give FHM some slack, it would take until March 18 for WHO to have its first socially distanced press briefing. Then again, on March 13, Dr. Michael “Mike” Ryan, Executive Director at WHO, shared his biggest learnings from Ebola outbreaks, which made me feel hopeful even for Sweden as Tegnell had also worked with Ebola outbreaks. Unfortunately, that hope died quicker than an ice cream melts in the sun as it became increasingly obvious that his learnings differed in such a grave manner from Mike’s, that at one point I was convinced they had been battling completely different outbreaks. I still revisit Mike’s advice from time to time just to lift my spirits, please enjoy. Naturally, when the world has found a way to make movies again, I dearly wish Brendan Gleeson will do us the pleasure as Mike in the upcoming COVID-19 Outbreak.)

Ironically, during the very same March 15 debate where Tegnell had bashed Italy for not being able to protect its elderly, he also argued against social distancing, suggested by epidemiologist Joacim Rocklöv, as “highly uncertain” but something that could possibly have an effect. Even a recent JPMorgan study of 30 million Chase debit and credit card users could show that higher in-person spending at restaurants, not takeout, directly results to an increase of COVID-19 cases three weeks later.

On July 7, four months into the pandemic, Johan Carlson, director general FHM, credited the current slowdown in infections, ICU patients, and death rates to social distancing, and even urged people to refrain from making any new friends during the summer holidays. I guess we’ll find out soon enough how well Swedes applied, but at the latest when statistics on the summer months STD cases are in.

On his June 24 prerecorded summer radio talk Tegnell acknowledged that Sweden should’ve been able to avoid the high mortality rates.

The Swedish Strategy Is Successful – If You Don’t Count The Dead

“That so many elderly have died has nothing to do with the strategy, but entirely an effect of insufficiencies in our society that we’re now course correcting”:

Swedish PM Stefan Löfven, on June 14 prime time national live TV interview when questioned about Sweden’s strategy.

Total deaths had by then reached 5,107 and confirmed cases were up at 52,695. That’s approx. one death in every ten confirmed cases. At the time Sweden also reported highest number of new cases per 100,000 inhabitants, and the 5th highest COVID-19 death rate per million inhabitants in Europe. A month earlier, the week of May 13, Sweden had recorded the highest COVID-19 per capita death rate per day (6.08) in the world on a rolling seven-day average. The prime minister didn’t seem to find these high contagion levels troubling, and neither did he agree on the correlation between high contagion levels in a society and higher mortality rates in elderly care units.

When asked Tegnell the same question on June 3, he argued that it’s with high certainty possible to have high contagion levels and low virus spread in the elderly care units, adding: “Recent experience in Sweden doesn’t indicate a very strong connection”. At the time Sweden saw on average 1,000 daily new confirmed cases and 40 deaths. One could say that it indicates quite the opposite type of connection, considering that testing was also limited.

I still have trouble processing the statement made by the prime minister, not simply because it’s outrageous, but because it makes over 5,000 deaths sound as if they were a bi-product of, or a rounding error in a statistical modelling.

The statement reminded me of Johan Giesecke, former chief epidemiologist (1995-2005) and advisor to the Swedish Government, who on April 17 spoke with Freddie Sayers of UnHerd about why lockdowns are the wrong policy, and how the results will eventually be similar for all countries.

It’s hard to pick a favourite memorable quote, but this one gives a hint: “At least 50 per cent of the population of both the UK and Sweden will be shown to have already had the disease when mass antibody testing becomes available”. He maybe saved by the bell on this one, as both vaccine and mass antibody testing lie far off on the horizon, or if immunity turns out to be for long term, but until then: Bets anyone?

On May 9 with a death count of 2,080, he doubled down stating that Sweden’s COVID-19 situation is the best in the world, and that Finland would catch up with Sweden’s death rate within a year. It would mean that as of today (July 17) COVID-19 has to take 18 Finnish lives per day in the next 294 days to catch up with Sweden’s current death rate, given that no more deaths will occur in Sweden (+20 deaths July 20). Finland has so far reported 10 or more daily deaths on three occasions, all during the worst peak in April. (Total deaths: 328, latest new one death June 26)

It would be easier to occasionally find humour in the ramblings of an overconfident white male, as one must do with Trump, but when the government has his ear and Sweden has lost additional 3,539 lives since May 9, it’s just unnerving.

Things do change rapidly when it comes to a pandemic, but I certainly hope that we all have learned our lessons from Sweden and stay safe.

Culture Eats Strategy For Breakfast

Culture eats strategy for breakfast is a common advice used in the corporate world when a best suitable strategy to achieve new goals is considered. There are many reasons for a strategy to fail, but it often does so due to underlying organizational and workplace culture issues that effectively prevent positive outcomes. Underlying issues aren’t always readily known, why a careful look under the hood is crucial prior deciding on a way forward.

A good strategy takes into account the “what if”, or to quote Nicolette Louissaint, PhD, executive director and president of Healthcare Ready, focusing on U.S. natural disasters and disease pandemics: “To work in preparedness is to constantly stare at society’s vulnerabilities and imagine the worst possible future.” For Tegnell to repeatedly say that Sweden, and Stockholm in particular, got unlucky due February ski holiday travels is to me beyond words. On his June 24 summer radio talk he once again mentioned how Sweden had received great and early information from both China and Italy regarding COVID-19, and the high risk the virus poses to the elderly.

With all that in mind, here’s what to me is the most troubling part of the Sweden’s COVID-19 strategy, i.e., to flatten the curve and protect the elderly and risk groups:

The underlying issues that would effectively send Sweden’s strategy straight to hell in a handbasket were very well known by the decision makers.

One can of course ask if it is even possible to apply an open society strategy to a global, highly infectious disease? Apparently so, which I will later showcase using Japan as an example. When facing a virus of which effects we still know fairly little about, an open society approach should be met with highest caution, not just to protect the elderly and risk groups, but to avoid otherwise younger healthy people to be put into ICUs for weeks leaving them with PTSD, in some cases even to relearn how to eat and walk.

Not to mention the hidden number of people that have recovered without hospital care, and have now been left with long term health conditions. A shocking June study of 1,600 previously healthy people from Netherlands, with average age of 53, found that over 90 per cent of those recovered still have health issues months later. Reports on strokes and brain and neurological damages are increasing in number. We’re clearly not dealing with a regular flu.

A research from The University of Glasgow, at the time not yet peer-reviewed, confirmed that regardless of age and underlying conditions, the Years of Life Lost (YLL) was 13 for men and 11 for women due to COVID-19.

An active Swedish Facebook group “COVID-19, Vi som är drabbade (we who are affected)” with over 11,000 members functions today as a support group where the healthcare system is currently failing to provide care for them. (Naturally the membership count doesn’t equal to people with long term COVID-19 health issues.)

Three Fundamental Requirements For Open Society Strategy

It seems clear to me, that for an open society strategy to be considered and work in the first place, the following three fundamental requirements need to be met. Sweden didn’t fulfil any of them, and yet it went ahead to stay open anyway.

1: PPE, Personal Protective Equipment

In addition to protect healthcare and emergency personnel, PPE is crucial to maintain an open society and workforce availability.

A newly released report reveals, that over 10,000 Swedish healthcare workers have been diagnosed with COVID-19, of which many have needed ICU care and an undisclosed number of them have died. That’s 13 per cent of all confirmed cases, and almost 50 per cent of all new cases during the first three months of the pandemic. As early as beginning of April, the Swedish ambulance association pleaded Finland for help with PPE when its own government failed to provide any protection, and the virus had already sent several ambulance personnel to ventilators and ICUs.

Even if one can’t for certain confirm that all of them contracted the virus while caring for the sick without proper PPE, they then most definitely did so on their way home through the virus infested public places. It’s a dire look when a country can’t provide better safety for its essential healthcare workforce than Amazon does for its warehouse workers.

Statistics also show that essential workforce including transport and food supply professionals (yes, pizza is essential food) have been overrepresented with four times higher risk for infection. Public transport personnel have threatened to close down traffic due to lack of PPE and safe social distancing working conditions.

An investigation discovered that tens of municipalities and regions had purchased false and dangerous protective masks used in hospitals and elderly care without testing them. Meanwhile, experts at Arbetsmiljöverket, The Swedish Work Environment Authority, had been fighting its leadership and FHM since April to recommend face masks and visors to healthcare personnel, until FHM finally agreed to do so on June 25. The incident was later reported to Ombudsman by the Kommunal trade union.

Sweden was by no means alone to face a fierce competition of PPE when the entire world at once turned into scavenger hunting mode, but the fact that it had over the years reduced or partly discontinued its national emergency stockpile didn’t help. E.g. just a few months prior COVID-19 hit the world, region Skåne in Southern Sweden, a popular holiday destination, decided to discontinue its central PPE stockpile without any counter arguments. Timing, or stupidity, at its worst.

Even if Finland has kept its national emergency stockpile, it too ran into temporary problems when some of the masks turned out to be too old, in addition to a large fraudulent order including untested masks.

2: Testing And Tracing Capacity

To keep an open society functioning, it’s a no brainer that PPE needs to be matched with adequate testing and tracing capacity. By March 25 only 24,000 tests had been completed with help of then already struggling healthcare system facing downsizing, budget cuts, and a growing health debt. For the longest time only hospitalized patients and healthcare personnel were able to get tested, and now that the country has managed to ramp up testing to 80,000 per week, still only 8 out of 21 regions offer tests without a doctor’s referral or based on priority group.

Many regions won’t be able to offer antibody tests until later in the fall. Some regions with low number of cases have been able to conduct contact tracing, but in most regions the task is left to patients themselves, a standard not approved by WHO.

To meet the testing level of 100,000 tests per week, issued by the government on May 4, the increased testing efforts have led to mishaps of various severity. The more serious ones include tests of 1,000 healthcare personnel gotten lost in the mail by Postnord, the federal postal service, and test results getting mixed up between people. Nothing on the level of Theranos’ fraudulent blood testing practices so far, but whenever demand is higher than supply, one must stay vigilant. Fraudulent masks cases are already beginning to pile up.

The test booking app called Alltid Öppet, “Always Open”, crashed immediately during its first day when it saw 25 simultaneous bookings per second, with test booking codes leaked to the Internet. Oh, the irony. On a press conference three days later media still received “no comment” on the question whether Stockholm could maintain test capacity without the app. The entire ordeal is just very telling of the current state of testing, and anyone who has ever worked with any technical development knows to under no circumstances agree on an app name “Always Open”. It’s destined to crash, so one might as well never release it.

The dire situation of PPE and testing capacity is perhaps best demonstrated by Corona Buses, new mobile testing units, that are now threatened to have to shut down immediately due serious health risks for the testing personnel. They normally work as bus drivers, but are now also conducting tests without training, wearing non-approved PPE in a wrong way. Really?

3: Highly Functioning Elderly Care

“I don’t think anyone is surprised about the fact that there are serious insufficiencies in the elderly care”: Lena Hallengren, Minister for Health and Social Affairs

She made the comment on July 7 press conference where the devastating IVO investigation on elderly care units was presented. Not that anyone disagrees with the statement, but it’s a mighty bold comment coming from her, taking into account that she on March 4 held a meeting to practice different COVID-19 scenarios with possible effects on the essential functions of the society. Documents show that impacts on the elderly care was on the agenda, but was never discussed.

On July 12, seven directors of elderly care units published an op-ed outlining how they had been left alone by the government to fight COVID-19 without timely instructions, PPE, and testing capacity, and now feel being wrongfully blamed for the thousands of deaths.

In particular, the op-ed vehemently opposes a frequently used statement “We just didn’t know it was this bad” as a plain lie, when trying to explain the high mortality rates. Both Tegnell and the prime minister have repeatedly stated in interviews that the problems with elderly care have been well known since many years, they just didn’t know the depth of it.

The group of directors represent Sweden’s elderly care that partly runs on temporary personnel without training, and who get called to work via text message when needs arise. 40% of units don’t apply to basic hygiene routines, despite that SKR, Association of Local Authorities and Regions, have the past ten years conducted follow ups. Staggering number, which also only shows how all parties have been aware of the dire situation at least the past ten years.

On the other side of the isle, IVO, Health and Social Care Inspectorate, have since March 15 received over 1,300 COVID-19 related reports on its anonymous tip line for healthcare personnel and relatives, of which 171 were of highly severe character. Reports on mismanagement in elderly care have stuck out nationally.

So there we have it: The management of elderly care units and the government blame each other for not caring for their elderly. The dead have no say, but I have no doubt that their loved ones will. This is already happening in Spain where over 100 relatives are suing the government for the mismanagement of pandemic and causing the death of another.

Before it’s settled who’s to the blame in Sweden, I let a comment on SVT, public service broadcaster, COVID-19 live news feed from July 6 questioning why it appeared to report that WHO was praising Swedish strategy, when it in fact was welcoming Sweden’s initiative to appoint COVID-19 commission, to summarize:

“Are you all drunk?”

Good Example: Japan’s No Lockdown Strategy Including Three Cs Plus

An interesting case is Japan, where voluntary stay-at-home and closing of businesses measures, instead of enforced lockdowns and wide testing, has so far been successful. A country with dense population of 125 million, world’s highest elderly population per capita, and a household consumption that makes over half of its GDP are all factors that if choosing a wrong strategy or losing ones eyes on the ball could easily throw the country into a death spiral. According to scientists, the low mortality rate can’t alone be explained with probable higher immunity due previous SARS infections, or the lowest coronary heart disease and obesity rates in the developed world, but with Japan’s early cluster-based approach with effective contact tracing, social distancing including masks, and early detection of high risk activities and spaces to avoid, the so called Three Cs: Closed spaces, Crowded places, and Close-contact settings. There is now also “Three Cs Plus” including loud talking and singing.

Within less than a month from the first patient who had not travelled abroad, all large-scale gatherings were suspended and schools closed. Like many other countries, Japan also ran into problems to deliver timely testing and experienced strain on the healthcare system during its worst peak, but the low positive cases rates were an indicator of sufficient testing despite having tested less than many other countries. The effective reproduction number (R0) remained below 1 during the entire state of emergency (April 7 – May 25).

Its capital Tokyo with 37 million people, 15 times the population of Stockholm metro area (2,4 million) and 3,5 times of entire Sweden, has seen nearly seven times fewer deaths (326** vs 2,366) and three times fewer confirmed cases than Stockholm (8,933** vs 22,076). More than twice as many people have died just in Stockholm alone than in Japan in total (984***). Japanese and Swedish GDP are set to contract about the same, respectively 5.16 per cent (+3.01 per cent 2021) and 5.3 per cent (+3.1 per cent 2021). That leaves Sweden with five times more deaths with similar consequences on the economy.

What’s been truly discouraging to witness, is how dramatically these two open society approaches with voluntary measures differ from each other, other than just by actual death rates, or counted per million inhabitants: Sweden has 552 deaths compared to Japan’s 8, and 7,589 confirmed cases to Japan’s 203.

In Tokyo, a recent surge (July 9-17) by on average 200 daily new confirmed cases directly led to coronavirus “red alert”, while Stockholm has constantly since week 14, beginning March 30, reported on average 200 daily new confirmed cases, but has never issued any type of alert. It was only as recently as during July 6-12 that Stockholm for the first time saw on average “only” 100 daily new confirmed cases.

On the contrary, instead of issuing “red alerts”, a poll shows that Tegnell is Swedes’ favourite person to go out and have a beer with. Certainly one way to try to forget about its 5,000 dead elderly people.

Not everyone is up for a beer with Tegnell, though, as op-eds from the research and medical community have demonstrated, the latest from June 29, signed by 23 researchers and doctors with a clear message in its title: “To limit the number of deaths is your most important task, Tegnell”.

On July 16 press conference the 385 daily new national confirmed cases were briefly shown on a slide but not even commented by Johan Carlson, director general FHM, other than:

“The Swedish situation remains favourable.”

While all this is a very early and highly simplified comparison, with the pandemic far from over, it shows how a strategy with less restrictions is possible in larger scale if taken early and precise actions to go after the virus, a strategy that Mike Ryan of WHO has pressed since the beginning of the pandemic.

In conclusion: Before considering an open society strategy or feel tempted to follow the “Swedish model”, there are many questions to be asked, but one in particular: What does one get when combining an open society with high contagion levels together with poorly functioning elderly care, severe lack of PPE, and subordinate testing and tracing capacity? Answer: 5,619 deaths to date* including the loss of 5,000 elderly. Update: The day after I hit the publish button, 25 Swedish doctors and scientists published an op-ed on USA Today titled: “Sweden hoped herd immunity would curb COVID-19. Don’t do what we did. It’s not working.” When conclusions of science experts and a nonexpert person meet.

Let Them Eat Cake! – Consequences Of The COVID-19 Strategy So Far

There is perhaps no more telling sign that the economy is tanking and in dire straits, than when not even the royal family can afford their annual 300 seasonal employees. Please, let them at least eat cake!

The way Sweden’s economic situation is being communicated sounds like it’s betting heavily on its economy to decline less and recover faster than others, to have at least something to justify its high mortality rates with. Swedish GDP is expected to contract “only” by 5.3 per cent this year, the third best in the European Union after Poland and Denmark, whereas the European Union GDP is expected to decline by 8.3 per cent. The catch? Export makes nearly half of Sweden’s economy with 73 per cent of goods exported to European Union. As of writing, European Union’s mutual COVID-19 emergency fund is still under tough negotiations.

The pandemic has stricken countries economically around the world and naturally there’s no reason to feel especially sorry for Sweden. Tegnell has denied that any economic calculations or outcomes have been part of forming the strategy, which leads to my question: Should they have? Economy and health are tightly intertwined, as we have seen socially vulnerable groups and areas been hit the hardest and overrepresented in mortality rates around the world, not just in Sweden’s migrant communities.

Sweden defends its strategy to not close down society and schools, or enforce wider freedom of movement restrictions, by arguing that the long term consequences on public health would be way too wide reaching, why it’s relevant to look at the consequences so far on the economy as domestic violence, substance abuse, and mental health are all worsened by unemployment. As someone who grew up in a home with domestic violence, alcoholism and unemployment without outside help, or social networks and Netflix to seek shelter on, I feel qualified to understand the dire consequences related to hardships caused by economic downturns.

Bankruptcies are up 16 per cent between January and June from previous year, taking the pole position with 36 per cent of all bankruptcies in the Nordics (Iceland not included). That has a direct effect on unemployment, which is expected to almost double from 6.8 per cent in 2019 to 11.4 per cent in March 2021, with youth unemployment to rise as high as 16.9 per cent in February 2021. It translates to over 600,000 unemployed and already close to 90,000 people have been furloughed since March including major employers like SAS and Volvo.

The unemployment benefit programs became quickly overwhelmed with over two months long application processing times, and people unable to work due increased risk for infection or caring for one can’t apply for any compensation until end of August due technical difficulties.

Swedish tourist industry keeps losing MSEK 316 (€30,3 million) daily, and on June 16 it could be heard screaming Edvard Munch style when Tegnell argued why it was right out audacious to deny Swedes from travelling to other countries:

“Citizens who travel to countries and areas with COVID-19 infections are the ones spreading the virus once back at home. COVID-19 was brought to Sweden by its own citizens, not by the tourists visiting Sweden.”

Let me translate: “As long as you don’t travel to Sweden you won’t bring the virus back to your country, but Swedes who travel abroad won’t somehow miraculously spread the virus when visiting your country.” Unsurprisingly, neither WHO nor its Nordic neighbours and most of the tourist destinations felt the same way and are now largely pretending not to be at home when Swedes ring at the door.

Tourism makes only 3 per cent of Sweden’s GDP which may partly explain the slack attitude towards the high contagion levels despite that many rely on tourism for extra income, especially young people. Neither am I confident, that the additional MSEK 70 government aid will make the industry stop screaming when it’s losing 4 times the amount per day. A compilation of all economic measures taken in response to COVID-19 by the ministry of finance can be found here.

Thus, social welfare costs are expected to rise with 30 per cent this year, tenant associations are receiving a record high 150 calls per week from worried tenants unable to meet monthly rent, and 40 per cent of debt collection companies report increasing payment problems.

Youth helplines are reporting children being worried about their parents becoming unemployed and what will happen to them if their parents die. Their grandparents already have. This is confirmed by a study of over 1,000 children in ages 4-18, where 80 per cent report worrying about COVID-19 related deaths and illnesses.

MIND, a helpline for elderly has seen 70 per cent increase since March with over 3,000 monthly calls answered, and priests have extended their availability online during evenings and nights as monthly calls have also spiked by 3,000. Almost three out of four ages 65 and older say that they now feel more insecure and uncomfortable in public places due to poor social distancing measures.

Domestic violence cases have risen in April compared to previous year and are expected to further rise during the summer when cases usually see a spike. At least 44,000 medical surgeries have been postponed and over 150,000 people are waiting in line for an operation.

From a public health point of view, that’s a lot of added stress and anxiety on top of all the grief caused by over 5,000 deaths, just four months into a long term strategy.

Any good news? The largely debated closing of high schools has actually made students perform better than previous year, nothing that surprised the Swedish National Agency for Education, quote: “It would be strange if short period of distance studies would lead to negative results.” I couldn’t agree more.

Further, I will disregard from the obvious counter argument: “Yes, it may look bad, but think how much worse things would be with wider enforced restrictions.” My counter argument to that would be: If this is the long term strategy such as FHM has presented it, this would be the new normal. It’s a far from a pretty picture, at least until there’s a vaccine available as Sweden continues to allow high contagion levels in society, and the current antibody studies and estimates are yet to show reliable data on long term immunity.

I would like to believe that Sweden’s strategy strives for the least human suffering possible, but until then: Cake anyone?

“Why Are People Still Dying?”: Anne-Françoise Hivert, LeMonde, May 19 – The Media Response

Communication is an essential component of any successful strategy and helps minimize the virus spread during a pandemic by keeping the public informed and safe, why it’s also as important to look at the narrative chosen by the authorities, their media response, and how the ongoing COVID-19 pandemic is being reported by the media. To quote Mike Ryan of WHO again: “You need to engage with the communities very deeply, acceptance is hugely important”.

Swedish media have been criticised for being overly positive and uncritical to Sweden’s strategy, at least in the beginning of the pandemic, which many news outlets after some self critiquing have agreed with.

FHM has to date held 77 press conferences with great both national and international interest, and I have followed them all. To report on deaths is by nature an unpleasant task, why it’s been a painful watch to follow the transition from reporting on Sweden’s bold open society approach in front of a curious world media to try to explain its high death toll.

There are only so many ways to spin the narrative and the increasingly dire statistics until one ends up with Trump style comments such as “Swedish strategy is successful”, “The more we test, the more cases we find”, “The rise (in new cases) is entirely an effect of increased testing”, or Tegnell’s June 26 response to how WHO had completely misunderstood Sweden’s high contagion levels when listing it among at-risk countries:

“We’re in the end of the pandemic”

It all played out on national morning TV, and I’d like to think that I wasn’t the only one cleaning up coffee stains afterwards and playing back the clip to make sure I had heard correctly. (WHO walked back the statement later the same day, while noting that the number of positive cases per 100,000 people continues to be high, 12-13 per cent, despite increased testing.)

Already by April 11 when the deaths were skyrocketing over the Easter holidays, Tegnell had stated that using death rates is a very one-sided way to look at the pandemic. My question: Exactly what other way is there to look at the response to a pandemic if not through the lens of over 5,000 deaths? Deaths that also could’ve been avoided.

He continued by saying that Sweden has the most accurate and precise way to report deaths compared to basically any other country. The underlying message from FHM has been consistent throughout; other countries report lower death rates because their reporting sucks. Karin Tegmark Wisell, legal expert FHM, started the July 14 press conference by saying: “The number of confirmed cases depends on how much you test, and the number of deaths depends on how you report”. Gotcha.

“In Sweden we don’t wear face masks, in Sweden we stay home when we’re sick. I think that makes a big difference.”: Tegnell on BBC HARDtalk with Stephen Sackur, May 18

Tegnell has often expressed his views on the precautionary principle in a way that strongly suggests he’s not a fan, but I wish he would argue as passionately for saving lives, especially of the elderly and ethnic minorities, as he argues against wearing a mask.

Masks together with asymptomatic spread have been constant subjects during the press conferences, where FHM now is scraping the bottom of the barrel for explanations that would make more sense than Trump’s claim in February on how “COVID-19 would miraculously be gone by April once the weather warms up”. The only miracle so far has been that Trump wore a mask before Tegnell did. Who could’ve have guessed? Even I didn’t see that coming.

On June 16 when international media reported on the sharp increase in new Swedish cases, FHM switched its reporting to display daily new confirmed cases by dividing them into serious (doctor’s appointment) vs mild cases, a practice I haven’t seen any other country to use.

Somewhat remarkable is also that Sweden is the only country in the world that doesn’t report confirmed COVID-19 recoveries (Johns Hopkins University), nor does it report daily new hospitalized cases. They are instead reported per week by Socialstyrelsen, but nonetheless not available on FHM’s statistics page.

FHM prefers to provide a weekly information heavy report instead of a short daily situation brief like many other countries, thus one must navigate through tiny graphs on its statistics page to find daily new confirmed cases. E.g. THL, Finnish equivalent to FHM, provides a short daily situation brief even in English.

It seems almost as if FHM has taken a position where it on behalf of the Swedish public and media decides what piece of information and statistics one should find relevant. It’s correct to argue that the information is available, but they’re certainly not always easily interpreted, or found. Like when TurboTax offers a free version to file your taxes (Thank you Hasan Minhaj, Patriot Act, for taking a long due shot at dark patterns and Intuit, true pet peeves).

Thank You, We Must Round Up Now”

When occasionally met with tough questions by journalists, unsurprisingly regarding elderly care and death rates, the FHM press conference moderator routinely turns into “Trump mode” by telling to keep it short, or quickly moving on due “lack of time”. The only thing that’s been missing is the “That’s a nasty question”. Here are three such memorable occasions with excellent journalists asking highly relevant questions:

On May 15, Florencia Rovira Torres, ETC, questioned whether FHM and Socialstyrelsen were aware of the CFS (clinical frailty scale) level 5 prioritizations that would effectively deny elderly care residents any hospital care, implemented by region Stockholm March 20 to avoid declaring emergency mode. She has previously exposed far right movements on French universities, why I’m confident that she will leave no stone unturned to seek justice for Sweden’s elderly. (Daily deaths May 15: 57, Total: 3,891)

On May 19, Anne-Françoise Hivert, LeMonde, pressed on why people are still dying, and moreover, who is still dying as ICU admissions showed slow decline but daily death rates had plateaued on high level, despite Tegnell having declared the situation in Sweden as pretty stable and measures to protect the elderly had been taken. (Daily deaths May 19: 39, Total: 4,091)

On June 3, the moderator literally ended the press conference before Marianne Sundholm, YLE, Finnish public broadcaster, got an answer to her second question about how Swedish excess death rates are calculated and reported. (Daily deaths June 3: 26, Total: 4,728)

And how has Tegnell felt about holding these press conferences so far? This is how he closed his June 24 summer radio talk when speaking about his summer holiday:

“It’ll be nice to switch from press conferences with predictable questions I have kindly been answering.”

I’m yet to hear Dr. Anthony Fauci, Director NIAID, use passive aggressive language despite the White House doing opposition research on him and vowing not to let science stand in the way to reopen schools, while U.S. is having a COVID-19 party with record breaking 77,225* daily new confirmed cases, over 3,5 million confirmed cases, and 138,360 deaths.

SVT, Swedish Public Service Broadcaster, Independent Or FHM Mouthpiece?

I have followed the media reporting closely, but in particular by SVT as it lies in its mission to provide unbiased reporting and inform the public. It has also received a fair amount of critique on being a mouthpiece for FHM, but has done a thorough work on its debate programmes, investigative journalism, and rightfully so on reporting the everyday life and challenges of ICU personnel.

What’s been a delight to follow is its COVID-19 live news feed functioning as a common 24/7 help desk, a true AMA of COVID-19. I sincerely commend their patience, positivity and kindness in their answers. Maybe my all time favourite question / answer so far is from March 28, 07:54 a.m. when reporter Dante Thomsen replied to a question whether is was allowed to get ones eyelashes done. Not a joke, a real question. Here’s how Dante answered: “Hey there! There are no restrictions to do that, but you shouldn’t go if you feel sick. Hope your eyelashes turn out fine!” Probably not what one expected to write, or report on, when studying journalism, but unquestionably public service in its purest form.

On a more serious note, many of these type of questions during the pandemic also show how confusing the stay-open strategy has been, and still is, to the public. The following observations of SVT’s reporting and decisions are less delightful:

Daily New Confirmed Cases

“We have chosen not to report the number of newly confirmed cases day by day, because according to the FHM it doesn’t in itself provide a sufficient overall picture of what the spread of infection looks like in Sweden.”: Kaisa Lappalainen, SVT, July 8.

SVT doesn’t report the number of daily new confirmed cases on its statistics page, which already is questionable, but instead publishes daily statistics summary on its COVID-19 live news feed at 2 p.m. when FHM publishes them. Beginning July 1, after WHO on June 25 had listed Sweden as an at-risk country, it discontinued reporting daily new confirmed cases on its summary, quoting FHM’s position, see above. Another highly questionable and disappointing decision, to say the least, and nothing one expects from an independent public broadcaster. Speaking of being accused to be a mouthpiece for FHM.

This was temporarily corrected on July 14 before discontinued again until July 16 after readers started questioning the missing statistics. Reporter Julius Bengtsson updated the report but denied any policy decision despite July 8 statement. Notable is that this never stopped it from reporting daily new confirmed cases from other countries, and not just from the large global outbreaks such as Florida and India one expects to read about.

Daily new confirmed cases were also the only statistics not mentioned during live news coverage of July 16 press conference, or even found on its on-screen news ticker as usual. It doesn’t seem like an unfortunate mishap or coincidence that both FHM and SVT would suddenly forget to mention them and instead have keen focus on emphasizing how several countries with enforced lockdowns now are seeing outbreaks.

Meanwhile, YLE, Finnish public service broadcaster, has had no problems to report Sweden’s daily new confirmed cases within few minutes after 2 p.m. as an adequate public service to its readers.

I fully agree on the importance of reporting “good news” in the midst of dire times, but there is no benefit to the public, quite on the contrary, to deliberately refrain from reporting facts in order to build up a more positive narrative around Sweden’s current COVID-19 status. This type of reporting is the oldest trick in the book when aiming to disorient or mislead with statistics; numbers alone have very little meaning if not reported in comparison to something, as in this case, the previous day. To not include them at all, or make it an extra effort for readers to find them is a clear attempt to narrate the facts.

Speaking from eight years of experience; news rooms are busy places with constraint resources, why a set of formats and rules are necessary when several people are involved in reporting, especially live reporting. The responsibility to define these formats and rules lies on the editor in chief, why no individual reporter is to blame for these inconsistencies. I’m glad that the daily new confirmed cases now are back, hopefully even added to the statistics page.

ICU Survival Rate After Minimum 30 Days, Regional Data And Daily Hospitalizations

More confusing statistics: The choice to report ICU minimum 30 days survival rate cases using combined interval ages 60-79 instead of common praxis interval ages 60-69 and 70-79 is troublesome. As 50 per cent as many between ages 60-69 are admitted to ICUs than between ages 70-79, but deaths among ages 70-79 are three times higher than among ages 60-69, the combined interval can easily conceal e.g. high mortality rate between the ages 70-79. The combined interval is not used anywhere else, why I have no reason to believe that this would be due to any technical issue, but a conscious choice.

Statistics per region including its capital Stockholm, are no longer available by daily new confirmed cases and deaths. They have been replaced with non clickable and highly confusing graphs showing new cases per average 100,000 inhabitants and deaths on a rolling seven-day average. The link to FHM regional data source used to return “Page not found”, but is now missing altogether.

Statistics that are completely absent in any form are daily hospitalizations. Socialstyrelsen provides hospitalization data only per week in Excel format, but it occasionally reports daily hospitalizations during press conferences, why one must pay close attention to at least get a glimpse. This also means that hospitals report them daily, which is both natural and critical during a pandemic, but for some reason that information is not available for the general public.

Interviews With Authorities Responsible for COVID-19 Response – Historical Significance

COVID-19 pandemic is a historical event that has already changed many peoples’ lives and continue to do so with far reaching consequences, why it will be important to be able to look back at what was being said and done by the people in charge.

How did Tegnell respond to early critique on Sweden’s strategy on March 15 when Sweden had seen its first deaths and WHO declared COVID-19 a global pandemic? How did the prime minister comment on the Swedish COVID-19 strategy three months later on June 14 with a death toll of 5,107? I find these two interviews in particular to have historical significance, both which I also reference to, but that now no longer are available to the Swedish public (both expired July 14). All that is left is a one minute soundbite from the prime minister.

I sincerely wish that all COVID-19 related interviews with authorities will be made available to the public and not only benefit the COVID-19 commission, who most definitely will require access during its investigation. I also think that all the excellent journalists on Agenda who have conducted these interviews deserve nothing less. So please, as a service to the public, and out of historical significance, republish them. Having to rely on screenshots and screen recordings to preserve such important documentation feels very subpar of SVT.

SKR, Swedish Association of Local Authorities and Regions – The Spin Master

The award for best attempt to spin the narrative and mislead with statistics goes to SKR, the central organization for municipalities and regions responsible for Sweden’s elderly care. This is how it explained the high death toll on its June 25 70-page report “Facts about elderly care in the light of the corona pandemic”:

“In relation to the total number of infected and dead, the elderly in Sweden have not been affected worse than the elderly in other Nordic countries.”

“A comparison with the Nordic neighbouring countries shows that the proportion of deceased people who are 70 years and older is largely identical to what it looks like in Sweden.”

Deaths ages 70 and older of total deaths in Nordics are as follow: Sweden 89 per cent, Denmark 88 per cent, Finland 87 per cent, and Norway 87 per cent. Let me put the facts about Sweden’s elderly in another way, here in comparison to Finland:

16 per cent of Finland’s population is 70 years and older (874,000). Finland has to date reported 285 deaths ages 70 and older of total 328 deaths.

12 per cent of Sweden’s population is 70 years and older (1,251,925). Sweden has to date reported 5,000 deaths ages 70 and older of total 5,619 deaths.

Largely identical? Sure, if you don’t count the dead. Let’s give the numbers one more spin, just to point out how the following headline would be as correct:

For every Finnish elderly death, 17,5 Swedish elderly have lost their lives.

Finland’s population is roughly half the size of Sweden’s, so even if we leveled the playing field and doubled the population and the number of total deaths in Finland, it would still result in almost 10 times more Swedish elderly lives lost.

Most troubling: SVT reported these “findings” without any critique using the astonishing title: “Sweden and the Nordics equally affected”.

Narrative Of The “Good Swede”

A fact that has entirely been missing from the Sweden’s broader dreamy narrative that the country can remain open because Swedes always act for the common good, is that Swedish constitution doesn’t allow wider lockdowns. In order to enforce such measures it would need to make changes in it, something Tegnell didn’t consider necessary and advised against in the beginning of the pandemic. Thus, Sweden welcomed COVID-19 into its home, only to quickly lose control of the messy and predatory houseguest.

I think it’s important for the future to remember, that it was a conscious choice not to make changes in the constitution, something that e.g. Finland did in order to quickly slow down the spread.

So, how are the good Swedes doing so far? Media have been reporting on the elderly being belittled, told to stay home, and discriminated in the society by younger people, so that they themselves can roam free without having to apply social distancing measures. This was addressed by Johan Carlson, director general FHM, as recent as on July 7 press conference, and has been confirmed in a study where 70 per cent of people ages 65 and older say that they now feel insecure and uncomfortable in public places. Reports and images from crowded restaurants, tourist spots, and public transports have been widely shared. One may ask, what ever happened to the good Swede?

Regarding Sweden’s strategy and narrative, I second FOI’s, Swedish Defence Research Agency, conclusion in its report:

“Whether the Swedish approach, which is based on an internationally frugal use of coercive measures, will be a proof of the state’s good efficiency or a naive belief in the citizens’ ability to prioritize collectively and long-term, remains to be seen.”

Right To Life

“Freedom of movement is a fundamental right guaranteed by the constitution, but the right to life is the most fundamental right.”

That was the message from Johanna Ojala-Niemelä, Chair of the Finnish Constitutional Committee of the Parliament, on March 25 when commenting Finland’s decision to enforce lockdown of Helsinki and Province of Uusimaa.

The newly appointed commission set to investigate and evaluate how the pandemic has been managed by the government, authorities, regions, and municipalities in relation to other countries will present its final findings in the end of February 2022. Thus far, Sweden has undeniably failed to protect its elderly and ethnic minorities, and frankly, I’m not sure if we need to wait until 2022 to determine whether Sweden’s strategy to flatten the curve can be considered a success when the nation’s elderly have deliberately been denied adequate care and hospitalization, and left alone in the room to wait COVID-19 take its course.

One must ask: Is the right to life truly the most fundamental right for everyone in Sweden?

One More Thing – Say Cheese!

Sweden stayed open, slaughtered its elderly and ethnic minorities only to be put into house arrest by the rest of the world. The travel intense nation between 14-16 million yearly travels is now making the most of the situation by (re)discovering its own turfs, while exhausted healthcare personnel keep working to save lives in +28C (82F) hot ICUs.

Being the last person instead of a loved one to hold a hand of a dying patient has already taken a high toll on them. The very people who have been risking their lives by treating patients with inadequate PPE and falling ill themselves, now see their sacrifices being rewarded with delayed or cancelled holidays and risk bonuses, or like in one of the regions, with a 50€ gift card for cheese. Yes, CHEESE. Ok, also a t-shirt.

So, for those yelling at the elderly to stay at home and causing crowed tourist streets and beaches, and last but not least, for those in charge of the Swedish strategy: Don’t forget to say cheese when instagramming your perfect summer selfies.

* All COVID-19 related statistics dated July 17, data sources: FHM , Johns Hopkins University, SIR.
** Tokyo Coronavirus Tracker
*** Coronavirus Disease (COVID-19) Situation Report in Japan

FHM, Folkhälsomyndigheten, Swedish Public Health Agency
Socialstyrelsen, National Board of Health and Welfare
IVO, Health and Social Care Inspectorate
FOI, Swedish Defence Research Agency
SVT, Swedish Public Service Broadcaster
SKR, Swedish Association of Local Authorities and Regions
SIR, The Swedish Intensive Care Registry
THL, Finnish Institute for Health and Welfare

“All that is necessary for the triumph of evil is that good men do nothing”: E. Burke.

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Paula is Digital Product Advisor and Top 100 Women in Tech in Europe, focusing on Product, Go-to-market, and Internationalization strategies. Rated as one of the very best startup mentors in Europe, she has to date mentored over 150 digital technology companies on product, marketing and growth. Pick My Brain! is her fixed price service tailored to early stage startups, gender wage gap adjusted for female founders. More

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