What’s Going on With Sweden?

By John Banks

While the Western world zigged, Sweden zagged.

The United States, Canada, the United Kingdom, and most of Europe — including Sweden’s Nordic neighbors, Norway and Finland — issued shelter-in-place orders to deal with COVID-19. Sweden did not.

Meanwhile, in country after country, the virus is wreaking havoc. And yet Sweden appears to be floating above it all. No shelter in place, no problem. How is this possible?

Due to this paradox, “Be like Sweden” has become a rallying cry for some who doubt the pandemic. They point to Sweden as evidence America has made a huge error.

Others are simply perplexed by Sweden’s outlier status.

COVID-19 is highly contagious, we know this for a fact. There are countless stories of choir practices, card games, and business or family get-togethers that turned deadly afterward. Meanwhile, in meat packing plants and prisons — two places where social distancing is close to impossible — contagion rates have repeatedly soared past 50%.

We also know COVID-19 is deadly for the vulnerable, with some U.S. nursing homes reporting dozens of deaths in a single location.

There is also a growing body of evidence that survivors of COVID-19 who had a rough experience — including adults under 50 and even young children — are seeing their long-term health impacted in ways we still don’t understand.

And yet there is Sweden, an almost total outlier, floating above the fray. What is going on?

The mystery clears up when you take a closer look.

When it comes to the pandemic and dealing with its fallout, in certain ways, Sweden as a country is exceptional. In other ways the “mystery” of Sweden, when it comes to COVID-19, is little more than a misread of the data, perhaps with some wishful thinking thrown in.

Then, too, there is no way America could “be like Sweden” even if it tried. The United States could not have replicated the Swedish model.

All told, for the United States at least — and for many others, too — “be like Sweden” is a fantasy.

Let’s start with population numbers and socioeconomic factors. Sweden has a population of 10.23 million. By comparison, Los Angeles County has a population of 10.04 million (both figures as of 2019).

So the entire population of Sweden is roughly on par with Los Angeles County. To put it another way, the Swedish population is about 3% of the U.S. population (328.2 million). 

Then, too, the U.S. population is widely distributed, both geographically and economically.

Some Americans live extremely close together. Others live far apart. A modest percentage of Americans are wealthy, a fair percentage count as comfortable or well off, and the majority of Americans (60%) are either economically struggling or poor.

Some Americans have excellent insurance, excellent access to health care, and excellent hospitals to choose from. Other Americans — tens of millions of them — have no insurance, no real access to health care other than the emergency room, and, for many in rural areas, no hospital within 50 or 100 miles.

This matters because access to health care, and the functional quality of the hospital system, is a major factor in a country’s ability to respond to a pandemic.

As a case in point, consider this: In March 2020, Sweden’s health care system doubled its ICU bed capacity in the Stockholm region (the country’s main metro area) within a span of 10 days.

The next step, Stockholm regional health director Bjorn Eriksson said at a press conference on March 30, was to go from doubling that capacity to tripling it.  

Prior to the pandemic, Sweden had slightly fewer ICU beds per capita than the United States (perhaps because the population is far healthier).

But Sweden was able to double, and then potentially triple, its ICU capacity on demand. Could the U.S. system have done that? No. It would have been impossible.

This matters because, in late April, Sweden’s top epidemiologist, Anders Tegnell, bragged of 20% spare capacity within the Swedish system.

But guess what — if they hadn’t doubled that capacity or more a month earlier, they would have been overrun.

If you remember those “flatten the curve” graphs, what Sweden did was double (and then more than double) the volume of “hospital system capacity” under the critical dotted line, through sheer force of will, in a matter of weeks.

Rather than flatten the curve, in other words, Sweden “raised the line” of health care system capacity.

Sweden could do that because of the already existing logistics of its well-run health care system, as applied to a small country of just over 10 million people with equal access to health care.

America, with its privatized and “balkanized” hospital system, far-flung distribution, and more than 328 million citizens, would have no chance at all of doubling its ICU capacity on a quick-turnaround basis.

As a result, the American system would have been overrun had shelter-in-place orders not been issued — just as Sweden would have been overrun had they not doubled their capacity swiftly. 

For Sweden, the ability to “raise the line” was a big advantage. But in spite of that unique ability, the Swedes still have problems.

As we have mentioned before, Sweden’s COVID-19 death toll is alarmingly high. In the rankings of COVID-19 death rates per million, Sweden is in the top 10 of all reporting nations with a population size of 1 million or more.

Sweden’s COVID-19 fatality rate per million is also more than six times next-door-neighbor Finland and seven times next-door-neighbor Norway, according to Worldometer data. Not all Swedish citizens are comfortable with this, and some are angry at the risks borne by the elderly and infirm.

You can track Sweden’s COVID-19 progress, by the way, via this link from the Worldometer tracking site.

As of this writing, again according to Worldometer data, Sweden has more than 3,000 COVID-19 deaths. Sounds low, right? Not for a small country with 10 million people — and not in the early stages of a pandemic, where the sting is in the tail due to an exponential rate of spread. 

Next we’ll compare some hypothetical outcomes. But first we should note that Sweden, as a country, is much healthier than the United States. Compared to Americans, the Swedish people have a higher life expectancy and far lower obesity rates.

This matters because “comorbidities” — the presence of an illness or conditions of poor health — are a significant factor in COVID-19 fatalities.

So let’s say Sweden comes through the pandemic with a 0.4% COVID-19 fatality rate when all is said and done. That conserative number is arrived at via starting with a 0.5% fatality rate — a growing general consensus as to where fatality rates could shake out — adjusted slightly lower for Sweden’s good health.

That number, 0.4%, would result in roughly 41,000 deaths from COVID-19 in Sweden.

Could Sweden, with a current tally of 3,040 COVID-19 deaths, wind up with 41,000 deaths by the finish? Absolutely it could. The gap is not that large, especially given the tail-driven nature of pandemic outcomes.

Obviously, we don’t know what Sweden’s final tally will be — but we know that the current wave is ongoing, that there is likely to be a “second wave” in the fall, and that, based on how pandemics work, fatalities are a lagging indicator relative to early spread, and can sometimes lag by many weeks. 

(If you remember the Diamond Princess — the COVID-inflicted cruise ship that departed Japan on Jan. 20 — there are still active cases associated with that ship, some of them serious or critical.)

The point here is that, if Sweden winds up with tens of thousands of COVID-19 deaths — which it very well could — that number might sound small to American ears, where the United States death toll is already approaching 75,000 as of this writing.

But that is only because Sweden’s population is small by comparison.

If you take an implied 0.4% fatality rate for Sweden and bump it up to 0.5% to account for America’s far higher obesity rates — a modest adjustment to be sure — and then apply it to a country of America’s far larger size (more than 328 million people), you get 1.64 million deaths.

Would America be willing to tolerate 1.64 million deaths from COVID-19? That seems doubtful.

Especially given that the actual American death toll would be much, much higher still — if not doubled or tripled — if America actually, and foolishly, tried to “be like Sweden,” due to inevitable rampant breakage in the U.S. hospital system.

To even have a chance of keeping long-tail fatality rates in the low decimal percentage range, you would need a smooth-functioning hospital system that grants uniform access to the whole population. Does America have that? No.

Instead, the U.S. hospital system is fraught with shortages, can often be chaotic and hard to navigate, and is shunned by many Americans who either lack insurance and fear a huge bill, or otherwise fear getting sick. On top of that, the existing system leaves a great many Americans (particularly rural Americans) stuck in “medical deserts,” with no meaningful care facilities within an hours’ drive or more.

So, to briefly sum up (and reiterate some key points):

  • Sweden, a small country the size of L.A. County with a smooth-functioning hospital system, was able to double (if not triple) its ICU bed capacity within a matter of weeks in March. If they had not done that, they would have been overrun, as evidenced by their later-reported numbers.
  • Sweden was able to “raise the line” as opposed to flattening the curve. America never had this option — even with the political will, it would have been logistically impossible.
  • Not everyone is convinced Sweden is doing fine. Their COVID-19 death toll per million is alarmingly high compared to their neighbors — and in the world’s top 10, not a ranking anyone wants. And the ongoing story is far from over.
  • It’s entirely possible Sweden gets through with a COVID-19 fatality rate in the reasonably low decimal range, e.g. 0.4%, that would nonetheless result in millions of deaths if applied to the United States — with a significant multiple applied due to U.S. hospital system breakage.

We wish Sweden well, though we fear the numbers will turn grim.

Either way, though, the mystery of Sweden isn’t so much a mystery when you consider the data — and Sweden’s ability to “raise the line” rather than flatten the curve.

Then, too, if America tried to “be like Sweden,” it would kill us — first in terms of hospital system breakage, then in terms of psychological turmoil, and finally via economic fallout relating to both of those.