Why did Sweden have more covid deaths than its neighbors?

Other factors, not the less severe lock down might be why

By Sebastian Rushworth, M.D. He is a practicing physician in Stockholm, Sweden.

"One of the arguments that has been used in support of strict lockdown is that Sweden has had significantly more covid deaths than its nordic neighbours. On the 19th of November, Sweden had registered 637 covid deaths per million people. For comparison, Denmark had registered 140, Norway had registered 57, and Finland had registered 69.

But, as I wrote about recently, the studies that have been done have not been able to find any correlation between severity of lockdown and the number of covid deaths. Which must logically mean that Sweden’s higher death rate was not due to the fact that it didn’t institute a severe lockdown. So, if that is the case, why did Sweden have more covid deaths than its closest neighbors?

A paper written by three economists at the end of August sought to answer that question. The research didn’t receive any specific funding, and the authors reported no conflicts of interest. The authors provided 15 different factors that could potentially explain the difference. I’m going to focus on the few that I think are likely the most important.

The first hypothesis is that Sweden, and in particular Stockholm, imported many more cases of covid-19 from abroad before measures were put in place to stop the spread between countries. The main reason for this is that Stockholm has a half-term holiday (“sportlovet”) in late February, when many people go skiing in the alps. The other nordic countries have similar holidays, but they have them earlier. So any Norwegians, Danes, or Finns who went skiing in the alps, would have gone there before the pandemic exploded in that region, while the people from Stockholm were there when infections were spreading at their worst.

The two other large-ish cities in Sweden, Malmö and Gothenburg, provide a useful control for this hypothesis. Both cities have their half-term holiday a week or two before Stockholm, and both were hit far less severely than Stockholm in the first wave. Stockholm experienced 40% of Swedish covid deaths, despite having only 24% of Sweden’s population.

Apart from this, Swedes travel internationally far more than their nordic neighbors (80% more per million people), which would have resulted in significantly more cases of covid being brought in to the country at the beginning of the pandemic.

The second hypothesis concerns the fact that Sweden has a much bigger population of immigrants than its nordic neighbors. 19% of Sweden’s population is foreign born, as opposed to 14% for Denmark and Norway, and only 8% for Finland. What this means in practice is that Sweden has a bigger population of people with darker skin, and it has been clear since early in the pandemic that darker skinned people in western countries are much more likely to develop severe covid than lighter skinned people.

As an aside, Much of the media debate around this phenomenon has centred around the idea that darker skinned people generally have lower status, higher rates of poverty, worse access to health care and so on – basically, that the difference is due to institutional racism.

But there is one big problem with that idea. It doesn’t fit all the facts. An article in the Washington Post on May 20th reported that 27 of 29 doctors who had died of covid in the UK up to that point belonged to ethnic minorities. In other words, 93% of doctors who had died at that point came from ethnic minorities, even though they only constitute 44% of all doctors in the country. Why is this important? Because doctors with darker skin are still doctors, which means that they are members of a high status, well paid, well-off segment of society.

Note, I’m not saying that institutional racism doesn’t exist. I’m just saying that it can’t explain why darker skinned people in western countries are hit much harder by covid than lighter skinned people.

Vitamin D deficiency could though. Darker skinned people in northern Europe are more likely to be vitamin D deficient for the simple reason that their skin isn’t as good at producing vitamin D from the feeble sunlight we get in this part of the world. A number of observational studies have shown that people with low vitamin D levels do worse when infected with covid, and there is even a randomized trial in which patients treated with high dose vitamin D did much better than the control group, which I’ve written about in a separate article (funnily enough, that study gained pretty much zero media attention, while remdesivir, a highly expensive drug that is almost completely useless against covid, has been talked about endlessly).

Anyway, what the authors are saying is that Sweden has a larger ethnic minority population than its nordic neighbours, and people from ethnic minorities do worse when they get covid.

The third hypothesis, and from my perspective the most important, concerns the fact that Sweden had a much larger vulnerable population at the beginning of 2020 than its nordic neighbours. This can be seen in multiple different ways in the statistics.

The first is that Sweden has a large nursing home population. Relative to population size, Sweden’s nursing home population is 50% larger than Denmark’s. And as I’ve mentioned previously, in Sweden, people don’t go to nursing homes until they are near the end of life.

The second way this can be seen in the statistics is by looking at overall mortality for the immediately preceding year, 2019. If unusually few people die in one year, then unusually many will die in the following year, since there is a carry forward effect (due to the fact that humans are not immortal). 2019 was an unusually un-deadly year in Sweden, and the early part of 2020 (pre-covid), was also unusually un-deadly, which means that there was an unusually large number of very frail old people in the country when covid struck. This same effect was not seen in Sweden’s nordic neighbours – for them 2019 was normal in terms of overall mortality.

To clarify exactly how big this difference is, let’s look at the numbers. In Sweden, overall mortality in 2019 was 2,5% lower than the average for the preceding five years. In Norway, mortality was exactly in line with the average. Denmark and Finland both had mortality rates that were 1% above the average. Denmark, Finland, and Norway were in a much better position in relation to covid from the start. Sweden was always going to have more deaths, regardless of the actions it took.

As I think this article shows, there were a number of big differences between Sweden and its nordic neighbors at the beginning of the pandemic, which are altogether certainly sufficient to explain the big difference in covid mortality.

Correlation is not causation. Many people have chosen to see a causative relationship between Sweden’s lack of severe lockdown and relatively high number of deaths, because it supports their prior beliefs about the effectiveness of lockdowns. Those beliefs are, however, not supported by the evidence.

You might also be interested in my article about how deadly covid really is, or my article about how effective lockdowns are."