What Sweden Got Right About COVID

The U.S. botched the pandemic—overprotecting kids at low risk of serious illness and under-protecting older Americans. Stockholm pursued a light touch and fared far better. 

By Shannon Brownlee and Jeanne Lenzer. Shannon Brownlee is a lecturer at George Washington University School of Public Health. Jeanne Lenzer is the author of The Danger Within Us; America's Untested, Unregulated Medical Device Industry and One Man's Battle to Survive It.

"Talk about killjoys. While the rest of us are enjoying what’s starting to feel like a return to everyday life, some experts are warning that there’s another COVID-19 variant coming. Philadelphia has reinstituted its mask mandate. The wave of new infections in Europe will hit us soon, they say, and failing to maintain at least some of the lockdowns we’ve endured for the last two years is “denialism.” That message is echoed by the People’s CDC, a group of epidemiologists, doctors, and other people with long COVID. They argue that the federal Centers for Disease Control and Prevention’s recommendation to focus on protecting those at the highest risk and a return to “normal” for everybody else is precisely the wrong course of action. 

But is it? 

While most countries imposed draconian restrictions, there was an exception: Sweden. Early in the pandemic, Swedish schools and offices closed briefly but then reopened. Restaurants never closed. Businesses stayed open. Kids under 16 went to school. 

That stood in contrast to the U.S. By April 2020, the CDC and the National Institutes of Health recommended far-reaching lockdowns that threw millions of Americans out of work. A kind of groupthink set in. In print and on social media, colleagues attacked experts who advocated a less draconian approach. Some received obscene emails and death threats. Within the scientific community, opposition to the dominant narrative was castigated and censored, cutting off what should have been vigorous debate and analysis.

In this intolerant atmosphere, Sweden’s “light touch,” as it is often referred to by scientists and policy makers, was deemed a disaster. “Sweden Has Become the World’s Cautionary Tale,” carped The New York Times. Reuters reported, “Sweden’s COVID Infections Among Highest in Europe, With ‘No Sign Of Decrease.’” Medical journals published equally damning reports of Sweden’s folly. 

Stockholm Solution

But Sweden seems to have been right. Countries that took the severe route to stem the virus might want to look at the evidence found in a little-known 2021 report by the Kaiser Family Foundation. The researchers found that among 11 wealthy peer nations, Sweden was the only one with no excess mortality among individuals under 75. None, zero, zip. 

That’s not to say that Sweden had no deaths from COVID. It did. But it appears to have avoided the collateral damage that lockdowns wreaked in other countries. The Kaiser study wisely looked at excess mortality, rather than the more commonly used metric of COVID deaths. This means that researchers examined mortality rates from all causes of death in the 11 countries before the pandemic and compared those rates to mortality from all causes during the pandemic. If a country averaged 1 million deaths per year before the pandemic but had 1.3 million deaths in 2020, excess mortality would be 30 percent.

There are several reasons to use excess mortality rather than COVID deaths to compare countries. The rate of COVID deaths ignores regional and national differences. For example, the desperately poor Central African Republic has a very low rate of fatalities from COVID. But that’s because it has an average life expectancy of 53. People in their 70s are3,000-fold more susceptible than children to dying of COVID, and even people in their 20s to 50s are far less likely to die than the elderly. So, it’s no surprise that the Central African Republic has a low COVID mortality rate despite its poverty and poor medical care. The U.S., by contrast, with its large elderly population (and general ill-health compared to most wealthy countries), was fertile soil for the coronavirus. 

Excess mortality is the smart, objective standard. It includes all deaths, whether from COVID, the indirect effects of COVID (such as people avoiding the hospital during a heart attack), or the side effects of lockdowns. And it gets rid of the problem of underlying differences among countries, allowing a direct comparison of their performance during COVID.

Using data from the Human Mortality Database, a joint project of the CDC and the Max Planck Institute in Germany, Kaiser compared mortality during the five years before the pandemic and mortality in 2020, the first year of the pandemic. Sweden had zero excess mortality in 2020 among people younger than 75. In other words, COVID wasn’t all that dangerous to young people. 

Even among the elderly, Sweden’s excess mortality in 2020 was lower than that in the U.S., Belgium, Switzerland, the U.K., the Netherlands, Austria, and France. Canada, Germany, and Australia had lower rates than Sweden among people over the age of 70—probably because Sweden failed to limit nursing home visits at the very beginning of the pandemic. 

The U.S., by contrast, had the highest excess mortality rate among all 11 countries in the Kaiser study. We also had a stunning number of COVID deaths—more than 1 million. Our lousy rate is probably due to multiple factors, says Jay Bhattacharya, a professor of medicine at Stanford University and senior fellow at the Stanford Institute for Economic Policy Research. Our underlying health is worse than most wealthy countries because of our wide wealth gap, high rates of poverty and obesity, spotty access to high-quality health care for the poor, and an aging population. 

The Kaiser results might seem surprising, but other data have confirmed them. As of February, Our World in Data, a database maintained by the University of Oxford, shows that Sweden continues to have low excess mortality, now slightly lower than Germany, which had strict lockdowns. Another study found no increased mortality in Sweden in those under 70. Most recently, a Swedish commission evaluating the country’s pandemic response determined that although it was slow to protect the elderly and others at heightened risk from COVID in the initial stages, its laissez-faire approach was broadly correct. 

This brings us to the other insight from Kaiser researchers. By looking only at 2020, before the advent of vaccines and other medical treatments, the researchers could measure the effect of lockdowns. While those who could retreat to home computers may have viewed restrictions as simply annoying disruptions, for many Americans they were devastating, as reflected in our high excess mortality rate. 

One of the most pernicious effects of lockdowns was the loss of social support, which contributed to a dramatic rise in deaths related to alcohol and drug abuse. According to a recent report in the medical journal JAMA, even before the pandemic such “deaths of despair” were already high and rising rapidly in the U.S., but not in other industrialized countries. Lockdowns sent those numbers soaring.

The U.S. response to COVID was the worst of both worlds. Shutting down businesses and closing everything from gyms to nightclubs shielded younger Americans at low risk of COVID but did little to protect the vulnerable. School closures meant chaos for kids and stymied their learning and social development. These effects are widely considered so devastating that they will linger for years to come. While the U.S. was shutting down schools to protect kids, Swedish children were safe even with school doors wide open. According to a 2021 research letter, there wasn’t a single COVID death among Swedish children, despite schools remaining open for children under 16.

Of the potential years of life lost in the U.S., 30 percent were among Blacks and another 31 percent were among Hispanics; both rates are far higher than the demographics’ share of the population. Lockdowns were especially hard on young workers and their families. According to the Kaiser report, among those who died in 2020, people lost an average of 14 years of life in the U.S. versus eight years lost in peer countries. In other words, the young were more likely to die in the U.S. than in other countries, and many of those deaths were likely due to lockdowns rather than COVID. 

Looking to the Future

Lockdowns may not come back when the next COVID surge hits, but many public health officials say masks likely will be. Even that may not be worth the effort, at least for kids in schools. Despite headlines claiming that they work, the only two decent scientific studies of masks found minimal benefit against COVID. 

The more extensive study of the two, published last September, was used as ammunition to support school mask mandates—even though children had been excluded from the study. The study found that masks failed to prevent 90 percent of infections; only the elderly benefited modestly. Ashley Styczynski, one of the principal investigators, said “further study” was needed to know if masks provide any protection to kids.

Last month, the Senate Committee on Health, Education, Labor and Pensions voted overwhelmingly to establish an independent panel to investigate the nation’s response to the pandemic, modeled on the much-heralded 9/11 Commission. Such a COVID commission should study Sweden, even if the American medical and public health establishment continues to scoff at this Scandinavian success. Whether it was Sweden’s light touch or America’s lockdowns, no public health response could have prevented COVID deaths entirely. But the data shows that Sweden did better and suggests we’d be better off with their light touch when the next coronavirus crisis comes ashore."