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Swedish government response to the COVID-19 pandemic

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Through COVID-19 pandemic and Pathogen transmission

Sweden had made preparations for a pandemic in previous years, with the Public Health Agency of Sweden designated as the responsible body in a disease outbreak but without the authority to pass laws itself. In the Swedish political system, the cabinet with legislative authority is mandated to follow the advice of government agencies (in this case the Public Health Agency) and very rarely overrules this, as ministerial governance is prohibited under the Basic Laws of Sweden. Crisis management in Sweden instead follows the "principle of responsibility".

Upon the outbreak of the COVID-19 pandemic, the Public Health Agency initiated contact tracing and outlined its strategy to protect the country's most vulnerable citizens and prevent the health care system from being overwhelmed. As the outbreak spread, the agency advised those with respiratory symptoms to avoid social contacts, work from home if possible, minimise travel, and adhere to social distancing. The government passed a law banning large gatherings, and secondary and higher education institutions were advised to switch to distance education. Press conferences and public communications campaigns were also launched. Unlike most other countries, face masks were not recommended in public or healthcare settings.

On 18 December 2020, Stefan Löfven, the prime minister of Sweden, announced new and tougher restrictions and recommendations including the use of face masks in public transportation and closure of all non-essential public services. In January 2021, a new pandemic law was passed that allows for the use of lockdown measures and legally limited some gatherings. Further measures were introduced in July and December 2021, such as vaccine passports.

Reception for the government's response has been mixed. An independent commission was launched to evaluate the measures taken by the government, the administrative health authorities, and regional municipalities. The commission criticized the response of the government, citing among other things a failure to protect the elderly population, that the Swedish response was marked by slowness, with initial measures "insufficient to stop or even substantially limit the spread of the virus in the country," and that the Swedish healthcare system would face long-term consequences due to "the price of extreme pressure on staff and of cancelled and postponed care." In their final report, the commission described Sweden not introducing lockdowns as "fundamentally correct" for maintaining personal freedoms, but were critical of the decisions not to introduce "more rigorous and intrusive disease prevention and control measures" in February and March 2020.

Sweden's unique approach also became a divisive topic of debate, receiving significant international media coverage and criticism both domestically and internationally, and with those who oppose or support public health restrictions often citing the Swedish response as an example.

Background

Outbreak of a novel coronavirus disease

On 12 January, the World Health Organization (WHO) confirmed that a novel coronavirus (nCoV) was the cause of a respiratory illness in a cluster of people in Wuhan, in Hubei, China, who had initially come to the WHO's attention on 31 December 2019. This cluster was initially linked to the Huanan Seafood Wholesale Market in Wuhan City. A few days later, on 16 January, the Swedish Public Health Agency issued a press release highlighting the discovery of the novel coronavirus, and the agency monitoring the situation. The risk of spread to Sweden was described as "very low" as there was yet no evidence that the virus could spread between humans, but they recommended that individuals developing cough or fever after visiting Wuhan should seek medical care, and asked for healthcare professionals to be observant.

After the World Health Organization classified the novel Coronavirus as a Public Health Emergency of International Concern on 30 January and demanded that all member states should cooperate to prevent further spread of the virus, the Agency requested for the Swedish government to classify the novel disease as a notifiable infectious disease in the Swedish Communicable Diseases Act as both dangerous to public health (allmänfarlig) and dangerous to society (samhällsfarlig), where contact tracing is required, giving the disease the same legislative status as Ebola, SARS and Smallpox. The agency also announced that they have analysing methods that can diagnose a case of the novel disease ‘within hours’ after testing, and that such tests had already been carried out, but that all had turned out negative.

Planning

Following the 2005 outbreak of the H5N1 avian flu, Sweden drafted their first national pandemic plan which since then had undergone several revisions. Since a 2008 revision to prepare for the 2009 swine flu pandemic, the plan includes the formation of a National Pandemic Group (NPG) in the event of a possible pandemic. The group involves several Swedish government agencies and defines each agency's role.

The plan states that the Public Health Agency of Sweden will be the expert agency responsible for monitoring diseases with a pandemic potential, and with the mandate to assemble the National Pandemic Group to coordinate pandemic preparations and strategies on a national level between the relevant agencies. The pandemic group includes four additional Swedish government agencies: the Swedish Civil Contingencies Agency, the Swedish Medical Products Agency, the Swedish National Board of Health and Welfare and the Swedish Work Environment Authority, as well as the county administrative boards of Sweden and the employer's organisation Swedish Association of Local Authorities and Regions.

Swedish crisis management is built on a principle of responsibility which means that the organisation who is responsible for an area of activity under normal circumstances is also responsible for that area of activity during a crisis. As the Public Health Agency of Sweden, headed by director general Johan Carlson, is the agency responsible of monitoring and preventing the spread of infectious diseases, the agency had a central role in the Swedish response to the pandemic. The Public Health Agency also tasked with having a coordinating role for the national response to a pandemic according to the National Pandemic Plan, together with the Swedish Civil Contingencies Agency headed by Dan Eliasson and the Swedish National Board of Health and Welfare headed by Olivia Wigzell.

Preparedness

In 2013 risk and impact assessments by the Swedish Civil Contingencies Agency, the Swedish expert agency on crisis management, the risk of Sweden in the future being affected by a severe pandemic was assessed as "high" with a "catastrophic" impact on human health and economics. They believed that a future pandemic would be inevitable within 5–50 years.

In the 2019 Global Health Security Index of the ‘most prepared’ countries in the world for an epidemic or a pandemic published by the Johns Hopkins Center for Health Security, Sweden was ranked 7th overall. Sweden received high rankings regarding prevention of the emergence of a new pathogen, early detection and reporting of an epidemic of international concern and having a low risk environment. However, the Swedish healthcare system received a lower score, questioning if it was sufficient and robust enough to treat the sick and protect health workers.

In 2013, the Swedish Civil Contingencies Agency investigated Sweden's ability to cope with a pandemic through a simulation where a severe avian influenza infects a third of the population, out of which 190,000 gets severely ill, and up to 10,000 die from the disease. They concluded that Sweden was generally well prepared, with pandemic plans on both national and regional level, but that the health-care system would be the weak link. They noted that Swedish hospitals were already under heavy burden, and wouldn't have the capacity to treat everyone who become sick, even when alternative facilities (like schools and sports centres) were used as hospitals. They also pointed out that issues concerning prioritising, including triage, would become central during the crisis, and that they believed this subject needed to be addressed. Before the outbreak of the new coronavirus, Sweden had a relatively low number of hospital beds per capita, with 2.2 beds per 1000 people (2017), and intensive care unit (ICU) beds per capita of 5.8 per 100,000 people (2012). Both numbers were lower than most countries' in the EU. The total number of ICU beds in Swedish hospitals was 526.

By the time of the Fall of the Berlin Wall in 1989, the Swedish Defence Forces was equipped with a total of 35 field hospitals, with what some considered to be the most modern battlefield medicine in the world, with the Swedish Navy having an additional 15 hospitals. The field hospitals had a combined capacity of treating 10,000 patients and performing 1000 surgeries every 24 hours, as well as stockpiles with drugs, medical supplies and personal protective equipment to treat 150,000 war casualties. Additionally, the Swedish state had several preparedness hospitals and Swedish schools were constructed to be converted into hospital units in case of a military conflict and with a total capacity of treating 125,000 patients, supported by a network of preparedness storages containing medicine and medical equipment.

From 1990 and onwards, the system was gradually dismantled to eventually disappear altogether, with the equipment, including more than 600 new ventilators, being either given away or disposed of. At the start of the 2020 COVID-19 pandemic, the Swedish Defence Forces owned 2 medical units with a total of 96 beds, out of which 16 were ICU beds, and there were no civil preparedness storages for medical equipment left in Sweden. The National Board of Health and Welfare did however keep an emergency storage of reserve ventilators.

Until 2009, the Swedish state-run pharmacy chain Apoteket had the responsibility to ensure drug supply in case of emergency. Following a controversial privatisation, the responsibility was handed over to the private sector. However, a lack of regulations meant that the companies had no incentive to keep a bigger stock than necessary, effectively leaving Sweden without an entity responsible for medicine preparedness.

At the start of the pandemic, the Swedish healthcare system were instead relying on a "just-in-time" deliveries of medication and medical equipment, and Sweden had no medicine manufacturing of its own, which was considered to make the country's drug supply vulnerable as it relied on global trade and long supply lines. The Swedish healthcare system was already experiencing a growing number of backordered drugs in the years leading up to the pandemic.

The lack of medicine preparedness had been strongly criticised in several inquiries and reports since 2013 by a number of Swedish governmental agencies, including the Swedish National Audit Office, the Swedish Defence Research Agency and the Swedish Civil Contingencies Agency. The latter had regarded disturbances in the drug supply as one of their biggest concerns in their annual risk assessments.

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