Exit from Lockdown: Lessons from The Swedish Challenge
As of the fourth week of April 2020, most countries, the Philippines included, are preoccupied with crafting a phased exit from mandated lockdown. The consensus seems to be that a prolonged induced coma can precipitate an economic collapse leading to a tsunami of fatalities only remotely connected to COVID-19. Already, food banks are running low and protests against the lockdown are growing in some states of the USA. Most countries that is, except Sweden and Taiwan.
Sweden from the start rejected a mandated lockdown in favor of an admonitional program that relies on citizen responsibility to follow softer anti-COVID-19 protocols — stay and work at home as much as possible, open restaurants, groceries, bars, and public transportation provided light social distancing is observed, schools open for students under 16 years old, avoid gatherings of 50 people or more, targeted isolation for high-risk groups only, etc. The idea is to let the less vulnerable groups acquire some immunity through exposure while shielding the vulnerable ones and keeping economic train going, albeit at a much reduced pace. Taiwan too imposed no internal lockdown because, having caught the pandemic at birth, Taiwan’s fully loaded armory was able to smother it.
Sweden’s strategy is a true gamble; it risks a higher infection rate and thus a higher mortality rate especially at the start and at mid-cycle in the hope of evening the score at full cycle. The Swedish medical authority and the Swedes, we think, know the stakes and consider the gamble worthwhile. Will the Swedish authority withstand the call for reversal when the report on the cost (higher deaths mid-cycle) start to come in before the report on the benefits (at full cycle) do?
Sweden attacks the COVID-19 spread through a hybrid program combining soft social distancing to reduce Ro and controlled exposure to raise H. Among epidemiological modelers, the role of herd immunity is summarized by the relation Re = Ro (1 – H) where Re is the effective reproduction rate, Ro is the natural reproduction rate, and H is the proportion of the population having immunity from the virus. When Re < 1, the epidemic dies naturally.
A high enough H produces Re < 1. If Ro = 2 (one infected in turn infects two), a herd immunity of H > 0.50 (say, 51% of the population) renders Re < 1 and the epidemic is damped down. The higher the Ro, the higher is the required H for a damp down. The logic of hard lockdown and strong social distancing is to directly hammer down Ro to less than one. The view is that lockdowns, to be effective, have two components: universal coverage, meaning all socio-economic interactions, and tough sanctions.
Sweden’s maverick approach has been the target of withering attacks from other countries under lockdown since, like them, Sweden is a late responder. Many well-meaning observers view the lockdown as a sine qua non for late responders to avoid visiting Armageddon upon their populations. Trump attacked the Swedish program and claimed that bad outcomes were forcing the Swedes to join the lockdown fold (fact-checked as false); even some Swedish doctors and scientists have admonished harder measures. But the Swedish authority of specialist and scientists (not politicians) is holding fast — it maintains that the Swedish way is more sustainable; it craters the economy much less; and, anyway, the right question on lockdowns is not whether but when it be lifted thus risking an infection resurge upon exit and a possibly more deadly second wave. Has the Swedish gamble produced the doomsayers’ Armageddon?
As of April 19, Sweden had 13,440 confirmed cases of COVID-19 infection compared to the following locked-down countries: Ireland has 14,758 confirmed cases; Norway has 7,069 confirmed cases; and Denmark has confirmed 7,242 cases. But these countries have each only half of Sweden’s population so if Sweden’s cases is corrected for population size just for this group, it actually has fewer confirmed cases (13,440/2 = 6,720) than comparator locked-down countries. But the number of confirmed cases is problematic due to testing deficiency. Fatality rate per capita is better. This is where the gamble would have become politically unbearable for other countries.
By April 23, Sweden had a higher number of confirmed COVID-19 deaths at 1,937 with a death rate per capita of 0.019%; locked-down Ireland had 769 deaths or a per capita rate of 0.015%, Denmark has 384 deaths or 0.0054% per capita; and Norway with 187 deaths or 0.0038% per capita; the USA has about 0.0015%. When the death rate spiked in early April, the call for a reversal of the Swedish model reached its loudest. Sweden did not buckle under. The death rate has now slowed easing the pressure.
Clearly, the Swedish experience to date does not reveal an Armageddon that doomsayers predicted. The death rate is higher but not outside reasonable expectation. Within the logic of exponential expansion of pandemics, one month is more than enough time to reveal an awful catastrophe. We know now that the Swedish economy is wounded but not to the lockdown extent. Not to be overlooked: lockdown countries have to worry about infection resurge upon exit and second waves. Lest we forget, the second wave of the Spanish flu infection in November 1918 was more lethal and killed 185,000 in the USA that one month alone!
It is too early to say whether Sweden’s gamble is a winner or a loser relative to lockdowns. Only at full cycle will a proper accounting be possible. Even then the answer will differ depending upon one’s ethical posture. And Swedes by and large still support the gamble.
How did the Swedish hybrid model dodge to date the doomsday scenario? Two sub-questions: how much did H actually rise and how much did Ro fall due to admonitional social distancing? We can only guess at the moment. Perhaps the Swedes’ widely acclaimed social coherence that celebrates personal responsibility over hard government mandates resulted in reduced Ro if not as much as hard lockdowns did. And there is growing evidence that voluntary compliance sometimes trumps compliance under the gun.
As countries decide when and how to exit lockdowns, Sweden’s program — if current trends hold — deserves a second look. It is, after all, already out. Exit need not be so threatening. Since Sweden’s vaunted social coherence is non-exportable, the Swedish model may have to be hybridized further: in the phased exit from lockdown, a more robust surveillance and enforcement of protocols should be pursued to reduce the likelihood of resurgence especially since these countries are missing the Swedish population’s acquired immunity. Beyond that, we owe it to ourselves as a nation to begin to import-substitute a Swedish-standard social coherence and self-regulation. It will help us in all our future endeavors.
Raul V. Fabella is an Honorary Professor of the Asian Institute of Management (AIM), a member of the National Academy of Science and Technology (NAST) and a retired professor of the University of the Philippines. He gets his dopamine fix from hitting tennis balls with wife Teena and bicycling.
