The world has watched in amazement as Sweden eschewed draconian lockdowns and instead trusted its citizens to manage this virus for themselves. Now the head of the Health Emergencies Programme of the World Health Organization, epidemiologist Michael J. Ryan, M.D., has praised the approach: Sweden “relied on the relationship with the citizens, and on the citizens’ ability and willingness to implement physical distancing and self-regulation… I believe that if we are to reach a new normal situation, Sweden can in many ways represent a model for the future.”
How exactly did Sweden do this and why? Below we run the transcript of an April 17th interview with Professor Johan Giesecke, M.Sc., M.D., Ph.D., the State Epidemiologist from 1995 to 2005 and a leading consultant on the Swedish model.
He worked as infectious disease clinical doctor working with AIDS patients during the 1980s and trained at the London School of Tropical Medicine in the 1990s before returning to Sweden. Since then he has been chief scientist at the European Center for Disease Control, provided advice to the World Health Organization’s Director-General, and continues to serve as a consultant advisor to Anders Tegnell at the Swedish Agency for Public Health.
Dr. Giesecke speaks out against draconic measures, which so far are not evidence-based, elaborating on how the Swedes have done things differently and how they could have done even better.
Q: There’s been a lot of confused thinking and a lot of confusion about what the correct response to a threat such as COVID-19 and should be – and I just wanted to begin by getting your, kind of summary, thoughts of – of you know, how Sweden is differing from other countries and why you think that is.
A: The main reason is that we, or the Swedish government, decided early in January that the measures we should take against the pandemic should be evidence-based. And when you start looking around for the measures that are being taken now by different countries you find that very few of them have the shred of evidence base. But one we know, that’s known for a hundred and fifty years or more, and that is washing your hands is good for you and good for others when you’re in an epidemic. But the rest – like border closures, school closures, social distancing – there’s almost no science behind most of these.
Q: So what is the current policy in Sweden? Social distancing is part of the policy, isn’t it? What is the regime that Sweden has gone with?
A: The main difference to other countries is that there is no – you’re not locked up in your home. If you go out to buy food, or groceries, or drugs – I mean medicines – there’s no police to stop you in the street and ask you what you’re doing here. That’s one thing. People are asked to stay inside, but there is no reinforcement or enforcement of that. People do it anyway. So that’s one. We have the rule that the crowd cannot be bigger than 50 people.
Q: So I can still have an event for 49 people? (Although I won’t.)
A: Yes, you could. The schools – the upper schools are closed; secondary education and universities closed; schools up to age 15, 16 schools are open. What more do we have? Don’t – the nursing homes, or houses for old people, are closed to visitors.
Q: So it sounds like it’s a moderate social distancing regime then, at the moment?
A: Yes, it is. Sorry it’s very similar to the one that the UK had before there was a famous paper in – by – the Imperial College, by the modelers who made models for infectious diseases that came out on the day after you made a u-turn in England.
Q: Yes, tell us the original strategy in the UK and became known as a kind of herd immunity strategy, that’s what it was called. Before we get on to talk about the Imperial model – which I would like to talk about – is it correct to call it herd immunity and, and is that the Swedish strategy?
A: It’s not a strategy, but it’s a by-product of the strategy. But the strategy is to protect the old and the frail; try to minimize their risk of becoming infected, and taking care of them if they get infected. If you do that – the way we’re doing it – you would probably get herd immunity and then – but that’s a byproduct order, it’s not the main reason to do it.
Q: So you were saying and so the initial UK response seemed to be similar to what you – Sweden – is doing now, and you thought that was better?
A: Yeah. No, I think it is very good actually, and we were very pleased we were having the same policies as the UK: that gave some credibility to what we were doing. But then Mr. Johnson made his hundred and eighty degree turn.
Q: Yes, so there might have been a lot of other political factors involved. He was definitely under a lot of pressure, because lots of European countries were doing a formal lockdown at that point, but the turning point did seem to be that Imperial College report which forecast 510,000 deaths in the UK with a completely unmitigated approach 250,000 deaths with a mitigated approach – which is roughly equivalent to what you’re doing in Sweden – and then it suggests that he might be as few as 20,000 if we did a full suppression or lockdown. What was your impression of that paper?
A: I think it’s not very good. And the thing that they miss little is, any models for infectious disease spread are very popular – many people do them, they’re good for teaching – they seldom tell you the truth because, I make a small parenthesis, which model could have assumed that the outbreak would start in northern Italy in Europe? Difficult to model that one. And any such model – it looks complicated, there are strange mathematical formulas and integrals signs and stuff – but it rests on the assumptions, and the assumptions in that ought to be heavily criticized for – I won’t go through that it; would take to the rest of your day if I went through them all. The paper was never published – scientifically – it’s not peer-reviewed, which scientific paper should be. It’s just an internal departmental report from Imperial, and it’s fascinating, I don’t think any other scientific endeavor has made such an impression on the world as that, rather debatable, paper.
Q: So it’s your impression that it was overly pessimistic?
A: Yes – oh yes, very much so.
Q: So what you know I mean I guess it comes down to some degree of speculation but, what’s your impression of how serious the disease is and what kind of fatalities we would be looking at if we had a more moderate or more mitigated approach?
A: What’s the number of deaths in the UK now? I don’t know. [13 thousand.] So you’re getting close to 20 now. [Yeah.] But probably not 510,000. I think – well let me go back one step. One thing that the model has missed is that it assumes that a hospital capacity will remain the same, and that’s not what’s happening anywhere. I mean in Sweden we tripled our intensive care capacity, and I think there’s happening in the UK as well, but the paper completely overlooks that. It’s, as I said it’s such a static thing.
Q: Hmm. So just to sort of to come back on this, we had the argument, what people watching will be asking – and I think what most people who support the lockdown would say, and that is the overwhelming majority of people in politics and in the media – is that the reason the curve is now flattening, and the numbers of deaths are gradually coming down on a daily basis, is because of the lockdown and that it shows that the policy has worked. And Professor Neil Ferguson who wrote the, or led the Imperial papers, suggests that he stands by his prediction that 500,000 people would have died had that not taken place. So if it wasn’t the lockdown that has been flattening our curve what else could it have been?
A: One thing is immunity; the other is that the people who are frail and old will die first. And when that group of people is sort of thinned out, you will get less deaths as well. The other thing is that when you start your exit strategy – that’s the favorite word now in all this public effort: the exit strategy – when you start that one you’ll have some other deaths that we had already.
Q: Yes so, I mean, does that mean then that, as the disease passes through the population, you know, are we gonna see second and third spikes now after this?
A: It would be part of the exit strategy, because the only way to check that your, if you’re taking away one restriction and – say we open the schools again as an example – how do you evaluate that? You have to see numbers are going up again; more people are dying. We have to stop that. We have to pull back that softening and try another. That’s what exit strategy will be in all countries. Countries will ease up a little on a restriction; see what happens over the next 2-3 weeks. “Oooh, it didn’t work very well, we’d assumed that.” We try another restriction. Well if that one – “Oh, it worked!” And that so this is every country will have to do it that way. And that means that the increasing number of deaths will be part of checking which strategy should be kept and not…
Q: So what should we be doing instead?
A: Well you can’t. When I first heard, which is now six week ago, about the different draconic measures that were taken I asked myself: How are they going to climb down from that one? When will they open the schools again? What should be the criterion to open schools? Did any one of them – strong and very decisive politicians – even think about how to get out of this when they introduced it? And I think that would be a problem for the UK as well.
Q: So yes let’s take as a comparison your – the neighboring countries in Scandinavia. A lot of people are sending around these charts that show that Denmark and Norway and Finland have had much fewer deaths on a per capita basis and Sweden the rate is still climbing and they take that as proof essentially that Sweden should have gone into a more draconian lockdown. What do you say to those people?
A: Well first it’s not crooked Denmark. Secondly, one important thing is that Norway – the nursing homes in Norway are usually quite small. Whereas the nursing homes in Sweden are quite big, with hundreds of people. Which means that if you get in – if the virus gets in to one nursing home in Norway which will affect far fewer people than a big one. So that’s part of the reason, not all of the reason. For Finland the epidemic never really took up to cope there: they started their measures before it had even started. But I think we should have this discussion a year from now – let’s decide that on the 17th of April 2021. I think that the difference between countries would be quite small in the end.
Q: So that you don’t think that the severity of these intervening measures are gonna make that much difference?
A: No, I don’t think so. I think it – should I tell you what I really think? [Please.] I almost never do this. I think what we’re seeing is a tsunami of a usually quite mild disease which is sweeping over Europe – and some countries do this, and some countries do that, and some countries don’t do that – and in the end there was very little difference.
Q: So when you say it’s a usually quite mild disease, what do you mean by that?
A: That most people who get it will never even notice they were infected.
Q: So does that mean that you think the actual fatality rate of this disease is much lower than the numbers that have been talked about?
A: Much, much lower.
Q: So do you – have you made any speculations as to what sort of zone the real fatality rate might be in?
A: I think it would be like a severe influenza season, the same as, and which would be an order of 0.1 percent maybe.
Q: So that would suggest then, for a country like the UK that has already had its heading towards 20,000 deaths, that would suggest that millions – many millions – of people have already had it?
Q: And you believe – do you think that is also true in Sweden then? That a substantial percentage of the population has had it?
A: Yep. I’m rather certain on that, actually. And when we get – we don’t have the tests really yet as you know – you have these two kind of – you know this don’t you – two kinds of tests. Yeah, one that tells that you have it now, another one that tells you that you had it at some point before. An immunity or serology tests, and they are just being developed and just being employed. I know from discussions with friends in the UK that you started last week with 3,500 such tests and you were gone with in one week and it will be about 8,000 per week. And when you get tests that show that people have had the disease, you’ll see that most of them never even dreamt they had it.
Q: But we don’t have yet any effective antibody tests?
A: You’re right, but it’s coming.
Q: And you’re confident that we will get those tests?
A: Oh yes, that’s only a matter of time.
Q: And so, what sort of percentage of the population do you think we will discover has had it, once once we get mass antibody testing in place?
A: At least half.
Q: In the United Kingdom, or do you mean in Sweden as well?
A: Both countries.
Q: So, the whole sort of rationale for introducing these lockdowns across Europe, that has created such unbelievable side-effects and pretty much stopped the whole world in its tracks, you believe is a misguided policy. And do you think it’s doing more harm than good?
A: Yes, I think so, on the whole. Although I mean if you listen – what I’m saying is that people who will die a few months later are dying now, and that’s taking months from their lives, so that’s maybe not nice. But comparing that to the effects of the lockdown which may be – I mean, what am I most afraid of? It’s the dictatorial trends in Eastern Europe. That Orban is now dictator for Hungary, forever. There’s no finishing date. I think the same is popping up in other countries. It may pop up in more established democracies as well. I think the ramifications can be huge from this, we don’t even start seeing them.
Q: So you think the correct policy from the start, just to get this clear, should have been to shield old and vulnerable groups?
A: There we’ve failed. Sweden failed. We were not on our toes enough, to really shield people. We should have banned visitors earlier. Many of the people working in nursing homes are from other countries, they’re refugees or or asylum seekers in Sweden, their Swedish may not be perfect; they may not always be – understand the information that has been spread to the population. There are many things we could have done better a couple of, a couple of months ago.
Q: So this at the point we are now – what you’re advocating is we protect those groups better and, as far as the rest of the population is concerned, we just allow it to pass through the population, essentially?
A: Essentially, yes.
Q: Which is, I mean, I know that it is now, what’s commonly understood by what we call the herd immunity strategy, basically.
A: I mean obviously, it’s not just the old and frail. I mean there are the people that should be protected, but I don’t think you can stop it. It’s pretty – so try, you can stop it for some time, but then – I mean countries that have been successful – South Korea is giving up now, they can’t maintain their policy. Taiwan, I don’t know about Taiwan. They were quite as successful. Singapore, similar problem.
Q: So countries that are held up is the most successful, in some cases once they’ve totally managed to suppress the outbreak, you think that it’s just a question of delay and actually they won’t be able to hold that back for –
Q: So, so how should we judge success then? It seems like numbers of deaths does seem like a fair a measure, if you’re saying that they’re essentially deaths that are just going to happen later. You know it will sound to some people that it’s a slightly cold-hearted approach they suppose that, you know, if you’re saying they’re going to die anyway so we should allow the disease to take its path – I think a lot of people might feel that a government can’t sit back and do that. If they’re, you know if now having had this locked and we were headed towards 20,000 deaths how many deaths might we have had if we had had no lockdown? Would it have been more?
A: Yeah, we have probably a bit more, but in the end the result would be rather much the same. And I agree that it’s a bit callous to say that people – we’re not saying that, we’re saying protect the old, try to slow the spread of the epidemic a bit so that the health care system will manage when we have many sick people, many severely ill people. But it’s more, yeah, I don’t think – you can’t really. At some point the, it’s like – a tsunami is not a bad – it will roll over Europe no matter what you do.
Q: And will it, as it rolls over Europe as it sooner or later will, presumably treatments will improve?
Q: We’ll get better at knowing how to treat it. It already feels like the initial focus on ventilation is shifted to other ideas and people are thinking of new ways to treat it. Is that in itself not an argument for suppressing it as much?
A: But how long in a democracy do you think it would keep a look down? How long will it take before people say, “no I’m not taking it”? You can do it in China. In China you can do it: you can tell people to stay at home and you can weld back that door, so they can’t get out. But in a democracy you can’t. And so it will be 3-4 weeks people will say, “Well, I don’t know anyone who had the COVID, and I haven’t met – and I want to go out; I want to go down to the pub.” And so how long do you think you could lock people up like this? Stay in your home, you need a permit to go to the shop.
Q: Yeah, we don’t actually need a permit, but yeah I mean I I think we’ve now just had it extended by three weeks. You know, there is an enormous amount of public support for it, and that’s one of the interesting factors about this: that at the moment the public is very much on side with the lockdown in the United Kingdom. Some people seem to like it.
Q: Though it may be that it’s hard to persuade people to go back, in some way. But do you feel, doctor, years ago that the policies that have been put in place by the UK and by other European governments, how did they come about? You’ve been a leading epidemiologist for your whole career; you’ve dealt with influencers; and SARS; and you advise the World Health Organization. What was it about this pandemic that was so different that has led to this global shut down?
A: New disease: a lot of people dying. You don’t know really what will happen… and this fear of contagion I think is almost genetic in people. And showing political strength: decisiveness, force. Very important to politicians.
Q: Do you think the fact that it came out of China, and did it – we witnessed such an enormous response, quarantining whole provinces and so on – set the tone in some way, and that that felt like the appropriate response?
A: Could be, wouldn’t, let’s do like the Chinese using – but again, you can’t compare to China. It’s a different world, and do you think you could keep them locked in to protect the old people until we have good drugs and good vaccines? Six months? A year? 18 months? I think people would get a bit tired of it even if they support the policy in the UK.
Q: So a couple of specific things that have occurred to me during our conversation: one, is how many deaths do you foresee in Sweden? You’re up at, is it 1,400 or something?
A: I think it will be like a severe influenza – and it’s interesting with influenza, when the flu comes we all say, “Oh the flu is coming.” Like every winter it’s in the papers, “The Flu is here.” Okay, and it usually kills, i n this country around 1,000 [or] 2,000 people, but it’s normal, its influenza. We have it every year, and they’re old and they’re going to die soon anyway, so no one is very upset about influenza. But I think even if in plans I came around as a new disease – you never had it before, but suddenly this new disease called influenza popped up – we would have exactly the same reaction as we have now. So I think the number of this will be about the same as in a severe influenza in winter in Sweden. How many are you, 50 million? [Yeah, 65.] 65, so multiply by six. So it would be… 12,000 cases in the UK – [Yeah well, we’ve already had around 13,000 –] …maybe 18. And a lot of influenza deaths are not booked, or they’re not recorded in that way anyway, in a normal influenza season. So I think this is similar; about the same. It may be double as much, but it won’t be ten times as much.
Q: The reports from hospitals that are very different, are made that it – the way disease progresses seems different from influenza.
A: Oh yeah – it’s different, it’s not the same disease as influenza. But it’s not, the shape of the epidemic is not that different. There are a few differences. For example, the influenza is driven by children. An influenza outbreak is driven by children in society: they are the ones who pass it on between the generations, and this does not hurt children very much, they don’t have any symptoms and they’re not very infectious. So that – there are epidemiological differences.
Q: When talking about all people like you did, as opposed to children, a lot of people will say that young people have been dying of COVID-19. There are examples of young people dying, and some of the data out of America suggest that, a large degree, a large number of hospitalizations are among younger people. Is it responsible to describe it as just a disease for elderly people?
A: No, but influenza kills people too, even though not that many. And it is much more, makes more headlines right now. And if you look at the data, I mean the people under 50 are a clear minority of all the cases.
Q: So if I’m 38, I’m on the – sort of borders – between young and old, okay if you’re younger than me what is your advice to young people? I mean should they be campaigning to have the lockdown eased because it’s inappropriate? What is, what are other risks for young people? We’re told that it’s about carrying the disease to other people and they act as spreaders even though they’re not vulnerable themselves. What should we be doing with younger people?
A: No I think it’s a good thing you do no they won’t hurt that much. I mean you can’t say that it’s completely without, and what you would say in it, but it’s not completely safe. I mean there will be young people who die but for the majority it’s… but what you said, is correct that they should think about protecting other people, that’s important. Because they move around a lot, then they shouldn’t meet the grandmother and grandfather too much until they’ve had it themselves.
Q: Yeah. So I’m just trying to – nearing time now. I just want to get a sense, what should the British government do now in your opinion? Do we – should we say, “Okay lockdown is canceled.”
A: No you can’t do that, then you have a wave of all cases: then you really have a peak. One week, two weeks later, if you took away all the doctor. No – you’ll have to climb down, one rung of the ladder at the time. and probably start with the school closures maybe. it’s a good thing it makes society – I mean in this country Sweden we have 1 million people, children between 0 and 10, they need to be looked after. If they’re not in school, then someone has to stay at home with them. And one of my friends is a nurse, and head of an emergency room here, emergency ward here in Stockholm; she prays every morning when she wakes up that the government will not close Junior School, because then she loses her office staff. So school closure is one thing – but I think one step has to be taken at a time. And it’s interesting how the countries in Europe are sort of after the, approaching the Swedish policy. Now they’re opening up schools in all the Nordic countries; in Austria you can shop in a job that’s more than 400 square metres; in Germany they did the same thing on Monday. In Germany they were also thinking about opening the schools again. So countries are approaching the Swedish, but they had a lockdown first.
Q: So you don’t think – because there’s two that people get very hopeful about. One is a vaccine and then we can suppress the disease completely until the vaccine comes? Is that a feasible strategy?
A: No, it’ll take too long, it won’t work in a democracy.
Q: And one other idea are these so-called immunity passports for the people who have proven to have had the disease, they could then carry a wristband or something, and they would then be allowed back into jobs and in full society. Is that a feasible strategy in your view?
A: There are some technical problems with – like you indicated the antibody tests are not that perfect yet so it will be – but it’s not a bad idea. Do you need a passport, do you tell your boss at work that, “I’m immune”? Maybe he wants to see a paper. No but, I mean that’s the way it will work that you find people are immune and they can go back and you can work in the house but without all this spacesuit on things like that –
Q: Will that be part of the Swedish strategy?
A: Yeah, yeah.
Q: So in terms of what happens next then, in Sweden, you know there’s a huge amount of pressure, a lot of people are looking to prove that it was a mistake in some way, do you think the Swedish strategy will just stay as it has been?
A: I don’t think it will be tougher. No. We’re talking now about opening the final year of schooling, so that people who spent 12 years in school can celebrate, which is a big thing in this country, it’s not because of the celebration is being done but it’s to see that those who finish school get grades and finish all the tests they have to take in things like that.
Q: And so, you feel like the curve is improving sufficiently in Sweden to start releasing further the suppression measures.
Q: And how did that happen, without a lockdown? Well what if just by voluntary social distancing has already achieved that you believe?
A: Mm-hmm. And there are some. Maybe we should finish this now. But one, it’s not a little what – do you call a minor law in English? An ordinance? That’s something that is not as strong as a law – but anyway, yeah, in restaurants the rule is you can only eat sitting down; the food should be hot and served at the table; you don’t go out; you can’t stand up drinking; if you want your beer you have to sit down at the table which is five feet away from the nearest table. And that’s being checked now so that but it’s not the government, it’s the local medical offices of health that go out and check restaurants and when they close two or three restaurants – because the tables are too close or people are standing at the bar the other follows suit – you don’t need a law for that. They know that if the MOH, the municipal medical officer of health, comes in, they’re closed for business.
Q: When do we get past that, when can we just be back to normal then, and no social distancing at all? What will be the metric for making that decision?
A: That’s a good question; I’m not quite sure I can answer that. But it will take a couple of months to climb down, from a lockdown. You can’t climb down from a lock down.