Strategy: Isolate the Vulnerable

What really happened when COVID-19 reached Sweden? Reporting in international media paints a picture that something different is going on there, but it can be hard to make sense of whether it is good or bad. The health authorities in this small Scandinavian country decided to go against the grain and never imposed a lockdown. This distinguished it from its Nordic neighbors: in those countries, similarly famous for their welfare states, quarantine measures were quickly imposed and are still in place to various degrees. Sweden’s population, it could be said, instead became test subjects for a divergent, ostensibly laissez-faire strategy of “personal responsibility.” People were asked to follow the authorities’ advice and guidance in the face of a global pandemic — unexpected for a country known for its far-reaching interventionist state.

At the beginning of the outbreak, Sweden experienced a sharp rise in case numbers, just like its neighbors. In early April, Norway and Sweden were the countries in the region with the most confirmed cases. When Denmark, Finland, and Norway soon thereafter imposed lockdowns and other measures, Sweden quickly diverged from the group. At the end of April, when Denmark reached similar per-capita infection rates, it reacted swiftly with measures then regarded as “harsh,” closing the borders to the other Nordic countries. Yet as the pandemic progressed, all but Sweden followed suit. And today, it has a little over 124,000 confirmed cases — more than all the other Nordic countries combined. To this, it should be added that Sweden has tested a substantially smaller part of the population compared to its neighbors — almost twice as many tests that are done there come back positive.

In Sweden, restaurants, hairdressers, and shops remained open even as they closed down in the other Nordic countries. The strategy was, instead, to keep vulnerable groups in society isolated, primarily the elderly. In March, Prime Minister Stefan Löfven appealed to the elderly to stay home. He admitted that it would be “boring” to be limited to one’s home or care facility but appealed to their self-interest by saying that “it’s for your own health’s sake.” Even though this was not mandatory, Sweden’s older population came closest to experiencing something like a lockdown.

But the strategy quickly failed — the spread of the virus did not decline, nor did this approach protect the elderly. In fact, almost half of those who died were living in elderly care home facilities — places that were supposed to be keeping them safe and isolated. So, what went wrong?

Scandalous Treatment

Part of the answer came with a scandal that broke in mid-October, as it came to the public’s attention that in Stockholm, health care providers had been instructed not to treat the “weakest” among the elderly population. Dagens Nyheter (DN), the country’s biggest right-wing newspaper, revealed how elderly care home facilities in the capital had, as per the instructions of the elected regional body, been barred from calling in a doctor if a patient exhibited symptoms of COVID-19. Updated guidelines for medical prioritization instructed the care homes to treat the patients on-site — in facilities without doctors or advanced medical equipment. But even if equipment had been available, they were specifically instructed not to be used for examination of the patient if they exhibited problems with memory or drowsiness, and furthermore, if the person struggled with walking on stairs, emergency care was completely ruled out.

The for-profit health care providers responsible for care in these old-age homes had been “given the green light to ration visits” by medical professionals — resulting in more deaths than necessary. People who could have been treated and saved were instead given palliative care without any medical examination. The DN journalist put the blame on incompetence among the politicians running the regional authority, the institution responsible for health care in Sweden, in not understanding the consequences of their own guidelines. A finger was also pointed at the Elderly Reform Bill of 1992, which put the responsibility for care of the elderly on municipalities, while simultaneously prohibiting municipalities from employing medical professionals to work in these facilities — a monopoly granted to the regional government that would otherwise lose prestige.

In one of the first academic evaluations of the Swedish strategy, a professor researching public health understood this situation as fueled by anti-traditional stances against the elderly and overconfidence in individual responsibility. The former implies that Swedes are simply okay with the elderly being sacrificed for the freedom to enjoy a beer in a bar. This is an absurd conclusion, easily disproven by the fact that reports of high mortality in care homes have sparked opposition and outrage. He also argues that the coordination reveals neglect on the part of the people in charge. The representatives of the Stockholm region have, indeed, shown their incompetence, and the law barring elderly care homes from hiring doctors is unfathomably stupid. But this argument is too shallow to capture the full scale of what is going on. Instead, it has become almost impossible to coordinate the contemporary Swedish health care sector, however competent its leaders. This is because a dramatic restructuring has been imposed on the previously universal health care system, making the country ill-prepared for a concerted effort to combat the virus.

Mass Privatizations

Most people working in the Swedish health care sector are underpaid and overworked, especially those employed in the elderly care home sector. The labor market in Sweden has been progressively deregulated, and precarious contracts are becoming the norm in the already disadvantaged care sector.

Jobs there have increasingly become reserved for the most exploited people in Swedish society — in many cases, immigrants living paycheck to paycheck. They are forced to accept contracts that do not meet their household needs, compelling many of these workers to take on multiple jobs, often in the same sector. What’s more, these workers are more likely to live in cramped apartments, oftentimes with other people working in low-paid service jobs, and more likely to be exposed to the virus.

In summary, the people working in the care sector are more prone to be exposed to the virus, unable to stay home if exhibiting symptoms (for fear of losing their jobs), and also go from care home to care home.

Added to that, only half of the workers have access to personal protective equipment (PPE) such as face masks, making transmission near inevitable. The people most likely to be exposed to the virus care for the people who need the most protecting — revealing the impossibility of maintaining a partial lockdown for only the vulnerable.

In Stockholm, where the spread of the virus has been most severe, we also find the highest number of care home workers on limited, precarious contracts. There is, however, a differentiation within Stockholm’s care homes, between the ones run as private, for-profit businesses and the public ones.

Unsurprisingly, the former more frequently offer bad working conditions. The private facilities that now make up half of the sector in the capital employ fewer workers per patient, and fewer of the workers who are there have a medical background. Even before the pandemic, the health care sector at large was struggling to keep up, and the crisis is now threatening the functioning of the whole system.

This is the result of a long onslaught against socialized care, brought on by processes of neoliberalization. In the start of the pandemic, when it became evident that the worst-off patients in the COVID-19 emergency wards needed respirators to survive, it came to public attention that Sweden did not have nearly enough of these lifesaving machines. In the early 1990s, hospitals nationwide maintained a stock of two thousand respirators, and an equivalent number of additional respirators were available in emergency stockpiles. But now, the total number of available respirators is one-tenth of that, with none in stockpile. The number of intensive care units in Sweden is the lowest in Europe per capita — half that of Italy — and since the 1990s, all of the country’s thirty-five military hospitals, intended to be taken into use in the event of a crisis, have been closed.

Sweden also has chronic shortages in medicine, after the privatization of the pharmacies and dismantling of the state stockpile. Added to that, the state’s own vaccine production has been privatized. All in all, the previously consolidated, socialized health care system has been smashed to pieces, turned into discrete units in competition with one another. Swedish COVID-19 patients are now reliant on a global network of just-in-time production, on wards made “efficient” by cutbacks and lower staff density, instead of the previously well-prepared, meticulously planned system that guaranteed care even in the face of multiple possible crises.

Popular Confidence?

So far, the strategy is widely appreciated by the public — the government led by the Social Democrats and Prime Minister Stefan Löfven boasts the highest approval ratings in years, rising from 35 to 65 percent during the crisis. And not only the government saw such a rise in confidence, but also public institutions such as the health care sector. It may seem odd that Swedes are celebrating a strategy that has cost more lives than the ones of its neighboring countries — and one may even think that such a hands-off approach is simply what Scandinavians prefer. But a comparison with other Scandinavian countries shows that this is not the case.

The harsher measures taken by the other Nordic governments (all but Norway’s headed by Social Democrats) have resulted in soaring support for the governing parties there — more so than in Sweden. In Denmark, Norway, and Finland, support has been hovering between 65 and 88 percent since April, the highest of all governments in Europe, while Sweden’s never surpassed 65 percent. Moreover, the public in other Nordic countries has been highly exposed to reports on the Swedish strategy, sometimes presented as a competition between the countries. Regular comparisons show death rates, infection numbers, and admissions to emergency wards in the different Scandinavian countries — and this information is also displayed side by side during live TV debates on the pros and cons of the diverging approaches.

Hence, on September 18, the Danish public broadcaster’s popular debate show Deadline aired with the title “Does Sweden Have the Best Corona Strategy?” During the show, the host felt the need to intervene by saying that “it’s not a competition,” illustrating how much reporting seems to have been reduced to something resembling a football match. But it could be speculated that such reporting plays some small part in explaining why Sweden’s neighbors hold such high support for the measures of their own governments — for now, they are winning the competition.

Back to Socialized Health Care!

The strategy of isolating risk groups and letting everyone else live on as usual might have worked in the Sweden of the past — the social-democratic Sweden that was well prepared for crisis and could act in coordination. But the Sweden of new public management, privatizations, and an increasingly precarious labor market has fared far worse than its neighbors. One estimate has it that if Sweden had imposed a lockdown on par with its neighbors, the number of infections could have been halved, and deaths could have been a third lower.

This does not seem to have dented the public’s captivation by the architect of this strategy, state epidemiologist Anders Tegnell, even amid the current surge in new cases. Instead, the public now grants him and the Public Health Agency he heads their highest approval ratings since the start of the pandemic, at 72 percent. But if Swedes thus express support for policies that have resulted in more deaths than necessary, the governments of neighboring countries enjoy even higher favorability — suggesting that this public confidence does not actually owe to the particular strategy Sweden has chosen.

Today, Sweden is run by a minority coalition government consisting of the Social Democrats and the Green Party. Yet this coalition also relies on support from two smaller liberal parties through an agreement that specifically guarantees the Left Party will be excluded from any influence over government policies. This coalition has attracted scorn from both the Left and Right, but its right-wing aspect was clear as it released a seventy-three-point compromise deal proposing a list of neoliberal reforms going further even than the platforms of previous right-wing governments.

This shows just how far Sweden’s Social Democrats were willing to accept neoliberal policies in order to keep governing. Indeed, there is no end in sight for the continuation and deepening of the deregulations, privatizations, and austerity that have become the defining features of Swedish politics over the last decades, all of them factors that have contributed to the failure of the country’s COVID-19 strategy. To be better prepared for the next pandemic, Sweden needs to stop the onslaught of neoliberal politics — and resocialize health care.