Saturday, May 16, 2020

What Is Really Happening In Sweden?

As some sources are touting how well Sweden's approach to C19 is working, and more importantly, how it is going to work, while other sources are rating it a disaster or more importantly, going to be a disaster, I thought I would try and find out what is really happening. I had a couple of little thoughts about some pieces that might be overlooked, as everyone chose their favorite data trying to prove their points.  My little thoughts turned out to range from very true to completely mistaken.

Composing this post in my head, I have several times put together a lead sentence beginning "FIRST,..." or "The first thing we need to keep in mind..." but I keep changing what the first thing is.  I have to say I don't know what of the following is most important, nor what bits are better introductions to the rest.  Should myth-busting be primary or should I attempt to find what are the most likely driving forces going forward and hammer those home?  Dunno.

FIRST, the Swedes are not at all unified on this.  While the Prime Minister is not acting solo, his idea of keeping things open has most of his own medical community up in arms.  The epidemiologists think he is flat wrong. Doctors, nurses and other health care workers are petitioning the government to institute stricter measures. Their repeated argument is that the very lax standards of the early weeks, where nursing home workers were not even encouraged to wear gloves and masks, nor given hand sanitiser at work, led to many needless deaths.  The government's response has been "Yes, that's true, sorry about that, but that's fixed now so we aren't going to do more."

It is unusual for Swedes to act this way.  Getting along, compromising, smoothing things over, not making a scene in front of the public - those are second nature to them.  Those are my mother's people and "Don't make a scene," said quietly through clenched teeth was a cultural anchor point. Relatedly, there is usually an elephant in the room whenever Swedes hit controversy. Up until about 1990, it was their behavior during the Second World War and the Cold War, and since then, the elephant has been the behavior of immigrants. A commenter a month ago over at Maggie's had said that the deaths in Sweden have been wildly disproportional among immigrants and residents of large nursing homes in Stockholm.  From that I suspected that Malmo and to a lesser extent Gotheberg were going to have high numbers because of their African and Middle Eastern populations, but this did not turn out to be so.  Stockholm is the center, all other regions trail.  I did eventually find an article that discussed C19 and immigrants, unsurprisingly written by researchers from Georgetown, GWU, and Australia, not Sweden. The short version is that the Somali population follows none of the guidelines and are heavily overrepresented among the deaths. As they are less than 1% of the population, this will burn through them, and they will carry the disease to others during that time, but that this may be self-limiting.  I don't know that I'd want to rely on that, frankly. I can't think of an historical example where that has happened.

I had heard that Sweden was partially shut down, but as it is voluntary it has avoided the overreach of the governments of other countries.  Sweden is actually quite shut down, not much more open than other European countries.  I can see a considerable advantage to the voluntary nature, as it removes some of the arguments about end points, and government officials can be less worried about being blamed if things go wrong.  However, that may not provide the advantage we expect. Sweden already has "recommended guidelines"

...most preventative measures don’t involve involuntary quarantine.  Instead, individuals are expected to act responsibly and follow the given recommendations, including immediately seeking out medical assistance if signs of infection appear.  If the recommendations are not adhered to, a designated physician in the relevant medical region can decide on mandatory quarantine or isolation. (underlining in original)

Swedes are a responsible, cautious people, and thus their level of voluntary compliance may be similar to Americans' mandated compliance.  They themselves say they don't think America has the culture for this.  Here are the guidelines put in place April 1 according to the US embassy in Sweden.



On April 1, Swedish Public Health Agency expanded guidance for individuals and organizations to comply with Sweden’s Law on the Prevention of the Spread of Infectious Diseases:

    Shops and shopping centers should limit the number of customers at the same time, develop alternative solutions for lines or indicate how far customers should stand between each other.
    Local sports teams should hold practice outside, postpone matches and competitions, and limit the number of spectators.
    Employers should ensure that staff and visitors stay away and that employees work from home to avoid unnecessary travel.
    Public transport companies should limit the number of passengers and adapt their schedules to avoid crowds.
    Individuals should keep distance in public places, refrain from attending events such as parties, funerals and weddings, and avoid travel during rush-hour and any unnecessary travel.
    People who are over 70, or belong to other risk groups, should limit all social contact and avoid public transport, shopping in pharmacies, supermarkets, or crowded places.

The Government of Sweden has banned public gatherings of more than 50 individuals.

This looks very similar to everyone else's mandates.  If they are following this, their situation is actually not that different from other countries.  As I noted above, however, if it is voluntary you can get a lot of the overkill eliminated quickly.  People will say - this is nuts.  I'm going fishing anyway. Having the default be that the citizens are trusted is just not the same thing as mandating.  Whether that will work with Americans is another discussion, which I am not having here.

The Swedes do put the pressure on, also , whatever you have heard.  They covered  a park with chicken manure so the college students wouldn't break distancing by drinking there.  Also, however voluntary they say it is, if you break those guidelines they will close you down.

The current data is that Sweden is 6th-worst in the world in deaths-per-million, and pulling away from 7th-11th slowly.  It may pass France for 5th in the next month or so. I don't see how it goes higher than that, though.   Stacked against that are the bits of expanded information I noted above:  Okay, we got it badly wrong on the nursing homes, but we fixed that and things should level, and also if you take out the Somalis and a few other immigrant groups who just don't get it, the conditions for the other Swedes look pretty good.  I find that only marginally persuasive, because every country could advance some exceptions why their numbers are better than they look.  The US could say "well, take out New York."  The Swedes have decided not to call out the Somalis and other Muslims and treated the added deaths as a sunk cost, but think they are still going to be okay in the long run.  The evidence for this is that they can recite the new magic words "herd immunity," which is somehow supposed to stop all further discussion.

Sweden has an economy that is less tourism-dependent than others, and has a lot of jobs that can be done remotely. The other Scandinavian countries, plus Estonia and Germany are their best comps , and they are doing far worse than all of them in deaths-per-million, but only marginally better in economy.  Even if their idea plays out moderately well and they don't get hit as hard this fall, they are already so far ahead of Norway, Finland, and Denmark in damage that they will still be worse.

Their hope has been that keeping their economy afloat while others are tanking will be good in terms of general prosperity, and better in the long run in terms of economic advantage. Yes, I hear that.  I get it that this is the theory. I also know that Sweden started with enormous initial advantages, but is still behind.

So far, it hasn't worked, and  it hasn't worked, but you can find lots of articles that say it might work, or that the theory is that it should work, or that, well, it's not any worse than what's happening elsewhere. The places that have reduced deaths in practice are South Korea, Singapore, Japan, Taiwan, and Hong Kong.

We actually don't know what the herd immunity numbers are for this disease, and neither do the Swedes or anyone else.  Native Americans did eventually get herd immunity to European diseases, yes, after 90% of them had been wiped out. Europeans still don't have a lot of herd immunity to malaria, though, and even Africans still die in droves from it.

There may be good evidence for the relative safety of opening up the American economy from our own experience here, or perhaps from other countries.  There isn't much to write home about from Sweden.  The most one can say is that 1) maybe it might not be worse in the long run, 2) we have this theory how it could be better, 3) the higher death rate might be mostly fixed, and 4) all this is dependent on have a culture like ours.

13 comments:

  1. Thanks for doing the research. It did seem a little odd that Sweden would be going all libertarian at a time like this.

    IIRC there was a story (quillette or city-journal?) about a review of public transit numbers showing a sharp decline beginning before rules were imposed. I haven't found it again, though.

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  2. To some degree Sweden is serving as a rhetorical stopgap for Democrats to discuss the unorthodox approach favored by Republicans in say Georgia and Florida. They cannot openly ponder that Georgia might be right, or that Florida is doing much better than New York. They can voice curiosity about whether a Scandinavian approach might be better than the orthodox American one that they, of course, support.

    These are interesting findings.

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  3. I have seen a few articles from liberal sources about Sweden, but mostly I just hear it over and over again from conservative sources. We are in the Tim Tebow effect here, where everyone is sure they aren't being heard. I hear people at work referencing Florida and New York, and I'm surrounded by liberals.

    There are a couple of differences though, which the advocates for "Let's all be Florida" keep overlooking. Population density. Public transportation. Sunshine and warmth. International travel. Florida usually has a lot of that last one, but with Disney and Universal down that has plummeted. No matter what any governor did, NYC and Florida were going to have wildly different situations.

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  4. There's a dangerous assumption that something will "work"--even that something will work without causing more damage than the disease. No one has issued us any such guarantee about this virus, any more than about cancer or heart disease. It follows that, in countries where it doesn't work, someone screwed the pooch. That may be true of a few extravagantly boneheaded policies, like discharging virus-positive patients into nursing homes, but it's not necessarily true of every idea the Karenwaffe came up with and tried to enforce to the hilt. New bad ideas don't become good because someone in charge failed to implement early an approach that now looks good to us.

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  5. @AVI:

    I think I often don't know to what you're responding because I rarely read right-wing blogs; InstaPundit is the only one I look at regularly. I occasionally look at Ace of Spades, especially on Saturdays for the chess thread. There are a lot of thinkers and writers on the right that I respect, but the invitation to join a bubble is too apparent and I just tend not to go that way. I don't even read mainline right wing publications like National Review anymore, with the exception of specific authors whose opinion I follow closely (like Andy McCarthy).

    I have, though, read 'Maybe Sweden is right' articles all the way up to 'We will all be Sweden soon' in Foreign Policy, the Washington Post, and even one of the NY publications -- I can't recall if it was the NYT or the New Yorker or which. So that is what I was thinking of when I made that comment.

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  6. Good for staying out of the bubble. Maggie's Farm, The New Neo, and Powerline have been regular stops for me over the last few years on top of Instapundit, and they link on to further sites as well. They all have few writers or major commenters who are out-of-control at this point, quoting every minor official who says the deaths aren't all CoVid, every locality with ridiculous rule enforcement, every study that says masks or social distancing is pointless or off-brand scientist who says none of our interventions make any difference, every anecdote of people who didn't die, all while cherry-picking the predictions that fared worst and dismissing all advice they don't like by putting "experts" in quotes, and attributing the differing opinions of others as evidence of cowardice, timidity, panic, desire for power, or lack of sympathy for those who have lost jobs. They are awash, in fact, with conservatives who are now arguing like liberals have for years.

    One model predicted 2.2 million dead. One. But that's the one people quote now to prove that all models are wrong and we shouldn't listen to any of them, because they somehow know better. We are just now hitting the lower end of the numbers that many models did predict, and we're not done yet.

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  7. Great thread by Nicholas Christakis: https://twitter.com/nachristakis/status/1262012815663149058?s=21

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  8. It was a great thread, from a researcher I respect. I made the mistake of reading the comments...

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  9. I’ve been watching both Iowa and Kentucky during the pandemic because of my familiarity with both. I think they are roughly comparable though Kentucky’s population is more urban and about 1/3 larger than Iowa but both have significant rural areas. Looking over the Worldometer and IHME data, Iowa has fared worse in some respects. Though the number of fatalities is about the same for both, Iowa’s per capita rate is significantly higher. Iowa has also reported substantially more cases of COVID than Kentucky but that’s partially because Iowa has been testing more. Both are running below the IHME projected fatalities as of today. Neither state appears to have ever been in danger of exceeding the overall capacity of hospitals to care for COVID patients though hospitals in rural areas might have had difficulty with a sudden surge. I don’t believe that occurred in either state, however.

    As far as I can tell the response, both official and unofficial, to the pandemic has been about the same in both states according to the data at IHME. Both restricted gatherings and closed businesses at about the same time. Iowa actually closed all non-essential business about a week sooner (March 17 vs March 26). IHME lists Kentucky school closure as March 20 and Iowa as April 4, though from news reports Iowa schools were given guidance to close in mid-March and did so. IHME lists neither state as fully implementing a stay at home order, which is consistent with my experience here. The IHME mobility data show that both states had the greatest decrease in mobility in the first two weeks of April. Kentucky’s trough was a bit lower with two days at -44%. Iowa’s greatest decrease was 42%, and it has rebounded faster as the state has moved to open up more. I also expect that the start of spring fieldwork has played a part in that change.

    However, I still hear people claim that Kentucky’s results are exemplary because we ‘locked down’ while Iowa was a disaster because they “didn’t listen to the experts.” From looking at actual data I don’t see that to be the case. I have no reason to doubt that the governors of both states emphasized the need for adherence to the guidance and orders they issued, and from the mobility data is certainly looks like they were complied with. I have observed that the tone and emphasis of the news coverage from each state corresponds pretty well to those views, however. Interestingly, the Iowa governor is a Republican, and the Kentucky governor is a Democrat. Funny how that seems to happen a lot.

    As far as I can tell, claims that a given area did or did not ‘lock down’ in response to COVID usually convey very little information about the actual official response, and probably more importantly the polity’s adherence to those orders. At this juncture, I’m rejecting pretty much anybody’s claim that COVID impact was materially affected by whether or not a ‘lock down’, i.e. some set of restrictions beyond what appears to have been normal social distancing practice, was put in place.

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  10. Great comparison. As to the effect of lockdowns, I'm not sure what the US will eventually show state-to-state when accounting for density, etc. It's not just apples and oranges, it's a dozen kinds of fruit. But the experience of South Korea, Taiwan, etc surely tells us something? They did things differently and comparisons may not work there, either.

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  11. A third installment on the discussions with Dr. Jay Bhattacharaya from Stanford Medicine, about 56 minutes. https://www.youtube.com/watch?time_continue=1&v=289NWm85eas&feature=emb_logo

    All 3 of these discussions have had pretty good insights and reflect results from his on-the-ground research. Peter Robinson drives me a little nuts with his smarmy 'thoughtful interviewer' act, but the discussion is a good one.

    It's not going to go away and it will probably get worse before it gets better, is the conclusion. Impatience by the populace is coming up against the indefensible arbitrary rules-making, and the actual disease progression is taking the back seat at the moment. The spread-out nature of 'most of America' is going to be our second curve-flattener.

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  12. The relatively high death rates in Sweden, I believe comes partly from Sweden being better at reporting all deaths from and with Covid-19.

    And to put things in perspective; more people died in Sweden the first seventeen weeks of 2018 than the same period this year. I can't remember anyone talking about the slightly elevated death rates (because of the flu), back then.

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  13. That argument has been used here as well, that overall deaths may not be much higher. The difficulty is that with the shutdown there have been spillover effects of less flu, fewer accidents, less pollution and asthma, less contagion in general.

    The "from and with" argument is going to be interesting going forward, because different types of reporting are going to make apples-to-apples comparisons difficult.

    There is also the chronic and even permanent damage that some C19 survivors have, which keeps getting shoved back under the rug no matter how many times it is brought up. There is still a lot we are finding out.

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