Sweden’s Anders Tegnell: We did not pursue “herd immunity” against Covid-19

The Swedish state epidemiologist defends his country’s handling of the virus and gives his verdict on the UK’s coronavirus response.

By George Eaton

In March of this year, as Covid-19 spread through Europe, states across the continent imposed dramatic lockdowns on their citizens. Only one country stood apart: Sweden. Unlike France, Germany, the UK and Italy, it did not close restaurants, bars, shops or gyms. Schools for pupils aged below 16 remained open, mask-wearing was not mandated, and public gatherings of fewer than 50 people were permitted.

Though Swedes were advised to work from home if possible and to socially distance from others, there were no penalties imposed on those who refused. For some, this approach was an act of enlightened statecraft; for others it amounted to reckless or even murderous disregard.

The architect of Sweden’s strategy was not the country’s Social Democratic prime minister, Stefan Löfven, but its chief epidemiologist, Anders Tegnell. “Locking people up at home won’t work in the longer term. Sooner or later, people are going to go out anyway,” he declared in April.

The Swedish constitution affords the Public Health Agency, which Tegnell has led since 2013, significant autonomy from government – ministers are expected to abide by its recommendations. In England, by contrast, Boris Johnson rejected Sage scientists’ call for a national lockdown in September.

Tegnell, 64, a previously obscure bureaucrat, has now become a figure of global renown. In Sweden, his bespectacled face has been tattooed on admirers’ bodies and features on Obama-style pop art posters. But he has also faced death threats and the far-right Sweden Democrats – the country’s third-largest party – have demanded his resignation.

On 16 October, the day before a new ban on household mixing was imposed in London, I spoke to Tegnell by phone. “Well, it’s Friday,” he dryly replied when I asked how he was, with the air of a man grateful to have survived another week. “Strange, in a word,” was how he described his new cult status.

We began by discussing Sweden’s response in March – why did it diverge so strongly from its peers? “I want to make it clear, no, we did not lock down like many other countries, but we definitely had a virtual lockdown,” Tegnell said. “Swedes changed their behaviour enormously. We stopped travelling even more than our neighbouring countries. The airports had no flights anywhere, the trains were running at a few per cent of normal service, so there were enormous changes in society.”

He continued: “In March there was a situation where the health service in Stockholm, and many other places, was threatening to become overwhelmed. There was no possibility to test, contact trace and so on. So we did what you do in those circumstances when you have a pandemic: we went into a mitigation phase and did our best to diminish the speed of the spread.

“That was reasonably successful, the Swedish health service was never overwhelmed, there were always free intensive care beds; the results from our intensive care for Covid-19 is at least as good as other countries. The spread never really took off after that. We had a peak somewhere in April, and since then the spread has slowly been diminishing over time with the measures we had in place.”

Both supporters and detractors have described Sweden’s strategy as one of “herd immunity”: allowing the majority of the population to contract Covid-19 in the hope of building resistance to it. But Tegnell insists that this is not the case. “That’s incorrect – in common with other countries we’re trying to slow down the spread as much as possible… To imply that we let the disease run free without any measures to try to stop it is not true.”

He warned that a genuine herd immunity strategy could be disastrous: “If you have Covid-19 spreading, so that 50-60 per cent of your society eventually have the disease, it can rapidly overwhelm your health service and possibly cause a number of deaths indefinitely and leave people with long-term consequences. If you can avoid that I would say that you definitely should.”

But Sweden’s approach has not been cost-free: as of 18 October it had recorded the 15th-highest per capita death rate of any country (with 581 deaths per million people). This is still lower than the UK’s rate (655 deaths) but around ten times higher than neighbouring Finland and Norway.

“That is true, especially in the early phase of the pandemic,” Tegnell conceded. “But not since, we’re now down to maybe around five deaths a week, so I wouldn’t say there’s a huge difference any more. We can trace back a lot of the early problems to an unfortunate lack of preparedness in our nursing homes, which has been rectified and now works well.”

In Sweden, as in the UK, around half of all Covid-19 deaths occurred in care homes. Care workers initially avoided wearing masks and gloves (some for fear of giving offence to residents) and were discouraged from admitting patients to hospital. “We did not manage to protect the most vulnerable people, the most elderly, despite our best intentions,” Prime Minister Löfven conceded.

In June, as Sweden’s death toll rose rapidly, Tegnell admitted that “there’s room for improvement in what we’ve done in Sweden, absolutely”. But he does not blame the absence of a formal lockdown for the high number of deaths.

“The pandemic took off in Sweden in a different way to our neighbouring countries. We had a huge spread in Stockholm early on, which was much more like the spread you saw in London, Amsterdam, Brussels, which in many ways are more similar to Sweden than our Nordic neighbours are. Stockholm and those other cities have big populations from other countries, which is important, because the spread is much bigger and quicker among those populations.”

Again, as in the UK, ethnic minorities were disproportionately affected by Covid. Of the first ten deaths in Stockholm, six occurred among the Somali community (which accounts for 0.84 per cent of the city’s population). Swedish authorities acknowledged delays in translating health information into other languages.

Tegnell continued: “If you look at the south of Sweden, Malmö, which is a densely populated part of Sweden, just as densely populated as Denmark on the other side, with the Swedish measures in place they had a slower spread of the disease and less numbers of cases, less mortality. So the connection between strategy and mortality and other measures is not simple. It’s going to be tricky to figure out what did and didn’t work.”

Tegnell was born in Uppsala in 1956 and has devoted his life to the struggle against infectious diseases. At the age of 12 he moved with his family to Ethiopia, an experience that gave him an enduringly internationalist perspective. From 1990 to 1993 he worked for the WHO in Laos on vaccination programmes and later fought the Ebola outbreak in Zaire in 1995.

Today, Tegnell emphasises that there is no single model which can be transposed from one country to another. “I have had talks with British experts and we exchange experiences. I think it’s a good way to move forward; every country’s different, the epidemic looks different in every country and I don’t really understand completely why. It’s very important to work with the tools you have in place in your country, not to think that something that’s worked in China will work in Great Britain: it’s never that easy, you always need to adapt to your local conditions.”

Sweden’s approach has been cast by critics as one of neoliberal individualism. But it owes more to the country’s distinctive tradition of public health and the high levels of trust present in one of the world’s most equal societies. Sweden’s emphasis on child wellbeing – with sustained investment in early education – meant closing schools was never viewed as a viable option. Its impressive levels of social trust meant citizens were expected to behave responsibly without state coercion.

I asked Tegnell whether the flouting of lockdown rules by individuals such as the adviser, Dominic Cummings, and SNP MP Margaret Ferrier had undermined the UK’s approach. “I think it’s very important to have trust, and I think it’s been shown over time, with Ebola in west Africa, with many big outbreaks in the world, you need to have public trust to stop the disease. It’s important that the public understand what you are trying to achieve and work with you. I think that’s what we’ve managed to achieve in Sweden so far.”

Tegnell agreed that Sweden’s generous welfare system had also aided the country as individuals received the financial support necessary to self-isolate. “The Swedish social security system was further improved during this crisis.” Workers on sick pay receive 80 per cent of their previous salary, compared to a flat rate of just £95.85 per week in Britain.

After so far avoiding a second wave on the scale of those seen in France, Spain and the UK, Tegnell is more bullish than in June but remains cautious (Sweden recorded 970 new Covid-19 cases on 14 October, the highest number for nearly four months).

“For once we need to be humble, it is still early days… We feel we have [the virus] under control but things might still be happening, this disease continues to surprise us. On the other hand, we haven’t locked down and opened up again. We had a virtual lockdown and we still have a virtual lockdown in Sweden and so in that way I think we can feel a little bit confident that we will not land in any big changes.”

Tegnell defended his decision not to prescribe mask-wearing. “We are worried that it would diminish social distancing, which is definitely the most important part. The studies so far have not shown a dramatic effect, countries such as France and others, which have obligatory mask-wearing in place, have still experienced a big spread of the disease.”

In Britain, Conservative MPs and right-wing commentators have urged Johnson to emulate Sweden’s approach. But Tegnell is, for now, unwilling to say what the UK should have done differently. “I don’t think we are in a position to talk about mistakes anywhere. Maybe in a year or two we can sit down together, in a calm and peaceful situation, and try to figure out what worked well and what did not work well. But it is definitely too early to have reviews like that.”