Reflections from Living in Sweden during COVID-19

Part 2 of 3: Chronology of events

This is the second of a three-part post describing my family’s experience as visiting scholars in Sweden during the COVID-19 pandemic. In this post, I will provide a chronological description of Sweden’s response to COVID-19, including my husband’s personal experience with what was most likely COVID-19. In the final post, I will summarize where Sweden stands now and what can be learned from their experience. Through our personal experiences I hope to shed some light on what is happening in Sweden and to provide recommendations for the future.

Introduction

As noted in the original post, our family of four, including my husband and two children, was in Sweden as visiting scholars from August 2019 to what was supposed to be summer 2020. We ultimately returned to the United States earlier than expected, in May 2020. Why? "Recovery" for my husband from what was most likely COVID-19, which has been challenging and scary and included a 40-hour stay in a Stockholm emergency room in late April. This post documents these events from February to May 2020.

February

In early February, word of the coronavirus was circulating in Europe, but it felt very far away. A family member called, wondering about visiting in mid-February for a cross country ski race. We left it up to them on whether they came to Sweden, but we weren’t worried. Our family member came, we did the ski race, and our relative returned to the U.S. We then flew to Geneva and took a shuttle to ski in the Alps on February 24 for “sportlov”- Sweden’s sport week, returning to Sweden on March 2.

During sportlov 2020, an estimated 1 million (out of approximately 10 million people) traveled somewhere, many out of Sweden. While Sweden’s sportlov covers a three-week period, the week we traveled was the week COVID-19 really broke across Europe and Sweden in particular. Italy confirmed its third case of COVID-19 on February 3, and a total of twenty cases by February 21. Sweden’s second case was announced on February 24, with a total of 13 by February 29.

March

As we prepared to travel from France to Sweden in early March, COVID-19 had gone from an abstraction to a reality. Case counts were in the news and there were warnings posted at the end of the chairlifts. We received almost daily communications from our kids’ school in Stockholm, including a required quarantine if one had traveled to Italy. We flew home on March 2. While we saw evidence of COVID precautions in Geneva (signs, lots of masks, people cleaning seats), we saw much less on our flight from Paris to Stockholm (few masks, no signs). We wiped our seats and travel spaces down, trying hard not to touch anything or be near other people.

March ended up being a period of huge uncertainty for us and for Sweden. While our kids’ school asked anyone who had been to Italy self-quarantine for 14 days, it simply asked anyone else feeling sick to stay home. Feeling some doubt, we sent our kids to school on March 3. My husband also continued to feel a heavy weight on his chest. As noted in my first post, if you need healthcare in Sweden, you are supposed to call a number (1177) and ask them what you should do and where to seek medical care. My husband, Chris, called on March 3 and waited on hold for a while, then opted for the call back option. No call back ever came. He tried this repeatedly. In the meantime, he figured it was better to be safe than sorry and stayed home to work.

After five days of repeatedly trying to get through, he finally reached someone live on the phone on Saturday night at 11 p.m. and was reluctantly directed to a clinic the following Tuesday. On March 10 the doctor diagnosed him with bronchitis and gave him permission to travel across the country to give a talk if he wanted to go; he could not get a COVID-19 test as he’d been to France, not Italy. Fearing that he actually had COVID-19, he canceled his trip. By March 13, my normally very energetic husband couldn’t walk more than a block without needing to retreat home, badly fatigued. Our 10-year-old daughter was invited to a playdate at an indoor kids playground; we declined. The reality of COVID had clearly not yet registered in Sweden.

Confirmed coronavirus cases in Sweden ramped up day by day - close to 500 confirmed cases as of March 11 and the first death in the Nordic countries. Denmark closed all schools for two weeks and canceled all public events with more than 100 people, asking people to stay at home if they could do so. Norway followed suit, launching "the most far reaching measures in peace time" to stem the coronavirus. I spoke with a colleague in the Netherlands - she was asked to quarantine in place for 2 weeks because she lives in southern Netherlands (where there were more cases) and works in northern Netherlands (where there were fewer). No symptoms, just risk. In contrast, Sweden suggested that people stay away from elders older than 70 and that others work from home; schools remained open. Stores began to show shortages for the first time. On March 13, the first person died of COVID-19 in Sweden.

On March 16, Sweden closed universities and adult learning but kept elementary and schools for kids through age 16 open. We decide that we’d had enough and pulled our kids from school - figuring that we’d rather school them from home rather than a) risk infecting others, or b) having them bring an infection home.

By March 19, France mandated that while people could walk or run, no one could be further than 1-2 km from their home. Norway's government tried to pass a bill to suspend all laws until December except for the constitution and human rights laws and halted travel to country cottages (their summer homes), punishable by up to a $2,000 fine. Most European countries shut their borders. In Italy, people with symptoms who disobeyed the requirement to self-isolate were subject to manslaughter charges. Sweden continued to operate in a parallel world to every other country, though on March 18, our local grocery store announced elder only hours and on March 19, the officials requested that people not travel within Sweden “any more than necessary.”

On March 19the U.S. issued a level 4 travel alert - U.S. citizens should not travel and if abroad, should return home immediately. In response, the U.S. Fulbright Commission called all Fulbrights back to the U.S., effective immediately. An excerpt of their letter reads as follows:

The State Department’s Bureau of Educational and Cultural Affairs (ECA) continues to closely monitor the spread of COVID-19 globally. Today (March 19), the State Department issued a Global Level 4 Travel Advisory, the highest possible level, instructing all Americans abroad to either return to the United States or prepare to shelter in place, given the global threat of the coronavirus outbreak. In response to this Advisory, the U.S. Fulbright Program will be suspended worldwide, effective immediately.

We urge all current U.S. Fulbright participants to make arrangements to return to the United States as soon as possible (bold in original).

Sweden finally closed its borders the same day.

On our end, we had a discussion about whether to return to the U.S., deciding that for at least the time being, we were too worried about Chris’ health to travel, we were in a stable living situation, our kids could do a remote schooling, our international health insurance through Penn State continued, and we had no easy place to live when we returned to the U.S. (our house in the U.S. was rented out to a Spanish family who did not intend to return home early). We saw numerous stories about tickets from France going from $18,000 a ticket, and lines in U.S. customs lasting 6 plus hours. We could think of no better way to spread COVID-19 than trying to travel just then. Nonetheless, we started investigating ways to mail extra clothes and gear home to make traveling easier once we did make the jump.

As March concluded, there was mounting debate on whether Sweden’s approach was a good one. As of late March, Sweden was still not on lock down: colleges, adult education, and high schools were doing remote learning; however, retirement centers and care facilities were officially locked down. Finally, in very late March, groups larger than 50 people were banned; bars were supposed to be closed. However, you wanted to go shopping for anything? Fine. Want to go skiing in Northern Sweden? Go for it (to the dismay of the towns near the ski resorts). Gather in groups for fika (coffee)...? Fabulous. Our kids continued home schooling though a lot of kids were back in class.

Growing attention and tension over Sweden’s pandemic approach

Given the very different approaches being taken elsewhere, the world was starting to notice what Sweden was (or wasn’t) doing. On March 23, The Guardian published an article entitled Swedish PM warned over 'Russian roulette-style' COVID-19 strategy. A March 27 article in one of the Swedish papers, the Svenska Dagbladet, is entitled (translated) " The "Swedish line" against the corona virus is astonishing abroad. Not least in neighboring Norway where contagion doctors now sharply criticize Sweden." The New York Times contained an article entitled " In the Coronavirus Fight in Scandinavia, Sweden Stands Apart." Researchers continued to call for more evidence-based policies beyond that enunciated by FHM, the federal health administration (one provided an in depth overview of events in a blog).
Tension over differing approaches became specific quickly. Denmark, for example, struggled with Swedish workers coming across the border into a country that is locked down for all but the basics... should you let a Swedish healthcare worker come into a retirement center when they've just been out to a cafe?

As discussed in my first blog post, trust was a big issue. The Local Sweden published an article entitled " Sweden's coronavirus strategy is clearly different to other countries so who should people trust?" The article points out that there has long been a history of societal trust in government in what has been a relatively homogeneous country and where everyone received their news from the same sources. The article notes that today, however, there are far more people here from a variety of countries with different assumptions in government and different news sources.

There is also a different set of messaging happening in Sweden versus other countries. In Sweden, the prime minister's speech in March was lauded as really important and helpful. Apparently, the prime minister doesn't give speeches that often and the power of health care type decisions is really in the hands of the health agency.

The "who should we trust article" observed the following: "Compare the Swedish guidelines to what the Danes were told by their government on Monday: "Cancel Easter lunch. Postpone family visits. Don't go sightseeing around the country." The Swedish Public Health Agency's corresponding recommendation is: "Ahead of the breaks and Easter, it is important to consider whether planned travel in Sweden is necessary to carry out." Another statement from the Swedish Health Minister: "We all, as individuals, have to take responsibility. We can't legislate and ban everything. It is also a question of common-sense manners."

This approach did not resonate for all. An epidemiologist at Karolinska (the premier medical research facility in Sweden) noted that she is feeling gaslighted by Sweden as country: trust us and we'll take the best course. As someone quoted in the NYT article says "But I am worried Sweden will explode at some point. I feel like I’m living in a huge experiment, and I was never asked if I wanted to sign up.”

By late March, there was still not widespread testing in Sweden even while the officials were touting their success. For example, the Swedish health minister Anders Tegnell said "They [those in South Korea] succeeded in much the same way as we did when we prevented the infection from those who came home from Italy. They had a pronounced risk group that they followed very closely and tested frequently, just as we did with the Italian travelers. They managed to stop and limit the infection very well in that group, just as we did with the Italian travelers, says Anders Tegnell."

While congratulating themselves on testing travelers to Italy, they missed people traveling everywhere else (like our trip to France). The official stance didn’t match our own lived experience, nor our sense that a) infection was way more widespread than it was understood to be given the absolute lack of testing, and b) people weren’t taking the admonition to be distant from each other very seriously at all.

To get out of the house, we biked to Kungsträdgården in Stockholm to see the cherry blossoms -- lots of people and most not visibly distancing themselves from others (hard to see in the more distant picture below, but there are a lot of people taking pictures under the blossoms). Playgrounds remained crowded; restaurants had plenty of people. Life had slowed down-- noticeably-- but certainly not stopped.

A lot of people taking pictures under the cherry blossoms at Kungsträdgården in Stockholm.

Our own sense of disconnect was shared by others. On March 25, two days after Britain shut down, a group of more than 2,000 Swedish epidemiologist, professors, and doctors signed an open letter asking the health agency to reconsider its approach:

In an open letter sent to the government, signed by, among others, Olle Kämpe, who researches immunology at the Karolinska Institute, requires the government to severely limit contact between people and to test considerably more than it does today.

"Until we get a better idea of ​​the situation, I think it is a good idea to close schools, restaurants and entertainment venues.”

[One letter signer noted that] he "gets the feeling" that the Public Health Authority, with its strategy, wants to achieve immunity to the virus, something the authority previously rejected.

The debate over whether Sweden was pursuing “herd immunity” raged in the press. For example, the March 27 article from The Conversation was entitled " Sweden under fire for ‘relaxed’ coronavirus approach – here’s the science behind it." The basic gist seems to be that the Swedish health ministry saw a slower spread than elsewhere and that the requests for social distancing would work. Sweden seemed to be operating on the "herd immunity" approach- enough people get mild symptoms or remain asymptomatic to develop immunity and as long as the hospitals aren't overwhelmed, Sweden would be fine. However, Sweden went into the COVID-19 crisis with one of the lowest ICU bed count in Europe ( 5.8 ICU beds/100,000 people, second lowest in Europe above just Portugal).

The disconnect with the rest of Europe beyond the Nordic countries grew more profound by the day. In Switzerland, they tolled their 16th century warning bell in late March for 3 minutes to signify the country was at peril. Germany limited groups to no more than 2. Even Britain—officially pursuing the herd immunity approach until late March—shut down.

Restrictions in Sweden continued to diverge from the strict shutdowns seen elsewhere: travel was not forbidden within country and groups up to 50 were still allowed (down from 500 just the week before), avoid social contact if over 70 or ill, try to work from home, table service only in bars and restaurants. Suggestions to avoid care facilities became a ban only in late March 2020. Emphasis continued to be on personal responsibility:

Prime Minister Stefan Löfven has announced further restrictions in Sweden, and underlined once again the individual responsibility of people in Sweden to help limit the spread of the coronavirus. The announcements came at a press conference together with Deputy Prime Minister Isabella Lövin and Health and Social Affairs Minister Lena Hallengren.

"Every Swede has a responsibility to protect themselves with the aim of protecting others," said Löfven, urging everyone in the country to cancel planned Easter travel, in line with Public Health Agency recommendations to avoid non-essential travel.

As of March 30, 2020, the impact on Swedish hospitals ramped up and Sweden had seen 180 people dead, with the outbreak centered in Stockholm. Health director in the Stockholm region Björn Eriksson noted that "We can see right now that storm is here and it is increasing in strength. The trend is very clear and it is that the need for care is increasing rapidly day by day.” A field hospital was set up at a convention center south of Stockholm [ only to be shut down in June without being used. More on this in blog #3].

By this point, it was clear that the other Nordic countries were taking one approach through locking down, while Sweden was taking another approach. In a piece entitled “Coronavirus: why the Nordics are our best bet for comparing strategies,” a researcher at Lund University in Sweden succinctly summarized the situation: “Currently, 15 million people here [in Denmark, Norway and Finland] have been assigned to a lockdown, while a further 10 million [in Sweden] have been asked to simply act responsibly. While it is too early to have definite answers about what works best, interesting insights can already be gleaned.”

April

The daily news conference at 2 PM Swedish time announced an ever-increasing number of hospitalized and dead, with death rates highest for the elderly and foreign born (more in blog post #3). Our world shrank by the day- no more busses, subways, or trains. While we hoped to travel for the Easter break, we reached the decision that traveling was not possible. I learned to cut my son’s hair, refusing to go to the still open hair salon. We cooked, refusing to go to the still open restaurants. The two Asian owned restaurants were the only ones in our neighborhood taking precautions, and the only place we’d buy takeout from. Masks on anyone were unusual. [In late March, bars and restaurants were restricted to table service only; spot inspections to check for compliance and crowding in restaurants only occurred in late April].

The admonition against travel was echoed by the King of Sweden. On April 5 th, the King gave a speech focused on setting an example about staying home at Easter, of acting with personal responsibility for their grandparents: “ For their sake, we must act responsibly and selflessly. Everyone in our country has this obligation. Each and every one of us. There is still a great deal of uncertainty. But one thing is certain: we will remember these times and look back on them. Did I think about other people? Or did I put myself first? We will have to live with the choices we make today, for a long time to come. They will impact many.”

Why was the King giving this kind of speech? It turned out that Sweden may have lacked the power to enact stringent quarantine measures. A law professor at Stockholm University wrote about Sweden’s limited ability to mandate anything in an essay entitled " Between normalcy and state of emergency: The legal framework for Sweden's coronavirus strategy." The author noted that Sweden has not been at war since 1814 and does not in fact have the powers of emergency that other countries have. On 8 April, Sweden's parliament met (just 55 out of its 150+ members to avoid spreading the virus) and gave itself broader powers to combat the coronavirus if needed.

This time period was another important one in Sweden. Between April 6 - 13 was another 10-day period of vacation from school; this break is one in which Swedes (and Norwegians and others) typically travel, often to ski. Prior to the Easter holiday, the Swedish government finally asked the ski areas to shut down, well after the rest of Europe. People held their breath during the Easter break- would people travel? At this point, there were an estimated 10,000 confirmed cases and around 1,000 dead in Sweden.

Reports afterwards indicated much less movement within Sweden, based on one telephone provider’s records:

Travel from Stockholm to the island of Gotland fell 96 percent between April 8th and April 10th compared to the same period last year, according to Telia's anonymized mobile phone data, reports the TT news agency. And travel to ski resort Malung-Sälen dropped by 92 percent.

Travel from Gothenburg to Gotland decreased by 94 percent, and from Gothenburg to Stockholm and from Malmö to Stockholm fell 85 percent. Travel from Malmö to Mörbylånga municipality on the Öland island fell 96 percent compared to last year.

On our end, we stopped traveling completely and apparently entered into “recovery” hell. By mid-April, my husband had been feeling somewhat better, so he went for a run. During the run, he felt great, happy to get some exercise. The next day, he felt like he had been hit by a truck, with a monster sitting on his chest. He felt like this for 10 days, then felt better. He tried a shorter run. Same thing: felt good getting exercise, then felt horrible for ten days. He tried to get an inhaler to see if that would help. Multiple phone calls later, he gets one. It doesn’t seem to make much of a difference, though makes his throat feel tight when he uses it. Our daily conversations are “do we stay?” or “do we go back to the U.S.?” It is draining. We try to explore our neighborhood as much as we can, limited by health and transportation, a pandemic and a city apparently oblivious to it.

April 19 comes, a Sunday. We learn from our kids’ school that they will be revoking the online learning option. All kids must be back in school by April 27; more absences past 10 days will be reported to the authorities with the City of Stockholm. By April 23, our “do we stay or do we go” has changed- we are going, new plane tickets bought for May 2. There are a lot of reasons for it- the kids’ school, Chris’ struggle to feel better; concern about what might happen with our kids if something happened to me; etc.

April 24. We have a normal-ish morning. Mid-day, Chris comes to me, feeling dizzy. We call 112, Sweden’s emergency number. He is still on his feet, ambulatory; they recommend a clinic. We try to reach the clinic. No luck. Try the general health hotline 1177, get them to let us go to an emergency room instead. We take a taxi to the emergency room at Karolinska Hospital, homemade masks made of handkerchiefs. We find the entrance, get sent to the COVID ward around the corner. He disappears inside. I took a bus home to wait. His oxygen levels are tested- he appears fine, is sent home with a warning about tapping into the health care system. He takes a taxi home, still not feeling good.

Figure 1 The door to the unassuming Karolinska Hospital Covid Ward (April 23, 2020; photo by author).
Figure 1 The door to the unassuming Karolinska Hospital Covid Ward (April 23, 2020; photo by author)

April 25. We are having a quiet morning when we get a call; Chris’ 100-year-old grandmother has died, not unexpectedly. Sad, we have a quiet day, go for a gentle walk around the woods to get outside. Go to bed. I awake at 3 AM to a thud. Chris has woken up, thinking he’s had a stroke- face and arm numb, slumping. He’s screaming on the floor that he’s had a stroke. I call 112 again- am able to communicate our neighborhood and our need for an ambulance. It takes hitting the ground and lying in a pool of blood to get an ambulance, but we finally did. I send our 13-year-old out into the dark to wait for an ambulance at 3:30 a.m. I put our 10-year-old next to her dad to keep him warm while I scramble, packing a bag with a change of underwear, some shoes, a cell phone charger. The emergency technicians arrive, spend an eternity putting on COVID protective gear. They check him out, load him on the stretcher, and he is gone, elevator doors closing behind him.

To watch a loved one disappear on a stretcher is pain. To be unable to reach them in a hospital is horrendous. What seems to be less understood than it should be in these days of COVID: you are on your own in the hospital. Your loved ones cannot help, they cannot reach you. Chris spent a night with a heavily impacted neck sleeping on a metal tray for a pillow. I could do nothing. Our advice? Hope you can fend for yourself and take a cell phone charger.

Somewhere during his stay in the hospital, doctors wanted him to get an MRI, but the place to do so was in a different hospital. Because he’d not yet received the results of his COVID test, they took him in an ambulance. He waited for the EMT technicians to suit up again, transferred to the new hospital. They couldn’t do the MRI without the COVID results. They tracked the results down- negative. Ran the MRI. Now in the “COVID-negative” category, they wanted to transfer him back to the original hospital and ordered a cab for him. Still dressed in his bloodstained clothes, he waited for the cab, which then dropped him off outside the original hospital in the wrong place. He waited in the cold for twenty minutes before someone let him in. While care in the hospitals is generally good, the system doesn’t function well to transfer people between places. The risk of COVID slows everything down, stretches the system.

More than 40 hours later, he is sent home in a taxi, bloodstained pajamas and a t-shirt for clothes. No major stroke, no broken neck from the fall. A hematoma on his brainstem. Nerve pain. Having a Swedish identity number allows him to navigate the hospital, but we are not citizens of Sweden, so he is not eligible for physical therapy. The doctor recommends not flying home in a week.

We redo our logistics, set up a CT scan the following week, arrange to fly home on May 9. Life again blurs. I pay less attention the daily 2 pm death count for Sweden (it is increasingly daily). Chris stabilizes. I pack up, helped by our kids, who are now re-enrolled in school in the U.S.; school starts for them at 3 PM.

On April 30, Swedish experts publish an op-ed in the country’s largest newspaper, asking for a change in Sweden’s approach to COVID-19, asking for more testing, contact tracing, and public health measures. April 30 is also Walpurgis Eve - a night Swedes traditionally celebrate with picnics and bonfires. While many public celebrations are canceled, the City of Lund takes its efforts a step further by spreading chicken manure in the park commonly used for picnicking.

May 2020 - return to U.S.

I have no idea what happened in the beginning of May- I must have spent a lot of time making sure Chris was okay, our kids were okay, and handling international insurance, our landlords, our families, healthcare providers. I have no idea how many people have died of COVID-19 each day in Sweden; I just want to go home. As I bike to run errands, I see the crowded cafes (though downtown Stockholm is less busy than usual). Chris’ second CT scan indicates at least not a worsening bruise on his brain. We procure a clearance letter allowing us to fly.

Chris has a telehealth appointment with his care provider in the U.S., who decides that he must have had bronchitis, not COVID. We feel like we’re going back in time to a health care system in Central Pennsylvania that has not seen the impact of this virus, yet.

May 9. Bags packed, a couple of boxes shipped, apartment cleaned, we take a taxi to the airport and quietly let ourselves out of Sweden. We hope to return one day, ideally under better circumstances.

So what now? I’ll summarize what happened from May-July in my next and final blog post, with more on what the results of Sweden’s COVID-19 experiment have been.

Article Topics: health, prevention, international, health care
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