COVID-19 cases and deaths internationally have fallen to their lowest levels in four years. The data now permits a comparison between the controversial laissez faire strategy of Sweden and the more restrictive approach of the United States, which emphasized lockdowns, a strategy also adopted by most of Western Europe.
The Swedish tack relied on personal responsibility and voluntary measures rather than government coercion and restrictions. This attitude, ultimately vindicated, was attacked at the time by health officials and the press in Western Europe and North America.
How did America and Sweden fare comparatively?
COVID-19-related cases: COVID-19 outcomes were similar. According to the statistics site Worldometer, in terms of officially reported cases since the beginning of the pandemic, Sweden had roughly 27 cases out of 100 people, the U.S. had 34 cases out of 100. This was only reported cases, and the best estimate is that considering all cases, whether reported or not, both countries had between 80 and 90 cases per 100, so the difference in infection rates disappears. Neither a lockdown-intensive nor a permissive strategy minimized the ultimate number of COVID-19 cases.
COVID-19-related mortality: The numbers once again lean slightly toward Sweden, but it is likely the health of Swedish citizens versus that of the U.S. was responsible, instead of the superiority of the Swedish strategy. In the U.S. overall, there were 3.7 COVID-19 deaths per 1,000 people; in Sweden, 2.7 COVID-19 deaths per 1,000. Based on this, no one can claim the U.S. did better than Sweden, but it is not a ringing endorsement of the Swedish approach. Neither country protected high-mortality nursing home patients, especially early in the pandemic. Many countries, including their Scandinavian neighbors, had fewer COVID-19 deaths per population than Sweden. Norway, Denmark and Finland all quickly closed their national borders; Finland erected internal borders.
The lesson is that COVID-19 cases and outcomes are probably not primarily determined by national strategy. After four years, no major country avoided high COVID-19 infection rates. While approaches to protect high-risk patients may limit morbidity and mortality at the margins, COVID-19 deaths are related more to national health, age and demographic breakdown, and population immunity. Assessing lockdown strategies by measuring COVID-19 cases and deaths is fraught with error; counterexamples abound.
Non-COVID-19 outcomes: Public health experts use the term “excess deaths” to describe deaths from all causes in a given interval when comparing with the number of expected deaths based on historic patterns. From 2020 to 2023, excess deaths were elevated in every developed country but were up only 5% in Sweden compared with between 10% and 15% in the U.S. The 5% figure is the lowest figure in any industrialized Western country, including the Scandinavian countries with lower COVID-19 mortality. Many excess U.S. deaths can be attributed to lockdowns and include deaths of despair — suicides, drug overdoses and alcoholism — and deaths resulting from delayed health care. Sweden almost certainly avoided many of the deaths associated with lockdowns in the U.S.
The economic figures during the pandemic tell a similar story. According to the Organization for Economic Co‐operation and Development, the U.S. economy, although fairly resilient, shrank by 1.2% after 2021 against what was forecast. (The Eurozone’s fell by 2.1%.) The Swedish economy grew by 0.4% against what was forecast. Inflationary pressures post-pandemic are not as severe in Sweden as in the U.S., where the government employed a greater, potentially inflationary fiscal stimulus.
The most important outcome difference between the U.S. and Sweden was in children’s education. Prolonged U.S. school closures caused educational damage to students not seen in Sweden. Beginning in March 2020, public schools in the U.S. closed, sending 50 million students home. Some private and religious schools, as well as some schools in Florida, opened up in the second half of 2020, but as many as half of all American public school students stayed out of school until the second half of 2021.
Several researchers from American universities found that by the spring of 2022, the average U.S. student lagged by approximately one-half year in math and one-third of a year in reading.
The Public Health Agency of Sweden recommended that secondary schools and universities switch to remote education for the final three months of the 2020 spring term, but schools opened in autumn. There was another two-month in-school hiatus in December 2020 and January 2021 during a variant outbreak, but almost all preschools and elementary schools remained open. Swedish researchers concluded there was no evidence of a learning loss in early reading skills in Swedish primary school students, and the decision to keep schools open benefited Swedish primary school students.
Taking into account all aspects of the pandemic — excess deaths, economic health and children’s education — the long view suggests that while not ideal, the Swedish strategy was superior. The coronavirus was so contagious and mutated so quickly that tight lockdowns were unsuccessful in controlling spread. And the longer the lockdowns, the greater harm to the populace from factors other than COVID-19.
The effectiveness of lockdowns during COVID-19 is an important question, scientifically and historically — but not a definitive blueprint for the future. The next contagion may spread differently and require different measures.
The most important takeaway from the Swedish COVID-19 experience is not that Sweden controlled COVID-19 better, but that any national strategy must account for the effects on the country’s economic, social, educational and mental health.
Dr. Cory Franklin is a retired intensive care physician and co-author of the new book “The COVID Diaries 2020-2024: Anatomy of a Contagion As It Happened.”
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