Comparative Analysis of Strategies adopted by United Kingdom and Sweden to tackle COVID-19 - Story so far

The curious case of UK and Sweden

United Kingdom and Sweden fall in the similar cohort of developed countries. Both the countries have a decent per capita GDP, with 51,455$ for Sweden while 42,146$ for UK (2019). The expenditure of government towards health is also quite similar to around 18%, with health system for both the countries facing similar clinical challenges of an ageing population, lifestyles related diseases and co-morbidities. Thus both these countries since long have been focusing on their preventative care by having Long term plans towards it in place.

However, the major difference comes in the political administration and the society of the two countries at large. Sweden is a very different democracy with the governmental agencies having freedom to take decisions according to scientific advisers without any political intrusion since very few political appointees exist in any government agency. Also Sweden has built a culture of trust among its citizens and government and thus the people follow authority decisions without any force. With around 85% of the population urbanized and enjoying almost similar educational and other facilities, there is a level-playing ground for most of the people and hence decision-making and implementation becomes little easy. In contrast to this, United Kingdom has an excessive centralization under National Health Service (NHS) with excessive political influence in public health decisions made by Public Health England (formulated post 2012) leading to less of scientific freedom towards public health mechanisms. Also unlike Sweden, the country lacks on an equitable ecosystem across all four of its regions and thus the trust culture is amiss. 

COVID STRATEGIES AND ANALYSIS

 Sweden

Sweden followed a slow-herd immunity approach since the start of the pandemic. Going by the timeline; it was on 17 January 2020 when diagnostics for COVID were established, as soon as cases of COVID in China came to the surface globally. First COVID case was reported in Sweden on 31 January 2020 and thus by 1st February (before WHO declared it as pandemic on 11th March), COVID-19 was declared as dangerous to the society. While Sweden took most of its measures for restricting transmission of infection by February end through various travel restrictions domestically and globally; on 10th March Public Health Agency (PHA) upgraded the alert level to high throughout Sweden.

One of the striking feature of Sweden’s response remains that several actors are involved in tackling the pandemic and all interact constructively with one another. PHA, which is overseen by Transparency Council, has played a strong role in formulating evidence-based measures against pandemic and providing key information to the Government. The onus to ensure sufficient beds and other access issues falls under National Board of Health and Family Welfare. Public information and awareness campaigns were organised by Swedish Civil Contingencies Agency and Department of Education along with Swedish National Agency for education made online and distant education run smoothly. Constitutionally, the Infectious Diseases Act 2004 and Code of Conduct 1993 are responsible for regulating COVID-19. While the former puts the onus on individuals to work towards limiting transmission of infection, latter is responsible for protecting public health. Imposition of stringent general lockdown becomes difficult due to constitutional provisions for Government against any restriction on rights of movement of individuals freely. Hence, less invasive measures were resorted to by the government. Public places like bars, restaurants, kindergartens and schools were kept open with strong recommendation for physical distancing at all times and mandatory distancing at bars and elderly care homes. Schools for children above 16 was kept closed for initial three months and for children below 16 it was opened but with measures like small class sizes, social distancing and proper hygiene measures. Government relied more on the sensibilities of the citizens and thus voluntary recommendations were resorted like wearing masks was not recommended, people were urged to avoid travel and work from home. It was evident in an opinion poll conducted in May which showed that around 87% Swedes maintained physical distancing by themselves in public places. Sweden preferred to rely on slow community spread based on the scientific opinion that only immunity can beat the virus in long term and thus avoided following the cycle of lockdown and then opening up again, as done by other countries, to even save itself from other economic and emotional downturns associated to lockdown. Prof. Johan Giesecke who advises the Swedish Government conveyed that the scientific community were convinced that  everyone will be exposed to the virus and hence get infected, thus lockdown can only delay the spread but eventually almost all the countries would register similar death counts and hence Sweden continued with the no-lockdown approach.

Looking at the statistics around COVID-19 in Sweden,

On August 2020, data by WHO revealed; Total confirmed cases were 81,181 and total deaths were 5,747 and community transmission was reported.

Latest statistics by November shows, Total confirmed cases as 146,461 and total deaths as 6,0229.

 United Kingdom – UK, unlike Sweden has followed several approaches and has tried to customize the strategy according to the evolution of knowledge revolving around the virus. Going by the timeline, it was on 29th January when UK reported its first two positive cases of coronavirus in China, while on 28th February first case of virus was confirmed inside the borders of the country. While by early March, the death toll reached to 6 with 373 positive cases, UK’s Scientific Advisory Group for Emergencies (SAGE) led by Patrick Vallance, which is responsible for government response to national and regional emergencies, rejected the idea of lockdown and also the WHO standard containment approach of “find, test, treat and isolate” but rather went for herd immunity strategy. The officials initially compared it with mild influenza and hence urged people to work from home and follow social distancing by themselves and not going for any country-wide lockdown. It was only by 25 March 2020 that an emergency Act was legislated called the Coronavirus Act 2020, after a mathematical model predicted that strict physical distancing measures might limit deaths to 20,000 from the huge figures otherwise of 250,000. 

The response to COVID-19 in UK is coordinated centrally by a series of scientific groups (like SAGE) and through two legislations namely Coronavirus Act 2020 and Public Health (Control of Disease) Act 1984. The former provides for powers to increase the number of healthcare workers, provide for financial assistance to individuals and industries and powers to certain officials to detain or screen covid suspects; while the latter was invoked to impose severe restrictions on freedom of movement and liberty of individuals during emergencies and even impose criminal charges on violators. Thus, after around two months of strict lockdown, UK started with its reopening of society in a phased manner from 10th May 2020. Various public places like bars, restaurants, work places were opened with instructions of wearing masks, working from home if possible, maintaining physical distancing and imposing fines on violators. While UK tried to follow Test, Track, Trace strategy post unlocking of the society, failure to implement it made the administration resorting back to lockdown. 

On August 2020, WHO data reported, Total confirmed cases as 3,06,297, total deaths as 46,299 and community transmission. Post lockdown since the cases have been witnessed to be rising thus, the government has resorted for restrictions like maximum of six people to be allowed to gather in group (rule of six), work from home as much as possible, spreading slogans of “Hands.Face.Space” among citizens.

Latest statistics by November shows, Total positive cases as 1,192,013 and total number of deaths as 60,051.

Comparative Analysis – While both the countries have aspired towards similar goal of reducing transmission and hence flattening the COVID curve, the strategies followed and the philosophy behind them can be very well compared and pitted against each other in order to reflect upon the various data sets available as of now for both the countries.

Sweden and UK, both reported their first COVID case on 31st January 2020, with Sweden reporting its first death on 11 March while UK on 28 February. Sweden opted for herd immunity strategy with its scientific community being convinced on the fact that the infection chain would be broken by the immunity adopted by the whole community against the virus. Other factors which backed the decision include, trust culture of Sweden society (70% by a poll), a high-trade dependent economy which already suffered from closed borders and belief in the idea that the cycles of lockdown and un lockdown would ultimately result in similar numbers as compared to no lockdown at all. On the other hand, UK when initially went for herd immunity was not based on thoughtful and scientific opinions but on a belief by SAGE that the society of UK would not accept such restrictive lockdown. Also initially the health advisors to government, themselves believed that corona virus was just like any other mild influenza. Thus initially UK even didn’t pay heed to the WHO containment measures and the independent public health leadership and trust, as seen in Sweden was completely lacking in UK and it was misguided. This difference in strong public health leadership between two countries is quite evident from the fact that very soon by March end, relying on a predictive mathematical model, UK changed its strategy quickly from herd immunity to imposition of lockdown. Thus, comparisons between the two countries even help us in knowing the effect of lockdown on flattening the curve quite holistically.

Pre-lockdown, when both the countries had same strategies, the daily death per 10 million people exceeded in UK by 1.5 as compared to Sweden14. However once the lockdown began by March end, daily death rate dropped by 2 deaths per 10 million individuals in UK as compared to Sweden. Comparing the first 100 days of lockdown in UK with that of Sweden, it was seen that relative case incidence of UK was 1.32, while relative death incidence was 1.42 with case fatality rate being 17% and 16% respectively. Further with the uplifting of lockdown, UK didn’t see a surge in either the daily case incidence nor the death incidence, since the un-lockdown was accompanied by measures like social distancing, wearing masks and maintaining hygiene. Thus the implementation of lockdown in UK, as seen by the above data, definitely helped UK in bringing down its rapid growing mortality rate as compared to Sweden during pre-lockdown phase.

Another contrast can be seen in the treatment of high-risk group category of patients. While Sweden completely shielded such individuals, UK divided them into high and moderate risk with high-risk individuals under strict restrictions and moderate were advised to follow general guidelines but in a more careful manner. Since these shielding effects lead to adverse situations of beneficiaries, hence the contrast in the handling by the two countries becomes quite important in the long-run studies on impacts of COVID-19 on such individuals.

Post the lockdown period in UK from June, the Test, Track and Trace system was adopted, however it proved ineffective due to various reasons like systems in place were poor, lack of trust among people on government and crowded populations with job insecurities unlike Sweden. Thus the return of virus forced the helpless administration to resort back to lockdown. Hence lack of clear strategy differentiates UK from Sweden to a great extent. Unlike UK, Sweden though has stuck to its initial strategy but hasn’t been able to decode the virus effectively. State Epidemiologist Anders Tegnell, accepted the miscalculations regarding the effectiveness of COVID strategy which might have gone otherwise. High number of deaths in home cares or a mere 6% of population developing antibodies by late July, reveal the loop holes in the effectiveness of herd immunity.

Difference in testing rates between the two countries from the start of the pandemic till now is another significant contrast. While Sweden started with its tests only by start of August, with mostly asking people to notify their own contacts, UK resorted to the track and test policy and has been increasing its testing rate quite effectively. UK reported of more than 3.5 daily COVID-19 tests per thousand people, Sweden remains at around 2 per thousand people (October 2020).

CONCLUSION AND WHAT LIES AHEAD

COVID-19 is still looming upon us and thus none of the countries, be it UK or Sweden can be declared as winners in the effective tackling of the pandemic. While both the countries initially resorted to similar strategy, UK quickly followed the world and resorted to strict lockdowns in order to delay the spread of infections. While researches claim that the lockdowns can only be effective if the time bought from them is conclusively used by the administration in strengthening its public health preparedness, rising number of cases in UK and failure of Test, Track, Trace strategy points towards the inability of the administration to use lockdown constructively. Further even Sweden has been witnessing a surge in its cases and with winters approaching, the administration might be forced to rethink about its strategy. There is even strain among epidemiologists regarding ineffectiveness of the rather “soft-strategy” and with increasing doubts from the world at large, coming few months will be quite crucial for the country in deciding its way ahead.

Famous epidemiologist and member of Scottish expert group on coronavirus, Prof. Devi Sridhar quite conclusively opines how despite having the best of public health systems, the developed countries (be it UK or Sweden) have not been able to tackle the pandemic effectively mainly due to lack of memory of tackling the infectious diseases in particular, with contrast to some Asian countries which took the cognizance of the virus in a much more serious manner, and also because of the sheer arrogance of being developed and hence lacking the humility to learn from other developing or emerging economies. With vaccine still in the pipeline and the sheer unpredictable nature of the virus, its high time that countries, specially of a particular region (case in point here, UK and Sweden) act in a more responsible manner like a team and contribute towards fighting this deadly virus efficiently. The example set by leadership in these challenging times, can go a long way in designing a more equitable and healthier world.  

Note: The article is based on various resources and literature available in public domain for the two countries.