History Will Remember Tegnell’s Covid Heroism

As is well known, Sweden handled the Covid pandemic in a different way than the rest of the world. There were no closures of economic activities or schools and national borders were kept open. Anders Tegnell worked as the state epidemiologist in the Swedish Public Health Authority (FHM) during the pandemic. He was not the top leader of FHM, but in his capacity as state epidemiologist became its external face. Together with journalist Fanny Härgestam, Tegnell has written a book about the pandemic and here is a summary of it.

There is a difference between Sweden and other countries when it comes to responsibility for public health. FHM has significantly greater responsibility in Sweden than corresponding authorities do in other countries, and the role of politicians is subordinate. In Sweden, it was unthinkable that the politicians would listen to the advice from FHM and then decide how to handle the pandemic. It was FHM’s task to do that. FHM has to think about the whole, while the public health authorities in most other countries do not have to. Not only is the epidemiological side important for FHM, but also the consequences of possible measures. According to Swedish law, the measures must be proportionate to the risk.

In February 2020, one million Swedes were on winter holiday in the Alps and represented a major threat of infection upon return, but FHM did not want to coerce them into home quarantine after returning home. The risk of the spread of infection was not considered great enough and Tegnell believed that the Swedes would voluntarily do the right thing, which would turn out to be true.

Tegnell understood that it would not be possible to prevent the infection from spreading in society. He writes that testing can be useful at least in the early phase, and the purpose is to break chains of infection. This will possibly delay the spread of infection and during this period the hospitals can prepare for mass admissions. It also provides opportunities to learn which treatment can be effective and which risk groups exist. In retrospect, Tegnell writes that the measures may have delayed the spread of the infection by a couple of weeks, but he is now unsure of what lessons are possible in such a short time. Seen in light of this, it is particularly important that measures and restrictions do not have serious social consequences.

It is always more important to treat the sick than to carry out infection tracing, which at some point anyway becomes useless when enough people are infected. Tegnell was skeptical about the extensive testing that took place in Sweden and other countries even after the infection had spread to a large extent. There was no proper discussion about this in FHM. He believes that there were political reasons for the extensive testing and points out that this was not authorized in old pandemic plans.

Internationally, the pressure on large-scale testing was colossal. According to Tegnell, extensive testing had become dogma for the WHO. After a while, he gave up the fight against the extensive testing. It was a battle he couldn’t win. In retrospect, he is amazed that the testing appeared early on as the solution to the pandemic. According to Tegnell, advice to stay at home in case of symptoms delayed the spread of infection in Sweden. It was important that the measures should not go beyond society’s ability to function normally.

That Denmark and Norway decided to close schools in March 2020 was a shock for Tegnell. The information at the time indicated that children did not spread infection to any great extent. Tegnell had a few years previously co-authored an article that looked at the consequences of school closures during epidemics and the conclusion was that closures only had a limited effect on the spread of infection and the negative consequences were significant. Tegnell believed that the world was affected by panic. He wanted to inform without scaring the public and he writes that volunteerism is typical of Swedish public health work.

Sweden never closed the borders. The world depends on global trade and the movement of people. The consequences of border closures would be enormous and it was already known that travel bans had little if any positive impact on the spread of infection during a pandemic, writes Tegnell.

He writes that lockdown was not an established term to prevent the spread of infection and it had never been used in modern times. Nevertheless, lockdowns were introduced at breakneck speed in many countries. The precautionary principle was used as justification. It is a principle that did not exist in the Health and Hospitals Act.

Tegnell points out that the precautionary principle can be interpreted in different ways and believed that the principle dictated that the measures must not have excessive economic or social costs. It is too simple to just apply the principle with regard to the spread of infection. FHM carried out impact analyzes both in terms of the effect of measures and consequences and it was Tegnell’s impression that few others did so. He saw another problem with lockdowns and that was how to wind them down responsibly.

Experience from the past showed that it is impossible to stop a pandemic. The aim was therefore to follow the pandemic plans that already existed, keep society going as well as possible, and ensure enough resources for the hospitals. The fact that Sweden followed pandemic plans from the past stood in contrast to countries that unilaterally invested in reducing the spread of infection regardless of cost. New Zealand, Australia, China, and South Korea were examples of such countries. Tegnell does not know why some countries apparently tried to get rid of the disease altogether.

In Sweden, it was decided that gatherings should have a maximum of 500 participants. Tegnell writes that no one knew what a reasonable ceiling on the number of participants was and he admits that 500 was an arbitrary number.

An important question was how fatal the disease was. From experience, mortality is overestimated in the early phase of a pandemic. From China it was known that the risk of dying was highest among the oldest. It was important to measure the mortality of the disease, but difficult. Different countries had different ways of assessing mortality and in Sweden it was decided to register excess mortality. General excess mortality was previously used as a measure of influenza mortality. FHM had little experience of elderly care in Sweden from before the pandemic. It was the responsibility of the municipalities and regions. It was particularly in elderly care that many died from Covid in Sweden in 2020.

Tegnell points out that herd immunity is an epidemiological phenomenon and not a strategy for which he was accused. The term is used to understand how infection spreads in the population. Herd immunity occurs when so many people are immune that the disease no longer spreads. He writes that herd immunity is rarely achieved without vaccination and no viral disease has ever disappeared by itself. He points out that immunity against Covid is never perfect and herd immunity will therefore never happen.

In Sweden, as in many countries, there was a press conference every day. Tegnell believes it was excessive and that it should be limited to once a week. Because he was head of the department in FHM that handled data and epidemiological issues, it was natural that the press conferences fell to him.

Tegnell thoroughly studied the model from Imperial College in London and was skeptical. This model was probably an important cause of the panic that spread throughout the world. The uncertainty about various variables is no detail when forecasts are to be calculated and can lead to significant errors. Tegnell saw that some academic circles wholeheartedly believed in the Imperial College model, while others such as FHM were skeptical.

According to Tegnell, a model that does not take into account dark numbers when it comes to contagion is frivolous. There are forward-looking models such as the Imperial College model and backward-looking models. The last ones start from the last few weeks and predict what will happen next week. FHM used backward-looking models, but they were only indicative and never governing the introduction of restrictions.

It was Tegnell’s impression that the EU Commission wanted all EU countries to handle the pandemic in roughly the same way using computer models. Tegnell disagrees with this and believes that knowledge of one’s own population is important. According to the Imperial College model, there would be a need for 16,000 intensive care places in Sweden per day in spring 2020. The result was a maximum of 550 patients in one day. In the spring of 2020, there were fears that Stockholm did not have enough intensive care capacity. It was therefore decided to build a field hospital. It never came into use and was closed down after a few months.

FHM did not want to introduce a compulsory mask. The reason was that there was no scientific evidence that masks prevent infection. Tegnell was afraid that a mask would give a false sense of security and therefore sloppiness with other measures such as staying at home in case of symptoms. There was no scientific evidence that such a false sense of security would occur, but FHM did not want to take this risk as volunteerism was a crucial aspect of pandemic management. Tegnell emphasizes that the Swedes live in a free society. He is clear that this is no platitude for him, but something he really means.

It was known that infection could be spread from people without symptoms, but the infection occurred primarily from symptomatic people. As the aim was not to eradicate the virus, an impossibility, the aim was to slow down the spread of infection by asking symptomatic people to voluntarily stay at home. The aim was to prevent the hospitals from being overwhelmed.

Tegnell was aware that there would be new waves after the first wave in spring 2020 was over. The cause of these waves is unknown, but may be due to new mutations. In autumn 2020, it was clear that Covid was not as contagious as thought. This was both good and bad news. This could mean that the measures in the spring of 2020 had had an effect, but it could also mean that many people would become ill in autumn 2020. In autumn 2020, FHM invested more in local measures. As before, the main goal was to slow down the infection rate so that the hospitals would not be overwhelmed.

Tegnell initially thought that it would take several years before a possible vaccine was available. After the vaccines were put into use, he refers to reports from Israel that the vaccine was not as effective as first thought. In 2021, it turned out that the vaccine did not stop the infection, but Tegnell writes that the vaccine gave good protection against serious disease. The number admitted to intensive care units was lower than in 2020. According to Tegnell, it quickly became clear that patients at risk needed new vaccine doses, but he writes that the vaccines represented a watershed in pandemic management.

Tegnell resigned as state epidemiologist in May 2022. He subsequently concludes that Sweden’s handling by acting cautiously and not doing too much was correct. The latest studies show that excess mortality in Sweden is among the lowest in Europe and in line with the other Nordic countries, even though Sweden was hit harder in the spring of 2020. The hospitals did not collapse. Studies have shown that open schools did not affect the spread of infection.

Tegnell is afraid that many of the consequences of the pandemic will not become apparent for several years. Cancer investigation has been deficient in some countries, but to a lesser extent in Sweden. Chronically ill patients stopped going for checkups with their GP and the question is whether many do not continue to attend. Many have psychological aftereffects. In some countries, there is excess mortality for diseases other than Covid. School closures have had serious consequences for children.

Other studies show that those who died from Covid mostly had a short life expectancy anyway. Data from Sweden show that the negative consequences of the pandemic are minimal, according to Tegnell. A report from the telecommunications company Telia shows that the movement pattern among Swedes was restricted to about the same extent as in neighboring countries, but without coercive measures.

The consequences of the lockdowns have been particularly severe in poor countries. Poverty and malnutrition have increased. School pupils do not return to schools after the school closures. In Uganda, schools were closed for almost two years, but as in most African countries, the pandemic was mild there. The number of pregnant teenage girls increased by 350% in Uganda and domestic violence affected a quarter of households during the lockdown.

Tegnell reflects on why Sweden was accused of having chosen the wrong strategy. How could one claim that Sweden chose right and the rest of the world wrong? He believes the answer lies in politics. The handling of the pandemic had great political explosiveness and he believes that many governments felt pressured to act to protect the population. He does not know the reason why a black-and-white approach to pandemic management was established.

Conclusion

In Sweden, it was public health bureaucrats who managed the measures and not the politicians, as was the case in almost all other countries. For Sweden, it was fortunate that the public health bureaucrats, led by Tegnell, were rational actors who used established knowledge about pandemic management and assessed the effect of measures against the consequences for society, both economically and socially. Such cost-effectiveness assessment was not done in other countries.

That Sweden was able to stand up to the massive criticism from other countries is admirable and is probably due to a large extent to Tegnell’s strong character rooted in science and common sense. The country where the politicians had the least influence on the handling of the pandemic fared best. Whether that means that politicians should abdicate in favor of public health bureaucrats in the event of pandemics, I do not know. Personally, I believe that the most important lesson from Sweden is that volunteerism and sober information are crucial for the best possible outcome of a pandemic.