When the threat of Covid became a clear reality across the globe, Sweden chose to tread its own path. It refused to follow other western countries on how to handle a pandemic – in the form of strict lockdowns – attracting international criticism and drawing death threats against its scientists.
Now, five years after the World Health Organisation declared a Public Health Emergency of International Concern on January 30, 2020, it is considered to be a country that coped better than most.
So, what can the world learn from its approach if – or perhaps when – another pandemic strikes? Could things be worse next time? Some scientists, academics and health workers, who spoke to by The National, believe they could.
The Swedish way
Sweden’s success lies in a simple-sounding strategy: be prepared. It had a plan and understood its people. There was no blanket lockdown. It allowed its population to gather in groups of fewer than 50 while keeping its junior schools and restaurants open. Unlike most European children who lost the equivalent of one third of a year’s education, Swedish youngsters’ learning remained constant. Swedes were asked to follow the recommendations on social distancing, work from home, avoid unnecessary travel and remain indoors if they felt ill.
Horrendous death tolls and overrun hospitals were predicted yet failed to materialise. Sweden fared among the best in terms of mortality, keeping its deaths lower than 31 European countries. Data collated since the outbreak and released this month showed that in comparison to Britain, with its strict lockdowns and 3,400 deaths per million, Sweden had a lower mortality rate of 2,700 per million, which was also lower than the EU average of 2,800.
To date, Sweden has lost 28,423 people to Covid out of a population of 10.5 million. By comparison, the US lost 1.2 million from a population of 335 million. However, it should not necessarily be assumed that the Swedish approach can work for everyone.
Gunilla Herolf, of the Swedish Institute of International Affairs, acknowledges that Nordic countries were helped by broad open spaces accommodating a relatively small population. But it also had solid preparations in place for a potential flu outbreak.
“Sweden did really well and the main reasons are people obeyed the recommendations to a very large degree,” she said.
The last time
Seven million people died in the global catastrophe that devastated communities, tormented families by keeping them apart and sank economies. On all three counts, some are yet to recover.
Children’s mental health issues have soared, an addiction to screens and social media has created a series of issues and lost schooling for some has still to be recovered.
University College London
If the world does not learn and retain the lessons of 2020, then when the next pandemic hits – and hit it certainly will, scientists say, possibly in the next 40 years – the battering society and economies took will be repeated.
Excess deaths
An issue that remains unresolved to this day is that the number of excess deaths has continued to rise since the pandemic.
In 2020, from a group of 41 countries, 87 per cent reported excess deaths which rose to 91 per cent in 2022. Few countries now routinely report the figure, but up to June last year there were thought to be more than 27 million excess deaths worldwide, according to Our World in Data, which tracks statistics.
It is unclear what the cause might be, with lower take-up of Covid-19 vaccines, health issues caused by “long Covid” and rising levels of obesity among the theories.
“Excess mortality has remained high in the western world,” reported the British Medical Journal, which also recommended governments “need to thoroughly investigate the underlying causes”.
Economic treacle
Economies too are weighed down by the sudden debt that the coronavirus placed on them. In the West, the recession hit hard. Germany’s GDP shrunk by five per cent while Britain’s veered from a record 19 per cent fall in the first lockdown to rebound to 17 per cent upon reopening.
However, both countries are still struggling to get their economies to pre-Covid growth figures, as is China which is barely achieving its goal of five per cent growth.
Pandemic awareness
Asian countries such as South Korea, Vietnam and Taiwan suffered about 400 deaths per million. Part of that was previous epidemic experience, such as bird flu, with the knowledge that a rapid response was required as well as tracing outbreak areas. They were able to conduct “surgical lockdowns” targeting a specific outbreak area rather than sacrificing the entire country’s economy with a national lockdown.
Gulf States, which were close to the epicentre of China and Covid-hit Iran, were also uniquely exposed due to being a main destination for international travel. However, with the legacy of dealing with the Middle East respiratory syndrome-related coronavirus a decade earlier, the Gulf was prepared to deal with the approaching crisis.
UAE experience
Dealing with tourists, alongside surveillance technology and good PPE supply led to a lower UAE death toll. The Emirates even sent shipments of PPE to Britain during the pandemic.
The first Covid case in the UAE was reported on January 29, 2020. By July 7, Dubai was once again open for business. Although Dubai was at the forefront of the global tourism recovery, a hard border remained in place with Abu Dhabi and permits were required elsewhere to prove people were Covid-free.
Public PCR testing centres were quickly established nationwide, allowing authorities to manage infection levels. While lockdowns were swift and effective, a cooperative population willing to be vaccinated at the earliest opportunity and strict border controls, allowed for a relatively rapid easing of restrictions.
That was reflected in some of the world’s lowest mortality and infection rates. The UAE suffered 229 deaths per million and Saudi Arabia 299. By contrast, Iran was hit with 1,640 deaths per million.
A contributing factor to the UAE’s success was the nation’s relatively young population, with older people more likely to experience severe symptoms. The average age of the UAE population is just 31, compared with 40 in the UK and 38 in the US.
The disparity between young and old was so stark that the US Centres for Disease Control said more than 81 per cent of Covid-19 deaths occurred in those over 65, 97 per cent higher than those aged 18-29.
Adapting as you go
Others were hit hard at first but recovered. Italy, with its strong trade links to Wuhan, China’s epicentre of the outbreak, suffered severely, showing how unprepared it was. However, the Italians quickly recovered by instigating bespoke lockdowns.
Based in Tuscany, David Alexander, London University’s professor of emergency planning, had a first-hand view of how the country dealt with lockdowns.
In February 2021, Covid broke out in the nearby town of Chiusu. With a population of 8,200, the town went into full lockdown, with police roadblocks and medical teams testing everyone. Within two weeks, they had the outbreak under control, and Chiusu reopened.
“Once they got the hang of it, things changed quite radically,” said Prof Alexander.
Politics at play
The UK government, led by prime minister Boris Johnson at the time, was criticised by Prof Alexander. He decried the “recipe for wasting billions” by not heeding the advice of civil protection experts and relying on medical doctors and politicians instead.
“Some of the things about the way Covid was managed are really very worrying in Britain,” he said.
It also appeared that the politics of Brexit played a role with Mr Johnson seemingly disdainful of how Europe was tackling the pandemic. “Britain did not look closely enough at the rest of Europe and there were a number of consequences for that, one of which was that they could have got the ‘best practice’ for Covid.”
Lockdown legacy
Prof Ilan Kelman, who specialises in disasters and health at University College London, argued that mandatory lockdowns “should be one of our last resorts” as the costs were so high.
“We don't want lockdowns because of the social bonds which are severed, the mental health impact and the devastation to people's livelihoods, especially in the service and entertainment industries. Lockdowns are highly damaging.”
However, he conceded that the severe Covid-19 restrictions were essential as countries were not ready for a pandemic. “We had plenty of time to prepare, and we didn't.”
Britain finally locked down in late March, a full month after the Italians, but it was also a strict nationwide shutdown that lasted more than three months. At least £37 million was wasted on an erratic track and trace system.
Prof Alexander pointed to British Covid hotspots, such as Bolton and Oldham, where local government could have used track and trace as well as surgical lockdowns to slow the spread.
Prof David Heymann, formerly of the World Health Organisation, argued that it was vital that healthcare systems were designed with the capacity to deal with a pandemic while continuing routine operations. Britain’s NHS has still yet to recover from the backlog created in 2020 with many cancer patients seeing their health decline without surgical intervention.
Breakthroughs
The worst of times can of course bring out the best in people. Despite the sceptics and conspiracy theorists, modern medicine proved it could, under extreme pressure, come to the rescue.
One of the few areas where Britain emerged with credit was due to its world-leading life scientists. The mRNA Covid vaccine was produced within 10 months of the outbreak, meaning the UK became the first to administer it in the world, outside of trials.
The UAE met the challenge of vaccine shortages elsewhere, delivering more than 100 million doses to about 65 nations during the pandemic. The HOPE Consortium was established to utilise the UAE's prime geographical location to bolster vaccine supply chains globally. The UAE was also the first nation to receive the antiviral therapy Sotrovimab, an antibody treatment developed by GlaxoSmithKline that proved highly effective in preventing extreme illness and death.
There were other positive developments too. The idea of home testing signalled the future potential to cut down trips to the doctor if people can self-diagnose at home.
The pandemic ushered in a new era in technology. Artificial Intelligence could have “transformative potential” in the next pandemic according to Molecular Biomedicine, proving a battle-winner through swift epidemiological modelling to understand and predict disease transmission.
“These models have significantly improved outbreak forecasting, allowing policymakers to implement timely and effective interventions,” the paper said. “AI optimises resource allocation and enhances the efficiency of public health responses.”
Come together?
One of the standout issues of the pandemic was unfairness. Those unable to look after themselves suffered greatly. Much was made of the determination of rich countries to ensure they were vaccinated first, leaving countries in Africa behind. It was thought that might change.
Unfortunately, it appears that, in a world of growing conflict, especially in Europe and the Middle East, there is little appetite for a responsible global approach.
Talks to establish an international agreement on how to tackle pandemics paused in June last year after two years of negotiations for greater global collaboration.
The WHO-driven discussions stalled on division over vaccine-sharing and pandemic preparation between rich and poorer countries, although it is hoped they will be resurrected in May at the World Health Assembly.
If not, then the world’s catastrophic weaknesses exposed by Covid in terms of response, communication and vaccines will leave it deeply vulnerable.
The sense of urgency is also driven by biodiversity loss, chemical pollution and climate change that could rapidly evolve future pandemic threats, especially with a zoonotic transmission risk caused by increasing interaction between animals and humans.
Another factor adding to the urgency is diet and its consequence, obesity. “We also need to talk about those who were overweight,” said Prof Heymann, a specialist in infectious disease epidemiology. “It was largely the obese that suffered the most.
“We need better health promotion for more healthy lifestyles as the majority of hospitalisations were those who were obese, struggling to breathe due to the pressure on their lungs.”
Forgotten Lessons
Some lessons have very clearly been forgotten, said Prof Kelman,
“I see people coughing and sneezing on to food or coughing then touching doorknobs,” he said. “I do not see proper hand washing or much masking on public transport.”
He also worries that several countries have elected leaders who would put their country first “rather than seeking international co-operation to properly monitor and respond to any potential pandemic threat”.
One of US President Donald Trump's first acts upon returning to office was to issue an executive order withdrawing America, along with its $1.2 billion of funding, from the WHO.
This was a “grave error”, said the UN organisation’s independent panel for pandemic preparedness and response the day after the inauguration, which would put Americans “at greater risk of outbreaks, death and economic losses”.
Five years since the outbreak of Covid-19 - in pictures
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This year marks five years since the World Health Organisation declared a Public Health Emergency of International Concern on January 30, 2020. The National looks at some of the most striking images taken during the Covid-19 pandemic. All photos: Getty Images -
A pedestrian walks along a near-deserted street during a lockdown imposed in 2021 in Mumbai, India -
An elderly woman wears a face shield as she attends Eid Al Adha prayers at a mosque in Yogyakarta, Indonesia, in 2021 -
An aerial view of Queen Square in Bristol, England, where hearts were sprayed on to the grass in an effort to encourage social distancing in 2020 -
Medical staff in protective gear move a Covid patient from an ambulance into hospital in Seoul, South Korea, in 2020 -
A Civil Protection member in a hangar where 18 coffins of victims of Covid-19 wait to be transported to Florence by the Italian Army in Ponte San Pietro in 2020 -
Military vehicles cross an empty Westminster Bridge in London in March 2020 -
Dental nurses embrace before treating a possible Covid-positive dental patient in Wrexham, Wales, in 2020 -
A health worker passes a vial got be used in a nucleic acid test to detect Covid-19 in Beijing, China, in 2022 -
A giant television beside a motorway urges people to stay home in Manchester in the early days of the outbreak -
Firefighters prepare to disinfect Wuhan Tianhe International Airport in 2020 in Wuhan, China's Hubei province -
A sign reminding the public of new social-distancing rules displayed at Manly Beach in Sydney in 2020 -
A woman lights a candle to commemorate victims of the pandemic at Prague Castle in the Czech Republic in 2021 -
Staff members of the Tokyo metropolitan government hold signs as they call for people to stay home in 2020 -
A man waves from a bus carrying passengers who disembarked the quarantined Diamond Princess cruise ship, as he leaves Daikoku Pier in Yokohama, Japan, in 2020 -
About 3,000 people gather in Stockholm, Sweden, to demonstrate against so-called vaccine passes in 2022 -
People rush to board buses to return to their native villages in Ghaziabad, on the outskirts New Delhi in 2020 -
Medical volunteers after taking blood and throat mucous samples from visitors to test them for Covid-19 in Berlin in 2020 -
Members of the Bangkok Metropolitan Authority sanitise classrooms at a school in Bangkok, Thailand, in 2021
It highlighted a distinct concern for the US that many thousands of its dairy cattle and birds carried the H5N1 “highly pathogenic” avian influenza virus.
“One single mutation could trigger a fatal type of influenza that would spread at speed from person to person and signal the start of a new pandemic,” the authors warned. “A pandemic, by its very definition, spares no country and incurs enormous and lasting costs to human lives, livelihoods and economies.
Fact Free Age
A concern in any future health emergency will be getting the scientific facts believed amid the flood of misinformation that will inevitably follow online.
In what has been described as the “Fact Free Age” the fear was how to manage “when anything you say that is factually correct is likely to be countermanded by people who are spouting nonsense”, said Prof Alexander.
There does not as yet appear to be any serious pushback against the “anti-vaxxers”, and a vaccination sceptic, Robert F Kennedy, has been nominated by Mr Trump as his health secretary.
“We haven't yet developed a strategy for vaccination refusal,” said Prof Alexander. “Science in some respects is in disrepute, not because of anything it's done, but because there are people who stand to make a lot of money by untruths. That is very worrying especially if we’re confronted with something immediate, a crisis of major proportions that is also international.”
Hesitancy against proven vaccinations has been a damaging legacy of the global pandemic. Decades of good work to eliminate once rampant childhood disease threatens to be undone.
In the UAE, health authorities are pushing back against misinformation. A national measles campaign for all children aged one to seven, protecting them against measles, mumps and rubella launched in the UAE in October, calling on parents to vaccinate their children.
Before the first reported cases of Covid-19 in 2019, 86 per cent of children worldwide received their first measles vaccine dose, but that had fallen to 83 per cent by 2023.
Sweden’s freedom
Since Covid and Russia’s invasion of Ukraine, Sweden has increased its preparedness with its “total defence” approach, in which every adult must be able to survive a week without any contact with the authorities.
The Nordic country, said Ms Herolf, had become a prepper society in anticipation of another crisis.
“We’re all ‘prepping’,” she told The National. “We have a lot of tinned food in the basement to survive a week, whether it’s a Russian invasion, severe snowstorm or another pandemic. It’s a good time to become a ‘prepper’.”
