🦠 COVID-19 | How do we assess the "Swedish Experiment"?
I am a scientist by education, banker at JPMorgan for a few years, then mature PhD student in Chemical Biology at Oxford under the supervision of Christofer Schofield (FRS) and Peter Ratcliffe (Nobel laureate in medicine in 2019). Founder and tech investor focusing on media and education. I care about science, learning and Democracy which are good bedfellows.
📊 Daily Data Brief:
3,472,075 (+79,357) cumulative cases
Active cases: 2,113,102 (+37,434) (this is the number of currently infected patients)
Total Deaths: 244,105 (+5,927)
Serious/Critical Cases: 50,844 (-488)
Recovered: 1,114,868 (+36,996)
Source: Worldometers
Death curves (updated daily as ECDC releases). Major update with per country graphs now available (Link) (US, UK, France, Germany, Sweden) (👈NEW❗️)
Everybody seems to be looking at the Sweden experiment. As lockdown exhaustion creeps in the question is asked more frequently.
Firstly, it is right to label it an ‘experiment’. One might call it a trial, a very consequential one. The Bergstrom and Dean article in the NY Times featured in yesterday’s Corona Daily is also a good read to think about the Sweden trial.
I believe there is an idealisation about what the ‘Sweden experiment’ is. Even from a narrow utilitarian assessment point of view one needs to look at its economic impact as this is the reason people are asking the question in the first place: how much better is the ‘Sweden experiment’ from an economic standpoint that the stricter lockdowns in other countries. There is a belief that “creating herd immunity will potentially save lives in the long term and conserve other socially valuable goods”. It does not take into account what a failed trial does to trust and those same socially valuable goods. It has God-like powers in the hands of a human government advised by a human state epidemiologist called Anders Tegnell.
Contrary to an idealised belief, Sweden is also applying social distancing but not as strictly as the U.K. and is only advocating strict sheltering for the elderly. Looking at the Citymapper Mobility Index Stockholm is moving at 32% of its historical average. How is Sweden doing:
“Sweden has a population of 10 million people, about twice as large as its nearest Scandinavian neighbors. As of April 28, the country’s Covid-19 death toll reached 2,274, about five times higher than in Denmark and 11 times higher than in Norway.”
So the fatality numbers do not compare favourably. It is also unclear at this stage how much the reality of COVID-19 (independent of policy) will affect the consumer behaviour in any country and therefore the growth prospects of most economies. Look at South Korea department store sales:
As Bill Gates wrote: “There was never a choice to have the strong economy of 2019 in 2020.” We should therefore not compare loss of economic output versus last year when judging policy choices. We were in trouble as soon as Sars-CoV2 left Wuhan.
The main issue I have with Sweden is that we know that New Zealand, Taiwan and South Korea have a working strategy. South Korea mobility has been at 40% of normal mobility and has had one of the best COVID-19 containment. These 3 countries use testing-tracing-isolation at scale and with speed. They have a containment strategy accompanied by physical distancing. The real tragedy is that other governments have been unable and/or slow to implement this strategy which also buys time, gets us to know more the disease and allow us to have a better therapeutic tool box and not risk massive social unrest for governments not doing not as much as they could.
I believe that is the fundamental reason why we went in lockdown: liberal democracies would be shaken to their core if citizens were dying in hospital hallways or in the street if ICU capacity was overwhelmed. The lockdown was the only way to avoid such outcome because of our past funding priorities (such as underfunding of public health ), governments failing to take the threat seriously and acting swiftly, and China obfuscating the severity of SARS-CoV2. In a way and paradoxically, it is the success of the lockdown which afford us the luxury of asking the question about the Sweden trial.
It is also unconscionable to run such a strategy when you know something else works and does not cause higher fatalities. One should also realise that it is difficult to do country per country comparison because not all countries have the same age pyramid, proportion of people who can work from home, comorbidity prevalence and measure of physical distancing in normal times.
Rather than idealising the Sweden trial, citizens should all put pressure on their government to do the right thing as opposed to let them blame science or implement a trial to make up for its potential incompetence or laziness. Politicians around the world should look at what happened to the rulers of India post the Spanish Flu (“1918 flu pandemic killed 12 million Indians, and British overlords’ indifference strengthened the anti-colonial movement”). Any overlord in this pandemic should be expected to be treated in the same way.
The ethical consideration around the “Swedish experiment” go further when looking at the rightful debate ongoing with regards to the appropriateness of “human challenge trials” to potentially speed up the COVID-19 vaccine development. This complex issue was covered in an “Article of the Day” in a previous Corona Daily.
Human challenge trials are when people consent to be challenged with the virus (as part of a vaccine trial or not). It is regulated by very strict ethical rules but in certain cases these trials happen. There is a good article in Science on the issue. It could potentially speed up the time to a COVID-19 vaccine and yet a few scientists are against it because we do not know enough about the disease (including long-term effects).
It is not a straightforward decision even when 1) the ethicists and scientists in favour of it want to design human challenge trial for the COVID-19 vaccine candidates alongside the ‘Sweden experiment’ (i.e, only get consent from people who have no comorbidities and who are young) and 2) it affects a much smaller cohort than that of a country. The “Sweden experiment” is like a human challenge trial at scale. The Swedish ‘scientist’ leading it claims that “[legally] we cannot lock down a geographical area” but believes it is ethically acceptable to have implicit consent from his human challenge trial at scale strategy.
Amongst the knowledge gap we have is also the actual death toll of COVID-19 from which we could better assess the case fatality rate and the human cost of the ‘Sweden experiment’ by country. There was another article which came out in the Washington Post on U.S. fatality count: “Excess U.S. deaths hit estimated 37,100 in pandemic’s early days, far more than previously known”.
There is also great follow-up article below “COVID-19 and the Global Ethics Freefall” to go further into the ethical consideration around the ‘Sweden experiment’.
Most of the articles today relate to the above. There is also a great simulation in the video section and a wonderful video tale for children about COVID-19
NEW❗️Open-sourcing my feeds from Cronycle
⚖️ Article of the day: Sridhar Venkatapuram writes “COVID-19 and the Global Ethics Freefall” for the Hastings Center. An urgent read❗️. (Link).
This article was written on March 19 at the time the UK was considering “herd immunity as a strategy” (as opposed to an outcome). Venkatapuram wrote at the time:
“Since the initial outbreak in Wuhan last December, the national and global responses to COVID-19 have been in ethics freefall.”
What he wrote then is very relevant to the way we look at the “Sweden experiment” as well as authorities re-opening policies post lockdown. In no uncertain terms he wrote about the “herd immunity as strategy”:
“It is classic and brutal utilitarian ethical calculation: creating herd immunity will potentially save lives in the long term and conserve other socially valuable goods which are greater than the costs of implementing socially disruptive policies and resource investments now to prevent as many deaths as possible of the 1% to 5% who are most vulnerable. The greatest risk is to older people and those with chronic diseases and conditions– and probably the most socially disadvantaged.”
In considering the decision then and now, Venkatapuram wrote the need for a transparent and public debate:
“If there are decisions to be made about whose lives are to be saved first, or what other socially valued goods need to be protected, justice demands that there be public deliberation, or as philosophers call it, the “publicity requirement.”
More water to the mill of citizens demanding more transparency and debate on the policy choices of their governments.
🧪 Video of the day: Angela Merkel Masterclass #2 (Link). Another great short video from a leader with a scientific education.
🦠 Tweet of the day: Scott Gottlieb looks at co-morbidities numbers for isolating the most at risk in the US. Not sure the proponent of the “Sweden experiment” have looked at what the growth rate of a US economy would be where those at risk are quarantined …
🇺🇸 Dhruv Khullar (physician and writer in New York City) writes “The essential workers filling New York’s coronavirus wards” in the New Yorker.
It is probably the realisation below which compelled Khullar to write the article:
“I can’t help but notice that many of the people still getting infected are those who don’t have the luxury of distance—those who, by necessity or by trade, expose themselves and their families to the virus every day. We’re now debating whether it’s safe to reopen the economy, but for essential workers it never closed.”
A he recounts the encounter with a “delivery man”, “a police officer, a grocery-store clerk, and a bus driver in hospital”, Khullar can draw a pretty compelling picture. As he researched, essential workers’ communities of origin have a different make-up than their overall representation in the population:
“The burden falls unevenly among racial and ethnic groups: in New York City, people of color comprise three-quarters of the city’s essential workers. Three-fifths of cleaning workers are Latino; more than forty per cent of public-transit workers are black.”
The picture is clear. Khullar laments also the fact that whilst patient care is better when patient and carer have the same background, he can see that as the mix of American society has evolved the make-up of the medical profession has not.
A poignant, thoughtful article from a physician on the front line. (Link)
🍖 Esther Honig ad Ted Genoways write “The Workers Are Being Sacrificed”: As Cases Mounted, Meatpacker JBS Kept People on Crowded Factory Floors” in Mother Jones. As reported yesterday in two excellent Twitter threads on the forgotten meatpacking plant workers, Honig and Genoways provide an in-depth look at the spread of COVID19 and vulnerabilities of workers at one JBS plant. The authors acknowledge that the problem outlined and the resulting outbreak at JBS are also prevalent at Tyson Foods and Smithfield plants.
The nature of the work make these plants particularly vulnerable:
“For eight hours each shift, Rodriguez stands elbow to elbow with a dozen other employees, pulling slabs of beef off a conveyor belt and swiftly trimming them into cuts of lean brisket.”
On Tuesday this week, “Trump issued an executive order to classify meatpacking plants as critical under the Defense Production Act, meaning that plants would be required to remain open.” The meat supply chain could be severely disrupted if plants are closed, and yet it is unclear from the article that PPE equipments have been prioritised for that sector or that the Federal Government has taken the necessary measures to prioritise financial support for this industry.
The workers at these plants are vulnerable not only because their families live “paycheck to paycheck”, but also because a number of them do not have US citizenship (an estimated quarter of meatpacking workers in America do not have legal working status) and therefore speaking up might not only result in losing your job but also facing deportation:
“These are the poorest of the poor, and they’re just thankful to have work—however that doesn’t mean we can forget about them.” It is not lost on Calderon how quickly the hateful rhetoric from people across the country surrounding immigrants and refugees suddenly turned into declarations about how they are “heroes” and “essential” workers. Many people don’t seem to realize that being declared “essential” during the pandemic carries few benefits for workers; instead, it allows employers to impose greater work requirements with fewer restrictions.”
Another example of the complex issues at work in determining the best public health policy and how all of us depend on some of the most vulnerable workers for something as critical as food. An essential yet grim read. (Link)
🇮🇳 Devi Sridhar and Genevie Fernandes write “Why Herd Immunity Won’t Save India From COVID-19” for Foreign Policy.
The simple narrative for supporting “herd immunity as strategy” for India, is the country does not have the means to tackle it any differently and it is one the youngest country in the world. Whilst the authors acknowledge the poor health capacity:
“With 0.55 hospital beds per 1,000 people, only 48,000 ventilators, and a population of 1.3 billion, many observers wonder how India can manage a crisis as severe as the coronavirus,”
they challenge herd immunity as strategy. They believe its outcome would be far more catastrophic than imagined by its proponents and politically dangerous. Maybe the acceleration of political transformation which followed the Spanish Flu should also be a warning to the current democratic leadership of India (see article link in the opening).
There are mainly three arguments which the author put forward for advocating against such policy alone: 1) current knowledge gaps about immunity to COVID-19 post infection; 2) prevalence of high comorbidities and risk factors in the population (including multi-generational households like African Americans in the US) ; 3) healthcare capacity needs to ramp up in parallel.
Another country, and another critical look at ‘herd immunity as strategy’. (Link)
🇹🇼🦠 Hao-Yuan Cheng et al. publish “Contact Tracing Assessment of COVID-19 Transmission Dynamics in Taiwan and Risk at Different Exposure Periods Before and After Symptom Onset” for the JAMA network. This is an important publication with patients data in Taiwan, a country which has been very successful at containing its outbreak. It concludes that transmission of COVID-19 occurs mainly before symptoms or at early stage of the disease. It is for this reason that speed of testing, tracing and isolation is key to getting effective transmission rate below 1 and contain COVID-19. (Link)
⚡️ Josh Gabbatis writes “IEA: Coronavirus impact on CO2 emissions six times larger than 2008 financial crisis” for Carbon Brief. The latest reduction forecast for carbon emission by the IEA (International Energy Agency) stand at 8%. As Gabbatis writes:
“An 8% cut is roughly equivalent to the annual emissions reductions needed to limit warming to less than 1.5C above pre-industrial temperatures. However, the stretch target laid out in the Paris Agreement would require similar reductions every year this decade.”
Whiles the IEA says that it is nothing to cheer about, it remains significant nonetheless. If their forecast is proven accurate, it is unclear how the fact that the pandemic has helped us achieve our goal this year, will affect the international community to achieve it without a pandemic going forward… (Link)
🎬 Videos and interactives
🧮 “What happens next”: COVID-19 Futures, Explained With Playable Simulations. If you have 30 minutes, this simulation prepared by Marcel Salathé (epidemiologist) & Nicky Case (art/code) is well worth it. (Link)
🧒 “The Great Realisation”: a dad tale to his child about COVID-19. (Link)
📊 A picture is worth a thousand words: Global (🌎) and local (with relevant flag) visualisation and forecasting tool
🇺🇸
NEW❗️“Is your community ready to reopen?”: A map of the US (50 states and 2,100+ counties) looking at reopening risks with metrics around 3 criteria: 1. Is COVID in retreat? 2. Are we testing enough? 3. Are our hospitals ready? (Link)🌎The Financial Times (NEW❗️visualisation) has a data tracking page which is in front of the paywall, looking at cases and fatality curves for selective countries and metropolitan areas/region. It is not as extensive as the Madlag link below, where you can see static as well as animated images for a greater number of individual countries. (Link)🇺🇸 The John Hopkins University resource center was the first one I used back in January they have now made available in their latest iteration a county by county dashboard in the US including information about health capacity, insurance coverage, ethnicity and age breakdown of the population (New York example below) (Link)
💊 The "Map of Hope" provides a geographical overview of planned, ongoing and completed clinical trials. It is put together with data from WHO Clinical Trials Search Portal by the Heidelberg Institute for Geoinformation technology. (Link)
🌍 MRC Centre for Global Infectious Disease Analysis started to publish weekly death estimates for countries (Link)
🇺🇸 The US Center for Disease Control and Surveillance (CDC) publishes “A Weekly Surveillance Summary of U.S. COVID-19 Activity” (Link)
Google has published a new website to “See how your community is moving around differently due to COVID-19”. They have a lot of data to do so… (Link)
🌎 Country by Country Curves: This is a GitHub made by my friend Francois Lagunas. He has written a script to scrape deaths and number of cases in order to visualise the rate of growth on a logarithmic scale. Great resource (Link)
🌎A great resource put together by Ben Kuhn and Yuri Vishnevsky. At a time when we need solidarity and cooperation, I prefer their subtitle “We need stronger measures, much faster” than their title. It’s a simulator on what case growth looks like depending on your community’s measures. Fantastic resource to stir communities and governments to action (Link)
🇩🇪 The COVID19 dashboard for Germany is one of the best around. (Link)
🌎Data and chart regularly updated by the Centre for the Mathematical Modelling of Infectious Diseases at the London School of Hygiene & Tropical Medicine. It maps the effective reproduction number (also known as R0) of COVID19. You want to get it below 1 as fast as possible to contain an epidemic. (Link to see charts and more data about your country)
📰 Cronycle resource:
Cronycle has made available a number of open-access feeds on its website which I extensively use for the Corona Daily. The four first feeds are:
1. COVID-19 General (Link)
2. COVID-19 x Resilience (Link)
3. Gig Economy x COVID-19 (Link)
NEW❗️Human Challenge Trials x Covid-19 (Link)
5. Supply Chain x COVID-19 (Link)
Human Rights x COVID-19 (Link)