New Analysis: Sweden's Science Advisory Failures on COVID-19

Sweden's ad hoc approach to science advice in the pandemic has left much to be desired

COVID-19 deaths in Sweden, Norway and Denmark. Source: Our World in Data

A new study has been published that evaluates the roles of science advice in Sweden during the COVID-19 pandemic in Sweden, during 2020. The study is a national case study that is part of the EScAPE (Evaluation of Science Advice in a Pandemic Emergency) that I have lead for the past 2 years. The Swedish study was led by Nele Brusselaers of the Karolinska Institute, a leading medical research institution in Sweden, who was joined by seven other Swedish-based researchers. Their analysis offers a hard hitting evaluation of the roles of science advice in the Swedish response. The paper concludes: “scientific methodology was not followed by the major figures in the acting authorities—or the responsible politicians—with alternative narratives being considered as valid, resulting in arbitrary policy decisions.”

Here I’ll provide a concise overview of their results, and I encourage you to read the whole study. It is absolutely fascinating and troubling.

The tone of the study is one of incredulous disappointment. The authors observer that Sweden should have been prepared for a pandemic as over past centuries had “placed itself at the forefront internationally when it comes to preventing disease and death, and seemed well equipped and prepared for the COVID-19 pandemic.” But in contrast, “the Minister of Health and Social Affairs later stated during a parliamentary enquiry that Sweden did in fact have no strategy.” As a result, during 2020, “Sweden had ten times higher COVID-19 death rates compared with neighbouring Norway.” (See the figure at top of this post, via Our World in Data.)

Sweden’s approach to COVID-19 has been characterized by much less restrictive policies than found elsewhere. The authors explain that “Measures to prevent infections were not widely implemented or mandated to the same extent as in other countries (with local exceptions).” The aim of achieving so-called “herd immunity” was not formal policy of the Swedish government, but “internal documents and public statements from various officials during 2020 verify that attainment of herd-immunity was in fact a significant consideration.”

My reading of their analysis suggests that the role of expert advice during 2020 in Sweden as the pandemic ravaged the world can be characterized as adhocracy. Advice, such as it was, came in scattered form from many places, but apparently never in an organized, public manner from a high level advisory body or mechanism.

For instance, the Swedish Public Health Agency was given responsibility for pandemic response and relied on its internal experts. Later after the PHA was criticized for its apparent insularity the Swedish government established a new advisory group in April, 2020 and then later form a Corona Commission created in June, 2020.  However, neither of these groups actively participating in informing the pandemic response.

Early in the pandemic a putatively independent group of experts were empaneled by the Karolinska Institute but as the study notes:

“Yet, this selected group had clear ties with the Public Health Agency, leading to questionable independence. Hence the Swedish public was led to believe that several experts had separately come to the same conclusion that the unique Swedish strategy was the right.”

Other researchers who questioned Sweden’s approach in public found themselves,

“reprimanded by their superiors, e.g., that they were supposedly not allowed to use their university affiliation, or that they were criticised for undermining the authorities… Questioning the strategy, even in academic settings, the media, or the Government, was apparently not accepted by the Swedish society and considered disloyal, and critics were discredited as “hobby-epidemiologists” or lacking competence”

In the days that the study has been out I have already seen a considerable amount of vitriol from researchers targeted at the authors of the study and the journal in which it is published. I hope that some of these critics will instead choose to respond substantively to the paper. Of course, an ad hoc approach to science advice provides fertile ground for such sniping and attacks on reputations and motivations — just as described in the paper.

Some advice was provided by a working group of the Swedish Royal Academy of Sciences, but “Much of the advice from the Royal Academy of Sciences was not followed by the Public Health Agency or was later only partially implemented. The expert group did not explicitly deal with air filtration, schools; and virus variants were not of concern at that time.”

A shadow science advisory group – called “Science Forum COVID-19” (in Swedish: Vetenskapsforum COVID-19) – emerged in June, 2020, comprised of more than 40 researchers. Some of the researchers who co-authored the new study were affiliated with this group. Other scientists self-organized in the form of a sign-on letter to the Swedish government, urging stronger action. The roles played by shadow science advice are an important feature of the pandemic in many countries.

Ultimately, the Swedish analysis concludes:

“There was no official, democratic, or multi-disciplinary science advice during the pandemic. The Swedish strategy has been going against the international consensus (including WHO, ECDC, CDC) from the start. Several things which have been considered proven, or at least most probable by the international scientific community, have been or are still denied by the Swedish authorities. This includes asymptomatic and pre-symptomatic spread, airborne spread (and not fomites as the most common route of infection), the importance of testing and tracing, the efficacy of face masks, the waning immunity after COVID-19 infection and possibility for re-infection, the role of schools and children in the spread of infections, symptomatic and infectious children (and children who die), and “long-COVID”.”

The authors ask, but are unable to answer, whether the lack of formal science advisory processes in the pandemic was intentional or the result of incompetence, noting that it remains unclear if “the Swedish handling of the pandemic was a real strategy, or a consequence of the lack of a coordination, communication, and debate between all relevant parties—with especially the Government being absent from the scene.”

Their bottom-line conclusion is that science advisory mechanisms failed to perform as they should:

“We argue that there was failure of science advice from the start with “COVID-denial” and disregard of scientific evidence (2021e, Miller, 2020). The Government took a passive, hands-off stand, delegating responsibility to the Public Health Agency. The Public Health Agency did not base its advice on scientific evidence but on pre-conceptions on influenza pandemics and herd-immunity—relying primarily on a small advisory group with a narrow disciplinary focus and too limited expertise. A multi-disciplinary, democratic scientific discussion or debate has not taken place, leading to the rise of “shadow science advisory bodies.” None of the official actors took notion of what could have been done better, and no one took responsibility for the results. This institutional rigidity is illustrated by the self-protective reaction to external critique. The Swedish strategy was considered “internationally superior” from the beginning and should not be questioned, a position fuelled by the Swedish mainstream (and state-sponsored) media.”

Whatever one may think about the effectiveness of Sweden’s approach to the pandemic, the failures to implement effective science advisory processes is certainly problematic. Sweden is of course not alone here – the US has similarly followed an an hoc approach to COIVD-19 science advice at the federal level, a dynamic started under the Trump Administration and, remarkably, continuing today under President Biden.

Sweden’s experiences add to the growing body of evidence suggesting that national science advisory mechanisms in the pandemic around the world have considerable room for improvement. Read the full study here.