How Sweden And Portugal Went From Pandemic Role Models To Record Infections

They are the European countries with the most outbreaks recorded at the end of June, but their strategies to tackle Covid-19 could not be more different.

The decision to exclude Portugal from the UK’s list of quarantine-exempt countries last week came as a shock to British holidaymakers. Until recently, with its high testing rates, low death toll and political unity, Portugal was the model to follow to defeat coronavirus. In June, however, up to 700,000 Portuguese were suddenly forced back into lockdown.

In May, the World Health Organisation (WHO) congratulated Swedish society for keeping the virus at bay without going into lockdown. But come July, serious questions are being raised about the way the Scandinavian country is managing Covid-19.

On June 24th, the only two countries in Europe with areas where there were more than 120 cases per 100,000 inhabitants in the previous 14 days were Sweden and, far behind it, Portugal.

Confirmed cases per 100,000 inhabitants in the two weeks to June 24. In red, the areas where there are more than 120 infections per 100,000 inhabitants
Confirmed cases per 100,000 inhabitants in the two weeks to June 24. In red, the areas where there are more than 120 infections per 100,000 inhabitants

While the WHO recently praised the action of Spain and Italy for turning around the bad epidemiological situation they had started from, just a few days ago the agency included Sweden on a list of 11 European countries where the coronavirus had recently made a resurgence.

Sweden, far from making efforts to try to reverse the situation, replied that the WHO report was a ”total misinterpretation of the data” since the Scandinavian country is now testing more, hence more cases are being detected, argued Anders Tegnell, the Swedish state epidemiologist.

“It seems a bit arrogant, doesn’t it?” says Manuel Felices, a Spanish surgeon and head of the surgery department at the NÄL hospital, north of Gothenburg, Sweden. The country is also accused of arrogance by its other Scandinavian neighbours, where there has been a total of 1,200 deaths out of a population of 17 million, while in Sweden there have been over 5,000 deaths out of a population of 10 million.

“The virus has been underestimated,” says Felices. This statement, which could apply to almost everywhere in the world, is perhaps more appropriate in Sweden, taking into account that the government not only refused from the start to lock down the population, but also that at this point it is still not recommending the use of face masks nor extending the quarantine to those who live with infected people. “It has been, and is, a huge mistake, in my opinion, to fail to consider the contagious potential of presymptomatic or asymptomatic patients, whose role in spreading is still not officially admitted in Sweden,” says Felices. “The recommendations are based on ‘if you have symptoms, stay at home.’ So much so that family members who have a confirmed case among them, but who do not have symptoms, are not obliged to quarantine,” he explains.

Daily cases of coronavirus recorded per million inhabitants in Sweden, Portugal and Spain in the last month

The Portuguese attitude could not be more different from the Swedish one in this sense. Portugal did lock down its population in mid-March, just 11 days after recording the first case of COVID-19, and it “reopened” the country two months later, when the situation was considered to be under control. The reopening of economic activity and relaxation of the restrictive measures resulted in a rise in cases of the virus, mainly in the Lisbon region, where last week 19 districts in the Lisbon metropolitan area were ordered to quarantine.

The appearance of outbreaks with the economic reactivation is not new, but the act of locking down 700,000 people – who for two weeks (June 29 - July 12) will only be able to leave their homes to work, buy food and medicine, and exercise – came as quite a shock to Europe, and especially to Spain. While continuing to look at its neighbour out of the corner of its eye, in case the story could be repeated there, Spain has seen its worst fears come true after the El Segrià district in Lleida and A Mariña district in Lugo went back into lockdown last weekend.

“What we’re seeing in Portugal is going to become the norm in most countries,” João Júlio Cerqueira said in an email to HuffPost Spain. According to the Portuguese doctor, a specialist in occupational medicine and creator of the Evidence-Based Medicine Project (SCIMED), “there will be outbreaks of infections that will have to be dealt with by the authorities to mitigate the spread of the illness following the reopening of the economy. In that sense, there’s nothing abnormal.”

For Cerqueira, “everything depends on how the government acts to contain those outbreaks,” and although the measures taken by Portugal seem “sufficient to mitigate them,” in his opinion, he considers that the government “was a little slow in the Lisbon region,” adding, “we still need some time to see the results.”

He believes the government’s reaction to put the population back into lockdown is important, but even more so is the capacity for testing that will detect those outbreaks. And here, Portugal can set an example. “Portugal has always had an outstanding capacity for testing. It can give the impression that the country has lots more infections in comparison with other places, when that probably isn’t the case,” points out Cerqueira. It is worth noting that to date, Portugal has recorded more than 45,277 cases of coronavirus and 1,644 deaths, compared to 319,075 infections and over 44,000 deaths in the UK.

Tests done each day in Portugal, Sweden and Spain per thousand inhabitants since mid-April

“Test, test, and test some more” is one of the leitmotivs of Manuel Felices and the so-called Group of 22 scientists of which the Spanish surgeon is a part. This group, created in March by a group of internationally renowned researchers and doctors, has tried, “from the strictly scientific point of view,” to help change the Swedish strategy against the coronavirus.

Felices considers that the “active tracing of possibly infected people” is not sufficient in his host country, where he has lived and worked since 2012. Nevertheless, now the Group of 22′s main bone of contention is face masks, which are still not recommended in Sweden, something these experts deem a mistake. “We’re fighting to get the use of face masks recommended, in hospitals and nursing homes of course, but also on the street if it’s not possible to keep the social distance, on public transit, in restaurants, etc,” Felices says.

Despite Sweden’s controversial stance and data that proves its strategy has failed to stem infections, Swedish citizens have mostly supported this strategy and, until very recently, it was difficult to hear criticism of the government’s management. In mid-April, 73% of Swedes supported the country’s health strategy, according to a survey by the independent agency Novus. However, for some time now, more and more people are suggesting that the government – even though it has not openly acknowledged this – has tried to follow a herd immunity strategy, allowing a high percentage of the population to get infected.

“From my point of view – and this is an opinion – the strategy has been based on allowing a rate of ‘controlled’ infection, thinking about herd immunity,” Felices says. “The measures speak for themselves: They’ve only recommended that over-70s stay at home, while schools, gyms, etc, have always stayed open,” he explains. Nonetheless, antibody studies only show a prevalence rate between 5% and 7% among the Swedish population, similar to Spain and the rest of Europe, while the Swedish government “was hoping for around 40% in June,” notes Felices. To achieve herd immunity, at least 60% of the population would have to be immunised.

Finally, it seems that a bit of humility is also something important in this crisis, as the WHO indicated this week. “The sooner we assume there’s a problem, the better. The sooner we contain the virus, the less the economy and the country’s image abroad will suffer,” says João Júlio Cerqueira. “Right now, it’s not only a question of the virus, but of the image the country conveys to the world. Some countries, like Norway and the UK, have excluded Portugal from the reopening of their borders for this reason. It’s happened in Portugal, but it might also happen in Spain,” he says.

In the meantime, Spain and Portugal reopened their border last Wednesday in a formal ceremony that ended three and a half months of isolation between the Iberian countries. Sweden cannot say the same at the moment: Norway, Denmark, and Finland are still not accepting travellers from their Scandinavian neighbour.

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