Sweden: In Defence of Herd Immunity…

Sweden: In Defence of Herd Immunity… April 19, 2020

Before I go on, watch this video. Don’t read any further without watching this video (with Swedish former state epidemiologist Prof. Johan Giesecke):

For those of you who have been following my writing on the virus, you will notice a number of points of complete agreement, though I will add a few areas needing refinement. What do I agree with here? Here are a few either explicit points or those inferred from the video from implications made:

  • Lockdowns and mitigations are about moving around when people die, not really changing whether they will die, as it stands.
  • These policies are about delaying until vaccines or treatments are available, and trying to flatten the curve in order that healthcare systems would not get overwhelmed.
  • The people who are vulnerable now will be just as vulnerable when lockdowns are eased if no vaccines or treatments are yet available.
  • There is no difference between our reaction to COVID-19 and if the regular flu was newly found this year. See my Comparison: Flu vs Coronavirus.
  • The number of people who have or who have had it is wildly underestimated.
  • The lockdown has been an excuse for some totalitarian-minded leaders to seize more control – think Orban.
  • China is the sort of place a forced and longterm lockdown could work.

A few extra points from the video are worth noting:

  • Early modelling did not take into account expansions of medical provisions – the quick building of new hospitals in order to expand capacity.
  • In comparisons with Sweden, we need to be aware that Sweden has smaller nursing homes for the elderly, and are very good at self-regulating in terms of social distancing.
  • The older and more vulnerable will, statistically speaking, front-load the stats so that deaths will flatten out as these demographics pass through (die).
  • One big difference between regular flu and CV is in children – they are not particularly infectious or affected by CV, but are major spreaders of flu.

Epidemiologists vs economists

Prof. Johan Giesecke aside, epidemiologists are interested in saving lives. When the UK government sought advice as the NHS was becoming overwhelmed and as key decision-makers became ill, they went to the experts and asked, “Right not, how do we save lives?”, I would wager. And the “right now” part is important, because if you take the timeframe as (from the start of the outbreak for a given country), then a total lockdown is probably the most effective way of minimising deaths, and this is the remit of the epidemiologist in that scenario. It is the politician and the economist who need to take this information and weight it up in terms of cost to the economy and to society. This is why I think so many countries went for the lockdown approach – it was arguably short-termist and worked in this light.

But over time? As Giesecke said, you can successfully stop it for some time, but then what? The dam will always eventually burst, it seems. Governments don’t like callously saying, “well, you’re going to die anyway.” It’ll “roll over Europe, no matter what you do.” Joy!

The Swedish strategy

The Swedish strategy is to shield the old and vulnerable, whilst generally keeping society and the economy open, although encouraging and in some cases regulating for social distancing (personally or within retail establishments etc.). A herd immunity is a byproduct of this approach, where herd immunity is defined as follows:

Herd immunity happens when so many people in a community become immune to an infectious disease that it stops the disease from spreading.

This can happen in two ways:

  1. Many people contract the disease and in time build up an immune response to it (natural immunity).

  2. Many people are vaccinated against the disease to achieve immunity.

The problem with herd immunity is that, for it to work properly, you would need anywhere from 60-90% of the population to have the virus. The argument from the video above is that this kind of herd immunity will end up with about the same amount of fatalities as a lockdown mitigation, give or take (or, at least, the differences will not be stupendously significantly different). In the world at the moment, in terms of deaths per million, Sweden is in the top 10 with many other countries who are adopting completely different strategies. But Sweden will not have an economy that tanks.

What the argument is, then, is that such a Swedish approach will not have significantly more deaths but that the social, emotional, health and economic negatives of locking down will not be felt.

In other words, ceteris paribus, the Swedish model is far more preferable. I would generally agree.

But are all other things equal?

Flattening the curve

We know that flattening the curve is about spreading out the deaths so that one’s healthcare system is not overwhelmed and more people don’t die from a secondary healthcare scenario.

Let’s look at ICU beds per capita to see how the UK compares to Sweden. Unfortunately, with healthcare budget cuts, these 2012 figures are very much out of date. Stats show that, whilst Germany has 29.2 beds per 100,000 people, Sweden and the UK have 5.8 and 6.6 respectively. In terms of general beds in hospital per capita (2017), the UK is comparable, if a little better, than Sweden. Sweden does have considerably more doctors per capita, a generally better healthcare system, spend much more per capita, have lower deaths and health issues across the board (apart from perhaps in cancer), and these stats could be the pertinent ones. This could lead to more people succumbing to a serious case of COVID-19 in the UK due to more underlying health conditions.

The end result? It’s hard to see exactly how comparable the nations are – they are similar in many ways but different in others. Therefore, it’s hard to predict if both countries would behave the same and have the same outcomes in terms of an overwhelmed healthcare system.

What we do know is that the UK and Sweden were adopting the same approach until it looked like our healthcare system was to be overwhelmed where Sweden’s hasn’t been; or perhaps it was the fact that our Prime Minister, his primary advisor and our healthcare secretary became infected. It seems that once the UK government stopped focusing on testing and tracking at this juncture, it lost control and had to apply a universal instead of partial lockdown; although you could say it went for total lockdown and then or simultaneously lost control and shifted focus. They left it too late to respond to the sudden uptick in cases and so the unprepared resources were overwhelmed.

Where the expert above does admit failings is in Sweden’s record in effectively shielding the elderly and vulnerable, we can see from this article today. Indeed, their stats compared to their neighbours are far worse in terms of total deaths and deaths per million. This is perhaps one of the few disagreements with Giesecke that I have – he said the claim about Denmark was wrong, and that he puts it mainly down to nursing home sizes. He offers no evidence for this and he seems to be wrong about Denmark – all the stats show them to be doing much, much better than Sweden. Now.

But their healthcare system is still coping. And this is the point of advocates of this light-touch policy. More may die on the front-end, but over time, the stats will be pretty similar. That said, I think the lockdown for the UK was necessary to stop the NHS being overwhelmed. However, how many extra deaths would we have had form an overwhelmed system? Was it worth out? Perhaps we’ll never know.

The reason that the UK did the 180-degree turnaround was that the modelling looked disastrous and the NHS was looking at becoming overwhelmed. But that delay for the UK to adopt the lockdown from taking on herd immunity initially was the focus by an absolute excoriation of the government from the (usually Tory supportive) Times today, so much so that the UK government, for the first time I can remember, have issued an official response to the article. I advise you to read both, if possible.

Once you’re in, you’re in

In for a penny, in for a pound. Once that decision was made, it was arguably all-in or not at all because going somewhere down the middle would perhaps get the worst of both worlds. Whilst some of the protestors in the US might have a point, the way they are going about communicating it is stupid. The country is both on lockdown and economically suffering and the protestors are breaking lockdown procedural advice and mixing and moving.

The UK, I wager, was right to have changed course for a lockdown, economy aside, and once that decision was made, were good on their word and have stuck to the guidance. But where now? You can’t lock down until a vaccine is developed, for that long. And so we come to a phased easing that looks like approaching the Swedish model anyway.

Easing the mitigation

Here’s the rub. As I have said many times in several places, those who are vulnerable now will be just as vulnerable when the lockdown and mitigation practices ease as it all “blows over”. They are not, then, magically immune to the virus having spent a month or two indoors at home. This is when, in places that have had lockdowns, you will see second and third waves. This is to be expected. As advised, we will need to introduce one variable and then measure the impact. The problem is, impact follows two to three weeks later, so this is a long, long process. For example, we might want to open schools again, but this can be the only measure (or we won’t be able to tease apart the effect of a given variable – fair testing). We then wait two or three weeks or so, measure the impact, and either reverse it or accept it and add another change.

But many people in the UK, I wager, will let their guard down during this easing and then those waves will hit. However…

UK wouldn’t have effectively shielded

I’m going to be harsh about the UK here and add an argument for our lockdown strategy. I don’t think we would have done a decent job of shielding the vulnerable, or social distancing like Sweden, if we had not experienced this enforced lockdown in the first place. We just would have been lax. I think we are in a much better position to understand what isolation really means now, so that when the lockdown is eased, we will better be able to shield the vulnerable and know what it takes. I think this will have saved an awful lot of lives had we opted for the Swedish strategy right the way through. This raises the question as to whether we will see those old and vulnerable people die now rather than then. We will definitely see a bump – a wave or waves of some sort – but I think that our experience of a lockdown will somewhat mitigate these waves as people will have had experience and understanding of how isolations should and do work.

Other deaths

In a BBC analysis looking into death stats, they report:

…in the week ending 3 April there were 16,000 deaths – 6,000 more than could be expected at this time of the year when the number of deaths normally starts to fall with winter over…. Not all these extra deaths were down to coronavirus, but a significant number were….

The 6,000 extra weekly deaths identified by the ONS contained 2,500 which were not reported to be because of coronavirus infections.

Experts have suggested they could be related to people being deterred from seeking treatment for medical emergencies such as strokes or heart attacks.

In other words, even if Sweden has a higher death rate eventually, the full lockdown measures may have prompted further deaths as a secondary result of the virus.

Will it have been worth it?

This is the multi-trillion dollar question, for many, many countries. If Sweden comes out of this with perhaps even double the deaths that the UK will have had (proportionally) over time until a vaccine is developed, but with its economy largely intact, will this have been a policy worth the cost in terms of lives? This goes back to what I have previously asked: how much is a life worth?

Let’s say, in pulling a number out of my posterior, that the UK saved proportionally 50,000 more lives over time than Sweden’s approach (bearing in mind that Prof. Giesecke thinks there will be more or less no or little difference), would this have been “worth it” in terms of the cost to the economy, other deaths, other healthcare issues, and social and emotional ramifications? We can look at a monetary figure, as I have discussed before, and say: “[Insert country name here] was prepared to pay this much for each life they saved.” We could look at the total cost over and above the cost to Sweden and divide this by 50,000 and get our answer.

That’s a tough and sombre discussion to be having, but one that will no doubt come about.

I have previously argued that there is some safety in numbers – if everyone’s economy around the world, broadly speaking, is ruined, then in some sense, nobody’s is ruined – there is an element of relativity. Even though, in absolute terms, our economy may be hugely impacted, it might not “matter” as much given that everyone else’s (bar Sweden) is also similarly affected. Mayhaps.

We look to be eventually going towards where Sweden already are, and this leads me to two questions to be answered in the coming months:

  1. Will Sweden’s deaths rise to an intolerable level or stay under the overwhelmed healthcare line (bearing in mind they are also already some weeks behind we are chronologically)?
  2. Will there be a meaningful difference in total deaths, eventually (i.e., up to when a vaccine is developed), between the two approaches?

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