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Sweden’s Pandemic Policy: Arguably Best Practice

14 Monday Nov 2022

Posted by in Health Care, Pandemic

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When Covid-19 began its awful worldwide spread in early 2020, the Swedes made an early decision that ultimately proved to be as protective of human life as anything chosen from the policy menu elsewhere. Sweden decided to focus on approaches for which there was evidence of efficacy in containing respiratory pandemics, not mere assertions by public health authorities (or anyone else) that stringent non-pharmaceutical interventions (NPIs) were necessary or superior.

The Swedish Rationale

The following appeared in an article in Stuff in late April, 2020,

“Professor Johan Giesecke, who first recruited [Sweden’s State epidemiologist Anders] Tegnell during his own time as state epidemiologist, used a rare interview last week to argue that the Swedish people would respond better to more sensible measures. He blasted the sort of lockdowns imposed in Britain and Australia and warned a second wave would be inevitable once the measures are eased. ‘… when you start looking around at the measures being taken by different countries, you find very few of them have a shred of evidence-base,’ he said.

Giesecke, who has served as the first Chief Scientist of the European Centre for Disease Control and has been advising the Swedish Government during the pandemic, told the UnHerd website there was “almost no science” behind border closures and school closures and social distancing and said he looked forward to reviewing the course of the disease in a year’s time.”

Giesecke was of the opinion that there would ultimately be little difference in Covid mortality across countries with different pandemic policies. Therefore, the least disruptive approach was to be preferred. That meant allowing people to go about their business, disseminating information to the public regarding symptoms and hygiene, and attempting to protect the most vulnerable segments of the population. Giesecke said:

“I don’t think you can stop it. It’s spreading. It will roll over Europe no matter what you do.”

He was right. Sweden had a large number of early Covid deaths primarily due to its large elderly population as well as its difficulty in crafting effective health messages for foreign-speaking immigrants residing in crowded enclaves. Nevertheless, two years later, Sweden has posted extremely good results in terms of excess deaths during the pandemic.

Excess Deaths

Excess deaths, or deaths relative to projections based on historical averages, are a better metric than Covid deaths (per million) for cross-country or jurisdictional comparisons. Among other reasons, the latter are subject to significant variations in methods of determining cause of death. Moreover, there was a huge disparity between excess deaths and Covid deaths during the pandemic, and the gap is still growing:

Excess deaths varied widely across countries, as illustrated by the left-hand side of the following chart:

Interestingly, most of the lowest excess death percentages were in Nordic countries, but especially Sweden and Norway. That might be surprising in terms of high Nordic latitudes, which may have created something of a disadvantage in terms of sun exposure and potentially low vitamin D levels. Norway enacted more stringent public policies during the pandemic than Sweden. Globally, however, lockdown measures showed no systematic advantage in terms of excess deaths. Notably, the U.S. did quite poorly in terms of excess deaths at 8X the Swedish rate,

Covid Deaths

The right-hand side of the chart above shows that Sweden experienced a significant number of Covid deaths per million residents. The figure still compares reasonably well internationally, despite the country’s fairly advanced age demographics. Most Covid deaths occurred in the elderly and especially in care settings. Like other places, that is where the bulk of Sweden’s Covid deaths occurred. Note that U.S. Covid deaths per million were more than 50% higher than in Sweden.

NPIs Are Often Deadly

Perhaps a more important reason to emphasize excess deaths over Covid deaths is that public policy itself had disastrous consequences in many countries. In particular, strict NPIs like lockdowns, including school and business closures, can undermine public health in significant ways. That includes the inevitably poor consequences of deferred health care, the more rapid spread of Covid within home environments, the physical and psychological stress from loss of livelihood, and the toll of isolation, including increased use of alcohol and drugs, less exercise, and binge eating. Isolation is particularly hard on the elderly and led to an increase in “deaths of despair” during the pandemic. These were the kinds of maladjustments caused by lockdowns that led to greater excess deaths. Sweden avoided much of that by eschewing stringent NPIs, and Iceland is sometimes cited as a similar case.

Oxford Stringency Index

I should note here, and this is a digression, that the most commonly used summary measure of policy “stringency” is not especially trustworthy. That measure is an index produced by Oxford University that is available on the Our World In Data web site. Joakim Book documented troubling issues with this index in late 2020, after changes in the index’s weightings dramatically altered its levels for Nordic countries. As Book said at that time:

“Until sometime recently, Sweden, which most media coverage couldn’t get enough of reporting, was the least stringent of all the Nordics. Life was freer, pandemic restrictions were less invasive, and policy responses less strong; this aligned with Nordic people’s experience on the ground.”

Again, Sweden relied on voluntary action to limit the spread of the virus, including encouragement of hygiene, social distancing, and avoiding public transportation when possible. Book was careful to note that “Sweden did not ‘do nothing’”, but it’s policies were less stringent than its Nordic neighbors in several ways. While Sweden had the same restrictions on arrivals from outside the European Economic Area as the rest of the EU, it did not impose quarantines, testing requirements, or other restrictions on travelers or on internal movements. Sweden’s school closures were short-lived, and its masking policies were liberal. The late-2020 changes in the Oxford Stringency Index, Book said, simply did not “pass the most rudimentary sniff test”.

Economic Stability

Sweden’s economy performed relatively well during the pandemic. The growth path of real GDP was smoother than most countries that succumbed to the excessive precautions of lockdowns. However, Norway’s economy appears to have been the most stable of those shown on the chart, at least in terms of real output, though it did suffer a spike in unemployment.

The Bottom Line

The big lesson is that Sweden’s “light touch” during the pandemic proved to be at least as effective, if not more so, than comparatively stringent policies imposed elsewhere. Covid deaths were sure to occur, but widespread non-Covid excess deaths were unanticipated by many countries practicing stringent intervention. That lack of foresight is best understood as a consequence of blind panic among public health “experts” and other policymakers, who too often are rewarded for misguided demonstrations that they have “done something”. Those actions failed to stop the spread in any systematic sense, but they managed to do great damage to other aspects of public health. Furthermore, they undermined economic well being and the cause of freedom. Johan Giesecke was right to be skeptical of those claiming they could contain the virus through NPIs, though he never anticipated the full extent to which aggressive interventions would prove deadly.

Excess Deaths and Avoidable Deaths

07 Monday Mar 2022

Posted by in Public Health

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Understanding the severity of the coronavirus pandemic is more straightforward when measured in terms of excess deaths, rather than total Covid deaths. We’ve had a large number of excess deaths in the U.S., but not all of them can be attributed to Covid. It’s also worth asking whether some of the deaths were avoidable, because that reflects even more profoundly on the success or failure of public policy and the health care system in dealing with the challenge. Unfortunately, while the precise number of avoidable deaths the nation has suffered is speculative, it is nevertheless significant.

Bad Metrics

A huge problem with using total Covid deaths as a measure of pandemic severity is that no one is confident in the accuracy of official statistics. There are reasons to suspect over-counting in the U.S. due to financial incentives created for hospital systems by the CARES Act. These were exacerbated by the CDC’s absurd 2020 recommendations for the completion of death certificates. Essentially, any non-primary Covid entry on a death certificate was sufficient to count the death as from Covid. No other disease is or has ever been tallied like that.

There is an important distinction between deaths “with Covid” and deaths “from Covid” that has been acknowledged only recently by health authorities. A death “with Covid” can occur when a patient tests positive for Covid after being admitted to a hospital for another primary ailment. Thus, deaths from other causes like heart failure have been improperly coded as Covid deaths under the CDC’s guidelines. Even tragedies like auto fatalities have been coded as Covid deaths.

At the same time, some public health “elites” insist that many Covid deaths in the community have gone unreported. That might have been true in the early weeks of the pandemic. However, post-mortem testing by medical examiners began to spread by April 2020, though there was a shortage of tests, and the CDC issued guidelines to encourage it late in the year.

Counting excess deaths from all causes avoids these controversies, including differences across countries in the way they record Covid deaths. It’s also possible to break down excess death into broad categories of causes, though the task is complex.

How Many?

First some simple accounting. Let’s define all-cause mortality during a period (Mort) as Covid deaths (C) plus plus all other mortality (M), or Mort = C + M. Expected mortality in the absence of a pandemic would be Exp(Mort) = Exp(M). Usually this expected value is taken as an average of deaths over several previous years. Therefore, excess mortality during the pandemic is:

EM = C + M – Exp(M)

How many excess deaths have we actually seen during the pandemic? According to Our World In Data, the figure was 950,000 as of Jan 9th. USMortality.com puts the excess at about 965,000 through the end of 2021. So these two sources are in close agreement, which says a lot given the usual difficulty of getting pandemic numbers to tie-out across sources

Through 2021, cumulative Covid deaths (by date of death) were almost 850,000. That’s less than excess deaths, so it’s obvious that other factors have contributed to the excess. Interestingly, 2021 was worse for excess deaths than 2020 for all age groups except 85+. Some have suggested the most vulnerable in this highly vulnerable age group had already succumbed to Covid in 2020, but there may have been other reasons for the difference.

Non-Covid Excesses

As noted above, some of the Covid deaths were misattributions. If we understand C to include only deaths “from Covid”, then we must acknowledge that M includes deaths from other causes but “with Covid”, as well as all deaths without Covid diagnoses. For example, because of the confounded way in which Covid deaths have been counted, a death from heart disease could end up in the official count of C, but it should be included in M instead.

The figures above imply 100,000+ excess deaths during the pandemic not associated with Covid diagnoses. If we add to those the “with Covid”, incidental total, then perhaps 300,000 – 400,000 excess deaths during the pandemic were from non-Covid primary causes!

Lockdown effects are a prime suspect in these non-Covid deaths. For example, if health care was deferred because hospitals cancelled or delayed elective procedures, or because patients feared the hospital environment, that would certainly manifest in premature deaths. Deaths of despair or neglect were also in excess, as one should expect when populations are subjected to prolonged periods of isolation.

These kinds of deaths are so-called “lockdown” deaths because they could have been avoided without such stringent policy measures and the propagation of fear by public health authorities. Those who might protest this nomenclature should note that lockdowns have been unsuccessful in mitigating the pandemic (and see here). After all, in terms of excess deaths, the Swiss approach was quite successful!

Avoidable Deaths

Many of the excess pandemic deaths were avoidable. Prolonged lockdown policies were driven by politics rather than sound public health reasoning. However, within the Covid death totals there is another category of avoidable deaths, and it is every bit as controversial. This post from The Ethical Skeptic (TES) goes into great detail on the matter. He takes a strong position, and some of his assertions and his accounting are subject to challenge. I sometimes find that TES’s posts contain ambiguities, and the graphical evidence he presents is often poorly labeled. Still, he has proven correct on other controversial issues, such as the ancestry and surprisingly early “vintage” of the Omicron variant.

Most of the “avoidable” Covid deaths (again, as distinct from the non-Covid lockdown deaths) occurred well after the primary symptoms of the infection (fever, cough, and cytokine storm) had passed. In the end, the real killers were follow-on problems induced by Covid, primarily related to blood clotting and compromised vascular integrity from endothelial dysfunction. These deadly complications were known very early in the pandemic. The following schematic from TES shows a Covid “death timeline”. The figures listed under the schematic show the large share of clotting and vascular problems involved in these deaths.

Over the past two years, not all of these patients were placed on anticoagulants or blood thinners early in the course of their infections. Indeed, many of them were told to “go home and sleep it off”. This is what happened to TES as well as a number of commenters on his Twitter account. I know several individuals who received the same advice from medical professionals. Even among the hospitalized, many were not placed on these drugs in a timely fashion, or until it was too late. TES adds the wrinkle that his physician indicated he should have been vaccinated! Short of that, tough luck, said the healer.

TES blames this medical “malfeasance” on the CDC’s Emergency Use Authorizations (EUA) for the Covid vaccines. In fact, he calls these deaths “EUA Shadow Deaths”, citing legal requirements associated with EUAs that would appear to prohibit alternatives such as therapies and even tests or studies of alternatives. That contention seems questionable given the CDC’s issuance of other EUAs for certain treatments, and there was no shortage of published experiments conducted during 2020-21.

The vaccine EUAs were not issued until late 2020, but TES claims that forces leading up to those EUAs were responsible for the failure to put patients on anticoagulants/blood thinners even earlier in 2020. The schematic says more than half of Covid deaths through the end of 2021 involved blood coagulation issues, and I have no reason to doubt those figures, which TES sources from the CDC. But He uses a value of 50% of Covid deaths to estimate that 421,000 Covid deaths were avoidable.

I’m not sure about that total, or rather, the use of the term “avoidable” in all those cases. I am sure, however, that we’ve seen a remarkable under-emphasis on therapeutics (and see here and here) relative to the emphasis on vaccines. The news media contributed to the dysfunction by condemning certain promising therapies for political reasons.

I’m also sure that there have been a meaningful number of patients who should have received anticoagulants/thinning agents but did not. Why did they not? Plausibly, the restrictions imposed by the vaccine EUAs made a difference, but clearly the medical community was not tuned into what should have been an obvious treatment regimen.

How many Covid deaths were truly avoidable? TES’s estimate of 421,000 seems too high if only because we can’t expect the dissemination of information through the medical community to be perfect. Moreover, some of these patients were undoubtedly on blood thinners already, or there might have been contraindications preventing the use of anticoagulants/thinners.

Nevertheless, a substantial number of deaths could have been avoided by more timely use of therapeutics and less stringent lockdown measures. Here is a chart from a tweet by TES showing another accounting for excess deaths:

Here, TES uses a slightly longer time frame, through about February 5, 2022, so the “EUA Shadow Death” total is somewhat larger, about 437,000, than shown in the earlier schematic. He attributes about 800,000 excess deaths, or 77%, to Covid, most of which he believes were avoidable deaths.

Lockdown deaths account for some of the additional 236,000 excess deaths reported in the chart, and probably a large share of the roughly 90,000 non-natural deaths labeled #3 (SAAAAD = “Suicide Addiction Abandonment Abuse Accident & Despair”; the two other categories in #3 relate to non-Covid illnesses acquired in-hospital or adverse reactions to medications). The Unknown/Abnormal category may include some lockdown deaths, but more on that category below.

If TES is correct about shadow deaths, the “avoidable” pandemic death total might account for well over half of all excess deaths. I suspect it might account for half, but even if less, it’s clear that avoidable deaths have been a huge part of the pandemic’s toll.

Vaccine Adverse Events

There’s been much speculation about the large number of Unknown/Abnormal deaths that have been coded during the pandemic: more than 65,000 in the chart above. One caveat is that an “unknown” cause of death usually means the cause is ambiguous: there might have been several factors contributing to the death such that the medical examiner was unable to assign a definitive cause. That status can be temporary as well. Still, the surge is noteworthy.

Unfortunately, there were an unusual number of excess deaths in younger age brackets in 2021, especially in the second half of the year after vaccinations had reached a fairly large share of the population. The pace of those deaths hasn’t yet abated in 2022. The next chart, from USMortality.com, shows excess mortality in the 25 – 44 age bracket in 2020 – early 2022.

Many of these prime age deaths could be a continuing hangover from deferred medical care and depression. There are claims, however, that the vaccines themselves killed a significant number of individuals. The upsurge in excess deaths suggests to some that the vaccines have had a much greater number of “adverse events” than we’ve seen reported by the CDC and the news media.

Here is how TES presents the data on excess deaths and vaccinations. The chart title is his somewhat confusing attempt to summarize the meaning of the lines plotted. The left axis measures the pace of vaccinations by week and the right access measures weekly excess non-Covid natural-cause deaths.

I have no doubt as to the efficacy of the vaccines against serious Covid outcomes in high-risk groups, though vaccine efficacy has been drastically overstated by the Biden Administration. The balance of risks for older individuals is clearly in favor of vaccination. Still, I’ve long felt that vaccination is less compelling for people in younger age brackets, and it’s possibly a bad idea. That’s both because Covid is a much smaller risk to them and because of possible vaccine risks, such as myocarditis.

To the extent that natural-cause, non-Covid excess deaths among younger age cohorts have been driven by unnecessary vaccinations, those deaths were avoidable. I’m not convinced of the significance, and it’s clear that among hospitalized Covid patients, outcomes have been better among the vaccinated. The following chart is from the link in the previous paragraph:

That sort of pattern might mean more deaths among the unvaccinated could have been avoided, on balance, had they opted for the jab. In almost all things, however, I believe we should eschew blanket mandates and instead offer protection to those seeking it in the high-risk population.

Conclusion

As many as 30% of Covid deaths to date are likely misattributions in which Covid was not really the primary cause of death. Nevertheless, excess Covid deaths “from Covid” as the primary cause are probably approaching 700,000 today.

The pandemic was certainly bad enough without a slew of bad calls by the public health and medical establishments. Of the 950,000+ excess deaths that occurred through the end of 2021, over 100,000 were not attributed to Covid. If we include deaths mis-attributed to Covid, the non-Covid total is likely in excess of 300,000 and could be as high as 400,000. It’s time to acknowledge that lockdowns and fear-mongering led to a large number of those deaths, and most of those deaths were avoidable. However, while I am skeptical, the number of deadly adverse effects from vaccines in the prime age population is an open question.

Another class of avoidable deaths was a product of the underemphasis on Covid therapies by the medical establishment. There were many cases of promising, repurposed drugs that were shouted down after so-called experts insisted that their use must be withheld until adequate randomized control trials (RCTs) had confirmed their efficacy. Not only did this ignore the long history of clinical evidence as a guide to medical practice. It also ignored the frequent real-world inadequacies that plague RCTs.

At the same time, obvious complications of the vascular system, primarily blood clotting, were not treated in a timely way or as a precautionary treatment’s, at least prior to hospitalization. Adding a conservative allowance for these deaths to the other avoidable deaths probably means that at least half of the excess deaths during the pandemic were avoidable. As of March 2022, that’s over half a million deaths! We can chalk it up to mismanagement and miscommunication by the public health establishment with a dash of ignorance, and perhaps some malfeasance, by health care practitioners. The death of expertise, indeed!

Lockdowns Subvert Public Health and Life Itself

15 Thursday Oct 2020

Posted by in Coronavirus, Lockdowns, Public Health, Uncategorized

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Acceptance of risk is a necessary part of a good life, and extreme efforts to avoid it are your own business. Government has no power to guarantee absolute safety, nor should we presume to have such a right. Ongoing COVID lockdowns are an implicit assertion of exactly that kind of government power, despite the impotence of those efforts, and they constitute a rejection of more fundamental rights.

Lockdowns have had destructive effects on health and economic well being while conferring little if any benefit in mitigating harm from the virus. The lockdowns were originally sold as a way to “flatten the curve”, that is, to avoid a spike in cases and an overburdened health care system. However, this arguably well-qualified rationale later expanded in scope to encompass the mitigation of smaller and much less deadly outbreaks among younger cohorts, and then to the very idea of extinguishing the virus altogether. It’s become painfully obvious that such measures are not capable of achieving those goals.

In the U.S., the ongoing lockdowns have been a cause célèbre largely on the interventionist Left, and they have been prolonged mainly by Democrats at various levels of government. In a way, this is not unlike many other policies championed by the Left, often ostensibly designed to help members of the underclasses: instead, those policies often destroy or wrongly obviate incentives and promote dependency on the state. In this case, the plunge into dependency is a reality the Left would very much like to ignore, or to blame on someone else. You know who.

The lockdowns have been largely unsuccessful in mitigating the spread of the virus. At the same time, they have been used as a pretext to deny constitutional rights such as the free practice of religion, assembly, and a broad range of unenumerated rights under the “penumbra” of the Bill of Rights and the Ninth Amendment. What’s more, the severity of the economic blow caused by lockdowns has been borne disproportionately by the working poor and the small businesses who employ so many of them.

Lockdowns are deadly. It’s not clear that they’ve saved any lives, but they have massively disrupted the operation of the health care system with major consequences for those with chronic and undiagnosed conditions. The lockdowns have also led to spikes in mental health issues, alcoholism, drug abuse, and deaths of despair. A recent study found that over 26% of the excess deaths during the pandemic were non-COVID deaths. Those deaths were avoidable or accelerated, whereas the lockdowns have failed to meaningfully curtail COVID deaths. Don’t tell me about reduced traffic fatalities: that reduction is relatively small relative to the increase in non-COVID excess deaths (see below).

What proof do we have that lockdowns cause excess deaths? See this study in The Lancet on cancer deaths due to lockdown-induced delays in diagnoses. See this study on UK school closures. See this Oxfam International report on lockdown-induced starvation. Other reports from the UK suggests that lockdown deaths are widespread, having taken nearly 2,800 per week early in the pandemic, and many other deaths yet to occur have been made inevitable by lockdowns. Doctors in the U.S. have warned that lockdowns are a “mass casualty incident”, and a German government study warned of the same.

The Ethical Skeptic (TES) on Twitter has been tracking a measure of lockdown deaths for some time now. The following graphic provides a breakdown of excess non-COVID deaths since the start of the pandemic. The total “pie” shows almost 320,000 excess deaths through September 26th (avoiding less complete counts in recent weeks), as reported by the CDC. COVID accounted for 202,000 of those deaths, based on state-level reporting. Of the remaining 117,000 excess deaths, TES uses CDC data to allocate roughly 85,000 to various causes, the largest (more than half) being “Suicide, Addiction, Abandonment, and Abuse”. Other large categories include Cardio/Diabetes, Stroke, premature Alzheimers/Dementia death, and Cancer Access. Nearly 32,000 excess deaths remain as a “backlog”, not yet reported with a cause by states.

Also of interest in the graphic are estimates of life-years lost. The vast bulk of COVID victims are elderly, of course, which means that any estimate of lost years per victim must be relatively low. On the other hand, most non-COVID, lockdown-related deaths are among younger victims, with correspondingly greater life-years lost. TES’s aggregate estimate is that lockdown-related excess deaths involve double the life-years lost of COVID deaths. Of course, that is an estimate, but even granting some latitude for error, the reality is horrifying!

John Tierney in City Journal cites several recent studies concluding that lockdowns have been largely ineffective in Europe and in the U.S. While Tierney doesn’t rule out the possibility that lockdowns have produced some benefits, they have carried excessive costs and risks to public health going forward, such as lingering issues for those having deferred important health care decisions as well as disruption in future economic prospects. Ultimately, lockdowns don’t accomplish anything:

“While the economic and social costs have been enormous, it’s not clear that the lockdowns have brought significant health benefits beyond what was achieved by people’s voluntary social distancing and other actions.”

Tierney also discusses the costs and benefits of lockdowns in terms of life years: quality-adjusted life-years (QALY), which is a widely-used measure for evaluating of the use of health care resources:

“By the QALY measure, the lockdowns must be the most costly—and cost-ineffective—medical intervention in history because most of the beneficiaries are so near the end of life. Covid-19 disproportionately affects people over 65, who have accounted for nearly 80 percent of the deaths in the United States. The vast majority suffered from other ailments, and more than 40 percent of the victims were living in nursing homes, where the median life expectancy after admission is just five months. In Britain, a study led by the Imperial College economist David Miles concluded that even if you gave the lockdown full credit for averting the most unrealistic worst-case scenario (the projection of 500,000 British deaths, more than ten times the current toll), it would still flunk even the most lenient QALY cost-benefit test.”

We can now count the World Health Organization among the detractors of lockdowns. According to WHO’s Dr. David Nabarro:

“Lockdowns just have one consequence that you must never ever belittle, and that is making poor people an awful lot poorer…. Look what’s happened to smallholder farmers all over the world. … Look what’s happening to poverty levels. It seems that we may well have a doubling of world poverty by next year. We may well have at least a doubling of child malnutrition.”

In another condemnation of the public health consequences of lockdowns, number of distinguished epidemiologists have signed off on a statement known as The Great Barrington Declaration. The declaration advocates a focused approach of protecting the most vulnerable from the virus, while allowing those at low risk to proceed with their lives in whatever way they deem acceptable. Those at low risk of severe disease can acquire immunity, which ultimately inures to the benefit of the most vulnerable. With few, brief, and local exceptions, this is how we have always dealt with pandemics in the past. That’s real life!