The Herd: how Sweden chose its own path through the worst pandemic in 100 years

Prologue

On Friday 6 March 2020, three doctors in their sixties arrived at an inconspicuous building on the border between Solna and Stockholm.

It was already late in the afternoon. All day, they had been trying to make the meeting happen. It had been pushed back again and again. But now it was going ahead.

The first doctor was Jan Albert. He was the leader. Albert was a professor in infectious-disease control at the Karolinska Institute. He was the one who had set up the meeting.

The second was Johan von Schreeb. He was the celebrity. Von Schreeb was a storm chaser who would get on a plane as soon as disaster struck anywhere in the world. Way back in 1993, he had founded the Swedish section of Doctors Without Borders; in 2014, he had been named ‘Swede of the Year’ by the news and current affairs magazine Fokus.

The third was Denis Coulombier. He was the Frenchman. Up until the year before, Coulombier had been head of the preparedness and response unit at the ECDC — the European Centre for Disease Prevention and Control, headquartered in Sweden.

Now he was formally retired, but remained an authority.

As they waited inside the offices of the Swedish Public Health Agency, the sky was darkening outside.

Finally, Anders Tegnell, Sweden’s state epidemiologist, came to meet them. They sat down in the agency’s empty dining hall and began to converse.

Denis Coulombier already knew Tegnell. In his position at the ECDC, he’d met with all the European heads of infectious-disease control on several occasions.

This time, he thought, the Swede looked tired.

Jan Albert was the first to speak: ‘There is an opportunity to act now.’

Six days earlier, the February school break had ended in Stockholm. Many of those who had returned from Italy and Austria had brought back an infection. They were carrying SARS-CoV-2 — a virus originating in China that gave rise to a mysterious pneumonia-like illness.

Jan Albert had helped Region Stockholm forecast the spread of the virus, and what he saw worried him. He told Tegnell about two studies he’d read that seemed to indicate that children could spread the disease even if they weren’t exhibiting symptoms. In Spain and Italy, he continued, the rate at which the infection spread was already exponential. Soon it would be here, too.

Johan von Schreeb recounted a few conversations he’d had with colleagues in Italy. Of the patients ending up in hospital, more than one in five needed intensive care.

Then Denis Coulombier stepped in. He argued that the February break was a textbook example of what is known as an ‘amplifying event’ — one that raises the rate at which a disease spreads to a new level.

If there were plans to introduce measures, now was the time.

Then Anders Tegnell replied: there was no need.

The Frenchman looked at the Swede across the table in astonishment.

Tegnell said that, so far, no secondary cases had been identified in Sweden — no individuals who’d picked up the virus from someone inside the country. There was thus no community transmission in Sweden at this point.

Coulombier felt a mounting frustration. That was no way to think. When dealing with a completely new virus, you couldn’t ask for perfect data before making decisions. You had to rely on your judgement and the guesses of other experts.

Anders Tegnell’s actions were surprising. In epidemiological circles, he was known as the man who’d mass-vaccinated the entire Swedish population against the swine flu in 2009–10. No other country had vaccinated such a large part of its population.

In hindsight, it had turned out to be an overreaction. The flu was mild and soon forgotten. Instead, hundreds of children and young people suffered from narcolepsy as a result of the vaccine.

Now — eleven years later — it appeared that Anders Tegnell was acting in the completely opposite way.

What had happened?

Part I

The patriarch

The new year was only a few days old when a white-haired Swedish state pensioner sat down in front of his computer to check what new diseases might be spreading around the world. Perhaps the plague in Madagascar? Meningitis on Zanzibar? A stomach bug in the US? There was always something exciting going on.

Johan Giesecke was like a retired marine officer following the movements of the US Navy on MarineTraffic with great interest, or like a pilot watching his old planes on Flightradar24.

The old epidemiologist’s favourite site was ProMED, a database sprung out of the early internet. There, doctors, veterinarians — indeed, pretty much anyone in the pathogen business — could post early indications and unofficial suspicions that a new contagion was brewing.

Every day there were a dozen or so new posts. In other words, only a fraction of these leads ever developed into epidemics, or pandemics, for that matter. But on here, you’d been able to read about both SARS and MERS in the early days — diseases first appearing in 2003 and 2012 respectively, and caused by entirely new coronaviruses.

Johan Giesecke looked at the screen of his MacBook Air. With age, the skin around his eyebrows had grown increasingly heavy. His eyes, formerly so bright, looked more and more like two diagonal slits.

On this day, he was reading about a new Chinese coronavirus.

Oh well, he thought.

For an epidemiologist, a new virus out of China was a bit like a new murder in Mexico. Serious, sure, but nothing that sparked thoughts other than a reminder of what the world looked like.

He’d seen this before.

Many doctors had been forced into the profession by their parents. We’ll meet some of them in this book. For Johan Giesecke, it was the other way around. When he came home one day and said that he wanted to study medicine, his father replied: ‘Why?’

‘I want to work with people.’

‘But do you have to work with sick people?’

His father’s name was Curt-Steffan Giesecke, and he was one of Sweden’s most powerful people. For twelve years in the 1960s and 1970s, he’d been CEO of the Swedish Employers Association — a position that came with power over millions of workers’ salaries, and over thousands of companies’ competitiveness.

Curt-Steffan dreamt that his son would one day be the head of one of the crown jewels of Swedish trade: Ericsson, SKF, Sandvik, Astra, SCA, or Volvo. Not that he’d be taking old ladies’ temperature and listening to the pulse of geriatrics, or whatever it was that doctors spent their time doing.

Initially, Johan Giesecke followed the trajectory his father had thought out for him, studying engineering and physics at the Royal Institute of Technology in Stockholm. But one day he changed his mind.

And so Giesecke became a doctor. Then he married a doctor. And his three children grew up to become doctors.

Johan Giesecke himself used to say that having so many doctors in the family was idiotic. It would have been more practical if his children had become something else. A car mechanic, a lawyer, and an electrician would have been perfect. And perhaps their conversations at home would have been a little more exciting if his wife had been a literary critic.

In any case, the doctor Johan Giesecke eventually became — despite Curt-Steffan’s objections — did contain elements of the engineer and business executive his father had envisioned. The books he wrote were full of equations — if perhaps not as advanced as the ones in the books at the Royal Institute of Technology — and he helped build the European Centre for Disease Prevention and Control, in Solna, as its first chief scientist.

That was a long time ago. Now he was 70 years old and should really have been spending his time at Skärfsta — his manor south of Stockholm, which had once belonged to the famous author Elsa Beskow — raising his sheep, or perhaps sending corrections and letters to the editor to one of the magazines he subscribed to. There was always someone misspelling ectopic pregnancy.

But the virus he was reading about on ProMED this morning would change everything. And not just for Johan Giesecke.

An unclear pneumonia

January of 2020 was a mild month. No snow had settled over the Swedish capital. So when Anders Tegnell arrived in Stockholm by train, he could hop on his old, blue, single-speed bike — the one he always kept locked up outside the Central Station — and pedal north along Vasagatan, across the Norra Bantorget square, and up the gentle but extended incline toward Solna.

Most people cycling in Stockholm wore a helmet. But not the 63-year-old doctor with a physiognomy like a map of Chile, who, sporting a brown jacket and with AirPods in his ears, pedalled through the twin skyscrapers about to be finished at the top of Torsgatan.

When people asked Anders Tegnell why he didn’t wear a helmet, he’d say pretty much the same thing as any other grown Swede would: really, it was ‘careless’ of him, ‘bad’, and he ‘actually did have a helmet at home’.

Once he had passed the towers, he was almost there. The tall buildings formed a portal into the area that was home to Sweden’s medical elite. Here was the Karolinska Institute, biomedical startups vying for space, and a newly built colossus of a hospital called New Karolinska, at the time best known for gobbling up tax funds for more than a decade.

The issues troubling Swedish healthcare were well known. Sweden had the lowest number of available hospital beds per capita of all the countries in the EU, and it was worst in Stockholm. A few miles away, on Södermalm, the Södersjukhuset hospital had been forced to go into a state of heightened preparedness a few days earlier — for the fourth time in two years.

The cause of the chaos varied depending on who you asked. Had there been too much privatisation? Too little? Was the organisation lacking? Was it the new digital health centres that were draining the healthcare system of its resources? Was it all because of the rapidly growing and ageing population?

A few hundred yards past the New Karolinska Hospital, Tegnell turned left, and then left again.

On Nobels väg 18, three five-storey buildings in red brick formed an incomplete square. In place of the side missing to complete the geometric shape, three flagpoles signalled that something official went on in the area. From the middle pole hung a shabby, faded flag with the Swedish Public Health Agency’s logo: three intersecting hearts under a royal crown. The idea was for the heart shapes to signal ‘life, water, and environment’, and the yellow colour of the crown to radiate strength and endurance. But without that prior knowledge, the logo looked a bit like a carpet beater without a handle, and was so ugly it had attracted the fury of the state herald, the official in charge of the arms of public offices.

During the first few weeks of the year, Anders Tegnell’s inbox was filled with messages about various projects that at first glance seemed peculiarly disparate, but which all fell within the agency’s curiously broad mission. The emails concerned everything from preparations ahead of a workshop in Saudi Arabia to a project in Somalia and the screening of newborns in Sweden.

That term — ‘public health’ — was at once both modern and antiquated.

Much of what the roughly 500 employees in those corridors were busy with were economic considerations; they could be calculating whether it would be cost-effective to offer free vaccinations against a certain infectious disease in a particular region, or evaluating how many years of life could be saved by raising awareness of gambling addiction.

This was a rational, modern, and scientific way of dealing with life, health, and death. In short, making a 40-year-old quit smoking was much cheaper — and more merciful — than surgically removing a tumour from his lungs 15 years later.

This was a science that worshipped metrics and evidence, and measured its victories in increased life expectancy and experienced quality of life. Most of all, it was founded on a belief that humans are malleable creatures, in full alignment with modern terms such as ‘nudging’ and behavioural economics. If you read the agency’s appropriation directions, you might easily gain the impression that its task was to create sober, sporty, and unbiased citizens with a high work attendance.

At the same time, the very notion of a ‘public’ that could be brought to do anything as a group was somewhat anachronistic: social equality had declined; for decades, there had been such high levels of immigration that, by now, one in every five Swedes had been born outside Sweden; and more than half a million people had signed up for private health insurance.

The social contract upon which public health policy rested — and which compelled Swedes to get vaccinated out of solidarity when the local health centre called, to collectively fund the healthcare system, and to patiently put up with its wait times — was under renegotiation.

When Anders Tegnell stepped into the agency’s offices for the first time after the Christmas holiday, he was aware of ‘an unclear pneumonia’ discovered in the Chinese city of Wuhan. He’d received an email about the mysterious disease while in Spain with his wife and grown children.

When he read the email, he’d reacted in about the same way as Johan Giesecke.

This looked like just another little outbreak that the Chinese could handle.

Chinese whispers

Anders Tegnell wasn’t alone in his assessment that the Chinese had the virus under control. On 14 January, the World Health Organization (WHO) confirmed that, as yet, there was no proof the new virus could spread from one person to another.

The problem was that this information came from the Chinese authorities. And for a person in charge of a nation’s infectious-disease control, being an expert in viruses and bacteria wasn’t really enough. You also needed an understanding of Chinese politics and culture.

After all, that was usually where it started. Almost all the influenza epidemics for which scientists had managed to trace the origins — from the first recorded outbreak in 1888, to the Hong Kong flu in 1968 — had started in China.

It was an ill-fated combination: the country spitting out new viruses each year was also run by a shady dictatorship.

Over the past few years, the situation had grown even more complicated. The outside world’s guessing was thwarted by the deteriorating relations between China and the West. Since Xi Jinping had come to power in 2013, China’s totalitarian leanings had grown more pronounced. Foreign journalists were finding it harder and harder to work in the country. And because China’s economic power was growing each year, the country could now afford to ignore the opinions of the outside world.

Since the Obama years, the Americans had been running a program called ‘Predict’, which allowed the US Centers for Disease Control and Prevention to place medical observers in locations around China. But after Donald Trump was elected president in 2016, the system fell into decay. Observers who left were never replaced. The last American epidemiologist left the country in 2019.

When reports of a new, mysterious disease began to spread among the world’s governments and infectious-disease agencies, the assessments that were made weren’t just medical and epidemiological. They were also Kremlinological analyses of what was really happening inside the country.

The suspicion was most evident among China’s neighbouring countries. As early as 21 January, Taiwan began to advise against travelling to China. A few days later, this was followed by cancelled flights to the entire country, quarantine for arriving travellers, and an export ban on protective equipment. Similar measures were soon introduced in South Korea.

Around the world, there were signals that the situation was worse than what was being indicated by official statements from China. Companies in the US making protective equipment received gigantic orders from Chinese clients. Reports circulated that hospitals inside China were advising their employees to self-isolate.

Anders Tegnell had a fairly positive view of China. His understanding of the country was that they’d got their act together significantly since the SARS epidemic of 2003. They reported new cases more promptly, and no longer tried to hide epidemics at all costs. Apparently, they had changed tactics.

Moreover, he trusted the global infrastructure that had been built up. Partly because it was the only one there was, and partly because it usually worked well: each country reported its cases, and the WHO acted like a hub, disseminating information to its member states.

To the media, Tegnell said there was no need for Swedes to avoid travelling to China. Not even to affected areas of the country.

The world was prepared, he thought.

What the world didn’t know was that, for several weeks, the Chinese authorities had been lying both to their own citizens and to the outside world. A number of doctors who had tried to sound the alarm about the new virus were being investigated by the police. One of them — the eye doctor Li Wenliang — was forced to sign a document in which he promised not to continue his warnings.

Much later, the news agency AP would unearth official documents showing that the regime had known since the middle of January that the situation was much more serious than it claimed.

On 20 January, the Chinese finally admitted that the virus could spread through person-to-person transmission. At the same time, information came in that healthcare workers in the country had been infected.

Transmission within the healthcare system was a classic warning sign. It was the kind of thing you’d see in connection with outbreaks of influenza, measles, or other particularly contagious diseases. It could indicate that isolation-and-control measures had been implemented too late and that there were gaps.

Most countries still chose to hold off on introducing restrictive measures. Both the British Cabinet Office’s crisis response group ‘COBRA’ and the German Robert Koch Institute assessed the level of danger was low.

After all, this wasn’t the first time they had received warnings of a dangerous virus out of China. Not even the US, where the authorities had access to the most comprehensive intelligence, issued more than a recommendation to check the temperature of travellers from Wuhan.

On 24 January, Anders Tegnell said to the public broadcaster Sweden’s Radio that Swedes had no reason to be concerned.

Desk doctors

In 1662, the British entrepreneur John Graunt published a book with the convoluted title Natural and Political Observations Made Upon the Bills of Mortality.

In his book, Graunt analysed the mortality statistics that the Church of England had been keeping for 50 years. Graunt wasn’t the only one interested in the numbers. Propertied people in London liked to buy the statistics, which were printed once a week. In this way, they could discover early on if the plague was spreading in the slums, pack up their belongings, and temporarily move outside the city.

But what Graunt did was to go back in history. He collated thousands of old documents, many of them hard to decipher, and sketched out mortality patterns: when and how many had people died, and of what?

Suddenly, a lot became clear. There were years when the plague completely vanished, and years when it swept through the population. In 1625, it had killed 46,000 people — 38,000 more than all other causes of death combined.

But it wasn’t just the ebb and flow of the plague that emerged from the numbers. What Graunt further discovered was a mortality rate that remained consistent during years without epidemics. There was an ‘expected’ number of deaths among the population — and when the plague raged you could subtract that number from the total death toll to find out how severe the epidemic was.

It was as though it was possible to be a doctor without even going near a patient.

Around this time, the theories held by physicians about the plague assumed there was a ‘miasma’, a kind of gas, influenced by the positions of the planets, that emanated out of the ground and infected people. That is why many doctors wore large ‘beaks’ filled with dried flowers, honey, and herbs when they went to see their patients. The plague doctors’ dress became a cultural icon — even today, their bird-like costume can be seen at carnivals and on theatre stages — but the face masks of the day didn’t offer any protection.

Using Graunt’s tables, it was possible to guess a lot of things about how the plague spread, how fast it arose, and when it would go away again. But the doctors of the time do not appear to have noticed what Graunt was up to. The belief in astrological causes lived on.

There are no signs that the contemporaneous medical sciences took Graunt’s statistical conclusions to heart. Possibly his theories may have gained a stronger hold among decision-makers of the time. At any rate, his book sold well enough for several editions to be printed in the seventeenth century.

The last big plague epidemic in London occurred in 1665. But what role the statistical gains may have played remains unclear; a lot happened in these years. Stricter quarantine rules were imposed, the rat population changed, and more houses were built of stone rather than of wood, separating the infectious rats from the humans.

Perhaps John Graunt’s theories were of no significance whatsoever to the healing arts. But long before anyone had ever seen a virus through a microscope, long before anyone even knew it was viruses or bacteria that caused common sicknesses, he took the initial steps in the science now known as epidemiology.

Three and a half centuries after Graunt compiled his death tables, epidemiology engaged tens of thousands of people across the world: statisticians, doctors, mathematicians, programmers.

But somehow it remained the same as in the seventeenth century: this was a discipline concerned with patterns and large-scale correlation, not individual cases.

Thinking in terms of ‘populations’, as epidemiologists liked to call their groups of people, didn’t come naturally to all doctors. Perhaps they once took up medicine for idealistic reasons. To save lives. To care for people.

And for most of medical history, doctors had been in the business of diagnosing individuals. But for the epidemiologist, a single death was just that — a single death — and meaningful conclusions could only be drawn if there were more.

Johan Giesecke liked to say that both kinds were needed. There was a need for doctors who looked after patients, and there was a need for doctors like him: the kind he called ‘desk doctors’.

Desk doctors disassembled patients into their quantifiable constituent parts — sex, age, location, profession, weight, height — to find a type of information impossible to discover at an individual level. Is exposure to asbestos dangerous? Is cervical cancer contagious?

Infectious diseases weren’t all they cared about. Any puzzle piece that could help people live longer and healthier lives was of interest.

But epidemiology wasn’t just about finding patterns and correlations in different populations. It was also a science about what to do with that information once you had it.

It’s one thing to treat a single patient. It’s quite another to treat a whole population. With these new tools came a number of thorny moral and ethical — political — problems.

The first one cropped up roughly a hundred years after John Graunt had taken the first step in epidemiology.

The casino

Every day, the people walking the Earth in the eighteenth century ran a considerable risk of catching the plague, tuberculosis, cholera, or one of the other diseases moving invisibly through the world’s populations.

Perhaps the most feared disease was smallpox. It had already tormented humanity for thousands of years. As the Spaniards conquered Mexico around 1520, they unknowingly brought it with them, causing 18 million Mexicans — out of a population of 25 million — to succumb almost immediately. Over the century that followed, smallpox continued to kill off the indigenous Mexican population, until only 1.6 million remained.

Across the world, the disease could decimate a population. An outbreak in Iceland in 1707 killed 18,000 out of a population of 50,000.

It wasn’t just the high death rate that frightened people. The symptoms were excruciating, and the course of the disease was slow. ‘The entire body from head to foot is encrusted with innumerable pustules flowing into each other and burning like fire … a brown crust finally covers the entire body and face, and out of its fissures a stinking, rotten pus emerges, which has often dissolved the flesh down to the bone: one no longer sees a human in the face of the sick,’ wrote the Swedish physician Eberhard Zacharias Munck af Rosenschöld.

But in the eighteenth century, the situation in Europe changed. Suddenly, there was an alternative to passively awaiting epidemics. Suddenly, it was possible to buy something that could be likened to a lottery ticket.

Around this time in England, there was a new practice of scratching secretions or pus from smallpox pustules into the skin of healthy people. It was a dangerous procedure. Many died from the inoculation itself, but most survived. And if they did, they appeared to have a strong protection against smallpox.

Many renowned Enlightenment philosophers endorsed these modern methods. The most famous of them, Voltaire, had been to England and witnessed it himself.

Others questioned whether such a risk could even be taken: there was insufficient information about the deadliness of the disease and the effects of immunisation.

In the years 1750–70, the issue was hotly debated all over Europe.

Buy the lottery ticket or not?

This was when epidemiology stepped into uncharted territory. And it started as a bit of a side project, a footnote in the career of one of the eighteenth century’s most influential scientists.

Daniel Bernoulli came from a family of prominent mathematicians — and wanted to become one himself. But, initially, Bernoulli’s father opposed his chosen profession. It simply didn’t pay well. Daniel’s father, Johann Bernoulli, was one of the leading mathematicians of his time, and constantly complained about his low salary. After all, this was almost three centuries before the hedge funds of the world discovered that it’s possible to trade stocks using algorithms, and started paying handsomely for any form of mathematical talent.

But even in those days, what led to riches was trade and finance. The Bernoulli family had once been wealthy traders, and Daniel’s father wanted him to make it prosperous once more.

Mathematics most certainly wasn’t the way. Daniel’s grandfather had grown rich trading spices, and something along those lines was the plan for the talented Daniel Bernoulli.

But Daniel wasn’t feeling it.

Slowly, his father softened. At first, he let his son study medicine as a kind of compromise. But, eventually, he started teaching him mathematics.

Daniel Bernoulli never married, never had children. Instead, he mass-produced mathematical proofs, technical innovations, and solutions to problems. The basics of today’s aeroplane wings and combustion engines