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Containment and Cultural Differences

Q: What is the scientific basis of Sweden’s approach to handling the Coronavirus outbreak, and why is it so different from other countries?

Over the last few days, we have seen a number of articles appear in the British media discussing the stark differences between COVID-19 life in Sweden and in the UK. These articles all have one thing in common; they all portray the Swedish approach to be different to that of the UK government. This is not quite true - it would be more accurate to say that the differences are between how the approach is being enforced. Government decisions relating to such complex issues have complex reasoning, but hopefully in this article we can lay out some of these factors so that you can understand why it may be necessary for different countries to make different decisions at different timepoints to one another.

We have heard the term ‘herd immunity’ thrown around a lot in both countries, firstly prior to the escalation of the situation in the UK and now in relation to the current situation in Sweden. Notably, this is not a term we have heard the Swedish government or health officials use. Herd immunity occurs when a majority of the population is immune to a disease, either 'naturally' or due to vaccination. Because the virus runs out of people to infect, it stops spreading. The exact number of people that need to be immune for this concept to work successfully depends on how infectious the virus is, and which demographics are more likely to get infected.

The best case scenario for COVID-19 is that once someone has had the disease, they will become immune (though whether or not this is the case is not yet known - see our answer to ‘Can you get it again after you’ve had it?’). Fortunately, this was the case for the H1N1 influenza virus responsible for the 1918 Spanish flu pandemic - this particular strain is still around today and has become part of our cohort of seasonal flus.

Containment is almost the opposite of herd immunity. The use of containment strategies means that measures will be put in place to stop the disease spreading between people. This can include social distancing, quarantines and lock downs. Containment can lead to the same result as herd immunity if the virus runs out of people to infect (break the chain of transmission), and this was the case in Hong Kong during the SARS outbreak. However in the case of such a large, uncontrolled outbreak like what we are now experiencing with SARS-CoV-2, containment is unlikely to achieve this - the goal is to slow the spread and ‘flatten the peak’ of infection.

It is clear that there are containment measures in place in both Sweden and in the UK. In the UK, the situation has escalated and a strict lock-down has been enforced, with people not allowed to leave their homes other than for a handful of essential reasons (which we’re sure you are all too familiar with by now, so we won’t list them!), public gatherings limited to two people, and socialising with people from outside your household is not allowed. Of course, there are a few other measures in place too. In Sweden, universities and high-schools have been shut, social distancing is strongly encouraged, people have been told to work from home where this is possible and the elderly have been told they must self-isolate. Again this is a flavour of the measures in place and there are many similarities between those in place in Sweden and in the UK - both have closed their borders to non-essential travel, for example. The key difference is that in Sweden, these containment measures are not being enforced using a lock-down. Primary schools are still open, bars and restaurants have been asked to take measures such as sticking to table service but haven’t been asked to close, and supermarkets are operating as normal (although workers are wearing gloves at the checkouts).

Governments have to balance the pros and cons of every containment measure taken. It would be wrong to presume that the ‘softer’ measures in Sweden have been introduced without good reason. Let’s take the decision to keep primary schools open. This is a decision that has the welfare of the healthcare system at its core; much like many of the UK measures. A decision to close primary schools would result in a significant proportion of frontline medical staff being unable to work due to childcare commitments. This has actually been reflected in the UK too, where schools have been kept open for the children of essential workers. Furthermore, it is believed that closing primary schools could pose an exposure risk to the elderly, as parents turn to grandparents for childcare support. The impact of closing primary schools could lead to more social interaction, not less. In Sweden, there is also a very high level of trust in the government - generally speaking, if they are told to exercise social distancing, they will. Furthermore, if they are told that a lock-down has become necessary, they will accept that too. The Public Health Agency operates with a high level of independence from the government, so political involvement in decisions relating to the pandemic is minimal. The government won’t take stricter measures until they are told this is necessary by the Public Health Agency.

One reason the Swedes have not been placed under lockdown yet is that social distancing is, to an extent, part of the culture. Less behavioural changes are required to introduce containment measures. More than 50% of Swedes live alone. If you hop on the tram or bus in Gothenburg, where I live, you’ll find that people are reluctant to take the seat next to you. There is a belief amongst Swedes that they can be sensible enough to abide by containment measures without the need for a full lock-down but, like everywhere, this will be subject to change if it turns out not to be the case as the situation develops.

There is so much more that could be discussed relating to the complex decision making that has led to particular measures being taken, however that is not the purpose of this article. The purpose of this article is to highlight the fact that between where you live and somewhere else, you might notice differences in how the crisis is being handled. Both the local outbreak situation and cultural elements must be considered. Ultimately, we all have the same end-goal - to delay the spread and protect our healthcare systems. Herd immunity will be necessary somewhere down the line, be that through vaccination or through the natural spread of the disease.

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