Sweden

Is Christopher Snowdon an Anti-Vaxxer?

Christopher Snowdon is plainly an anti-vaxxer, however well he tries to hide it. “Existing Covid vaccines are simply not good enough at preventing transmission and infection,” he writes. Hasn’t he read the trial results, showing 95% efficacy against infection for the Pfizer vaccine and 74% for the AstraZeneca vaccine? Or the large population study from Israel showing Pfizer’s 92% efficacy? Or the study from Public Health England showing 67% and 88% vaccine efficacy against the Delta variant for AstraZeneca and Pfizer vaccines respectively?

On what does he base his bald assertion that they are “not good enough at preventing transmission and infection”? Clearly not the science. He doesn’t appear to feel it necessary to give a single scientific reference for a claim that flies in the face of all these respectable studies, leaving the baffled reader assuming he must have picked it up in some article he read on an obscure website somewhere, presumably by a pseudo-scientific sceptic in denial.

This, of course, is not the way to go about intelligently criticising someone’s viewpoint. Which is precisely my point. As it happens, I agree with Christopher that the current vaccines are not very good at preventing infection or transmission, particularly now the Delta variant is in town. But I’m also aware that that is not the current mainstream scientific position (though it is based on recent official data and reports). Rather, it is currently a claim being circulated among the very networks that Christopher pillories in his recent piece in Quillette, naming and shaming the “coronavirus cranks”.

It seems, then, that Christopher is not averse to a spot of ‘crankery’ himself. But how helpful really is all this name-calling, mudslinging and smear by association? Science does not advance by consensus, by everyone agreeing, or by closing down dissenters. Christopher himself is evidently sceptical of one of the key mainstream vaccine claims – that they are highly effective against infection and transmission – so inadvertently places himself within the ambit of his own polemic. Indeed, at one point he fires a shot at the ‘smileys’, as he calls sceptics, for being sceptical of the vaccines, arguing the jabs “have been tested in clinical trials and have demonstrated their safety and effectiveness beyond reasonable doubt in recent months”. Yet he himself goes on to doubt their effectiveness!

Sweden Avoided a ‘Pingdemic’. Why Couldn’t We?

A reader, who wishes to remain anonymous, has sent the following post, comparing Britain’s enthusiastic embrace of a contact-tracing app with Sweden’s more considered approach.

As the U.K.’s ‘pingdemic’ spreads ever wider, wreaking havoc on hospitals, care homes, schools, supermarkets, and the economy, one person at least might afford himself a wry smile.

In the early months of the pandemic, many Swedish epidemiologists, virologists and other medical specialists implored their Prime Minister Stefan Löfven and Health Minister Lena Hallengren to build a contact-tracing app. Tech companies fell over themselves to claim they had the necessary expertise to do just that. Development actually got underway, but once state epidemiologist Dr Anders Tegnell and his team had evaluated the viability of such an app and come to the view it would cause excessive fear and large-scale disruption, Löfven was talked out of it and all work ceased.

In an interview on Swedish Television in May of last year, Tegnell said he didn’t think the idea of an app had been “properly thought through'” (He could have said the same of a great deal else of U.K. pandemic decision-making and implementation). He foresaw large numbers of ‘pings’ being generated and vast resources being expended on staffing and testing. Many people would be worried for no good reason and hospitals and care homes would come under more pressure as staff would have to self-isolate. He also questioned whether a distance as great as two metres for a period as short as 15 minutes were appropriate parameters.

Tellingly, when asked: “Wouldn’t it be worthwhile at least in controlling the spread of infections?”, he replied: “Few of the contacts (of a person with a positive test result) would be infected. For every person ill with Covid, I would reckon about 30 healthy people would be urged to self-isolate unnecessarily.”

Is there any evidence that the U.K. Government’s much-vaunted contact-tracing NHS COVID-19 App, run by NHS Test and Trace, has nevertheless been successful? According to politicians of all parties and medics of many disciplines, the answer is a resounding no.

Referring to the current £37 billion projected cost of Dido Harding’s test and trace operation, Lord Macpherson, who was Permanent Secretary at the Treasury from 2005 to 2016 and worked on 33 Budgets and 20 Spending Reviews, went so far as to say: “This wins the prize for the most wasteful and inept public spending programme of all time.”

To paraphrase Tegnell’s famous commentary on Sweden rejecting a large-scale lockdown of society: “It was as if the world had gone mad about contact-tracing apps, and everything we needed to consider was forgotten. The cases became too many and the political pressure got too strong. And then Sweden stood there rather alone.”

New Paper Claims Lockdowns Do Not Cause More Health Harms Than They Prevent, but It Misses the Big Picture

A new paper in BMJ Global Health purports to debunk lockdown sceptics’ claim that “the cure is worse than the disease”. However, it misses the big picture; in fact, it hasn’t shifted my priors one jot.

The paper contains no new data or analysis. Rather, it comprises a review of the existing literature. The authors focus on the claim that “lockdowns cause more health harms than COVID-19 by examining their impacts on mortality, routine health services, global health programmes and suicide and mental health”.

In other words, they attempt to show that lockdowns do not cause more health harms than they prevent. Notice: this is not the same as showing that lockdowns pass an overall cost-benefit test. Even if lockdowns were a net positive for public health, they could still be a massive net negative for society (taking into account their effects on the economy, education and civil liberties).

The strongest argument the authors make (with which I was already familiar) is that excess mortality in countries like Australia and New Zealand – which managed to contain the virus – was zero or negative last year. Since these countries did not experience an epidemic of COVID-19, but did see weeks or even months of lockdown, the lack of excess mortality suggests that lockdowns themselves do not cause many deaths.  

However, some lockdown sceptics would argue that – even if lockdowns don’t cause many deaths in the short-term – they do cause more deaths in the long-term, via missed cancer screenings, drug overdoses etc. And here the authors are much less persuasive.

They concede that “the connection between lockdowns and missed contact with health systems is very well established”. However, they claim this association “may be related to lack of capacity of healthcare services or impacts of the pandemic itself rather than measures taken by governments”.

There is “no doubt”, the authors admit, “that global health programmes have been disrupted”. But they argue such disruptions were caused by “multiple complex direct and indirect consequences of COVID-19, not just stay-at-home orders”.

So they acknowledge that lockdowns do have harmful long-term effects. And given that those long-term effects are yet to be quantified, the authors have little basis for concluding that lockdowns are “unlikely to be causing harms more extreme than the pandemic itself”.

COVID-19 Mortality Rate Among Children Is Even Lower Than Previously Thought

We’ve known since the early weeks of the pandemic that age is the single best predictor of COVID-19 mortality, and that the risk of death for young people is vanishingly small.

A letter in the New England Journal of Medicine reported that zero Swedish children aged 1–16 died of COVID-19 up to the end of June 2020. And only 15 were admitted to the ICU, of whom four had a serious underlying health condition.

Of course, England is a much larger country than Sweden, and it’s been a whole other year since those Swedish data were collected. So how many English children have died of COVID-19?

In an unpublished study, Clare Smith and colleagues sought to identify the number of COVID-19 deaths among people aged under 18 between March 2020 and February 2021. They examined data from the National Child Mortality Database, which was linked to testing data from Public Health England and comorbidity data from national hospital admissions.

The structure of their dataset allowed the authors to distinguish deaths that were plausibly from COVID-19 and deaths that were merely with COVID-19.

3,105 under 18s died from all causes in England during the relevant time period. Sixty one of these involved people who had tested positive for the virus. However, the authors determined that only 25 were actually caused by COVID-19. And of the 25, 76% had a serious underlying health condition.

Given that an estimated 469,982 under-18s were infected with the virus up to February of 2021, the survival rate in this age-group (the inverse of the IFR) was 99.995%. What’s more, 99.2% of total deaths were caused by something other than COVID-19.

Smith and colleagues’ findings underline just how small a risk COVID-19 poses to young people, and hence – I would argue – why a focused protection strategy was preferable to blanket lockdowns.  

As early as 10th April 2020, Martin Kulldorff – co-author of the Great Barrington Declaration – published an article on LinkedIn titled ‘COVID-19 Counter Measures Should be Age Specific’.

Based on the data that were then available, he estimated one would need to stop 3.5 million children being exposed in order to prevent the same number of deaths as one could prevent by shielding 1,000 people in their 70s. He argued, therefore, that Covid counter-measures must vary by age.

A similar argument was made by George Davey Smith and David Spiegelhalter in a piece for The BMJ last May. These authors called for “stratified shielding”, while noting that this would “require a shift away from the notion that we are all seriously threatened by the disease”.

According to the medical researcher Russell Viner, who spoke to Nature, “There’s a general feeling among paediatricians that probably too many children were shielded during the first wave.” And the epidemiologist Elizabeth Whittaker said that efforts to shield children “have probably caused more stress and anxiety for families than benefit”.

In addition to “stress and anxiety”, there’s also the learning losses associated with months of online teaching. All this compared to the marginal impact closing schools had on the spread of COVID-19.

When we look back at the response to Covid, serious questions will have to be asked about the costs of lockdown, not only to society in general, but to young people in particular.

A Response to Scott Alexander on Lockdowns

The prolific blogger Scott Alexander has written a long post about lockdowns. It’s not too objectionable from a lockdown sceptic’s point of view. For example, he concedes that “lockdowns weren’t necessary to prevent uncontrolled spread” and says that it’s “harder to justify strict lockdowns in terms of the non-economic suffering produced”.

Nonetheless, I do disagree with him on several points, which I will highlight here.

First, he ignores most of the academic studies that have found little or no effect of lockdowns on mortality. For example, he doesn’t mention Simon Wood’s studies finding that infections were in decline before all three U.K. lockdowns. Nor does he mention the paper by Christopher Berry and colleagues which observed “no detectable health benefits” of shelter-in-place orders in the United States.

Despite ignoring these studies, he dedicates a whole section of his post to something called CoronaGame, which he oddly classifies as “Actual Evidence”.

Second, he compares the official COVID-19 death rate up to August 2020 in Sweden with various other countries, and claims that “Sweden comes out looking very bad, but not the literal worst”. He then claims that “it looks even worse when you compare Sweden to other Scandinavian/Nordic countries”.

However, if he had used age-adjusted excess mortality, and had extended his window of analysis up to the end of 2020, Sweden would not have come out “looking very bad”. As I’ve noted several times, Sweden saw age-adjusted excess mortality up to week 51 of just 1.7% – placing it 14 out of 22 European countries.

And there are several reasons why the “neighbour argument” – the argument that we have to compare Sweden to its immediate neighbours rather than the rest of Europe – isn’t very convincing. Sweden saw unusually low mortality in 2019; border controls (not lockdowns) made the difference in the first wave; and once you include the Baltics, Sweden no longer stands out.

Third, he claims the cost of lockdown “is measured in psychological suffering and economic decline”, noting that in order to do a cost-benefit analysis “we should figure out how much stricter lockdowns affected the economy”.

While the economic impact of lockdown certainly constitutes a major entry on the costs side of the ledger, Alexander neglects to mention another negative impact of lockdown, namely the switch to remote learning. As several studies have shown, this resulted in sizeable learning losses, which were concentrated among children from the most disadvantaged backgrounds.

Alexander’s post offers a decent overview of the debate, but he’s too charitable to the lockdown side, leading him to overstate the benefits of lockdown and understate the costs. Not his best piece of work, in other words.

Keeping Schools Open Had Only a Minor Impact on the Spread of COVID-19 in Sweden

Sweden was one of the few Western countries that kept schools open in the spring of 2020. Pre-schools, primary schools and lower-secondary schools (for those up to age 16) continued with in-person teaching, whereas upper-secondary schools switched to online instruction on March 18th.

Despite this, zero Swedish children died of COVID-19 up to the end of June. In fact, only 15 were admitted to the ICU, and four of these children had a serious underlying health condition. 

So keeping schools open didn’t cause any deaths among Swedish children. But did it increase the spread of COVID-19? Although evidence suggests that children are less infectious than adults, their level of infectiousness is not zero. In addition, teachers could transmit the virus to one another in the staff room, and parents could do so when picking their children up from school.

In a paper published in Proceedings of the National Academy of Sciences, researchers from Stockholm and Upsala University examined the impact of keeping schools open on the spread of COVID-19 in Sweden. Their analysis focused on the period from March 25th to June 30th. 

The authors used rigorous methods to estimate the causal impact of keeping schools open on COVID-19 outcomes among parents, and among teachers. Specifically, they compared parents whose youngest child was in the last year of lower-secondary school (Year 9) to those whose youngest child was in the first year of upper-secondary school (Year 10). 

This method ensured that the two groups of parents were as similar as possible with respect to other possible causes of COVID-19 outcomes. But to be safe, the authors controlled statistically for characteristics like the age, occupation and region of the parents.

They found that there was only one additional positive PCR test per 1,000 parents among those whose youngest child was in the last year of lower-secondary school. They also looked at the number of diagnosed cases of COVID-19, but found this did not differ significantly between the two groups of parents. 

When the authors compared teachers from lower-secondary schools with those from upper-secondary schools, the differences were somewhat larger. However, the overall impact of keeping schools open on the spread of COVID-19 was small. The authors estimate that keeping schools open resulted in 620 more cases in a country that saw more than 53,000 up to mid June. 

They conclude that closing schools “is a costly measure with potential long-run detrimental effects for students”. And their results are “are in line with theoretical work indicating that school closure is not an effective way to contain SARS-CoV-2”.

Sweden’s Mortality Rate Last Year Was Lower Than in 2015

As I’ve mentioned several times, when you calculate mortality the correct way – as the age-standardised mortality rate, or as life expectancy – the year 2020 in England doesn’t look that unusual. Last year’s rate was a fair bit higher than 2019’s, but that was a year of unusually low mortality. 

Plotting the age-standardised mortality rate over time (as the ONS has been doing each month since July of 2020) shows that mortality last year rose to a level last seen in 2008. So while the year-on-year change was large, the level wasn’t particularly high – at least by historical standards. 

Interestingly, this point even found its way into a BBC article last September. The author noted:

And if you look at the age-adjusted mortality rates, which take into account the size and age of the population, you can see that while 2020 has undoubtedly been a bad year compared to recent years, what has been seen in terms of people dying is not completely out of sync with recent history. It is actually comparable with what happened in the 2000s.

Given that 2008 – which, to repeat, saw a higher level of morality than last year – wasn’t that long ago, one might argue the pandemic’s lethality has been overhyped. Of course, others would contend that, if we hadn’t taken the drastic measures we did take, mortality would have risen to a far higher level.

But I’m not convinced the UK’s lockdowns did do much to curb mortality, over and above the effect of restrictions on large gatherings and voluntary social distancing. And I’d argue that we could have saved more lives with a well-executed focused protection strategy.

However, many people continue to insist that mortality would have been far higher in the absence of lockdowns. It’s therefore worth looking once again at Sweden – the only major European country that didn’t lock down.

We already know that Sweden’s age-adjusted excess mortality up to week 51 was only 1.7% – below the European average. But when was the last time its mortality rate was as high as last year?

Going up to the end of week 52, the rate for 2020 – based on the European Standard Population – comes out as 16.4 per 100,000 (which is actually lower than in Denmark). And the last time Sweden saw this level of morality was in 2015 – just five years ago.

So despite taking the least restrictive approach of any major Western country, Sweden’s mortality rate only returned to the level of 2015. This casts doubt on the claim that mortality in the UK would have been much higher in the absence of lockdowns.

Taking the Average of 2019 and 2020, Sweden Had Lower Mortality Than Both Denmark and Finland

Faced with mounting evidence that lockdowns did not substantially reduce COVID-19 deaths in most of the countries where they were implemented, lockdown proponents have fallen back on what Paul Yowell calls the “neighbour argument” – i.e., the argument that comparing Sweden to its neighbours shows that lockdowns really do work.

On May 10th, a tweet plotting cumulative COVID-19 deaths per million in Sweden, Norway and Finland – which referred to the “Nordic natural experiment” – garnered over 6,000 likes. 

However, this argument isn’t convincing for a whole number of reasons, as I’ve outlined in two previous posts. For example: the other Nordics had a head start on Sweden; border controls – not lockdowns – made the difference in the first wave; and once you include the Baltics, Sweden no longer stands out.

However, suppose we just look at the mortality figures. Do they show that Sweden had an exceptionally bad year? Far from it. As I’ve noted before, the country saw age-adjusted excess mortality up to week 51 of just 1.7% – below the European average. 

Now, it’s true that all three other Nordics saw negative excess mortality (of up to –5% in Norway’s case). Because mortality rates declined gradually from 2015 to 2019, no change from 2019 to 2020 yields a negative value for excess mortality. In addition, there may have been fewer flu deaths and car accidents, thanks to social distancing. 

However, one reason why Sweden’s excess mortality figure isn’t lower is that the country saw particularly low mortality in 2019 (which brings down the average of the last five years). In that year, Sweden had the lowest mortality of all four Nordics – its rate was 4% lower even than Norway’s.

As several commentators have pointed out, this meant that there were more frail elderly people alive at the beginning of 2020 than there otherwise would have been. So even in the absence of a pandemic, you’d have expected to see a slight rise in mortality – owing to the “dry tinder” effect.

If we take the average of 2019 and 2020, then Sweden’s age-standardised mortality rate was 15.8 per 100,000, Denmark’s was 17.6, Finland’s was 16.4 and Norway’s was 15.5. In other words, Sweden’s was lower than both Denmark’s and Finland’s, and was only slightly higher than Norway’s. 

Of course, the average of the last two years isn’t a measure of the impact of the pandemic (and other relevant events). For that, we can need to compute the excess mortality for 2019–20, by comparing the average mortality rate in those two years to the average over the preceding four years. When we do that, the numbers come out as follows: –3.3% in Sweden, –4.4% in Demark, –4.8% in Finland and –4.9% in Norway. 

Although Sweden still saw the least favourable change (i.e., the smallest decline in mortality), the disparity with respect to its neighbours is much reduced. 

This exercise is not meant to obscure the fact that Sweden saw a moderate rise in mortality last year, unlike the other Nordics. It’s simply meant to put that rise in mortality into perspective. After all, having a sense of perspective is very important when trying to evaluate the measures that were taken during the pandemic.  

A Response to Dominic Cummings’ Pro-Lockdown Twitter Thread

Dominic Cummings – director of the Vote Leave campaign and former chief adviser to Boris Johnson – has written a pro-lockdown Twitter thread. However, I don’t find his arguments very convincing. What follows is a point-by-point response.

1/ Covid… Summary evidence on lockdowns. For UK political pundits obsessed with spreading nonsense on Sweden/lockdowns, cf. SW econ did a bit WORSE than Denmark which locked down, AND far more deaths in Sweden:

Not all sources indicate that Sweden did worse than Denmark in terms of GDP growth last year. For example, the IMF gives Sweden’s growth as –2.8% and Denmark’s as –3.3%. In fact, according to the IMF, only a handful of European countries had higher growth than Sweden last year.

It’s true that Denmark has had fewer COVID-19 deaths. However, it’s unlikely that lockdowns account for this difference. During the first wave, Denmark had zero days of mandatory stay-at-home orders, and did not introduce mandatory business closures until March 18th. But the country did introduce border screening on March 4th, followed by a total border closure on March 14th. Hence its success during the first wave is more plausibly due to border controls.

During the second wave, Denmark had about the same level of restrictions as Sweden, and in any case saw a moderate number of deaths. 

More importantly, the argument that “we have to compare Sweden to its neighbours” isn’t very convincing. Sweden’s age-adjusted excess mortality up to week 51 of 2020 was just 1.7% – below the European average. 

The epidemic in Sweden was already more advanced by the time its neighbours locked down. And since lockdowns don’t have much impact unless case numbers are low, locking down probably wouldn’t have made a big difference. What’s more, the Baltics are similar to the Nordics in terms of climate and population density, and once you include them in the comparison, Sweden no longer stands out.

Cumming’s tweet also links to an article by the economist Noah Smith, which argues that “lockdowns were good”. However, Smith doesn’t discuss any of the evidence contradicting his thesis, of which there is plenty. See herehereherehereherehere and here.

One of the biggest misunderstandings, spread by political pundits even now, is the ‘tradeoff’ argument. Fact: evidence clear that fast hard effective action best policy for economy AND for reducing deaths/suffering

The argument that lockdowns are good for both public health and economic output – that there’s no trade-off – only works if locking down enables you to completely suppress the virus. 

Once complete suppression has been achieved, the lockdown must be combined with a well-functioning system of contact tracing, and a well-functioning system of border controls. In the absence of these measures, a new epidemic will almost certainly emerge once the lockdown is lifted.

There is strong evidence that the UK’s lockdowns were bad for the economy. Indeed, the UK had the second lowest GDP growth in 2020 out of all the major countries in Europe, and its worst recession for 300 years. 

One could argue that the UK should have locked down earlier, but this is a bit like arguing China should have acted earlier to contain the epidemic in Wuhan. In other words, that ship sailed a long time ago.

What’s more, it’s doubtful whether the UK – which is much denser and more connected than, say, Australia – would have been able to contain the virus through measures like contact tracing and border controls. 

Dominic Cummings Blasts Boris for not Imitating China’s Policy of “Welding People Inside Homes” in Fact-Free Twitter Rant

Dominic Cummings has fired off his latest salvo against his former boss ahead of his appearance before MPs to give evidence on May 26th, laying into Boris Johnson and the Government for not locking down sooner, among other complaints.

The disgruntled former chief adviser to the Prime Minister wrote a series of posts on Twitter that began by criticising Sweden’s response before ranging over other issues including human challenge vaccine trials and the transparency of SAGE.

Those of us “obsessed with spreading nonsense on Sweden/lockdowns” are treated to Dom’s “summary evidence on lockdowns”. Unfortunately for him, however, he seems to get his facts from somewhere other than the real world.

Dom takes a shot at the “trade-off argument” – the argument that lockdowns intended to control disease have a lot of downsides. He argues that Taiwan shows how “fast hard effective action [is the] best policy for [the] economy AND for reducing deaths/suffering”, and that “if you REALLY get your act together not only is [the] econ[omy] largely unscathed but life is [close to] normal”. He claims the Government is “totally hostile to learning from East Asia” because they and their advisers believe “Asians all do as they’re told it won’t work here”.

It’s true that East Asian countries have suffered considerably fewer deaths during the pandemic than the countries of Europe and the Americas. But the idea that that is because they imposed lockdowns hard and fast is palpable nonsense. Japan has not imposed a strict lockdown and neither has Taiwan or South Korea (see below). Worth recalling that South Korea has more commonly been lauded for avoiding hard lockdown by being so good at contact tracing, not for being fast to lock down hard. Contact tracing is also very unlikely to be the main reason for South Korea’s epidemic remaining small, but either way there is no basis to Dom’s claim that East Asia’s success is due to hard and fast lockdowns. As for Taiwan’s current “normal”, that involves very tight border restrictions that have been in place since February 6th 2020, and the country has just imposed new restrictions on the capital region Taipei.