Q: We are joined from Sweden by Dr Johan Gisecke. Did you train originally at the London School of Hygiene and Tropical Medicine?
A: No, I used to be an infectious diseases clinical doctor and worked a lot with AIDS patients during the 1980s. That's what got me into epidemiology. And then I spent two years at the LSHTM in the early Nineties, and then I came back to Sweden and became State Epidemiologist, which means having control over all infectious diseases. I actually hired the current State Epidemiologist for Sweden, Dr Anders Tegnell, twenty years ago. I was his boss, and now he's my boss. He's working quite well.
Q: And you then became Chief Scientist at the European Centre for Disease Prevention and Control. What roles do you have now; who are you advising at the moment?
A: I am advising Anders Tegnell at the Swedish Agency for Public Health on a consultant basis. I'm retired, really, so I'm doing this mostly because it's fun.
Q: You were saying that you were on a call with the World Health Organisation earlier today. Do you have an ongoing relationship with them?
A: Yes, I'm advising the Director-General [Tedros Adhanom], together with a group of old scientists, but that's unpaid; an honorary post, in a way.
Q: So, having established your credentials to talk with confidence on this topic: There's been a lot of confused thinking, and a lot of confusion, about what the correct response to a threat such as Covid–19 should be. I wanted to begin by getting your summary thoughts on how Sweden is differing from other countries and why you think that is.
A: The main reason is that we, or the Swedish government, decided early in January that the measures we should take against the pandemic should be evidence-based. And when you start looking around for the [basis for the] measures that are being taken now by different countries, you find that very few of them have a shred of evidence base. One we know, that's been known for 150 years or more, is that washing your hands is good for you and good for others when you're in an epidemic. But the rest — like border closures, school closures, "social distancing" — there's almost no science behind most of these.
Q: So what is the current policy in Sweden? "Social distancing" is part of the policy, isn't it? What is the régime that Sweden has gone with?
A: The main difference to other countries is that you're not locked up in your home. If you go out to buy food or groceries or medicines, there's no police to stop you in the street and ask you what you're doing there. That's one thing. People are asked to stay inside, but there is no enforcement of that. People do it anyway. [Secondly,] we have the rule that a crowd cannot be bigger than 50 people.
Q: So I can still have an event for 49 people if I want?
A: Yes, you could. And the upper schools and universities are closed; schools up to age 15–16 are open. What more do we have? The nursing homes and homes for old people are closed to visitors.
Q: So it sounds like it's a moderate "social distancing" régime at the moment, then.
A: Yes, it is. It's very similar to the one that the UK had before there was a famous paper by Imperial College, by the modellers who made models for infectious diseases. The day after that came out, you made a U-turn in Britain.
Q: Tell us about that. The original strategy in the UK became known as a kind of herd immunity. Before we come on to talk about the Imperial model, is it correct to call [the original strategy] herd immunity, and is that the Swedish strategy?
A: It's not a strategy, but [herd immunity] is a by-product of the strategy. The strategy is to protect the old and the frail, to try to minimise their risk of becoming infected, and taking care of them if they get infected. And if you do that the way we're doing it, you would probably get herd immunity in the end, but that's a by-product of it; it's not the main reason to do it.
Q: You were saying that the initial UK response seemed to be similar to what you in Sweden are doing now, and you thought that was better.
A: Yes. I think it was very good, actually. We were very pleased we were having the same policies as the UK; that gave some credibility to what we were doing. But then Mr Johnson made his 180-degree turn.
Q: There may have been other political factors involved; he was definitely under a lot of pressure, because lots of European countries were doing a formal lockdown at that point. But the turning point did seem to be that Imperial College report, which forecasts 510,000 deaths in the UK with a completely unmitigated approach; 250,000 deaths with a mitigated approach, which is roughly equivalent to what you're doing in Sweden; and then it suggests that it might be as few as 20,000 if we did a full suppression or lockdown.
What was your impression of that paper?
A: I think it's not very good. And the thing that they miss a little bit [is this]. Models for infectious disease spread are very popular; many people do them; they're good for teaching. They seldom tell you the truth, because — I make a small parenthesis — what model could have assumed that the outbreak in Europe would start in northern Italy? Difficult to model that one!
And any such model looks complicated — there are strange mathematical formulae and integral science and stuff — but it rests on the assumptions [its authors make], and the assumptions in that article could be heavily criticised for … I won't go through that; it would take the rest of your day if I went through them all.
The paper was never published scientifically; it's not peer-reviewed, which scientific papers should be; it's just an internal departmental report from Imperial.
And it's fascinating: I don't think any other scientific endeavour has made such an impression on the world as that rather debatable paper.
Q: So is your impression that it was overly pessimistic?
A: Oh yes, very much so.
Q: So — I guess it comes down to some degree of speculation, but what's your impression of how serious the disease is and what kind of fatalities we would be looking at if we had a more moderate or more mitigated approach?
A: What's the number of deaths in in the UK now?
A: So you're getting close to 20,000 now — but probably not 510,000!
I think … Well, let me back up one step. One thing that the model has missed is that it assumes that hospital capacity will remain the same, and that's not what's happening anywhere. I mean, in Sweden we've tripled our intensive care capacity, and I think that's happening in the UK as well. But the paper completely overlooks that; it's quite certain that is a static thing.
Q: So, just to come back to this: I think what most people who support the lockdown would say — and that is the overwhelming majority of people in politics and in the media — is that the reason the curve is now flattening and the numbers of deaths are gradually coming down on a daily basis is because of the lockdown, and that that shows that the policy has worked. Professor Neil Ferguson, who led the Imperial paper, suggests that he stands by his prediction that 500,000-odd people would have died had that not taken place. So, if it wasn't the lockdown that has been flattening our curve, what else could it have been?
A: Well, one thing is immunity.
Another is that people who are frail and old will die first, and when that group of people is sort of thinned out, you will get less deaths as well.
The other thing is that when you start your exit strategy — that's the favourite word now in public health, "the exit strategy" — when you start it, you [in Britain] will have some other deaths that we [in Sweden] had already.
Q: So does that mean, then, that as the disease passes through the population, we are going to see second and third spikes now after this?
A: That would be part of the exit strategy, because the only way to check — if you are taking away one restriction; let's say we open the schools again, as an example — how do you evaluate that? You will see [officials saying,] "Ooh! Numbers are going up again; more people are dying! We have to stop that; we have to pull back that softening [of the lockdown] and try another [approach]. That's what the exit strategy will be in all countries: countries will ease up a little on a restriction, see what happens over the next two to three weeks, [and officials will say], "Ooh, that didn't work. We'll resume that [measure], we'll try another restriction, we'll lift that one — ooh, it worked!"
And every country will have to do it that way, and that means that the increasing number of deaths will be part of checking which strategies should be kept and [which] not.
Q: So what should we be doing instead?
A: Well, you can't!
Q: So …
A: When I first heard, six weeks ago, about the different draconian measures that were taken, I asked myself, "How are they going to climb down from that one? When will they open the schools again? What should be the criterion for reopening schools?" Did any of the strong and very decisive politicians in Europe think about how to get out of this when they introduced it? And I think that will be a problem for the UK as well.
Q: Let's take, as a comparison, your neighbouring countries in Scandinavia. A lot of people are sending around these charts that show that Denmark and Norway and Finland have had much fewer deaths on a per-capita basis and in Sweden the rate is still climbing — and they take that as proof, essentially, that Sweden should have gone into a more draconian lockdown. What do you say to those people?
A: Well, firstly, it's not true for Denmark.
Secondly, one important thing is that the nursing homes in Norway are usually quite small, whereas the nursing homes in Sweden are quite big, with hundreds of people — which means that if you get the virus into one nursing home in Norway, it will affect far fewer people than in a big one. That's part of the reason; it's not all the reason.
For Finland: the epidemic never really took off there. They started their measures before it had even started.
But I think that we should have this discussion a year from now. Let's decide that we do this on 17 April 2021. I think that the difference between countries will be quite small in the end.
Q: So you don't think that the severity of these intervening measures is going to make that much difference?
A: No, I don't think so.
Should I tell you what I really think? I almost never do this.
I think what we're seeing is a tsunami of a usually quite mild disease which is sweeping over Europe. And some countries do this and some countries do that, and some countries don't do that, and in the end there is very, very little difference.
Q: When you say it's a usually quite mild disease, what do you mean by that?
A: That most people who get it will never even notice they were infected.
Q: So does that mean that you think the actual fatality rate of this disease is much lower than the numbers that have been talked about?
A: Much, much lower.
Q: Have you made any speculations as to what sort of zone the real fatality rate might be in?
A: I think it will be like a severe influenza season. The same as that, which would be in the order of 0.1 per cent, maybe.
Q: So, for a country like the UK, that is heading towards 20,000 deaths, that would suggest that many millions of people have already had it?
Q: And you think that is also true in Sweden, then — that a substantial percentage of the population has had it?
A: Yes. I'm rather certain of that, actually. And we don't have the tests really, yet. As you know, you have these two kinds of tests: one that tells you that you have it now, and another one that tells you that you had it at some point before — an immunity or serology test — and [the latter kind] are just being developed and just being employed. I know from discussions with friends in the UK that you started last week with 3,500 such tests, and you will go on with about 8,000 per week. And when you get tests that show which people have the disease, you'll see that most of them never even dreamt they had it.
Q: But we don't have yet any effective antibody tests, I think.
A: No, you're right, but it's coming.
Q: You're confident that we will get those tests?
A: Oh, yes, that's [only] a matter of time.
Q: And so what sort of percentage of the population do you think we will discover has had it, once we get mass antibody testing in place?
A: At least half, both in the United Kingdom and in Sweden.
Q: So the whole rationale for introducing this lockdown across Europe, that has created such unbelievable side-effects and pretty much stopped the whole world in its tracks, you believe is a misguided policy, and you think it's doing more harm than good?
A: Yes, I think so. What I'm saying is that people who will die a few months later are dying now, and that's taking months from their lives — so that's maybe not nice — but comparing that to what the effects of the lockdown may be, I mean, what am I most afraid of? It's the dictatorial trends in Eastern Europe, that Orbán is now dictator of Hungary forever: there's no finishing date [sunset clause to the Hungarian regulations on rule by emergency decree]. I think the same is popping up in other countries. It may pop up in more established democracies as well. I think the ramifications of this could be huge: we're not even starting to see them.
Q: Just to get this clear: you think the correct policy, from the start, should have been to shield old and vulnerable groups?
A: There, we failed. Sweden failed. We were not on our toes enough to really shield the old people. We should have banned visitors earlier. Many of the people working in nursing homes are from other countries — they're refugees or or asylum seekers in Sweden; their Swedish may not be perfect, they may not always understand the information that has been spread to the population. There are many things we could have done better a couple of months ago.
Q: So, at the point we are now, what you're advocating is we protect those groups better, and as far as the rest of the population is is concerned, we just allow it to pass through the population, essentially?
A: Essentially, yes.
Q: Which is now commonly understood by what we call the herd immunity strategy, basically.
A: And there are others: it's not just the old and frail that should be protected. But I don't think you can stop it. You can stop it for some time, but then … I mean, [among] countries that have been successful: South Korea is giving up now — they can't maintain their policy; I don't know about Taiwan — they were quite successful; Singapore — similar problem. It's too …
Q: So [in] those countries that are held up as the most successful — in some cases, ones that totally managed to suppress the outbreak — you think that it's just a question of delay and actually they won't be able to hold that back?
A: No, [they won't.]
Q: So how should we judge success, then? Numbers of deaths does seem like a fair measure, but if you're saying that they're essentially deaths that are just going to happen later, it will sound to some people like a slightly cold-hearted approach. I suppose if you're saying, "They're going to die anyway, so we should allow the disease to take its course," I think a lot of people might feel that a government can't sit back and do that. If now, having had this lockdown, we are headed towards 20,000 deaths, how many deaths might we have had if we had had no lockdown? Would it have been more than we have?
A: Yes, probably a bit more, but in the end the result would be much the same. And I agree, it's a bit callous to say that we let people die. We're not saying that; we're saying protect the old, try to slow the spread of the epidemic a bit, so that the healthcare system will manage when we have many sick people, many severely ill people. But I think you can't [stop it], really. At some point — 'tsunami' is not a bad word — it will roll over Europe, no matter what you do.
Q: And as it rolls over Europe, sooner or later, presumably, treatments will improve?
Q: And we'll get better at knowing how to treat it?
Q: It already feels like the initial focus on ventilation has shifted toward other ideas, and people are thinking of new ways to treat it. Is that in itself not an argument for suppressing it as much as possible?
A: But how long, in a democracy, do you think you can keep a lockdown? How long will it take before people say, "Now I'm not taking it [any more]"? You can do it in China: you can tell people to stay at home, and you can weld their door shut so they can't get out. But in a democracy you can't, and after three or four weeks, people will say, "Well, I don't know anyone who's had Covid, and I want go out; I want to go down to the pub." And so how long do you think you could lock people up like this? "Stay in your home! You need a permit to go to the shop!"
Q: We don't actually need a permit, but yes. I mean, we've now just had it extended by three weeks. You know, there is an enormous amount of public support for it, and that's one of the interesting factors about this: that, at the moment, the public is very much on side with the lockdown in the United Kingdom. Some people [even] seem to like it! So it may be that it's hard to persuade people to go back, in some way.
But, Dr Gisecke, how did the policies that have been put in place by the UK and by other European governments come about? You've been a leading epidemiologist for your whole career: you've dealt with influenzas and SARS, and you've advised the World Health Organisation. What was it about this pandemic that was so different, that has led to this global shutdown?
A: A new disease, a lot of people dying, you don't really know what will happen — and this fear of contagion, I think, is almost genetic in people. And showing political strength, decisiveness, force, is very important for politicians.
Q: Do you think the fact that it came out of China, where we had witnessed such an enormous response — quarantining whole provinces and so on — set the tone in some way, and that that felt like the appropriate response?
A: Could be — "Let's do like the Chinese [did]." But, again, you can't compare to China; it's a different world. And do you think you could keep the lockdown [in place] to protect the old people until we have good drugs and good vaccines — six months, a year, 18 months? I think people would get a bit tired of it, even if they support the policy in the UK.
Q: A couple of specific things have occurred to me during our conversation. One is: how many deaths do you foresee in Sweden? You're up at 1,400 or so.
A: I think it will be like a severe influenza. And it's interesting with influenza: when the flu comes, we all say, "Oh, the flu is coming." Like, every winter it's in the papers: "The flu is here" — OK. And in this country, it usually kills around one to two thousand people. But it's normal; it's influenza; we have it every year; and they're old and they were going to die soon anyway, so no-one is very upset about influenza. But I think if influenza came around as a new disease — you never had it before, but suddenly this new disease called influenza popped up — we would have exactly the same reaction that we have now. So I think the number of deaths will about be about the same as in a severe influenza winter. There are 65 million of you, so it would be 12,000 cases in the UK.
Q: We've already had 13,000.
A: Maybe a peak [as heard]. And a lot of influenza deaths are not recorded in that way, anyway, in a normal influenza season. So I think this is about the same. Anyway, it might be twice as much, but it won't be ten times as much.
Q: The reports from hospitals, though, are very different, aren't they? That the way the disease progresses seems different from influenza.
A: Oh, yes, it's different. It's not the same disease as influenza, but the shape of the epidemic is not that different. There are a few differences: for example, an influenza outbreak is driven by children in society. They are the ones who pass it on between generations, and this does not hurt children very much — they don't have any symptoms — and they're not very infectious. So there are epidemiological differences.
Q: When talking about old people like you did, as opposed to children, a lot of people will say that young people have been dying of Covid–19. There are examples of young people dying, and some of the data from America suggests that a large number of hospitalisations are among younger people — and is it responsible to describe it as just a disease for elderly people?
A: No, but influenza kills people too — even though not that many — and [Covid–19] is making much more headlines right now. And if you look at the data, people under 50 are a clear minority of all the cases.
Q: I'm 38; I'm on the borderline between young and old. If you're younger than me, what is your advice to young people? Should they be campaigning to have the lockdown eased because it's inappropriate? What are other risks for young people? I mean, we're told that it's about carrying the disease to other people and [that] they act as spreaders, even though they're not vulnerable themselves. What should we be doing with younger people?
A: No, I think it's good what you're doing now. They won't hurt that much. You can't say that it's completely safe — I mean, there will be young people who die, but for the majority, it's [not a risk]. But what you said is correct: that they should think about protecting other people. That's important, because they move around a lot, and they shouldn't meet their grandmother and grandfather too much until they've had it themselves.
Q: I just want to get a sense of what the British government should do now, in your opinion. Should we say, "OK, lockdown is cancelled"?
A: No, you can't do that. Then you have a wave of cases; then you would really have a peak one to two weeks later, if you took away all the lockdown. No, you'll have to climb down one rung of the ladder at a time, and probably start with [reversing] the school closures. Maybe it's a good thing: it keeps society [going]. I mean, in this country, in Sweden, we have one million children under ten: they need to be looked after. If they're not in school, then someone has to stay at home with them. One of my friends is a nurse and head of an emergency ward here in Stockholm: she prays every morning when she wakes up that the government will not close junior schools, because then she loses half her staff. So school closure is one thing, but I think one step has to be taken at a time.
And it's interesting how the countries in Europe are, after the lockdown, approaching the Swedish policy now: they're opening up schools in all the Nordic countries; in Austria, you can shop in a shop that's smaller than 400 square metres; in Germany, they're doing the same thing on Monday. In Germany, they're also thinking about opening the schools again. So countries are approaching the Swedish [model], but they had a lockdown first.
Q. There's two things that people get very hopeful about: one is a vaccine, and that in some way we can suppress the disease completely until the vaccine comes. Is that a feasible strategy?
A: No. It will take too long. It won't work in a democracy.
Q: And one other idea is these so-called immunity passports for people who have been proven to have had the disease: they could then carry a wristband or something, and they would then be allowed back into jobs and in full society. Is that a feasible strategy, in your view?
A: There are some technical problems with it. As you indicated, the antibody tests are not that perfect yet, so it will be [a while], but it's not a bad idea. Do you [really] need a passport? [If] you tell your boss at work, "I'm immune", well, maybe he'll want to see a certificate. I mean, that's the way it will work: that you find people are immune and they can go back, and you can work in the hospital without all this spacesuit on.
Q: Will that be part of the Swedish strategy?
A: Yes, yes.
Q: In terms of what happens next, then, in Sweden: there's a huge amount of pressure; a lot of people are looking to prove that it was a mistake in some way. Do you think the Swedish strategy will just stay as it has been?
A: I don't think it will be tougher, no. We're talking now about opening the final year of schooling so that people who spent twelve years in school can celebrate, which is a big thing in this country. It's not because of the celebration that it's being done, but it's to see that those who finish school [this summer] get their grades and finish all the tests they have to take; things like that.
Q: And so you feel that the curve is improving sufficiently in Sweden to start releasing further the suppression measures?
Q: And how did that happen without a lockdown? Just voluntary "social distancing" has already achieved that, you believe?
A: Yes. There are some ordinances, not as strong as a law, for restaurants. The rule is, you can only eat sitting down; the food should be hot and served at the table; you don't go out; you can't drink standing up — if you want your beer, you have to sit down at the table, which [has to be] five feet away from the next table; and that's being checked now. But it's not the government; it's the local medical officers of health that go out and check restaurants, and when they close two or three restaurants because the tables are too close [together] or people are standing at the bar, the others follow suit. You don't need a law for that: they know that if the medical officer of health comes in [and they are not in compliance], they'll be closed for business.
Q: When do we get past that? When can we just be back to normal there, with no "social distancing" at all? What will be the metric for making that decision?
A: That's a good question. I'm not quite sure I can answer that for food, but it will take a couple of months to climb down from a lockdown. Can you "climb down" from a lockdown? I don't know. Open up.