Sweden and Singapore: The COVID-19 'Soft' Approach vs. Techno-Surveillance

Chronic coughing can be a sign of a cold or a more serious disease making it a symptom you shouldn't ignore.
By on 04/14/2020 2:00 PM

Source: MedicineNet Health News

It's a real tale of two cities.

In Stockholm, Sweden, elementary schools, restaurants and shops are still open in the face of the COVID-19 coronavirus pandemic, even as the virus infects and kills Swedes in the thousands.

In Singapore, too, schools and night clubs remained open and many people crowded public transit to get to work each day until early April while much of the world closed down. But even then, under the surface was a complex techno-medical-bureaucratic system monitoring the deadly coronavirus, tracing its spread, quarantining patients, and documenting its evolution.

It seems as if life in these cities -- at least until Singapore initiated its "circuit breaker" lockdown last week -- is bizarrely normal, considering the shuttered parks and restaurants and social distancing mandated in China, much of Europe, and the U.S. in response to the respiratory disease leaving misery across the globe.

As of April 14, 2020, Sweden's 10.3 million population had at least 1,033 of its citizens killed by the coronavirus to-date, whereas Singapore's 5.7 million population had only 10 deaths from the disease.

What's the difference? Is one strategy better than the other? The numbers make Sweden's approach look bad today, but they are a snapshot; we won't know what worked best until the pandemic runs its course.

(COVID-19 death and case numbers are based on statistics from the World Health Organization and change rapidly. They are assumed to be lower than the actual number of cases and deaths; testing regimes and reporting practices differ from country to country.)

What Is the Right Public Health Strategy to Contain COVID-19?

COVID-19 brings fever, terror and death wherever it spreads. As a government, the only option in the absence of a miracle cure is to shelter the population from the onslaught as best you can, keep deaths to a minimum, and make sure your nation's healthcare systems don't collapse under the strain.

There isn't a way to do that without deep costs in other arenas. For instance, the financial ruin this pandemic has caused for many will almost certainly lead to increased suicide, mental illness, and physical health problems exacerbated by a loss of health insurance in countries without socialized medicine, according to the World Economic Forum.

That's partly why both Sweden and Singapore have tried to keep life in their countries as normal as possible for as long as possible during the response. It does not explain the drastically different death tolls between the two countries, however.

How Is Singapore Fighting COVID-19?

Singapore has had much more success to-date because the government sprang into action in January, isolating the first recorded case and tracing that person's contacts. Within a few weeks, the government had developed a "Trace Together" app for Android and iPhone which had more than a million people using it as of April 14.

The app uses your phone's Bluetooth function to show health authorities your network of contacts in recent days - the app's website asserts that all the data is anonymized, so no names or identifying info will be transmitted.

That way, if you test positive for COVID-19, health authorities can send an anonymous warning to every other person with the app whose phone was near your phone in the previous days. This alerts those people to self-isolate and seek testing.

The Singapore approach, however, only works with a robust testing regimen for both viral DNA (this "molecular" test will tell you whether you are infected at the time of the test) and tests for viral antibodies (this "serology" test will confirm whether you have been exposed to the virus and recovered, meaning you are likely immune).

And there's no telling if it will hold now that their infections have begun to spike. Apparently as the world began to close in mid-March, many Singapore natives were sent home. And although they were tested and isolated when necessary, this seems to have spiked their number of infected, according to the BBC.

And would it work for others? Much of the world is still facing shortages of COVID-19 test kits, the linchpin of Singapore's approach.

How is Sweden Fighting COVID-19?

In much of the world, leaders recognized the severity of the threat late - long after the SARS-nCoV-2 virus that causes COVID-19 was well-established in their respective communities.

Sweden, like most of the rest of the world, did not have as prompt or as tech-based a response to the virus as Singapore did. Sweden, instead, is sticking to its softer measures, despite the sharp increase in the number of deaths over recent days.

Elementary schools remain open, as do restaurants. High schools are closed and vulnerable populations, like the elderly or people with existing respiratory conditions, are directed to self-quarantine, according to ABC News.

Anders Tengall, the country's chief epidemiologist, is making a grim wager.

The hypothesis is there will not be significantly more Swedes dead at the end of the pandemic than if the country had initiated stricter distancing protocols, but the looser approach will keep the number of cases from spiking when lockdowns are lifted.

Tengall's and the rest of the Swedish government's bet is this approach is more sustainable, and can help prevent some of those other bad health outcomes that accompany economic depression.

What is the right public health approach to fighting COVID-19?

As of April 14, the numbers of dead do not bode well for the effectiveness of Sweden's approach.

But an initial spike in deaths was expected, as Tengall told ABC. The bet is that spike now won't happen as a result of the lifting of draconian quarantine measures.

A signal whether Sweden's approach will be effective will happen in the coming weeks. Nearby Denmark instituted a public health protocol that looks more similar to California's or France's, instituting lockdowns and shuttering businesses and all schools.

Denmark with its population of 5.6 million has only seen 6,511 cases and 299 deaths. According to the BBC, Danish authorities are taking steps this week to re-open the country.

Swedish authorities will be watching the case numbers in Denmark in the coming weeks. If the Danish see a subsequent, overwhelming spike in case numbers, Swedish experts will likely see it as validation of their approach.

For Singapore, the mere 10 dead as of April 14 shows their approach is effective on the front end of a pandemic, but maybe out of reach for larger and/or poorer countries with a less centralized government.

And their numbers could change.

Furthermore, Singapore's health authorities ultimately decided last week its robust testing and quarantine regimens still weren't enough to keep COVID-19 patients from flooding the health system there, and has instituted measures that look more like the rest of the world's.

As with nearly everything else in this pandemic, the correct approach remains unclear. The Swedish government passed legislation this month providing legal authority for sweeping lockdown measures at a moment's notice if health experts there decide it's best to abandon the current approach, according to ABC.

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