A thought about the Public Health establishment pivot from "flattening the curve" to Zero Covid-lite

The Swedish experience is instructive.

In an interesting post about the evolution of his pandemic thinking published today, journalist Matthew Yglesias raised an issue that I think about a lot — the mysterious spring 2020 pivot by Public Health — I capitalize it to reflect the establishment consensus — from flattening the curve “to something more like a Covid Zero mindset.” I often refer to this mindset as “Zero Covid-lite.”

Why did this happen almost everywhere but Sweden?

Here’s how Yglesias framed the pivot (emphasis mine):

And because these were serious, sober-minded public health professionals, their harm reduction line was not infected by conspiracies, dismissiveness about the virus, the impulse to tout fake cures, or other hallmarks of Trump’s response in the summer of 2020. Importantly, the reason public health professionals converged on this curve-flattening idea in early March 2020 is that it’s what the pandemic response playbook written in the period between 9/11 and the swine flu scare of 2009 said we should do. Most of us did not pay a lot of attention to that pandemic planning work, but it resulted in some pretty good ideas and we should have stuck with them. I’m not 100% sure why we didn’t. But during Trump’s “15 Days to Slow the Spread,” two crucial things happened — Trump decided he didn’t actually care about slowing the spread, and the public health community flipped to something more like a Covid Zero mindset. I still don’t really know why either of those things happened.

Personally, I think the explanation is pretty simple. By April 2020, two things were happening at roughly the same time:

1. China ended its draconian Wuhan lockdown and credulous Public Health experts across Europe and the United States believed that the CCP had truly wiped out Covid-19 in a massive metropolis larger than New York City.

2. President Donald J. Trump announced Operation Warp Speed and gave the country — and much of the world — hope that sterilizing vaccines for Covid-19 would be quickly developed and deployed, at least for citizens of rich countries.

This led both Public Health and many individuals around the world to believe that, with the right combination of collective action and/or individual behavioral changes, infection could not only be delayed, but permanently evaded with the arrival of a vaccine. As a result, people were prepared to either comply with draconian restrictions — at least onerous mandates — or indefinitely shield themselves in communities without restrictions, because they thought “Wuhan worked” and sterilizing vaccines would be arriving at “warp speed.” They were prepared to accept great personal, social, and financial costs in order to hopefully never meet the novel coronavirus.

Former Swedish State Epidemiologist Anders Tegnell, however, never embraced this Zero Covid-lite thinking. Neither did the Swedish state. Why not? Well, Tegnell believed that the curve could be flattened, but disagreed with Public Health’s radical post-Wuhan consensus that pandemics could be stopped. He told an Irish audience in April: "We tried to do this, which is your classical pandemic [response]. I thought. Until this pandemic. Because in this pandemic, there was suddenly forces saying that we can stop it. It has never happened in history that we've stopped a pandemic."

Moreover, a September 2020 Financial Times interview with Tegnell ended with him suggesting that even vaccines wouldn’t be enough to stop the pandemic:

Our conversation ends with Tegnell again swimming against the tide, and warning that a vaccine — if and when it comes — will not be the “silver bullet”. He adds: “Once again, I’m not very fond of easy solutions to complex problems and to believe that once the vaccine is here, we can go back and live as we always have done. I think that’s a dangerous message to send because it’s not going to be that easy.”

Tegnell clearly believed widespread vaccination wouldn’t end the spread of Covid-19 in Sweden — or, presumably, anywhere. If you don’t believe that lockdowns and vaccines can achieve elimination — we now know he accurately predicted that the vaccines wouldn’t be sterilizing — you’re not going to indefinitely embrace extreme public health measures, like school and business closures. Instead, you’ll do what we were first told we would be doing in early March 2020 — flattening the curve (aka slowing the spread) with sensible strategies, like hand washing, banning large gatherings, avoiding crowds, working from home when possible, and focusing extra attention on the most vulnerable in society. The goal wasn’t preventing all infections, but slowing infections to preserve health system capacity and guarantee that those experiencing severe disease could receive appropriate medical attention.

And that’s exactly what Sweden, which never pivoted from flattening the curve to Zero Covid-lite, did in 2020 and 2021. Primary and lower secondary schools never closed, coffee shops remained open, and, during the worst part of the country’s late 2020 wave, the government responded with some conservative policy changes, like banning late-night alcohol sales and briefly sending the country’s oldest children back to virtual instruction. Unlike other countries, which imposed draconian travel bans for months at a time, Sweden always remained open to EU/EEA/Swiss citizens, never with mandatory quarantine and only briefly with pre-departure testing.

Later in his post, without explicitly mentioning Sweden, Yglesias seems to suggest the Nordic country got things right:

These are serious, sober-minded public health professionals outlining a fairly dovish stance on Covid. Not “let ’er rip” by any means, but a policy approach with fairly limited ambition. I think this approach would support things like the NBA bubble season and remote work, and would generally validate cautious behavior as virtuous. But most businesses would at least be allowed to continue operating, and critical social services like schools and the court system could have kept functioning, except when cases were threatening to overwhelm hospitals.

If Public Health had been more honest with themselves and the public — certainly a little more skeptical about the lockdown “miracle” achieved in Wuhan — other countries likely would have avoided disastrous Zero Covid-lite thinking and joined Sweden in flattening the curve without flattening society and harming a generation of children. But Public Health wasn’t particularly honest and hundreds of millions of people, including low-risk young people, were led to believe they could lock down, mask up, stay home, get vaccinated, and never get Covid-19.

Unlike most of the world during the pandemic, Sweden stuck with flattening the curve and never embraced Zero Covid-lite.