by David Crowe
Sweden has been a political football in the argument over whether lockdowns work. Lockdown enthusiasts point to the higher death rate than in other Scandinavian countries while skeptics point out that the rate is lower than Italy, Spain and the UK. But the more important question is why the death rate is in the middle. The answer is because Sweden actually did lock down, in the most important way.
Before I defend this counter-intuitive position it is important to note that the term “COVID-19 lockdown” is not well defined. In several countries people were confined to their homes, but in other places, such as in my province of Alberta, Canada, people could go out, although they would find that all restaurants, bars, playgrounds, concert halls, swimming pools and shopping malls were closed. In reality every country’s lockdown (and in places like the United States and Canada, every state, province and even city) was different. In Alberta, Canada, when hair salons were opened, massages were still banned, but in Ontario, hair salons were banned but massages were allowed.
Sweden only chose two dishes from the lockdown menu: banning large group events and visitors to hospitals and nursing homes.1I will use the term ‘nursing home’ for homes for the elderly, or seriously injured, who cannot look after themselves, who need help eating, dressing, going to the toilet etc. As opposed to retirement homes where people will perform these functions themselves. Different countries have different terms for the facilities that are provided for the oldest and sickest people in society who do not need hospitalization.
If we were God, we could assign two values to every item on the lengthy lockdown menu: the number of lives saved from death by SARS-CoV-2, and the number of deaths caused by that aspect of the lockdown. Of course we are not God, but there is evidence that the combined effect of whatever menu items were chosen has killed lots of people. For example, calls to suicide help lines and actual suicides are up. In Canada, opioid overdoses have been rising during the COVID-19 panic. Psychological distress among US adults has dramatically increased. We can guess that deaths from alcoholism, mental breakdowns, and domestic violence will also rise, although in many cases it will not be until next year that we have the statistics to prove this.
I am not the only person who believes that the intensity of the demonstrations, looting and rioting in the United States comes from keeping young people cooped up at home, taking away the socialization and stimulation that they get at school, at their part time jobs, at soccer practices, shooting hoops or just hanging out at the beach, park or shopping mall. Now that the murder of George Floyd by four white policemen has blown the lid off the pressure cooker it will take a long time for the pent-up energy to dissipate. But this is just a belief, nobody can prove that the anger and sometimes violence is partly due to the lockdown and not entirely due to the too frequent occurrence of abuse and killing of black men by police officers in the United States.
But, back to the issue of assigning relative numbers to the menu items. Readers of this article are likely not in the target zone for death by COVID-19. The majority are probably younger than 70, and those who are older are probably not suffering from multiple, serious pre-existing, health conditions. Naturally, you will see the effect of the lockdown on yourself most intensely, and may ignore the parts that do not affect you. During times and places where home confinement was mandated you couldn’t go out, you couldn’t visit relatives, you couldn’t go for a coffee with a friend, you couldn’t exercise, you couldn’t go for a drive, you might have had to try to juggle online work with online education of your children. You probably didn’t think about the people in nursing homes who were cocooned (to use a phrase recently employed on lockdownskeptics.org), out of sight, out of mind. If anything, you thought that perhaps their isolation had occurred too late, that the practice was protective, and if you had criticisms it might have been of events like the New York governor sending patients from hospitals to nursing homes where they could spread the virus, or that the banning of visitors occurred too late.
Each of our imagined relative numbers for the deaths from each lockdown menu item is the product of two factors: the likelihood of killing one person, and the number of people affected. Given that in many countries it is mostly old people in nursing homes or hospitals who are dying, we need to ask what aspects of the lockdown are most likely to harm these people. They are not affected by restaurants being closed, or playgrounds, or swimming pools, because they cannot use these facilities. But is the effect of their isolation in nursing homes (or hospital wards) purely benign, and protective from COVID-19? Are there any dangers?
I postulate that, in fact, the largest relative number for lockdown harms should be assigned to the dangers of banning visitors from nursing homes and hospitals, and the removal of almost all social contact from these frail old people. This may be the most dangerous aspect of the lockdown due to the severe impact on the elderly people housed there, and due to the large number of people affected (the largest portion of the population with deaths blamed on SARS-CoV-2). On this basis, Sweden, having banned visitors to nursing homes and hospitals like virtually every other European country, has a lockdown that is similar in negative affects to other western countries, hence the similar mortality rate.
Nursing Homes Under Lockdown
What is going on in nursing homes? Unless you work in one you are banned from entering, so it is difficult to know, but one can hypothesize a list of effects of the banning of visitors and the further isolation of residents within the nursing homes:
- Workers will be scared to death of being infected by their patients and therefore will keep contact to a minimum.
- Some workers will quit resulting in others being overworked.
- Other workers will test positive by the flawed COVID-19 RNA test and will be quarantined instead of working, for up to two weeks.
- The role that visitors play in ensuring that their loved ones are not neglected, not treated in unsanitary ways, and not abused will be removed.
- The assistance that visitors give the staff, in feeding their loved ones, helping them dress, and so on, will be gone.
- Any resident who is suspected of being infected will be confined to their room.
- Eating together will be banned.
- All social events will be cancelled.
- All outings will be cancelled.
- All non-essential health services, such as physiotherapy or exercise classes will be cancelled.
That there were horrors that were mostly hidden was actually known quite early, when in late March the Spanish army found abandoned people and dead bodies in nursing homes that they entered, because the staff had fled, out of fear.
More recently, we have more details on the nightmare within the nursing home walls, thanks to the Canadian Military. Soldiers were asked to go and assist in five of the most problematic nursing homes in Ontario, Canada, by the government, and what they saw shocked them so much that they wrote a detailed report to their superiors, which was released to the public, and needs to be read by everyone.
Awful treatment, that can easily be seen as leading to death, includes the following (read the entire report to be even more shocked):
- Unsanitary practices with parenteral (tube) feeding including liquid food that has curdled.
- Unsanitary catheter practices, and leaving them in too long (3 weeks in one patient).
- Fear of using supplies in a cost-conscious private facility.
- Wound changes that do not preserve sterility.
- Lack of wound care supplies, and consequent delayed changing of bandages.
- No mouth or eye care supplies.
- Poorly trained staff.
- Lack of staff (1 RN for 200 residents in one case).
- Patients sedated just because they are anxious, sad or depressed.
- Aggressive and rough treatment by staff.
- Forceful feeding and hydration leading to choking and aspiration.
- Leaving food in the mouth of a sleeping patient.
- Insufficient turning of patients in bed to prevent bed sores.
- Patients left in soiled diapers.
- Putting diapers on patients instead of letting them go to the toilet.
- Patients crying for hours without getting attention.
- Not putting patients in wheelchairs but leaving them in bed continuously.
- Taking mobility aids away from patients so they don’t wander.
- Cockroaches and flies.
- Trays stacked with rotten food.
- Lack of feeding and hydration.
- No way to receive personal supplies from outside, such as magazines, snacks, shampoo, and soap.
These horrifying practices of abuse and neglect need to be added to the intended neglect, the removal of virtually all sources of stimulation.
We could compare what is left for these unfortunates to the “Joy of Life” standards for nursing homes in Norway. They define five dimensions that they believe contribute to a nursing home that provides the best possible care:
- Positive relations: Relations with caring and loving family members and friends. Being cared for by a positive healthcare staff.
- Belongingness: The need of belonging to someone and the necessity of having someone to belong [to]. The need [to] love and care for someone and [to] be loved and cared for.
- Sources of meaning: Participating and engaging in daily activities, being valuable to others and [capable] of helping others. Make their own decisions in daily life.
- Moments of feeling well: Experience small glimpses of the world outside. Attend social and cultural activities like concerts, theatre, visit a restaurant and being out in the natural environment. Having visitors.
- Acceptance: Being able [to accept] one’s life the way it is. Adapting and accepting one’s life situation.
Although standard nursing homes have probably never provided all of these aspects, at least not very well, the lockdown of old people, the banning of visitors, the panicked and overworked staff, has resulted in a complete and absolute removal of anything that could contribute to the “Joy of Life”. Did anyone ask even a single resident whether they would like to take their chance on the virus and continue to live life as normal?
The Canadian Forces report briefly mentioned sedation, but Spanish medical documents indicate that this is the solution when hospitals don’t want nursing home patients which, in Spain, is all the time right now. SECPAL, a Spanish palliative care society, writes (my translation):
In patients with COVID + a poor prognosis, and poor control of symptoms, who are not candidates for treatment in an ICU it could indicate that palliative sedation is necessary when the ordinary treatment is insufficient, and symptoms cannot be controlled.
Palliative sedation is performed with Midazolam, a benzodiazepine medication, that has a side effect of suppressing efforts to breathe. If the maximum dose of Midazolam is reached, then Levomepromazine should be used instead, a neuroleptic drug. Some of its side effects include on blood pressure and the heart.
It is important to understand that these patients may have health conditions that could be treated, and that untreated may cause pain. Sedation will not make the cause of the pain go away, but as the pain increases the patient will be pushed closer and closer to a coma.
Finally, the SECPAL recommendations suggest the removal of various types of medication, but also hydration. Lack of hydration will lead to death.
Little is known about the specific situation in Sweden, but according to a BBC report, workers are coming forward to state that transfer of residents to hospitals is discouraged, and that nursing home staff are not allowed to administer oxygen without the approval of a doctor.
I believe that the isolation of patients in nursing homes has not prevented deaths, but has caused deaths. Elderly, infirm people have nothing to live for any more, and poor care and abuse can no longer be observed, and stopped, by visiting friends and relatives. Underpaid staff, those who have not quit or been put in quarantine, are even more overworked than normal, resulting in poor care, frustration and abuse. Hospitals do not want nursing home patients, and the recommended alternative for the nursing home is to sedate and, if that doesn’t work, sedate some more.
Sweden, like virtually every other country, imposed an absolute ban on nursing home visitors. If this is the most destructive part of the lockdown then it is fair to say that Sweden did actually lock down when they banned visitors to nursing homes on March 31st, and this explains why its death rate is in the middle of the pack. We will never know if Sweden would have had a far lower death rate if the doors of their nursing homes had been left open to the outside world.
David Crowe is a Canadian independent researcher of infectious disease models and the host of a weekly radio show in Canada called The Infectious Myth.