Episode from the podcastDie Wochendämmerung

Über den Umgang mit #Covid19 in Schweden: "Sie wollen einfach das Märchen glauben"

Released Monday, 30th November 2020
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Wie Politik, Wissenschaft und Medien sich monatelang ein Märchen erzählten, das mit Fakten über das Coronavirus nicht viel zu tun hat.
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Fußnoten


  • Fußnote 1: Englische Übersetzung des Artikels:
    "The debater: The studies do not show what the authorities claim
    PUBLISHED: TODAY 04.00
    UPDATED: LESS THAN 50 MINUTES AGO
    This is a debate article. It is the writer who is responsible for the opinions expressed in the text, not Aftonbladet.
    Studies on public compliance with the authorities' infection control councils do not show that Swedes have been good at following the councils. Anders Tegnell should know that, writes Markus Balázs Göransson, researcher at the Swedish National Defense College.
    DEBATE
    DEBATE. Studies on public compliance with the authorities' infection control councils do not show that Swedes have been good at following the councils during the pandemic. It is important that we do not lull people into a false sense of security that the advice is being followed. This can lead to incorrect
    decisions in the management of the infection.
    It is a general and accepted truth that Swedes have been good at following the Swedish Public Health Agency's infection control council. This conviction seems to be rooted in Swedish politicians and officials.
    Foreign Minister Ann Linde has stated that "over 80 percent of the people follow the recommendations" . MSB has said that "eight out of ten continue to follow the recommendations" . The Swedish Public Health Agency has claimed that a very large majority of the population follows the advice. There have rarely been any dissenting voices.
    Parts of the media have agreed. DN has written that "surveys show that eight out of ten Swedes follow FHM's recommendations" . SvD's Emma Frans has stated that "the majority seems to continue to follow the authorities' recommendations." Expressen has noted that "most" Swedes live according to the advice.
    Younger Swedes have sometimes gotten a boot or two. But for the most part, the reporting has conveyed that the public follows the advice.
    The evidence has been all the more sparse. It has been a bit like this with imperial clothes in a certain Danish children's story. Many have claimed that Swedes follow the advice, but few have seen the claims in the seams.
    If they had done so, they would have found that many of the threads are not in place.
    Take, for example, state epidemiologist Anders Tegnell, who at a press conference on June 23 said:
    "There is a very large majority of the population who really follow these tips."
    These were beautiful words, but unfortunately they are not true.
    In the weeks before the press conference, FHM, in collaboration with Novus, had examined Swedes' compliance with the advice. The material collected was classified as internal working material and was not initially released. But after a patient email exchange and a warning to try the case in court, I finally got the evidence.
    The documentation did not show at all that a "very large majority (…) really" followed the advice. The documentation stated that only 35 percent had stated that they followed the advice completely.
    A state epidemiologist should know that 35 percent is not a very large majority.
    Another study that has been reproduced incorrectly is a questionnaire study from Kantar Sifo. The study has been highlighted as evidence that the public follows the advice, but it suffers from serious shortcomings that make it unusable to assess this.
    In fact, the study does not at all measure compliance with the advice. What it measures is whether humans have changed their behavior during the pandemic. For example, it looks at whether people have washed their hands more often than before, not whether they follow the advice on hand washing, which is a crucial difference.
    Doing something more often does not mean doing it often enough, just as smoking less does not mean quitting smoking or saving your lungs from injury.
    Reasonably, many more have changed their behavior than those who follow the advice well. Therefore, there is an imminent risk that the design of the study has led to unreasonably high figures that do not reflect the actual degree of compliance with the advice.
    It is very worrying that the study has been used to substantiate claims that the advice is complied with.
    Other studies have given a gloomier picture. In May, Novus found that as many as 36 percent of Swedes who had cold symptoms went to work . In July, a compilation of status reports from 19 of Sweden's 21 County Administrative Boards stated that "a large number of municipalities have identified serious shortcomings in compliance" with the councils.
    This rhymes poorly with claims of a high degree of compliance with the advice.
    The Swedish pandemic management is based on personal responsibility. The core of it is that the public follows the authorities' infection control advice.
    The fact that government representatives, government officials and journalists describe the state of evidence about Swedes' behavior incorrectly may have lulled us into a false sense of security.
    This may have contributed to the failure to introduce certain measures, such as recommendations for mouth protection in public transport, in the belief that the public already follows advice on keeping their distance and staying home in case of symptoms.
    It may also have led to an excessive focus on individual behavior rather than on broader factors such as explanations for patterns in the spread of infection.
    The fact that the spread of infection decreased during the summer and increased during the autumn has probably been less about changes in people's individual choices than about, for example, the transition to teleworking, weather changes, long vacations, and closing / opening of colleges and colleges.
    As you know, ignorance is not a strength. It is high time that serious scientific studies are done on compliance with infection control councils and that we review the statements that are made to see if they are supported by the evidence.
    Markus Balázs Göransson, senior lecturer at the Swedish National Defense College and Ph.D. dr in international politics. Columnist on VLT's management page."

  • Fußnote 2: Englische Übersetzung:
    "Why did the elderly die without medical care?
    Why have so many elderly Stockholmers been allowed to die without medical care during the corona pandemic? How could a vague order from the region be enough to sweep away both professional ethics and the law? Maciej Zaremba finds the answers in a classified document - and in a system where those who decide do not know what they are doing.
    Claes Hildebrand is alive because his son Bengt forced the staff at Stockholm's nursing home to send his father to hospital. When Claes became ill with covid-19, he was only given palliative care. In a geriatric ward, he recovered quickly. There was not much he needed to recover: drip, blood-thinning drugs and oxygen.
    The Swedish Health and Care Inspectorate, Ivo, has received 350 reports concerning the health service's handling of covid-19. In over a hundred of them, the carers are accused of refusing the eldery treatment. The relatives who questioned this were told that there were "clear directives" from the Stockholm Region not to send any elderly people with covid-19 to hospital.
    Which directives? What exactly is in them? Ivo, who has been examining mortality in nursing homes since May, does not really know. Unit manager Anna-Karin Nyqvist replies that in the beginning of the pandemic in certain regions (Stockholm, Kronoberg and Västra Götaland) there were "local instructions", which Ivo hopes were never implemented. No, she has no details. Ivo has not asked to see them.
    Now I have studied these instructions from the Stockholm Region and one thing I know for sure: If you want to understand why the pandemic killed, or - rather – was allowed to kill so many elderly Stockholmers, a part of the answer is in these documents.
    But first a lesson in the county council's - which is now called the Stockholm Region - customs and usages. When I ask to see the region's priorities during the pandemic, the registrar cannot find them in the diary. Refers to the press service, which refers to a document from May. I point out that the pandemic began in March. So, after four days, I receive five pages. But it does not say who made the decision or to whom it is addressed. What's more, I should never have been allowed to obtain them. "Confidentiality" is written after registration number HSN 2020-0505. The press service has apparently been careless. Confidentiality for what reason? Well, if people get to know how the region prioritizes among the sick, it can hinder "opportunities to prevent and manage peacetime crises". That is the meaning of the Public Access to Information and Secrecy Act 18:13, to which reference is made.
    I write to the press service to say that the confidentiality stamp cannot be legal. I'm going to complain in court. And now it suddenly goes away. Within 24 hours, the region's lawyers decide to lift the secrecy of "Governing regulations for patient flows between care providers in the Stockholm region and municipal care activities during the ongoing spread of covid-19".
    It's been nine days since I asked to see the documents. What I don’t know is that already in May, the colleagues at Eskilstuna-Kuriren had obtained a copy. But their profound and thorough article publication received little response in the national media. Was it because society did not yet realize the consequences?
    Under "Guidance on medical prioritization" in the "Governing regulations" it appears: Elderly patients should preferably not be sent to hospital. "As far as possible, treat medical complications on site." If the person also has memory problems and easily gets tired during the day, no samples should be taken either. “Medical decisions are made on clinical assessment; laboratory examination and X-ray are used only in exceptional cases. " And if the patient has previously had difficulty walking up stairs, needed help with cooking or with hygiene and also easily forgets what has just been said, emergency care is excluded, except "in need of emergency surgical action". That is, if the patient has a fracture.
    It is also not necessary to visit a doctor: "Consider whether there are other possibilities than physical visits, eg telephone contacts…"
    I ask two doctors (and medical educators) to read the document. They agree. "It is free for the person who makes the decision not to do anything for the patient." "It is clear that not all patients should receive the care that hospitals can offer."
    I could not have simply drawn that conclusion. You have to have received some training in medicine to understand what is meant. The region writes in code language. It does not say "do not send a mild dementia sufferer who also has difficulty walking up the stairs to the hospital". Instead it states "for patients with CFS 6-8 care in an emergency hospital when emergency surgery is needed." Only when looking up that abbreviation does it appear that a CFS 6 is a category of pensioners who “need help with all outdoor activities and housework. Indoors, they often have problems with stairs, need help washing themselves… ”
    And now it becomes clear why the staff at many nursing homes, and the doctors who visited such locations, found it best to prepare the infected for death, even though there were beds in hospitals. They obeyed those in power in the Stockholm Region. Whether they obeyed the law is another matter. Chapter 6, Section 6 of the Patient Act: "Those who have the greatest need for health and medical care shall be given priority for care."
    The "Clinical frailty scale", was developed in 2007 by Canadian researchers. The relationship between the vitality of the elderly and their ability to cope with stress from illness was examined. The scale goes from 1 to 9, where 1 stands for the most alert for their age. They exercise regularly and can be in better shape than many middle-age Dads. At 4 they suffering from a chronic disease or more, at 8 we should consider the yearly flu as relief end. Somewhere in the middle of the scale, memory problems begin. A CFS-5 may need help paying their bills.
    According to geriatrician Gunnar Akner, the purpose of estimating patients' degree of fragility was legitimate. They wanted to help the fragile to become a little stronger. Elderly multi-sick patients are often malnourished, passive and often take a lot of medication. With more nourishing food, a little exercise and optimization of the medicine list, they can take a step back on the stairs at the end of which awaits what awaits everyone. But it soon became apparent that CFS could also be used as a statistical basis: to plan the need for care, estimate the remaining life expectancy, and assess the benefits of medical treatment.
    This is quite uncontroversial, as long as CFS is not used to lump patients into categories or replace a medical examination. It is not intended for handling individuals. The scale is not medical. The home care nursing assistant can also note that Lisa is forgetful, cannot lift heavy items and preferably lies on the sofa. But that says very little about how Lisa will cope with the flu. But according to "Governing Regulations", Lisa is no longer the individual Lisa but a CFS-5, who does not require care in a hospital. It certainly says that the CFS scale should serve "as a guide" and that "an individual assessment should always be made", at least as long as the covid patient is able to walk up staris. But it does not say that it should be done by a doctor. Or that the doctor needs to examine the patient first.
    Following these guidelines in March, doctor visits to nursing homes in Stockholm decreased by 25 percent. Many of the nursing homes have not seen a doctor since the pandemic began. An unknown number of patients were prescribed palliative care without a medical examination, which is usually a crime. Can the Stockholm Region claim that it has been misunderstood? I do not think so. If you write "handle medical complications on site" with the knowledge that there is neither oxygen nor a doctor on site, maybe not even a drip or oxygen saturation meter, you do not give the staff any other option but to administer palliative care.
    If it is as I think it is, DN's Anna Gustafsson and Lisa Röstlund made an effort that restore a reporter’s belief in the meaning of the journalist profession for many years to come. On May 19, they publish their tenth article about elderly patients who are denied care in Stockholm. Now it's about Jan, 81 years old, for whom a doctor from Familjeläkarna in Saltsjöbaden AB by phone determines is beyond rescue and prescribes morphine. Jan's son almost has to threaten the staff at the nursing home before they agree to connect a drip and inject blood-thinning medicine. The intervention is sufficient for the patient to survive. In the same article, two doctors say that the treatment of the elderly in the Stockholm Region can be interpreted as euthanasia.
    The DN reporters hold the person that is highest in the chain responsible. But unit manager Christoffer Bernsköld "feels confident" that the doctors know what they are doing.
    It is a shocking response. (Or just silly? I'll return to that question.) The doctor who discharged Jan without having seen him did what the region asked him to do. The patient Jan Andersson is probably a CFS-5, the category that Christoffer Bernsköld in practice excluded from "higher levels of care".
    Bernsköld is one of the four who are behind the decision on "Governing regulations" from 20 March. The others are the chief physician Johan Bratt and the department heads Anna Ingmanson and Maria Andersson.
    Three days after the DN report, these regulations are classified as confidential in the region's diary. In the new ones, from 22 May, there is no longer any talk of "prioritization". Gone is the order to apply the CFS scale as well as the division of patients into categories. The CFS scale can be used, as a guide, but only by a doctor who also "has sufficient knowledge and experience of the tool". Now it no longer says that fragile elderly people should stay where they are. But it is recommended that they be sent to geriatrics rather than to the emergency room.
    Seemingly small differences, but vital.
    I will not speculate on how many lives and consciences the Region Stockholm's regulations have cost. I can only hope that the Corona Commission under Mats Melin will not avoid this question. But already now we know for sure: that a vague order from the region is enough for some doctors, nurses and others to forget both professional ethics and probably also the law.
    What is it that gives this political level between the municipality and the central government such a demoralizing force?
    I suspect the Corona Commission is having the same problem as our journalist: Now we know what happened. But who is responsible? The Commission is likely to need language experts to bring out the spirit of the region's message.
    When it emerged that a number of doctors had written off elderly that were sick with covid disease medical treatment by telephone, the unit manager Christoffer Bernsköld in DN replied: "Remote visits must be of the same high quality as a physical visit."
    Analyze this sentence. What is it saying? Superficially, it is just idiotic, in the same way that "television should be as real as theater". You cannot give orders to the laws of physics. But there is a message. If you say "shall hold", you have also said "may hold". Those in charge of the private care homes responsible for delivering medical care in nursing homes have been given the green light to ration the visits.
    At regular intervals, the question arises as to whether the county councils, now regions, do no more harm than good. What do they do that cannot be done better by others? Would it not be more rational with state hospitals and health centers run by municipalities in collaboration? Or in some other way? Does it make any sense at all with political detailed control of healthcare? By the way, can it be rational with 20 principalities, each with its own parliament, computer systems for medical records and bureaucracies, which produce tons of directives but lack disposable gloves when it comes to it? To take the example of the small Region of Västmanland where investigator Göran Stiernstedt found 3 strategies, 20 policies, 264 guidelines and 281 action plans (SOU 2016: 2). Are these regions mainly a type of ‘special interest hobby’ for the politicians and officials whose livelihood depend on it? This would explain why they time and time again, guard this territory and prioritize keeping the status quo, despite the risks to public health.
    Why have many nursing homes been so ill-equipped for a pandemic, with poor hygiene routines, no oxygen, not even the simplest oxygen saturation meters in stock? Because medical doctors are not allowed into these institutions.
    If it sounds absurd, that's what it's supposed to sound like. This is how this happend: In connection with the Noble Reform in 1992 (yes, this is what it is called) when municipalities were given responsibility for the care of the elderly, it was proposed that they should also be allowed to provide primary care. Most consultative bodies, led by LO, endorsed this. The medical association were not keen on the idea and the then county council association were not happy with the idea at all . Under no circumstances would they relinquish the monopoly on hiring doctors. And they managed to get the party colleagues in government to overrule the investigation. And as an extra cherry on top of the county council's sundae, the municipalities were banned by law from hiring a doctor.
    "It is one of the biggest betrayals of elderly people in modern times," says geriatrician Gunnar Akner. "No one would move to a nursing home if it were not for medical reasons - but in these specific location no medical doctors who are responsible for patients are allowed to participate in the day to day care of the residents."
    Most recently, it was Amanda Sokolnicki who in this newspaper (3/5) asked the question about the purpose of the regions. And got the same answer you always get. According to Anders Knape, chairman of SKR, the regional level is an "unbeatable" force when it comes to representing the will of the people, making decisions close to those concerned and not least, demanding responsibility.
    Let us test this hypothesis.
    I call the representative of the vote by the people, the health and medical care regional councilor Anna Starbrink. I ask how she reasoned when the region decided that patients with CFS 5-9 should be excluded from emergency care. How would she describe this group of patients?
    "I cannot do that. It's a medical issue. " Does she know what the CFS scale is about? "Not in detail." Has the committee discussed the suitability of using the CFS scale for priorities? "No." Has she read this decision? Then Anna Starbrink answers that it was presented to the committee. Then she changes her response, she has read it, "absolutely". But has no reason to reconsider. Politicians should not interfere in medical assessments.
    I read aloud to her: "Certain patient categories should not be directed to the emergency hospitals during the covid-19 pandemic." It's a political decision, isn't it? What categories are meant? Anna Starbrink sounds surprised. "I think the description is strange… it should state individual patients… there should always be an individual assessment…"
    But now it says categories. No, I do not think Anna Starbrink read these vital decisions. Or she has read them without understanding them.
    It is often said that the opposition is the lifeblood of democracy. It guarantees that power will be scrutinized and abuses stopped in time. I ask the same questions to the S-leader in the region, Talla Alkurdi. No, she cannot say what the CFS scale is about. She has not read "Governing regulations". She remembers that it was presented to the board under the item "Information" and that no one had any objections. Unfortunately, it is not possible to read what was said. That item in the agenda is not usually recorded.
    So far the people’s vote, the power and the responsibility.
    At the end of the interview with Anna Starbrink, I rudely wonder how she could reconsider the "governing regulations" when she did not realize their meaning. She does not really know what the CFS scale is.
    The Regional Council replies that it is not possible to request that elected representatives be experts in the area they manage. But that she trusts that her officials possess the knowledge required.
    Let us also test this hypothesis.
    Christoffer Bernsköld is responsible for all healthcare in Stockholm outside the emergency hospitals. For emergency rooms, home care and nursing homes. He issues binding guidelines, "controls and coordinates" and will also develop employees' "knowledge and commitment".
    He is also behind the "governing regulations" which on March 20 in practice collectively excluded "the fragile" patients from hospital care. But pressured by the DN reporters (19/5), he made it clear that it was the doctors who were solely responsible for such decisions.
    I ask Christoffer Bernsköld what understood he when he asked the staff at nursing homes/special house etc not to send the most fragile patients to hospital. Were there resources to care for them on the spot? Oxygen Saturation meters, oxygen?
    "I have no idea what equipment is available in special housing," replies the unit manager. You should pose that question to the medical companies that the region has hired. But there are also mobile devices from ASIH (Advanced Home Health Care) that can supply with oxygen and other things.
    I ask if there was enough. How many are there, for the approximately 300 nursing homes?
    "I do not know exactly how many." But roughly? He searches the computer, "No it does not say… I have to get back to you." (He does this later with the message that he does not have the answer. There are many companies involved, it is not clear how many people they have. But it is stated in the agreements that there must be "adequate staffing".)
    I ask why he did not intervene when the medical companies hired by the region began to ration the visits to nursing homes. He has even told DN that there was no impact to the quality of care regardless of whether the doctor was physical there or not.
    Bernsköld then replies that the Stockholm Region has decided “that digital visits should replace physical visits. So that they have the same quality in form and content. But of course it's still different. ”
    Did they really say that? "Yes, I think it's called Digiphysical Care Guarantee." (I look it up. Calm down, Stockholmers. Unit manager Bernsköld has expressed himself carelessly. Not even the Stockholm Region thinks that a doctor on screen is as good as one in the room. "Digiphysical care guarantee" only states that all health centers should be able to offer digital visits and that they must be equal to a physical visit.)
    Did he see no problem with the doctors starting to make decisions remotely?
    "We saw no reason to say that it was fundamentally wrong," says Bernsköld. "The doctors only followed recommendations." He does not remember the wording, but surely the National Board of Health and Welfare also advised against physical visits to nursing homes? (Not really, they advised against unnecessary physical.)
    I ask how it is possible to decide which patient is not qualified for "a higher level of care".
    "It will be up to the existing doctor to make his clinical assessment."
    I get a bizarre suspicion. What does he mean by "clinical"? Can he define that term?
    "No, not straight off", Bernsköld answers. But clinical examinations can also be performed remotely, he says. Some online doctors do that.
    Really? Can he say which ones? Then the head of unit refers to a publication from the National Board of Health and Welfare: “Digital care services. Overall principles for care and treatment. " However, it does not say anything about "remote clinical examinations". It would be a sensation if it did, the expression itself is a paradox. "Clinical" is in the medical language and the opposite of "remote". From the Greek clinic's, "belonging to the sickbed". It is to sit there, listen to the person, his heart and lungs, take simple samples, feel, squeeze, knock, smell.
    The head of health care in nursing homes has most likely misunderstood what "clinical" means. This makes it clearer why he did not react when doctors started prescribing palliative care to patients that they did not examine.
    I believe that Christoffer Bernsköld does the best he can - within the framework of his competence. He has no education in healthcare except for the matriculation exam and individual courses. When he became head of General Medicine and a budget of 2.5 billion, he also had no experience as a state or municipal official.
    This is how it went.
    In 2017, the position "Head of Unit General Medicine and Geriatrics" was announced. A university degree was a requirement, experience in healthcare a welcome merit. 18 people applied. Their applications were discarded. But I have been able to help track all but two.
    Of these sixteen, eleven seem to have been medics or had other nursing education at a university level. Of the other five, four had a university degree. The last applicant had neither. In a normal administration, his application would be returned unread. But he got the job: Christoffer Bernsköld, 34, professional politician, at the time unemployed. His merits: county chairman of SSU and later chairman of the health and medical care committee in Östergötland, newly elected member of SAP's board.
    I bring up this example to highlight what the region is. Namely, an area where a politician without professional knowledge can, with little effort, be converted into head of an extremely knowledge-dependent organization and expert responsible for Stockholmers' lives and health.
    The Corona Commission has a formidable problem with pinpointing where the responsibility lies for the mortality in Stockholm's nursing homes. Is it due to incompetent regional managers or rather with those who appointed them in spite of all the rules? Or is it with politicians, who did not read their "governing rules"? Can it be required of the private companies that handle the care of nursing homes where a doctor takes care of 270 different patients? No, the companies will answer, this arrangement is approved by your own elected Anna Starbrink. But did she know what she was doing? Or will she say that she is not an expert on contracts either, but of course trusts her officials? On closer inspection, it turns out that he got the job on other merits than merit and skill.
    Perhaps we are all responsible, the citizens, who tolerate this order."

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