Opinion: Covid-19 and Sweden – What is the underlying strategy?

Published 30 April 2020, by Finn Nilson, Associate Professor in Risk- and Environmental Studies and Director of the Centre for Societal Risk Research, CSR

The Swedish handling and approach to the Covid-19 pandemic has been widely debated both within Sweden and throughout the world. With a softer more lenient approach, Sweden has chosen to go against practically all other countries who have chosen a hard “lockdown” approach, albeit with varying degrees of strictness.

Although it is too early to assess whether the Swedish approach is a success or failure, there are clear differences between countries. In regards to Sweden, the current (30/4 -20) mortality rate is 231.26 deaths per million people. Whilst this number can be difficult to compare to some countries (due to data issues and especially whether out-of-hospital deaths are included), comparations are possible with the Nordic neighbours, who all have reliable and comparable high-quality data and have all chosen a lockdown approach. In these countries the rates are considerably lower with Finland having a rate of 36.06, Denmark a rate of 74.86 and Norway a rate of 38.76¹.

Whilst this does not necessarily mean that Sweden will be worse off in the long run compared to the Nordic neighbours, given that (at least theoretically) countries that have chosen the lockdown approach will risk having increasing rates after opening up, the rates do differ considerably. As such, it is important to discuss some of the underlying theoretical approaches of the different risk management perspective in order to discuss whether there is a theoretical chance that Sweden’s strategy could be more successful than those who have chosen alternative routes.

Broadly speaking two alternative risk management approaches are possible to take in a situation such as the Covid-19 pandemic; the Precautionary Principle approach or the As Low As Reasonably Possible/Practical (ALARP) approach. Starting with lockdown countries, their strategy is strongly based on the Precautionary Principle.

The precautionary principle is a key feature of risk management, especially in cases where the objective level of safety is difficult (or impossible) to measure or assess. As such, it has increasingly come to be the foundation of risk assessments and risk mitigation. Even more so, the precautionary principle has become a fundamental feature of the protection of both public health and the environment (Lofstedt, 2003).

Originating in German environmental policy in the 1980s, the term precautionary principle comes from the German word Vorsorgeprinzip, literally meaning “foresight principle”. It has arisen as a consequence of the perception that the pace of efforts to combat problems such as climate change, ecosystem degradation, and resource depletion is too slow and that environmental and health problems continue to grow more rapidly than society’s ability to identify and correct them. As such, the principle is now one of the backbones of environmental laws in the European Union, treaties addressing North Sea pollution, ozone-depleting chemicals, fisheries, climate change, and sustainable development (Jackson and Steingraber, 1999).

In terms of definition, Jackson & Steingraber (1999) argue that the precautionary principle is characterised by the following statement; “when an activity raises threats of harm to human health or the environment, precautionary measures should be taken even if some cause and effect relationships are not fully established scientifically”.

Centrally in this quote is the aspect of uncertainty. Regardless of whether new, unknown risks are man-made or natural, high levels of uncertainty exist. With Covid-19, although some knowledge was ascertained early-on, several key risk aspects that are critical in our ability to manage the disease were unknown.

Not least, two key aspects were unknown. Firstly, the so-called R-value, i.e. the number of individuals that are infected by each infected individual was uncertain. Also, the existence or non-existence of asymptomatic spreading. According to the precautionary principle, when such uncertainties exist, strong decisions need to be taken in order to protect health. Therefore, a lockdown of a country until sound knowledge regarding the spread of the disease can be established could be a reasonable conclusion.

In Sweden, although not confirmed officially, it would seem that rather than following the precautionary principle, the As Low As Reasonably Practical/Possible (ALARP) approach has been applied. Not least, this is seen as contrary to other governments, the Swedish government were relatively quick in declaring and accepting that several thousands of people would die of Covid-19².

Whilst there are clear differences between ALARP and the precautionary principle, in terms of risk management strategy, there are also some similarities between the two approaches. For example, the responsibility of reducing risk is in both strategies clearly placed on the owner of the risks (in this case the state). However, using ALARP, the owner has a responsibility to reduce risks to levels that are as low as reasonably practicable (Ersdal and Aven, 2008) whilst the precautionary principle states that if something is unsafe or possibly unsafe it should be made safe or eliminated.

Specifically, according to the ALARP approach, risks should be made sufficiently low. With regards to what is sufficiently low, the ALARP approach can be conceptually illustrated as in figure 1, taken from The Health and Safety Executive (HSE) (1992) and Melchers (2001).

In the diagram, two lines are drawn. The first line marks the level at which above a risk should never be exceeded and the second line marks the level at which there is no need to further lower the risk. In-between is the ALARP range where cost-benefit analysis should be used to see if reduction is reasonably practicable (Kletz, 2005). By dividing risks in this way, it is presumed that an objective risk management is prioritised over a subjective perspective. As such, this approach is now used in much of society’s ordinary risk management, for example whether a road should be re-built in order to become safer, the implementation of protection for workers, etc.

Figure 1. Levels of risk and ALARP, taken from The Health and Safety Executive (HSE) (1992) and Melchers (2001).

Whilst applying a cost to an individual’s life or weighing a life against financial costs may seem morbid, there are a number of advantages in applying an ALARP approach to risk management. The most important aspect is that ALARP puts the specific risk in a larger context, thereby acknowledging that as a society we need to accept risks and balance these against costs (financial, time, effort, etc.). In terms of the Covid-19 pandemic, variables such as the financial collapse of societies in lockdown, the effect on mental health as well as the risk of increases in domestic violence, all need to be taken into consideration when assessing the level of accepted risk instead of merely focusing on one risk.

However, a key factor in applying an ALARP approach is known uncertainty. Given that levels of risk are clearly defined (in accordance with the model above) how certain one is of these levels is critical in order to place the risk in the model. In the case of Covid-19, the uncertainties were large and exact risk measurements low.

Also, as highlighted by Flüeler and Seiler (2003) the accepted or tolerated levels differ depending upon if a risk is forced on an individual or if the individual has chosen to take the risk. I.e. in extreme sports the acceptable risk level can be high given that the individual both takes the risk and has to take the consequences. However, when states take decisions that affect individuals, considerably lower risks are required. According to Flüeler and Seiler (2003), the acceptable risk in such situations is 10 deaths per million people, i.e. considerably lower than the current rates of Covid-19.

In conclusion, therefore, whilst the precautionary principle is not necessarily a better approach than ALARP, the element of uncertainty is critical in deciding which strategy to choose. As declared by Pike et al (2020) “when there is significant scientific uncertainty about either the nature and magnitude of the consequences or likelihood of occurrence of these consequences or both, the Precautionary Principle would be the appropriate approach to be applied. If there is sufficient experience with operations and consequently known uncertainty, it is more suitable to use the ALARP approach.”

Footnotes

References

Ersdal, G. & Aven, T. (2008) Risk informed decision-making and its ethical basis. Reliability Engineering & System Safety, 93, 197-205.
Flüeler, T. & Seiler, H. (2003) Risk-based regulation of technical risks: lessons learnt from case studies in Switzerland. Journal of Risk Research, 6, 213-231.
The Health and Safety Executive, HSE (1992) The tolerability of risk from nuclear power stations, HMSO.
Jackson, W. & Steingraber, S. (1999) Protecting public health and the environment: implementing the precautionary principle, Island Press.
Kletz, T. A. (2005) Looking beyond ALARP: overcoming its limitations. Process Safety and Environmental Protection, 83, 81-84.
Lofstedt, R. (2003) The precautionary principle: Risk, regulation and politics. Process Safety and Environmental Protection, 81, 36-43.
Melchers, R. E. (2001) On the ALARP approach to risk management. Reliability Engineering & System Safety, 71, 201-208.
Pike, H., Khan, F. & Amyotte, P. (2020) Precautionary Principle (PP) versus As Low As Reasonably Practicable (ALARP): Which one to use and when. Process Safety and Environmental Protection, 137, 158-168.