Elizabeth Olsson | 9 April 2020
Over the last few days, Sweden has entered a new phase in the coronavirus outbreak. With 9,141 confirmed infections and 793 deaths as of April 9, national statistics paint a bleak picture of a nation not only in crisis but also in peril. The last several days have given skeptics of Sweden’s relatively “relaxed approach” to containment a reason to say, “I told you so,” and left both Swedes and the world wondering, is Sweden failing to protect its citizens from the coronavirus? The answer to this question— like all answers in the time of pandemic— is far from certain. Rather than weighing in on the efficacy of trusting citizens to do the right thing by working from home, avoiding public transportation, and self-isolating when they become ill, I would like to do something else. I would like to share my story. It’s a story of living in Sweden with a pre-existing medical condition and what that will mean as the Swedish healthcare system soon becomes saturated.
Life in a risk group
I was diagnosed with type-1 diabetes in March of 1993 after an “opportunistic virus” attacked my pancreas, shutting down my body’s insulin production system. If you are unfamiliar with the physiology of the pancreas – don’t worry; most people are – the pancreas produces enzymes and hormones that help the body process food. One of these hormones is insulin, which the pancreas releases into the body’s bloodstream to break down sugar. Without insulin, a person dies quickly and painfully, and for someone like me, who has had type-1 diabetes for twenty-seven years, I would die within seven to ten days. The reason I haven’t died yet is that I closely monitor my blood sugar and inject insulin into my body multiple times a day. I am also under constant medical care and in close contact with both a doctor and a nurse who help me manage my condition and prevent life-threatening side effects.
Until recently, Sweden has been a wonderful place to live with diabetes – as opposed to the U.S., where I was born and lived for approximately 25 years. In Sweden, all diabetes-related prescriptions, including insulin, are free of charge, so I never have to worry about how I will pay for lifesaving medications. In addition to routine diabetes care, I received excellent prenatal care before the birth of both of my children, and, any time I have experienced a medical problem, I have received exceptional care.
What’s the problem?
Under normal circumstances, Sweden is one of the best places on the planet to live with pre-existing conditions such as diabetes. However, we no longer live under normal circumstances placing my life and the lives of others like me – many of whom find themselves in far more precarious positions – at risk.
There are four reasons for concern. First, poorly controlled diabetes suppresses the immune system making it more likely for some people with diabetes to contract the coronavirus that leads to COVID-19 than the general population. While my blood sugar is relatively well-controlled, I still shake on the rare occasions I venture out in public to get groceries or medicine. The coronavirus is already in my community, and it’s only a matter of time before I am infected.
This leads to the second concern. Any viral infection is challenging for a person with diabetes to handle. Typically, a viral infection such as a cold or flu elevates a diabetic’s blood sugar and, in extreme cases, can lead to a deadly condition called ketoacidosis. If people with diabetes are more likely to die during a viral outbreak, this is why. Uncontrolled ketoacidosis is a death sentence, and even mild ketoacidosis requires immediate medical attention.
Which brings me to the third and more worrying problem for diabetics living in Sweden in the time of coronavirus: If I were to contract the coronavirus, and if I was unable to control my blood sugar and required immediate medical attention, the Swedish healthcare system may be so overwhelmed that I will not receive lifesaving care. This may seem hyperbolic and, trust me, I wish it were. Countries with saturated healthcare systems are already advising medical staff about whom to save, and Sweden is no different. In mid-March, Sweden began moving away from a first-come-first-served model of care to a triage model based on need and resource availability. Since demand for ICU beds has not yet exceeded availability in Sweden, triage standards are still theoretical exercises in medical ethics. But if other countries are any guide, Swedish doctors will soon need to consider whether it is better to save those in risk groups or those with no underlying medical conditions. I have no doubt most will save the latter.
Of course, the chances of me, or anyone else, needing emergency medical care are still relatively slim – most people who contract COVID-19 never end up in the hospital at all. The problem is, people with pre-existing conditions such as cancer, asthma, and diabetes are more likely than the average person to need medical care on any given day and that medical care is being diverted elsewhere. This is concern number four: When the healthcare system is inundated with COVID-19 patients, it becomes increasingly difficult to care for anyone else. The problem is, people will still have heart attacks, children will still fall from trees and break their legs, and diabetics like me will still need routine care in order to survive.
I spoke with my endocrinologist last week, and she told me that the hospital where I receive care was preparing to shut down the diabetes ward in order to reallocate medical staff to the ICU. If and when this happens, I will be cut off from routine medical care for my diabetes, and the only place I can hope to receive help is in the emergency room – somewhere I would like to avoid at all costs. I also spoke with my general practitioner, and he said something similar. There is no place for non-emergency care; if I develop a medical problem that is not life-threatening, I am on my own.
Is Sweden to blame?
It is too early to tell. The Swedish government is acting on advice from the Public Health Agency of Sweden (Folkhälsomyndigheten), who base their advice on projections of viral spread and anticipated hospitalizations. Of course, these projections are mathematical guesses based on scant data. Consequently, they cannot accurately predict whether or not the Swedish healthcare system with have enough ICU beds and ventilators when infections reach their peak. What we do know is that Swedish models are much more conservative than models generated in the U.S., the U.K., and other Scandinavian countries. If the Swedish models are correct, the virus is spreading at a rate that the healthcare system can accommodate. If the Swedish models are incorrect, then it is only a matter of time before the healthcare system collapses – and since Sweden has a scant 5.8 critical care beds for every 100,000 people, this is a real concern. Of course, the reality of Sweden’s coronavirus outbreak is likely to fall somewhere in between these two projected extremes.
In the absence of reliable models, the best way to predict rates of infection and hospitalization is to conduct testing on a massive scale. Unfortunately, Sweden has not done this. For several weeks, the government has limited testing to “hospitalised patients and people that work in healthcare or elderly care, with suspected COVID-19.” As a result, we simply do not know who has the virus. We do not know how many asymptomatic individuals are going to restaurants and gyms, and we do not know if those who are staying home with fevers and sore throats have COVID-19 or the flu. There was talk of increased testing last week, but there is no evidence that the Swedish government will conduct testing of the scale required to understand the rate of community spread. In the absence of this vitally important information, Sweden has become a petri dish for infection. There is no escape because too many people are circulating freely, infecting others.
While Sweden’s healthcare system is not yet saturated, it is only a matter of time before Swedish doctors are making decisions about who should live and who should die. Who should receive a ventilator? Who is entitled to a bed in an intensive care unit? Who should be admitted to the hospital at all? When doctors are forced to make these decisions, the life expectancy of people like me, people with pre-existing conditions, will be dramatically reduced. While I hope that day will not come, I know it is fast approaching.
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