JFOA Journal

To put Sweden’s outcome in perspective, imagine two alternate scenarios. One resembling the average European pandemic impact (11% excess mortality) and one resembling Sweden’s. If Sweden had experienced the average European outcome, it would have seen roughly two to three times as many excess deaths as it did. Conversely, if countries with far harsher restrictions had matched Sweden’s outcome, tens of thousands of lives might have been saved in those countries (or at least, deaths deferred beyond 2022, we cannot know yet). This is paradoxical at first glance. Stricter measures did not translate into fewer deaths in the long run, and the country with one of the least stringent approaches had one of the fewest excess deaths. Such data challenges the initial narrative that Sweden’s strategy was a disastrous gamble. On the contrary, by this measure, Sweden outperformed the rest.

Other Impacts Beyond Mortality: A full comparison of Sweden versus other countries must look not only at mortality but also at the broader societal impacts of the pandemic and responses. Here, Sweden appears to have advantages precisely because it avoided many of the harshest measures. For instance, education outcomes in Sweden were far less impacted than elsewhere. Swedish elementary and middle schools remained open all throughout, while many countries kept children at home for months or shifted to inferior online learning. The result is that Swedish children suffered minimal learning loss. A study by Hallin et al. (2022) found no learning loss in Sweden during the pandemic for primary school students. Assessments of reading and word decoding skills showed that Swedish children’s performance in 2020–2021 was not significantly lower than pre-pandemic cohorts. Even children from low socioeconomic backgrounds, who in many countries were disproportionately hurt by school closures, did not experience learning declines in Sweden under the open-school policy. In contrast, another study by Betthäuser et al. (2022) reports that students worldwide lost on average more than one-third of a school year due to closures and disruptions. Many countries will suffer from these learning deficits, which are particularly pronounced in places that kept schools closed for long durations. Some countries in Europe and the U.S. had intermittent closures lasting a year or more in total. The World Bank and other organisations have warned of a generational catastrophe in education, with learning poverty increasing in low- and middle-income countries due to prolonged school shutdowns. While high-income countries provided remote education, outcomes were still worse than in-person schooling. By keeping schools open, Sweden spared its youth this educational setback. Only grades 10–12 went remote for some time. This is an important benefit that might not show up in death statistics but has long-term implications for human capital and well-being.

Economically, Sweden fared exceptionally well. The pandemic caused a global recession in 2020 as lockdowns and uncertainty suppressed activity. Sweden was not immune to these global forces; its economy, being very open and trade-dependent, saw GDP decrease as exports fell and consumer spending dipped. However, Sweden’s GDP decline in 2020 was smaller than that of most of Europe, and its recovery was faster. By the end of 2021, Sweden’s economy had not only rebounded but grown slightly above its pre-pandemic size, unlike many peers. Analyses by the OECD and others indicate that while the world economy in 2021 was still about 2.9% below the pre-pandemic trend and the Eurozone economy about 2.5% smaller, Sweden’s economy was approximately 0.4% larger than its pre-pandemic baseline. This occurred despite Sweden implementing far less fiscal stimulus than most countries. By comparison, the United States economy was still 1.2% below trend by the end of 2021, and many European countries lagged even further. In concrete terms, Sweden experienced a milder downturn and a quicker return to growth. Unemployment in Sweden did rise in 2020 but not drastically more than usual, and many businesses, especially in retail and hospitality, survived without the mandated closures that devastated such sectors elsewhere. Government finances in Sweden were also less strained: while many countries took on enormous debt to fund furlough schemes and bailout packages during lockdowns, Sweden’s fiscal response was more moderate, leaving it in a stronger fiscal position post-pandemic. Naturally, Sweden’s economy still suffered somewhat from the pandemic’s global impact (for example, its manufacturing and export industries were hurt by supply chain issues and reduced foreign demand), but it avoided the self-inflicted economic damages of domestic shutdowns.

Public Health and Mental Health: Another major area of impact is public health beyond COVID. Lockdowns and strict measures, while aiming to curb the virus, had side effects on mental health, healthcare access, and social well-being. Mental health problems rose worldwide during the pandemic. The isolation, fear, and disruption caused a spike in anxiety and depression: The World Health Organization reported a 25% increase in the global prevalence of anxiety and depression in the first year of the pandemic alone (WHO, 2022). Countries that endured long lockdowns often saw significant deteriorations in psychological well-being. For instance, youth mental health surveys in 2021 found very high levels of persistent sadness and hopelessness. In the U.S., over a third of high schoolers reported poor mental health during the pandemic and incidences of self-harm and suicidal thoughts increased (CDC, 2022). While Sweden certainly experienced bad times due to the pandemic, it did not subject its population to the same degree of isolation. People in Sweden could largely continue seeing friends or family, going outside freely, and maintain a fairly normal life. This mitigated some mental health harms. Sweden, by avoiding stay-at-home orders, spared many people the worst of these effects. Surveys in Sweden during 2020 showed some increase in worry and loneliness, but not as pronounced as in countries under lockdown. Moreover, maintaining open schools helped protect children and adolescents from some mental health harms associated with long periods out of school and parents forced to stay at home during what should have been school days.

There were also indirect health effects of strict pandemic measures. In many countries, hospitals postponed elective surgeries, cancer screenings, and routine care during lockdown periods, leading to untreated conditions and later-stage diagnoses. Fear of the virus kept people from seeking care even for urgent issues like heart attacks or strokes, contributing to non-COVID excess deaths. Alcohol and substance abuse reportedly rose in some countries as a coping mechanism during confinement. Domestic violence incidents increased as victims were trapped at home with their abusers. A United Nations report in 2020 warned of a shadow pandemic of domestic violence amid lockdowns. While Sweden likely faced some of these issues simply due to the global COVID stress, the continuous functioning of society at a moderate level may have reduced the severity of these secondary effects. Healthcare services remained accessible so people could leave home and seek help. Police data in some locked-down countries showed spikes in domestic disturbance calls during confinement. It would be worth examining Swedish data for comparison. Preliminary indications are that although domestic violence remained a concern, Sweden did not see the same jump correlated with a lockdown period, since there were no stay-at-home laws to trap people.

Thus, on a range of societal indicators, from economic output to student learning to mental and physical health side effects, Sweden appears to have mitigated the pandemic effects more smoothly than many nations that imposed harder restrictions. Its strategy sought to minimise disruption to normal life, consistent with a reasonable degree of infection control. By keeping much of society up and running, Sweden avoided some of the worst collateral damage of the pandemic response. Crucially, these benefits did not come at the expense of a high death toll. Quite the opposite, as we have seen with the excess mortality data. This combination of outcomes is what makes Sweden’s case so compelling and worthy of study: it challenges the assumption that there is an inevitable trade-off between saving lives and preserving normal life. The common narrative was that Sweden chose economy over lives, whereas others chose lives over economy. In reality, Sweden managed to preserve both lives and a degree of normalcy better than most. To understand how this happened, it is essential to examine the policymaking processes and frameworks behind these pandemic policies. The following sections will discuss how different governance structures and mindsets formed these different outcomes. Notably, the contrast between Sweden’s multicriteria long-horizon thinking and many other countries’ single-criterion short-term thinking.

Policymaking in Public Health Crises

A critical factor behind Sweden’s unique approach was the structure of policymaking and governance in the country’s pandemic response. This can be contrasted with how decisions were made in many other countries, highlighting how institutional setup and mindset can lead to very different policy choices during the same crisis.

Sweden’s Decentralised Expert Agency Model: Sweden’s public health policymaking is anchored by expert agencies with statutory independence. In a health emergency, Folkhäls omyndig heten takes the lead in formulating recommendations. During COVID-19, the agency became the primary architect of Sweden’s response. The government is role was largely to support and implement the agency’s advice, rather than to direct it. This model meant that decisions were driven by public health experts who were accustomed to weighing health measures against societal norms and scientific evidence, rather than by politicians facing immediate public pressures. Sweden also has a tradition of constitutional constraints on government power in peacetime. Before COVID, there was no legal provision for a general lockdown of citizens. Quarantine powers existed mainly for individuals who were sick, not for whole healthy populations. It was only in early 2021 that Sweden hastily introduced a temporary pandemic law to permit stronger measures such as capacity limits in shops or closing specific venues, but even that law did not allow for broad stay-at-home orders of the kind imposed in many other countries. Additionally, Sweden’s constitution protects freedom of movement and the right to education, making sweeping closures legally difficult to justify except under a declared state of emergency, which Sweden did not invoke during COVID. The Swedish government chose not to declare an emergency, instead operating within normal administrative law.

The policymaking structure in Sweden also emphasised consensus and public trust. The authorities communicated in a matter-of-fact, calm tone, with daily press conferences providing updates and rationale for guidelines. Surveys during the pandemic indicated that a majority of Swedes trusted the public health agency and complied with its advice (even absent legal coercion). The Swedish strategy was sometimes described as aiming for sustainable compliance: by not overreaching with draconian rules, they hoped to maintain public buy-in for the long haul. Indeed, one can argue that this strategy treated the pandemic as a marathon, not a sprint, in contrast to the more reactive strategies seen elsewhere.

Other Countries’ Emergency Command-and-Control- Structures: In many other European countries, policymaking during the pandemic quickly took a more top-down, politicised turn. Governments formed emergency cabinets or task forces; normal legislative processes were often sidestepped via decrees or special laws. In the UK, for example, pandemic policy was decided by the Prime Minister and a handful of ministers advised by select scientific committees (SAGE, the Scientific Advisory Group for Emergencies), with Parliament given little opportunity to debate before lockdowns were imposed. A similar pattern occurred elsewhere: political leaders, worried about an exponential spread, often centralised authority and acted quickly. While expert advice was sought, it frequently came from epidemiologists or modellers whose focus was the virus trajectory. Other domains of expertise (economists, mental health experts, educators) were usually not equally represented at the decision table in the critical early weeks. This meant that the policymaking structure was siloed, focused primarily on virology and acute healthcare capacity, with limited integration of other perspectives and not toward a multidisciplinary assessment of overall well-being. As one analysis noted, many countries acted in an apparently uncoordinated manner initially, with inconsistent measures even between neighbours, and decisions to lock down were not always based on transparent criteria but often on political and public pressure (Ekenberg et al., 2021). A sort of bandwagon effect occurred: once some countries locked down and were perceived to be successful (e.g. China’s Wuhan lockdown, then Italy’s), others followed suit in quick succession, fearing regret if they did not. This political dynamic can be described as better-safe-than-sorry, but sometimes it manifested as political leaders fearing blame more than they feared the harms of lockdown. In risk psychology, this is akin to aversion to visible loss: a death toll climbing on TV is a highly visible crisis for which officials might be blamed, whereas a rise in depression or a recession, being slower-moving and less direct, might not be immediately blamed on policy choices. Thus, the incentives in many policy structures skewed towards minimising COVID deaths at all costs, because those were being closely tracked in real time, easy to display and hard to refute on TV.

The institutional checks and balances also weakened in many places. Courts, legislatures, and civil society often rallied behind the executive in the interest of national unity against the virus, or they were undercut by states of emergency. This left few voices to advocate for considering alternative approaches. In some cases, experts who cautioned against overzealous measures or who pointed out the downsides were marginalised or accused of downplaying the threat. The public arena did not always allow for a balanced debate, especially in 2020 when fear was high. This environment nurtured single-criterion thinking: public health (narrowly defined as stopping COVID) became almost the sole lens of policymaking.

Precautionary Principle vs. Evidence-Based Balance: The decision-making divergence can also be framed as differing applications of the precautionary principle. In a scenario of uncertainty and potentially catastrophic outcomes, a precautionary approach argues for erring on the side of caution, i.e. doing more and sooner, to mitigate the worst-case scenario. Countries like New Zealand excelled at this by opting for a strict elimination strategy (aiming to reduce cases to literally zero) given the uncertainty. Sweden’s decision-makers took a different approach: they certainly did not dismiss the virus as harmless, but they also gave weight to the certainty of harm that extreme measures would cause. In other words, while much of the world fixated on the uncertain, worst-case fatalities from COVID, Sweden’s health officials also considered the certain, multi-faceted damage that draconian restrictions would inflict on society. This is a more evidence-based and pluralistic approach to precaution: it tries to minimise overall harm, not just harm from one source. For instance, Sweden’s officials explicitly mentioned early on that lockdowns could lead to long-term health problems by increasing unemployment (which is correlated with worse health outcomes), that school closures would harm children, and that severe curbs on movement could be unsustainable as the populace might eventually reject them or suffer fatigue. Folkhälsomyndigheten often raised the point that any measures must be feasible to keep in place, not just for weeks but potentially for many months, a valid concern given that the pandemic has last-ed over two years (and is not yet declared over in parts of the world). Many other policy-makers initially treated the pandemic as a short-term crisis where normal life should be paused for a few weeks and then return to normal after the virus was successfully sup-pressed. “When people have stopped coughing, it’s business as usual again.” When that strategy failed, they faced the dilemma of re-imposing measures repeatedly. Sweden’s structure, by planning for a long game, arguably avoided this situation.

It is also interesting that Sweden’s strategy was not entirely opposite to international expert circles. Many epidemiologists advocated approaches that were less invasive than full lockdowns. The difference is that Sweden’s system listened to and empowered those voices. The Great Barrington Declaration (an open letter in Oct 2020 by several epidemiologists and public health scientists from Harvard, Stanford, Oxford, etc.) is an example of an alternative strategy (focused protection of the vulnerable while allowing society to function for others) that aligns in spirit with multicriteria thinking. While that declaration was controversial and heavily criticised by proponents of lockdowns, Sweden’s actual policy in 2020 was not identical but closer to that approach than perhaps any other country. In other countries, even suggesting such ideas was often dismissed at the time. Folkhälsomyndigheten, by contrast, maintained a dialogue about how to protect nursing homes without shutting down schools and businesses completely. In short, the Swedish policymaking structure inherently forced a broader deliberation: the public health agency had to consider overall public health, not just COVID. By mandate, they oversee things like mental health, other diseases, etc., so they naturally were conscious of those aspects. In countries where COVID response was managed by a single-criterion strategy focused on the virus, that breadth of perspective was lacking.

Transparency and Accountability: One final structural aspect is accountability and evaluation. Sweden established its independent Corona Commission relatively early (in the summer of 2020) to investigate and report on the handling of the pandemic. This body provided interim reports during 2020 and 2021 and a final report in October 2021, offering critique and recommendations. This shows a structural commitment to learning and accountability even during the crisis. Other countries too would have inquiries (like the UK’s planned COVID inquiry, etc.), but often much later. The presence of a commission might have also influenced decision making by highlighting areas needing improvement (for example, after severe criticism, Sweden rightfully but very late intensified measures to protect the elderly by the fall of 2020). In contrast, some countries were so consumed by crisis management that little self-evaluation occurred until the worst was over. The constant self-reflection in Sweden may have helped correct errors where needed without abandoning the fundamental strategy.

In summary, Sweden’s decision structure, characterised by expertled policy, legal constraints against extreme measures, voluntary compliance, and a multi-dimensional notion of public health, enabled a response that inherently balanced multiple criterion. Many other countries, by centralising authority in political hands and framing the crisis as singularly about defeating COVID at all costs, predisposed themselves to a one-dimensional, shortterm strategy. This structural difference is key to understanding why responses differed and why outcomes like excess mortality converged paradoxically in favour of the more moderate approach. Next, we will delve deeper into the concept of single-criterion thinking and how it manifested in pandemic policies, and contrast that with what a multicriteria approach entails.

The Risks of Single-Criterion Thinking

Single-criterion thinking refers to a decision-making approach that fixates on one metric or objective to the exclusion of other important considerations. In the context of the COVID-19 pandemic, the singular criterion that drove many government responses was the short-term COVID-19 caseload and death count. Policies were often judged almost entirely by how effectively they could reduce the viral spread and prevent immediate COVID deaths. While saving lives is a paramount goal, the problem with this tunnel vision is that it can lead to policies that achieve the goal in the narrow sense but cause equal or greater harm in other domains. It also risks oversimplifying a complex problem: treating a pandemic as if the only thing that mattered was one virus’s death toll, rather than viewing it as a multifaceted societal crisis. In this section, three common mistakes by single-criterion thinking are highlighted.

One-Dimensional Metrics

Throughout 2020 and 2021, many officials and media outlets highlighted metrics like the R number (virus reproduction rate), daily new case counts, hospital occupancy, and daily reported COVID deaths. When these numbers rose, pressure mounted to impose or tighten restrictions; when they fell, restrictions eased. This feedback loop essentially made policy a function of one set of disease indicators. Little comparable quantitative weight was given to metrics of economic health (e.g., unemployment rate), educational progress (e.g., days of school missed), or mental health (e.g., rates of depression or anxiety). Indeed, some leaders explicitly stated that they were choosing human life over the economy. While sounding like a noble sentiment, it was a false dichotomy, ignoring that economic downturns also cost lives and well-being. In the heat of the moment, it may have seemed that every other concern was secondary and could be deferred (“We will deal with the economic and social fallout later; right now, we must stop COVID at any cost”). However, as months went by, it became clearer that “later” would be too late for many impacts. Many businesses would never recover, especially small and family-run ones. Some children would never fully catch up in school, and some health damage (suicides, advanced cancers from missed screenings, etc.) was irreversible.

Cost-Benefit Imbalance

By mid-2020, a few scholars began pointing out that many COVID measures were not subjected to rigorous cost-benefit analysis, the kind normally applied to major public policies. Allen (2021) early critically reviewed over 90 studies and found that most had overestimated the benefits of lockdowns and underestimated the costs. He noted that initial projections of lockdown benefits assumed unrealistically that populations would remain completely susceptible and not change behaviour unless mandated (whereas in reality, voluntary behaviour changes account for much virus mitigation). He also highlighted that many studies made heroic assumptions about the value of lives saved (using models that valued any life extension equally, even if only a few months for someone terminally ill, which can dramatically inflate the benefit side in calculations). When Allen performed a cost-benefit analysis in terms of life-years for a country like Canada, he found that the cost in life-years of lockdown (due to things like reduced healthcare, economic recession impacts, suicides, etc.) exceeded the life-years saved from COVID by lockdown by a factor ranging from about 3.6 to as high as 282 under plausible assumptions. In other terms, this means the collateral damage of lockdowns could be several times worse than the disease impact it prevented, in terms of years of life lost or impaired. He went so far as to suggest that lockdowns may rank as one of the greatest peacetime policy failures in modern history if evaluated on that basis. While that claim is strong, it underscores the extent to which focusing on one criterion (immediate COVID lives saved) and ignoring others (life-years lost elsewhere) can mislead policy.

Another way to see the imbalance is by comparing predicted lives saved versus actual. The infamous Imperial College model that influenced the UK and the US predicted that lockdowns would save hundreds of thousands of lives in each country (Ferguson et al., 2020). In reality, by the end of 2020, the UK still had one of the highest COVID death tolls in Europe despite multiple lockdowns, and the excess mortality suggests that even if many COVID deaths were delayed in the short run, other excess deaths or later COVID waves filled in much of that gap.

Overlooked Criteria

Let us look in more detail at four of the criteria that were underemphasised in typical single-criterion thinking:

Economic well-being: It is well-established in public health literature that economic downturns and poverty correlate with worse population health and higher mortality in the long run. Unemployment, for example, is associated with higher rates of suicide, cardiovascular disease, and overall mortality. The International Monetary Fund noted that the 2020 recession was the worst since the Great Depression in many countries. By prioritising COVID suppression above all, governments knowingly triggered recessions (some policy-makers said that “We can worry about the economy later”). While emergency financial aid blunted some immediate suffering, the long-term effects include ballooning public debt (which can crowd out future social spending), lost educational and employment opportunities for a generation, and small business failures. Sweden was not immune to a global recession but kept more of its economy functioning domestically, likely reducing business closures. To illustrate, countries like Spain or Italy saw GDP plunges around 10–12% in 2020; Sweden’s fell 2.8%. The Eurozone unemployment rate spiked while Sweden’s did not dramatically diverge from its usual (albeit high) levels. These differences mean fewer life disruptions. On the flip side, those countries that did “everything” to suppress COVID ended up still having similar total deaths (since once they reopened, the virus often came roaring back), plus economic scars. Viewing the concept of maximising health broadly, maintaining economic stability should have been a key criterion as well. Not just morally (to avoid hardship) but pragmatically for health (as economic distress translates directly to ill health).

Education and children’s welfare: This criterion was shockingly absent from many early pandemic decision processes. Schools were often closed with little consideration of their essential role beyond academics (food security for children, social development, safe havens from abusive homes, etc.). The assumption was that children are resilient or that remote learning could substitute. Only later did the magnitude of learning loss and psychosocial harm to children become clear. Students in the U.S. for example are estimated to be months behind in math and reading, with disadvantaged students suffering most. Some countries essentially lost an entire year of normal schooling. From a multicriteria perspective, protecting the younger generation’s development and future should have weighed heavily. Sweden implicitly gave this criterion more weight by keeping schools open (up to 9th grade) throughout 2020. The result, as discussed, was no measurable learning loss in primary school reading, versus severe losses elsewhere. The long-run health and prosperity of today’s children is a criterion that arguably was comparable to the shortrun survival of the elderly, but it was not framed that way in the heat of the crisis. Society faced a trade-off between the immediate risk to older people and the long-term well-being of the young. A multicriteria approach would have sought a balance.

Mental health and social fabric: We have already cited evidence that lockdowns increased mental health service needs and stress disorders. Social isolation, loss of community activities, and the general climate of fear all took a toll. In some countries, funerals, weddings, and religious gatherings were banned or severely limited, yielding an irreparable loss to social cohesion and human dignity. The fabric of society was stretched. A multicriteria approach would formally register these as costs to weigh: how many cases of depression is too high a price to pay for preventing one case of COVID? It is a difficult comparison, but neglecting it entirely means those depression cases were effectively ignored. Sweden did impose some limits (e.g., at times limiting gatherings to 50 or even 8 people in late 2020), so it was not fully spared the social restrictions. But because there was no blanket stay-home order, the ability to maintain some social contact (in a safe manner) likely alleviated the worst loneliness. The difference is qualitative: being legally forbidden to visit a friend or relative (as in lockdowns) versus being advised to use caution but ultimately allowed. The latter respects mental well-being and personal judgement, whereas the former prioritises infection control at any psychological cost.

Non-COVID healthcare: One particularly important criterion is maintaining healthcare for all conditions. Lockdowns and the overwhelming focus on COVID led to the cancellation of many non-urgent medical appointments. However, untreated chronic conditions or undiagnosed cancers can become lethal. Data from various health systems showed drops of 20–40% in new cancer diagnoses in 2020, implying many cancers went undetected until later stages. Heart attack and stroke admissions also dropped, implying people were either not reaching the hospital or not going in time. These will translate to higher mortality outside COVID. Indeed, some analyses of excess mortality in late 2021 and early 2022 in Europe noted a portion of excess deaths that were not COVID-related, potentially reflecting such deferred care. If decision-makers had explicitly considered all-cause long-term mortality as their criterion, rather than just short-term COVID mortality, they might have adopted less disruptive measures. Sweden’s all-cause excess was low, suggesting they did not see a big spike in non-COVID deaths due to their approach (though Sweden did struggle in spring 2020 with acute care load, they never formally rationed care to our knowledge, whereas some places effectively had to at peak moments).

In countries with a single-criterion focus, fear and worst-case projections often dominated the decision making, sidelining normal policy analysis. While it is natural for standard procedures to be initially short-circuited in COVID circumstances, it is not a time for single-criterion analyses. On the contrary, it is the time for formal multicriteria analyses to shine. Narratives such as “if it saves even one life, it is worth it” were politically popular but practically grossly misleading. No policy can be evaluated by that standard. If literally saving one life justified infinite cost, we would set speed limits at 5 mph (to save accident victims) or ban alcohol outright (to prevent any drunk-driving deaths), which we do not because society balances trade-offs. In COVID, however, this balancing logic broke down initially. Media contributed by extensively reporting COVID deaths and stories, while largely ignoring the voices of those harmed by restrictions (who were less visible). This asymmetry made the criterion of COVID suppression hyper-salient.

It appears that Sweden, if not by formal process then by culturalpolitical ethos, applied somewhat more of a multicriteria perspective. The Swedish authorities repeatedly mentioned that public health is holistic. It encompasses mental health, economic stability, and other medical outcomes, not just the virus. They recognised early that trying to completely suppress COVID at the expense of everything else might cause a public health disaster. This can be seen as a kind of multicriteria decision analysis (MCDA) approach, even if they did not use that terminology. Essentially, they tried to optimise a vector of objectives: minimise COVID harm plus minimise societal disruption plus maintain trust and compliance, plus keep the economy and schools running as normally as possible. Of course, they could not achieve all objectives perfectly (COVID still caused harm, and they did implement some restrictions), but their balanced approach arguably found a better trade-off than many other strategies did.

The final outcomes that we have reviewed (low excess mortality, preserved economy, preserved education, etc.) indicate that Sweden’s de facto multicriteria strategy was successful in optimising overall well-being through the crisis. On the contrary, the single-criterion approach of others may have reduced their COVID death count marginally in the very short term, but not enough to outweigh the damage when looking at the big picture by mid-2022. The fact that by mid-2022 those countries often had higher total mortality suggests that even the singular goal (fewer deaths) was not optimised in the long run, making their extra sacrifices even harder to justify.

To avoid misunderstanding, it is not that lockdowns and strict measures had zero effect. They did slow down transmission temporarily (3.2% fewer deaths in the first wave on average), and more in some cases. In certain contexts, initial lockdowns might have prevented hospitals from collapsing, which is a legitimate short-term goal, although Sweden’s healthcare system did not fold. Again, the one critical mistake in Sweden was the bad state the elderly care homes were in: management, staffing and emergency planning were all subpar. The elderly care was not resilient to community transmission. Yet there were no regulations on respiratory protection or rules that staff with sick people in their household should stay home. However, after that immediate crisis, the continuation or reinstatement of broad lockdowns became increasingly hard to justify as more data emerged about the virus’s true fatality rates: substantially lower than initially feared for the general population, though still severe for the elderly, and as the collateral harms mounted. Many countries, however, found it politically difficult to change course. They were in a sense locked into lockdowns by the precedent set and the public expectation that any surge must be met with the same response. This is another pitfall of single-criterion thinking: it can lead to policy inertia where one keeps doubling down on the same approach because the framework does not allow considering alternatives.

In summary, single-criterion thinking in the pandemic led to disproportionate responses: measures that were extreme relative to their diminishing benefit. This captures the self-defeating nature of an overly narrow strategy. By focusing only on shortterm fatalities as the only criterion considered, one might cause long-term fatalities through other pathways, thereby defeating the broader goal of saving lives. The challenge, then, is how to restructure decision making toward a multicriteria paradigm, which the final section will discuss.

Toward Multicriteria Thinking in Future Crises

The lessons from the Swedish experience and other countries’ missteps point to a clear recommendation: future pandemic responses (and crisis responses in general) should adopt a multicriteria decision making framework as standard. This means that instead of one single metric guiding policy (like daily or weekly infections or deaths), a set of relevant criteria is jointly considered and weighed when choosing interventions. Such criteria should reflect the diverse domains of impact, including direct health outcomes both from the disease in question and other health issues, economic conditions, education, mental health, civil liberties, and social equity. Decision-makers should employ tools from decision science, such as MCDA, to evaluate policy options on multiple fronts.

MCDA is since long being used in various fields, not least in policymaking such as environmental policy (balancing economic development vs. environmental protection vs. social impact) and healthcare resource allocation (e.g., weighing cost, efficacy, and equity of treatments). Applying it to pandemic policy would have involved steps such as identifying all major objectives, developing metrics or indicators for each, assessing how different interventions score on each objective, and possibly assigning weights to reflect priorities or societal values. Importantly, it also involves engaging diverse experts and stakeholders so that all perspectives (medical, psychological, economic, ethical, etc.) inform the deliberation.

In practice, how might this look? One approach is to establish a pandemic task force that is inherently multidisciplinary. Instead of just virologists and epidemiologists, it would include economists, sociologists, child development specialists, mental health professionals, ethicists, and representatives of vulnerable groups. This broader committee would issue recommendations that explicitly discuss trade-offs. For example, if considering closing schools to curb viral spread, the committee’s analysis would include not just the estimated reduction in COVID cases, but also the projected loss in educational attainment and mental health outcomes for children, and perhaps even quantify expected future life expectancy loss due to educational setbacks (since education level correlates with long-term health and longevity). A multicriteria scorecard might show that closing schools scores well on infection control but very poorly on education and mental health, whereas keeping schools open with precautions scores moderately on both infection control and education. Policymakers could then choose the option that yields a better overall balance, likely the latter. This systematic approach contrasts with the ad-hoc way in which many policy decisions were made, under pressure, during COVID-19. But being under pressure is not an excuse, it is a reason for bringing in ever-stronger decision-analytic tools.

There are already some proposals for formal frameworks. The author has, together with colleagues, participated in several projects aiming at multi-dimensional COVID-related decision making at the national policy level. One project proposed an MCDA model for evaluating mitigation measures, highlighting the need to consider criteria like healthcare capacity, public compliance, economic cost, and social well-being at the same time (Ekenberg et al., 2021). Another study discussed a riskbased decision framework for pandemics that includes societal and economic dimensions, not just epidemiological ones (Ekenberg et al., 2021). A third project suggested a policy for Jordan (Ekenberg et al., 2022). The same team wrote the national policy for Botswana (unpublished), which unfortunately was not followed through, as single-criterion political reasoning took over. Comparative studies of Sweden, Romania, Jordan and Botswana (Danielson et al., 2022b; Ekenberg, 2021) confirm the need for a more formal policy-analytic approach, which was then developed in a European Union project under the COSC Fast Track Funding and subsequently recommended as best practice in the EU by the European Open Science Cloud (Danielson et al., 2022). The framework uses scenarios and weighting to handle the uncertainty and value judgements inherent in such decisions. A multicriteria approach is also consistent with the principle of proportionality in public health. It means that the intrusiveness of a measure should be justified by the scale of the threat and balanced against the measure’s expected benefits. If an intervention causes more harm than the harm it seeks to prevent, it fails the proportionality test. Ensuring proportionality naturally requires considering multiple harms and benefits, not just one. Many critics of strict COVID measures argued they were disproportionate. For instance, banning outdoor activities might only marginally reduce the spread since outdoor transmission is minimal, yet it has a major cost to wellbeing, thus not being proportionate. Wearing masks outdoors was more of a political invention than a transmission-reducing one since the virus, even in the form of aerosol drops, is quickly dispersed in outdoor environments. A multicriteria analysis would catch this imbalance because the cost in one criterion (wellbeing) would significantly outweigh the marginal gain in another (infection control).

Institutionalising Multicriteria Thinking

It is not enough to know in hindsight; structures must be in place beforehand. One idea is that national pandemic plans and the WHO’s guidance should explicitly incorporate multicriteria objectives. Currently, pandemic preparedness plans often focus on how to ensure healthcare can cope and how to contain the pathogen. These plans should be broadened to ensure the continuity of essential services (like schooling), safeguarding of mental health, and maintenance of civil liberties to a reasonable extent. If such goals are built into plans, then when a crisis hits, officials are reminded that their job is not only to minimise infections but also to keep society functioning in a broader sense.

Another mechanism is requiring impact assessments for any major public health order. Just as big construction projects require environmental impact assessments, one could mandate that before, say, ordering a lockdown or closing schools, the government must publish an assessment of the likely economic, social, and health impacts of doing so, as well as of not doing so. This forces a comparison on multiple grounds. During COVID, decisions were often rushed, but even a rapid assessment noting “This measure may prevent X deaths over Y months but will likely cost Z jobs and disrupt education for W million children” would have provided more context for policymakers and the public.

Public Communication and Narratives

Multicriteria decision making could also extend to how leaders communicate in crises. Instead of one-dimensional slogans (such as “zero COVID” or “whatever it takes”), messaging could transparently acknowledge trade-offs and rationale. One reason Sweden maintained public trust is arguably because their officials spoke to citizens as adults, acknowledging uncertainties and asking for compliance in a voluntary manner. In some other countries, leaders resorted to fear-based messaging to ensure compliance, which heightened the sense of singular focus on the virus. A more measured communication could say: Our goal is to protect health in the broadest sense. We must shield those at risk from the virus while also protecting our children’s education and mental health. Thus, we will take these steps and avoid those steps, because we judge this course best for overall well-being. Such honesty can earn trust and also manage expectations, while it is of course not easy to convey. But if people understand the multifaceted goals, they may better appreciate why certain sacrifices are or are not asked of them.

Global and Equity Considerations

It is also important to consider that single-minded policies had different impacts across different groups. For example, lockdowns were a luxury of the affluent (who could work from home) while many lower-income workers lost jobs or had to expose themselves anyway as essential workers. School closures hurt disadvantaged children far more than well-off children who had better remote learning resources. So, a multicriteria approach is inherently more equitable because it does not sacrifice one group (e.g., children or the poor) for the benefit of another exclusively. It treats societal well-being as a whole. This is aligned with the principle of distributive justice in health policy: burdens of policies should not fall unnecessarily unfairly on certain groups. In retrospect, one could argue that the burdens of aggressive COVID suppression were not equitably distributed. Sweden’s milder approach, by keeping society largely open, possibly avoided some of those inequities (though Sweden did suffer higher early nursing home deaths, an inequity in itself, hitting the frail elderly).

Flexibility and Iteration

A multicriteria framework is not static; it should be dynamic and updated as new information comes in. Early in COVID, one justification for lockdowns was to buy time to learn about the virus. By the summer of 2020, we knew more. For in-stance, that outdoor spread was rare, that masks might help indoors and that the elderly were at high risk while children were at very low risk for severe outcomes. A multicriteria approach would iterate: perhaps initially you weigh infection control highly because of worst-case fears, but as you learn the infection fatality rate is lower than feared for most people, you might reduce the weight on that and increase the weight on restoring normal life. It appears some countries did not effectively rebalance their strategy as knowledge improved; they got stuck in one mode. Sweden’s approach, interestingly, did adjust in some ways. When evidence emerged in late 2020 that masks could actually have some limited benefit in crowded indoor settings, Sweden updated its guidelines to recommend masks on public transport during rush hours (though late and not strongly enforced, it showed flexibility). In many countries, though, the concept of masks was misused as a political sign of efficacy. It is well documented that properly constructed and tightly fitted masks provide protection for individuals who are regularly exposed to newly infected people emitting virus-laden droplets. These droplets, typically larger than 5 micrometres in diameter and transmitted over short distances (less than 1.5 metres), can be effectively blocked by high-quality masks. In contrast, low-cost generic masks with loose or inconsistent fit offer minimal protection against viral spread, though they may carry symbolic or political significance. Importantly, such masks are largely ineffective against aerosol transmission, which involves smaller particles (less than 5 micrometres) that can travel beyond 1.5 metres. This distinction guided Sweden’s public rules of thumb, which targeted maintaining distance in indoor public spaces rather than unreflective universal masking. Even so, there were exceptions. On domestic flights, for instance, masks were required, reflecting the authority of airlines to enforce their own regulations. However, this requirement had limited practical impact, as the droplet-sized particles that masks are designed to block were already being caught by the standard HEPA filter systems used in aircraft ventilation. When vaccines arrived, Sweden moved quickly to vaccinate the elderly (achieving high uptake) and then gradually phased out even its mild restrictions by mid-2021, albeit to reinstate some restrictions in December 2021 when facing the fast spread of the Omicron variant. Those were phased out when COVID-19 was downgraded from a pandemic in March 2022. However, other countries more frequently and with less deliberation oscillated between extreme lockdowns and then sudden liftings, rather than deliberated transitions guided by multiperspective analyses.

The Next Disaster

While this article focuses on pandemics, the argument extends to any large-scale crisis. Whether it is a pandemic, a climaterelated disaster, or a security threat, policymakers face multiple objectives and uncertainties. The experience of COVID-19 is a case study of the importance of maintaining breadth of perspective. Governments and international bodies should welcome the lesson.

Some are starting to acknowledge it. For instance, some public health leaders cautioned against repeating school closures given the harm done previously. The phrase “we must learn to live with the virus” began to replace “crush the virus now at all costs,” implicitly moving towards multicriteria thinking since living with the virus means balancing normal life with disease control. The key is to institutionalise these lessons so that initial responses to the next crisis are more measured and well-prepared.

Sweden’s outcome supports the idea that a well-considered, moderate approach can outperform more heavy-handed ones. It demonstrates that multiple goals can be pursued simultaneously. It is possible to keep society reasonably open and protect the most vulnerable lives, rather than viewing it as an either/or situation. However, it is important to avoid the simplistic takeaway that lockdowns never work or do nothing, and all will be fine. That is not what research shows or MCDA approaches preach. The real lesson is about balance and wisdom in policy. Partial lockdowns and restrictive measures were an understandable first reaction to a dire situation, but they overshot because they were not continually evaluated against all harms. The lesson is to continuously evaluate policies. Use multiple criteria to decide, and aim for strategies that are robust across many goals, not just excellent at one goal and disastrous at others. One concrete step could be developing an index of pandemic response that incorporates health, economic, and social indicators, something like a pandemic resilience index. Governments could track their performance on this composite index, not just on virus case counts. That would help keep a balance. For instance, if closing businesses improves one part of the index but crashes another, the net index might show it is not beneficial.

In conclusion, the Swedish example during COVID-19 makes a compelling case that multicriteria frameworks should become a standard tool in managing public health crises. Had such frameworks been in place globally in 2020, we might have seen much more nuanced policies: targeted protections for the vulnerable, moderate social distancing, voluntary measures, and keeping low-risk sectors running. And also, potentially a better overall outc ome in terms of lives saved and lives lived. Going forward, institutionalising this approach is not just an academic ideal but a practical necessity. It can help ensure that in the face of the next pandemic, or any comparable crisis, we remember to ask not only “How do we stop this virus?” but also “What do our actions mean for society as a whole, and how do we choose a path that safeguards our collective well-being in the broadest sense?” By having the courage to consider multiple criteria, policymakers can avoid the tunnel vision that leads to unintended harm, making responses both more effective and humane.

Conclusion

The COVID-19 pandemic has been a monumental test of governance and public policy under uncertainty and stress. Sweden’s journey through this crisis, marked by an atypically light-touch response and culminating in Europe’s lowest excess mortality rate, provides a valuable case study in the importance of broad-based decision making. Initially condemned by many, Sweden’s strategy ultimately achieved results that force us to question many assumptions about pandemic management. This article’s analysis shows that Sweden’s outcomes (low overall mortality under reasonably preserved societal functions) were not miraculous or purely luck, but tied to conscious choices embedded in its policymaking structures. By relying on expert agencies and adhering to a holistic view of public health, Sweden implicitly prioritised multiple criteria: protecting life and maintaining quality of life. In contrast, many countries adopted a one-dimensional focus on the virus, implementing draconian restrictions that, while well-intentioned, often overshot the mark and inflicted collateral damage that in some respects rivalled the harm of the virus itself.

The evidence from our six papers spans epidemiological data, economic indicators, educational research, and mental health studies. It consistently supports the notion that an exclusive concentration on minimising COVID-19 transmission, contraction and deaths without equal regard for other aspects of well-being led to suboptimal policy outcomes. Countries that imposed the harshest measures often did not significantly outperform others in terms of saving lives when looking at the full timeline, and they paid a steep price in other domains. Meanwhile, Sweden’s more balanced approach did not result in the mass casualties that critics predicted. Instead, Sweden ended the pandemic period with fewer excess deaths per capita than almost any peer (Norway is a nonEU exception), an outcome that seemed almost inconceivable to many observers back in 2020. This does not mean Sweden did everything perfectly, far from it. There were acknowledged major failures, particularly in elder care in the first wave where the elderly as a group were severely let down, but the overall strategy proved reasonably sound in mitigating total harm.

A key argument emerging from this analysis is the need to revamp how we approach crisis decision making. MCDA is not just a theoretical ideal but a practical framework that would have led to better policy decisions in this pandemic, and if adopted, can lead to better decisions in the future. By systematically evaluating trade-offs such as weighing lives saved from the virus against life years lost elsewhere and balancing disease control against societal function, leaders can aim for policies that are proportionate and sustainable. The pandemic has vividly illustrated that society’s wellbeing is a tightly coupled system: health, economy, education, and freedom are very interconnected. Neglecting any one dimension can cause harm to others. Thus, the only rational way to govern in a crisis is to consider all these dimensions together.

Honouring a multicriteria approach will require changes: institutional (bringing more diverse expertise to the table), cultural (resisting panic and simplistic narratives), and procedural (mandating impact assessments and transparent deliberation about trade-offs). It also requires humility and political courage, acknowledging that no single metric, however important, captures all that matters, not even on election day. The COVID-era mindset of tracking the daily death toll like a scoreboard, while understandable in a deadly pandemic, should be exchanged the next time for a multi-faceted view on public health and well-being. Excess mortality, ironically, is one such wider metric and it told a very different story than the daily COVID death counts did. Excess mortality revealed that the countries that seemed to be losers by COVID deaths in 2020 (like Sweden) had, by mid-2022, not lost more lives. Countries that “won” early by quenching the curve had those deaths occur later, together with several other unintended consequences.

As a conclusion, it is perhaps fitting to recall an essential insight of policy analysis: correlation is not causation, and intentions do not equal outcomes. Many nations intended only to save as many lives as possible the next day and were willing to impose severe measures to do so. Sweden intended to play the longer game by safeguarding public health in a broader sense by avoiding severe measures. In the end, Sweden’s approach may have saved more lives (when considering overall excess deaths) precisely because it averted some of the unintended health consequences of strict lockdowns, while still managing to protect most of those at risk from COVID after the initial wave. This suggests that a rational, measured response might outperform a single-criterion maximalist response. It also highlights the importance of learning from empirical outcomes rather than judging policies solely on their intent or initial appeal.

No doubt, debates will continue for years about the efficacy and ethics of various pandemic interventions. There will be national commissions in every country, trying to find out what actually happened and who to blame. In Sweden, the Royal Academy of Sciences published its final report already in November 2021 (KVA, 2021) after having published six intermediate reports during the ongoing pandemic. Ironically, ten days later, the Swedish government proposed new restrictions amidst the threat from the Omicron BA.2 strain (Danielson, 2022b). A month and a half earlier, in October 2021, the Swedish corona commission evaluated the measures taken by the government, administrative authorities, county regions and municipalities to limit the spread of the virus and the effects of the spread (Corona kommissionen, 2021). So, from a Swedish perspective, the society collected the information that was to be collected and drew the conclusions that were to be drawn, at least from a governmental point of view. While many other countries’ aftermath documents will surely follow, the Swedish perspective has, at the time of writing in August 2022, already been officially investigated and its conclusions documented.

This article does not claim that there was an easy policy process standing by that everyone missed. Every country faced difficult decisions with limited information. Rather, the aim here has been to synthesise available information to argue that, on balance, a more nuanced, multi-faceted approach was superior to an extreme, single-minded one. Sweden’s case is evidence of that. But even beyond Sweden, a few studies and some experts have started to discuss the view that full lockdowns and similar measures should be a last resort in the future, not a first response, given their broad societal costs. The ultimate goal should be to refine our crisis response preparations to be smarter and more balanced the next time.

In closing, the COVID-19 pandemic taught humanity a great deal about virology and science processes in general, about the interconnected world, and about values. If we narrow our vision to one dimension of a problem, we risk solving that one aspect but creating a host of new problems. A multiple-criteria framework helps keep our eyes on all the things that matter. Sweden’s pandemic experience, culminating in both low excess mortality and lesser societal disruption, illuminates the potential benefits of such an approach. This is not to say that Sweden had such an explicit policymaking process or that it was optimal. Far from it, the multiple perspective process is in the Swedish culture but could have been used to a much larger extent, had a more formal decision-analytic process been followed, as recommended by the European Union (Danielson, 2022). As uncomfortable as it may be for governments that poured all efforts into one-dimensional strategies, the global community must assess and learn from these outcomes. Doing so will not downgrade the efforts and sacrifices made; rather, it will honour them by ensuring we do much better the next time.

By adopting multicriteria decision analysis as a standard process for future public health (or other) crises, we can aim to protect lives effectively while also maintaining society. The next time we face a novel virus or similar threat, let us remember the Swedish example and the conclusion that a balanced approach can achieve the best overall results. Our goal should be to minimise total harm, not just the harm from the most obvious source. In effect, the lesson should be to keep the big picture in view, an approach that might well save both lives and livelihoods when it matters most.

Acknowledgement

This work was funded by the European Open Science Cloud, Covid-19 Fast Track Funding, grant agreement number 831644.

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