Sweden's per-capita coronavirus death toll is among the highest in the world — a sign its decision to avoid a lockdown might not be working

• Sweden never issued a mandatory lockdown to curb the spread of the coronavirus, instead asking its citizens to voluntarily maintain social distance.
• Sweden has a relatively high per-capita death toll and case count compared to other countries — signs the strategy might not be working.
• These graphs compare Sweden's per-capita deaths and cases, along with its current death rate, to other countries with major outbreaks.
• Visit Business Insider's homepage for more stories.

At least 45 countries issued lockdowns to slow the spread of the coronavirus in March and April. Sweden was not one of them.

Instead, the "Swedish model" encourages residents to voluntarily maintain social distance and allows businesses, restaurants, bars, and schools to remain open.

Data suggests the country may be paying a worrisome price, though: Sweden has a higher number of deaths per capita than many other countries with large outbreaks.

The following chart, based on data from Johns Hopkins, compares Sweden's per-capita COVID-19 deaths to those of 11 other countries.

More than 3,500 people have died in Sweden, of a total population of 10.23 million. That death count is small compared to the number of people the virus has killed in other big countries — the US' death toll has topped 85,000, for example. But relative to the size of Sweden's population, the number of people who've died is in line with countries that have had far bigger outbreaks.

Last week, the head of Sweden's coronavirus response, epidemiologist Anders Tegnell, said in an interview on "The Daily Show" that the country's high death toll was unexpected.

"We never really calculated with a high death toll initially, I must say," he said. "We calculated on more people being sick, but the death toll really came as a surprise to us."

Similarly, Sweden's death rate — a calculation that divides the number of confirmed coronavirus deaths by the total number of reported cases — is among the highest in the world. More than 12% of people officially diagnosed with COVID-19 there have died.

There are several potential explanations for these numbers. One is that Sweden is not testing sufficiently, so many cases are being missed, making its death rate seem higher than it truly is. Sweden's per-capita testing rate is 17.58 per 1,000 people, according to tracking by Statista. That's relatively low compared to Norway's, which is 37.86, and Iceland's, at an impressive 160.44.

The US has tested 30.14 people out of every 1,000, according to Our World in Data.

The number of tests coming back positive in Sweden also suggest this explanation could have merit. Sweden has confirmed around 28,000 cases of 177,200 tests done — a positive rate of about 15.8%. The World Health Organization has said that countries will know they're testing at a sufficient threshold when fewer than 10% of tests are coming back positive.

Another explanation, however, could be that half of Sweden's deaths have been in nursing homes. Older people are far more likely to die from the coronavirus than younger people, so outbreaks in long-term care facilities are likely to be more deadly than those among other subsets of the population.

Still, Sweden's total case numbers are also high relative to its population.

Lockdowns worked in other countries

Sweden's strategy relies on personal responsibility: The government asks residents to monitor themselves for symptoms, stay home when sick, practice good handwashing, and avoid crowds.

"It's definitely part of the culture to follow the rules, or guidelines, and to not be too pushy about it," archaeologist and art history professor Nancy Wicker, who's traveled frequently between Sweden and the US for nearly four decades, previously told Business Insider.

Evidence from other countries suggests mandatory lockdowns have prevented the spread of the virus: China, Germany, and Spain all saw their number of daily infections drop off after restrictions were implemented.

A team of Italian researchers recently simulated what could have happened if the country had relaxed its restrictions in March — or never imposed them at all. The results showed that the country's lockdown prevented around 200,000 hospitalizations between February 21, when Italy confirmed its first case, and March 25. The policy reduced transmission in the country by about 45%.

Another study found that Chinese cities that issued restrictions before they confirmed any COVID-19 cases saw one-third fewer cases during their first week of infections than cities with delayed responses.

Aria Bendix and Hilary Brueck contributed reporting.