CAMELIA DEWAN – 21 JAN 2021
In March 2020, as the pandemic strengthened its grip around Europe and the world, I wondered how I would manage my weekly work commute from Stockholm to Oslo when my native country, Sweden, went against the grain and took the controversial decision to keep the country open, while Norway embarked on a full lockdown, in line with the approach taken by other Nordic countries.
Norway and Sweden are not just neighbours geographically, they share strong historical, cultural and economic ties, once even forming part of the same country before Norway gained independence from Sweden in 1905.
Their national languages are mutually intelligible. Both countries have long traditions of social democratic institutions and values, and of universal welfare. They share a common commitment to the Law of Jante (janteloven in Norwegian and jantelagen in Swedish), a complex set of social norms that promote ideals of egalitarianism, while at the same time discourage going against group consensus or standing out from the crowd.
So if in both societies Jante is strong, how come they chose such radically different paths in dealing with the pandemic? This is the main question I tackle here, after providing an in-depth account of the Swedish approach to Covid-19 in comparative perspective with Norway’s response.
I write this as a less than detached academic. This essay has been hard for me to write, as I have, since my birth, identified as Swedish and Stockholmer. During this pandemic, I have lived in Stockholm – one of the European capitals hit hardest by Covid-19 – while working remotely at a Norwegian institution. I have witnessed the radically different strategies and stricter, faster measures implemented in Norway, while having to live through the Swedish authorities let the virus run through society.
Already in January 2020, the Norwegian Public Health Authority requested that municipalities make an inventory to check medicines and protective equipment and prepare pandemic plans. In February, incoming travellers to Norway were instructed to isolate at home for fourteen days. Early on in the pandemic, Norway had rising cases connected to a doctor who returned from the Alps and unwittingly passed the virus to his patients. This alerted the health authorities and they actively started testing, contact tracing and isolating confirmed cases – symptomatic as well as asymptomatic. By 17 March almost 6200 hospital workers were placed in quarantine across Norway, with a thousand alone in Oslo.
The situation was starkly different in Sweden. For incoming travellers from the Alps and around the world, there was little information about symptoms and actions. For example, one chartered plane filled with returning travellers from the alps, many of whom were coughing, were not given any restrictions or recommendations, nor were they tested – they were free to go about their business. By mid-March last year, only a few days after Covid-19 had been declared a pandemic by the WHO, Sweden had reached its testing limits and was no longer testing travellers, even if they had symptoms.
Sweden’s Public Health Authority, known by the Swedish acronym FoHM, told everyone to go to work and stay at home outside working hours, while parents who tested positive for Covid-19 were told that asymptomatic children had to go to school, or risk facing the consequences of violating skolplikt (mandatory school attendance) – something that is taken very seriously by Swedish authorities and child welfare services. The FoHM stated that quarantine of children without symptoms is “not an effective strategy”. The role played by asymptomatic transmission in the spread was ignored, despite several international studies already raising the alarm.
At that point, the available data came primarily from Asia, in connection with the Chinese outbreak. Fuelled by biased media reports, Swedes were suspicious of such information and there was widespread belief that, even if valid in its original context, the findings did not apply to Sweden. This kind of “Swedish exceptionalism” turned many in Sweden into what national commentators Kristofer Ahlström and Hugo Lindkvist called “public health patriots”. Those who questioned the approach of the public health authorities were often silenced by such “patriots”, invigorated by an emerging brand of militant health nationalism.
Around the same time in March last year, there was a debate about whether people should cancel their domestic ski trips. The FoHM told people it was fine to ski, and fine to leave Stockholm – the main epicentre of Sweden’s outbreak. Stockholmers were allowed to spread the virus for several more weeks before further local restrictions came into effect in mid-May.
The Swedish approach
In the spring of 2020, most European countries eventually heeded the WHO advice to test, trace and isolate, while the Swedish authorities took a different path. But what exactly was Sweden’s strategy?
State epidemiologist Anders Tegnell, who has been the most visible FoHM official in the public realm nationally and internationally, initially praised the UK highly controversial strategy to build herd immunity without a vaccine. This strategy entailed slowing the spread of the virus to avoid overwhelming hospitals and shielding elderly people and other vulnerable groups from infection, rather than trying to contain the infection across the population to keep the number of cases to a minimum through, for example, partial or full lockdowns when cases started to rise. Those who would have contracted and survived the virus, would then be immune to future waves of infection. If enough people became immune (by most counts, 50 per cent or above), the chain of contagion would have been broken.
Tegnell was disappointed when the UK government quickly backtracked and abandoned herd immunity after a report by Imperial College warned of hundreds of thousands of deaths if they followed that path.
Sweden, on the other hand, seemed to have embarked on a very similar strategy to that initially proposed in the UK. In the Scandinavian country, the mantra became to “flatten the curve” in order to avoid overwhelming hospitals, and to protect the elderly.
This explains why there was no widespread testing in Sweden until June 2020. Despite sound scientific evidence that children are key to transmission and may act as superspreaders, it was only in December last year that the FoHM reluctantly adopted quarantine rules for asymptomatic children. Government also recommended that high schools and universities do distance teaching in the spring semester of 2020, something they were slow to enforce in the autumn.
Protecting the elderly or palliative care?
By August 2020, Sweden’s Covid-19 death count was around 5800. The vast majority of them were elderly people, including a significant number in care homes. Norway, with around half of the population of Sweden, did much better with less than 300 deaths in the same period.
Despite its stated intentions, the Swedish public health authorities failed to protect the elderly. One factor that contributed to this was that, in the first months of the pandemic, Sweden experienced a shortage of personal protective equipment (PPE). Municipalities, which are in charge of care homes, were stopped from ordering PPE, because the government prioritised hospitals.
Many of these deaths could have been prevented. I remember thinking: how are they going to protect the elderly if no one is tested, there is no contact tracing and there are no face masks to prevent carers from infecting the people they care for? Carers have families, partners who work, children in school, all at serious risk of infection. The idea that the virus could be allowed to spread in a somewhat “controlled” fashion in the broader society, while shielding the elderly and the vulnerable, did not work in practice.
Another part of the strategy, the goal of not overwhelming hospitals, also produced perverse effects. Elderly patients with Covid-19 were generally not hospitalised, while care homes lacked oxygen facilities. Doctors were told to not visit patients in the care homes, and ended up giving instructions over the phone for palliative care – a protocol to ease pain in terminally ill patients expected to die, not for patients whose lives could still be saved. Many patients were given morphine rather than oxygen, effectively euthanising them, rather than trying to save their lives. “Protecting the elderly” turned into “end-of-life care” – a scandal that was not publicly exposed and investigated in depth until November 2020. This senicide was condemned by German Chancellor Angela Merkel.
Instead of taking stock of their shortcomings, health officials shifted the blame on immigrant and precarious workers employed in the care homes, who were reprimanded for “not following basic hygiene routines”. At the end of March, Agnes Wold, a professor in the Department of Infectious Diseases of the University of Gothenburg and a well-known commentator in Swedish media, downplayed the unfolding tragedy and said in a popular TV show that Covid-19 “kills people, but fortunately it mostly kills old people”.
This idea that it is more acceptable that older and sick people die emerged implicitly in the FoHM press conferences held during the first wave. A constantly touted message was that it is mainly old people and people with underlying illnesses that died from corona, and that young and healthy people were largely unaffected. The elderly and those with pre-existing conditions were told to self-isolate as a way to avoid catching Covid-19 – with the implicit message that everybody else should be allowed to go about their activities with minimal disruptions, and that the elderly and the sick were responsible for their own health.
The notion that the lives of elderly people can be sacrificed for the common good has a long lineage, and goes all the way back to the ancient concept of ättestupa, the Swedish name for certain cliffs which, according to Viking mythology, performed a specific social function: the elderly would jump off these cliffs or be thrown over them by family members to meet their death, once they had become a burden for their families and for society at large.
Norway shares with Sweden a common Viking heritage, including oral histories of ättestupa. And in Norway too, despite a much more effective strategy to contain Covid-19, infection in the care homes has been a major problem. Yet, the public health messaging has been significantly different: elderly people were not told to self-isolate, but rather all citizens, and especially young people, were asked to strictly adhere to social distancing and other Covid-19 restrictions. Protecting the elderly and the sick was seen as a social duty for all, and the general goal of the national Covid-19 response has been to curb the spread to make society safe for everyone, with the goal of keeping cases under a total of 20 confirmed cases per 100,000 inhabitants registered over a fourteen-day period.
For instance, when, in August 2020, the Norwegian municipality of Indre Østfold registered a spike in cases among the youth connected to travel from neighbouring Sweden, the local mayor emphasised the need to maintain strong social ties across generations, and that all lives are equal and they do not want to lose anyone, regardless of their age or health status.
From Swedish exceptionalism to public health failure
But the Swedish messaging was misleading on other grounds too: several reports indicated that it was not only the elderly who were denied hospital care, but also younger people, many of them under 50, who died at home because their symptoms were not taken seriously – they could talk.
Another aspect ignored by the official messages was the impact of what has come to be known as “long Covid”: Covid-19 patients across all age groups who experience serious and debilitating symptoms months after infection. At the end of October last year, Sweden had approximately 25,000 people with long Covid, including children. Since these data reached the public debate in the second half of last year, national attitudes have shifted somewhat, and public criticism is now tolerated.
As months went by, it became clear that one of the main rationales for the Swedish strategy during the first wave proved to be mistaken: by taking a bigger hit in the spring of 2020, Tegnell argued, Sweden would avoid a second wave and eventually outperform Norway. Despite several announcements by FoHM officials on immunity rates allegedly going up in the Stockholm region, Sweden experienced a second wave since autumn last year and regions that were badly affected in the first wave, have been hit hard again.
This is not surprising, given that there is contradictory scientific evidence as to how long, or how little, immunity from Covid-19 might last after infection. Also, despite the light touch approach of the authorities, the rates of infection in the worst hit areas were never even remotely close to the massive numbers expected to achieve herd immunity.
It should be noted, in any case, that Tegnell has rejected the accusation that the FoHM was indeed pursuing herd immunity. According to the FoHM, herd immunity could be seen rather as “an outcome, not an aim” of the national strategy. In October last year, Tegnell condemned herd immunity without a vaccine as “futile and immoral”, and in November he acknowledged in a press conference that immunity levels were lower than expected.
It is therefore odd that UK newspaper Sunday Times revealed that, in September 2020, Tegnell, together with Oxford epidemiologists professor Sunetra Gupta and professor Carl Heneghan, sat in a meeting with UK Prime Minister Boris Johnson, to convince Johnson not to impose a national lockdown. Gupta is one of the main signatories of the Great Barrington Declaration, which suggests that governments should allow Covid-19 to run through the majority of the population, who will supposedly have only very minor symptoms, while shielding the most vulnerable members of society. This is a fringe and unscientific view rejected by respected infectious disease researchers worldwide, as discussed in the Lancet, a prestigious international academic medical journal.
At the time of publication (21 January 2021), Sweden’s death count is nearing 11,000, while Norway’s one is around 540. Even if we double the Norwegian number to account for population size, Sweden would still have ten times more deaths than their Scandinavian neighbour.
The Law of Jante
Why did Sweden move in a different direction than Norway? How can we explain the major differences in the two approaches, given their many similarities and shared histories and socio-cultural norms?
In a previous essay in this blog, social anthropologist Thomas Hylland Eriksen rightly points out that one reason for the success of the Norwegian approach was the mobilisation of the broader society to fight Covid-19, driven by the notion of dugnad, which Eriksen defines as “unpaid, collective, cooperative work where every member of a community is expected to participate, regardless of their social position”. This term, he argues, is “a symbol of egalitarianism” that highlights longstanding traditions of collective solidarity invoked by politicians to mobilise citizens towards a common goal.
Eriksen stresses that the way Norwegians have complied with the authorities highlights higher levels of trust in state institutions than elsewhere. He invokes the Law of Jante to argue that this cultural norm pushes people to show solidarity and work for the common good, rather than for their own selfish interests. Indeed, Jante is “a celebration of the ethos of equality which is fundamental to Norwegian society”.
In this analysis, one could easily replace Norwegians with Swedes. Had the Swedish public health authorities pursued the same path as Norway, it is quite likely that people would have followed stricter guidelines against Covid-19.
Instead, by not adhering strictly to the recommendations, most Swedes effectively fell into line with the FoHM unofficial strategy of herd immunity – they continued with their normal activities almost as if it were business as usual, and did not contest the knowledge and authority of the FoHM. One injunction of the Law of Jante is that no one should think that they know better than the group, and in this case, one could say that this injunction was implicitly adjusted to mean that nobody should think they know better than the Swedish Public Health Agency.
This helps explain why when people like myself questioned what was going on in social media debates, we were called hobby epidemiologists and alarmists – the one that struck me the most in this sorry display of attacks and insults I experienced, was the accusation that mine was a “fake account from a Russian troll factory paid to slander our superior Sweden”.
Jante played a role in both Sweden and Norway, but has led to different outcomes due to the different routes taken by the respective health authorities and their governments. In Norway, korona-dugnad helped the state contain the virus, while in Sweden trust in the state and collective solidarity took a defensive form. The flawed decisions of the health authorities had to be protected from public criticism at home and abroad, and collective denial about the true extent of Covid-19 negative effects became entrenched across the board.
Institutional pluralism and charismatic leadership
What other factors can account for the difference in approaches between the two countries? For one, while, until very recently, the Swedish government headed by PM Stefan Löfven fully stood by the recommendations of the FoHM, Norwegian PM Erna Solberg went further than the advice provided by the Folkehelseinstituttet (FHI), the Norwegian counterpart of the FoHM. The FHI’s advice was often different from the Norwegian Directorate of Health, and the national government resolutions often took elements from both, which encouraged a more pluralist and democratic dynamic over what counted as science and scientific evidence.
In Sweden, on the other hand, there have been few, if any, checks and balances on the power and authority of state epidemiologist Anders Tegnell and his close associates at the FoHM. In the spring of 2020, Tegnell quickly became the face of the Swedish approach on national and international media. The brand of health nationalism highlighted before carried with it a personality cult of sorts, with Tegnell elevated as a national hero. He has a Facebook fan club (it used to have 80,000 followers but has now shrunk to 33,000), people got tattoos of him, and a TV programme on Swedish channel TV4 even showed how to make Christmas tree angels with his face.
Perhaps aligned with the expectations of many “public health patriots”, Tegnell has cultivated the image of a distant, tough man, who keeps emotions out of his work and believes to have special access to scientific knowledge that is purportedly unavailable to those who criticised him. When asked about his lunch break by journalists interviewing him, he replied “lunch is for wimps”, referring to the iconic phrase uttered by fictional greedy financier Gordon Gekko, impersonated by Michael Douglas in the classic 1987 movie Wall Street.
When it comes to scientific expertise, Tegnell maintained his own echo chamber, in close alignment with Johan Carlson, his boss at FoHM, and their expensive consultant Johan Giesecke. The three are family friends and have worked together for decades. Several critics have pointed the finger at this “boys club”, highlighting that the expert voices of those who were not part of it have been excluded or ignored.
As I think about Tegnell, his national hero status, and his expert clique, I am reminded of development scholar Robert Chambers’ reflections on power and charisma:
Are big people – the ‘heroes’ as they have been called, of ‘epic narratives’ – flattered and misled by the deference with which they are treated, and by the way their misbehaviours are tolerated because they are adulated as gurus? Do their charisma, ego, power and personal dominance combine to inflict on them awesome learning disabilities? Can this be researched and documented, and can future generations be warned of these dangers? Can personal critical reflexivity be part of the self-correcting compass of those with personal and professional power?
One wonders if the Swedish strategy would have been different if the people heading the FoHM had been less focused on being “right” and more on being attuned to the variety of scientific opinions and evidence available nationally and internationally? I believe that this failure of scientific leadership, compounded by the national government’s blind trust in the FoHM, explain a great deal of the difference in the Swedish approach to Covid-19 when compared to Norway and other Nordic countries.
Will Sweden change course?
Bowing to domestic pressure and from the political opposition, on 10 January 2021 the Swedish national government has put into place a pandemic law introducing legal restrictions with rules for reducing the number of people allowed in shops and sports facilities, and for limiting the number of people at public and private events. People and businesses can be penalised if they break the restrictions, thus seemingly moving away from FoHM’s laissez faire approach largely built on non-binding recommendations and indicating that they are now taking matters into their own hands rather than, as done previously, waiting for recommendations from FoHM. FoHM General Director Johan Carlson spitefully stated that the new pandemic law will be ineffective.
It is too early to say whether this new approach will work and what level of compliance will be achieved. Indeed, the neglect of asymptomatic and airborne transmission, and an unwillingness to mandate face masks in all public indoor settings, combined with the lack of a professional “test, trace, isolate” system, remain worrying, especially considering Sweden’s minimal efforts to detect the highly infectious UK coronavirus variant (B117) that is causing alarm across the world.
It will probably not be easy to overturn several months of mixed messages and scientifically suspect decisions by the FoHM, and it is to be seen how far government will want to go to enforce and expand the new rules. The last few weeks have seen new peaks in cases and deaths, and the vaccine roll out is turning out to be slower than expected – not only in Sweden, but across Europe.
To conclude, the Law of Jante in Sweden has enabled collective denial of the unethical and inadequate ways in which Sweden has handled the Covid-19 pandemic so far. Critiquing the strategy has been seen as critiquing the state and Sweden itself. Such a defensive attitude helps maintain strong trust in state institutions, while keeping an image of Swedish exceptionalism, regardless of global trends and emerging studies from beyond its own borders.
One can only hope that the Swedish government and the broader society will be able to admit these mistakes and will be open to learning from others, for instance, from the international scientific community, East Asian countries and their Nordic neighbours. The fight against Covid-19 is far from over, and decisive action is needed to prevent further suffering and loss of lives and to ensure the health and wellbeing of all citizens and residents, regardless of age, health status, nationality or ethnicity.
Dr Camelia Dewan is a postdoctoral research fellow at the Department of Social Anthropology, University of Oslo, and a social anthropologist working on power, discourse and knowledge from colonial times to the present, with an ethnographic specialism in South Asia. She was born and raised in Stockholm. Her forthcoming book is “Misreading Climate Change: How Development Simplifications Fail Rural Environment and Society in Southwest Coastal Bangladesh” (University of Washington Press). She holds master’s degrees from Edinburgh and LSE, and a PhD from Birkbeck and SOAS, University of London.
The views expressed in this article are the author’s own and do not necessarily reflect Corona Times’ editorial stance, or the position of any institution.
The article is from Corona Times. The writer is Camilla Dewan.