Deconstructing the high trust narrative in pandemic Sweden

Over the past two months dozens of articles have been published about Sweden’s controversial coronavirus response. Even if you’ve only read just a few, you will have no doubt come across mentions of the “high trust” culture which thrives between Swedish leadership and the people. This narrative rests at the core of why this risky pandemic response is deemed (perhaps) more likely to work in a country like Sweden than in others. One could very easily be led to believe that virtually all of Sweden enthusiastically supports its leaders throughout the pandemic, and with a high degree of trust.

But perhaps it’s time to reassess the tenacity of the Swedish high trust narrative.

First, (abundant) polling numbers:

Sweden’s overall response to the pandemic

In March, a Netigate survey revealed that over half of Swedes polled (53%) were either hesitant about the Swedish response (32%), or wanted to have a more stringent lockdown (21%). At the time, only 37% believed the Swedish response was the correct choice.

Research from multiple European institutions in April found that only 40-46% of 15-49 years olds in Sweden considered the country’s coronavirus response to be sufficient. Moving across all ages (15 to 70+ years old), only slightly more at 51% believed the Swedish coronavirus response had been “forceful enough” according to researcher, Erik Wengström.

Support from only half the population is certainly not a landslide win for Sweden’s high trust narrative.

In late April, a Novus survey found that while 64% held overall positive feelings that Sweden could cope with the coronavirus, only 27% of those with positive sentiments actually felt Sweden was coping “very well” with the pandemic.

In another popular Ipsos poll, researchers highlighted an overall confidence growth in Swedish healthcare and public authorities between March and April. They also reported that while 56% were confident in their leaders’ actions, 43% were unconfident, uncertain or neutral towards the Swedish authorities’ handling of the pandemic. Thus we do see more Swedes stating their definitive trust in the Swedish response, but only by an excess of 13% in this case.

Edited June 23, 2020: Between April and late May/June, a Demoskop survey showed a decrease from 65% to 55% confidence in Swedish authorities’ ability to handle the pandemic. Concurrently, those who expressed a lack of trust increased from 20% to 31% during the same interval.

An Ipsos survey similarly found that between April and June, general public confidence in Swedish leadership during the pandemic decreased from 56% to 45%.

The Swedish Public Health Agency

Other polls certainly exist, however, and generally show more favor towards the Swedish response.

Sweden’s chief epidemiologist, Anders Tegnell, has experienced a growing amount of support so far throughout the pandemic. In an Ipsos survey from April, 69% indicated he had their trust.

In mid-April, another Novus poll found 73% to be generally confident in the Public Health Agency. Likewise, a survey conducted by Demoskop in mid-April showed that 71% also felt generally confident in the same agency.

Edited June 23, 2020: A follow-up Demoskop survey showed confidence in the Public Health Agency dropped from 71% to 63% between April and early June.

Similarly, a follow-up Novus survey demonstrated that confidence in the Public Health Agency dropped from 73% to 65% between April and early June.

An Ipsos survey shows the same downward turn in trust. Confidence in the Public Health Authority dropped from 69% to 57% between April and June. For Anders Tegnell, confidence dropped from 69% to 60% during the same interval.

The Swedish Civil Contingencies Agency

In mid-April, a Novus poll found that 57% reported very high or fairly high confidence in the Swedish Civil Contingencies Agency (which is responsible for managing aspects of public safety and emergency management during the pandemic).

Two weeks prior, however, the confidence ratings for this agency had been higher at 61%.

Another Ipsos poll from the latter part of April reported an even lower confidence rating of 51% by the end of the month.

Edited June 23, 2020: A follow-up Novus survey showed 48% public confidence in the Swedish Civil Contingencies Agency in late May/June, down from 57% in April.

The National Board of Health

The National Board of Health is an important stakeholder in providing support to the health system and social services during the Swedish coronavirus response. In April, it had a confidence rating of only 45%.

The Swedish Government

To further muddy the waters, the Demoskop survey from April reported far less confidence in the Swedish government than in the Public Health Agency. 53% felt generally confident in the government, but only 22% actually described themselves as having “very great confidence” in governmental leadership.

Novus reported somewhat higher confidence ratings of 63%, but only 30% reported having “very high confidence”.

While we generally see a broader turnout of “trusting” Swedes in these polls, given the ample number voices who abstained from giving the highest possible confidence ratings available, is “high trust” the most accurate phrase one could use for describing the current situation in Sweden?

Edited June 23, 2020: A follow-up Demoskop survey showed a decrease in confidence in the government from 53% in April, to 41% in late May/June .

A Novus survey showed a similar change. In April, 63% had confidence in the government’s ability to handle the pandemic, but in in late May/June only 45% maintained the same opinion.

An Ipsos survey also reported a drop in confidence in the government from 50% in May, to 38% in June.

Geographical areas have lost their faith; others have grown

Parts of Sweden have lost their trust in the country’s pandemic response, again referring to the Novus survey from late April.

Consider two regions (Western Sweden and Southern Sweden) where 21% in Western Sweden stated in March they felt “very good” that Sweden could cope with the coronavirus. However by late April, only 14% maintained the same sentiment. Southern Sweden experienced a similar drop in confidence from 17% to 13% over the same time period.

Interestingly, Sweden’s coronavirus epicenter of Stockholm marked the highest increase in confidence, rising from 10% to 24% over the same time period.

It’s worth noting, however, that no single region, at any time, ever gave Sweden a “very good” coronavirus coping rating above 24%.

The generational divide

And there also seems to be a separation between the older and the younger generations on this matter.

The Netigate survey from March found that 60% of 20–29 year olds, and 52% of 30–39 year olds considered the government to have handled the corona crisis very badly, badly, or neither poorly nor well. Concurrently, only 23% of people aged 70-79 maintained those same sentiments.

Wengström’s findings seem to tell a similar story: “While 40% of 15-29 year olds state that the Swedish response has been sufficient, the corresponding figure is 61% for those above 70.”

Clearly the presence of such a firm generational divide on this topic should at least deepen the discussion of who the highest trusting Swedes really are. Unfortunately, most articles in the mainstream press do not typically explore this aspect, but instead attribute “high trust” with broad sweeps across the entire Swedish population.

Below are five societal groups, each of which illustrates the ever-growing cracks in the Swedish high trust narrative:

Families with school-aged children

Many families do not trust the government’s current in-schooling directives (which exists for all six to 15 year olds without symptoms). Concerned parents are more than willing to homeschool their children throughout the pandemic, but are threatened with fines and reports to social services if they don’t send their kids to school. This rule persists despite there being high-risk family members in the household. It even persists if someone else in the home is COVID-19 positive.

In fact, the Swedish Public Health Agency won’t even classify children who have any pre-existing medical conditions as at risk for the coronavirus, even if adults with the same conditions are given an “at-risk” label.

This is even more striking when compared with the Centers for Disease Control and Prevention in the United States, and the National Health Service in the United Kingdom, both of which consider children with numerous medical conditions to be at risk for COVID-19.

It looks as if the precautionary principle — “better safe than sorry” — has largely been left out of the equation in Sweden, especially regarding its pediatric population.

To further worry families, there are numerous cases of concealed COVID-19 infections in schools across the country.

There have been several reported cases of infections at schools where parents were never notified, and in the case of a school in Kåge (where a teacher with COVID-19 died), parents have openly criticized the school’s lack of transparency.

Recently, a teacher in Uppsala was found to be infected by the coronavirus, but the school and municipality decided not to notify their students’ families.

When a member of staff at a preschool in Malmö tested positive for the virus, the principal asked colleagues to keep it secret from the parents. In contrast, preschools regularly disclose information about lice and stomach ailments.

Teachers

A petition to close Swedish schools in order to stop the spread of the coronavirus has been signed by nearly 15,000 people since the beginning of the pandemic.

In early April, 913 educational staff members signed an open letter expressing their lack of trust in the government’s opinion that schools are capable of realistically implementing public health guidelines. They cite concerns about crowded classrooms, and classes being merged when teachers are absent due to illness. Preschool children still have the same need for physical closeness with their teachers. It’s impossible to refuse a young child who just fell down a much-needed hug.

Teachers with concerns for their own or their family’s health are still pressured to teach in the classroom. In one case, a teacher with COVID-19 in her late fifties died and nearly one quarter of the staff who were tested at the same school were also found to be infected with the virus. The school closed briefly on April 21st due to high teacher absences, but has since reopened its doors as of May 4th.

I personally know teachers with family members in risk groups. Despite this, many are still pressured to continue teaching in the classroom.

Elderly

Elderly persons over 70 have been directed to self-isolate and to stay out of shops since March. Worried about how some of my own neighbors would get groceries, I personally dropped off letters to my elderly neighbors and offered to help them with shopping errands. At least two thanked me, but said that they preferred to continue on doing it themselves.

And my neighbors aren’t in the minority. Despite direct instructions from the government, many elderly trust in their own judgements as a way to preserve their independence.

Peter Santesson, chief of staff at Demoskop spoke about a survey from March in which many elderly Swedes expressed little intent to change their daily routines even in light of the pandemic: “The general trend is that most pensioners do not at all see themselves as a risk group, but feel good and healthy.”

On the other hand, there is growing concern for how the elderly (especially those in nursing homes) have been treated during the pandemic.

Health and Social Affairs Minister, Lena Hallengren, admitted that Sweden “failed” to protect the elderly. Anders Tegnell acknowledged the research on face masks (that masks may prevent you from infecting others), but there are still no guidelines from the Public Health Agency for the general precautionary use of face masks in nursing homes.

National statistics from the end of April indicate that half of the people over 70 who died with COVID-19 lived in nursing home facilities.

Additionally, an ongoing investigation by a Swedish healthcare watchdog (Sweden's Health and Social Care Inspectorate) is underway to determine if intensive care beds were properly allocated to coronavirus patients in Stockholm.

Swedish authorities report a consistent surplus of intensive care beds throughout the nation, however medical staff have reported that despite this surplus, some patients were denied intensive care beds due to intensified prioritization guidelines.

Perhaps most concerning are reports that COVID-19 residents in nursing homes have been denied admission to the hospital, and in several regions of the country, also denied oxygen treatments for shortness of breath. Instead many are given palliative combinations of respiratory inhibitors such as morphine and other opioids.

In a recent investigation of regional protocols, several regions explicitly prohibited the use of oxygen therapy with nursing home residents who had shortness of breath in conjunction with COVID-19. In those cases, elderly patients were primarily given morphine as a palliative care measure.

Hallengren criticized these reports in an article on May 20, stating she didn’t understand why regions would definitively prohibit nursing homes from using oxygen with COVID-19 residents because that would violate the National Board of Health’s guidelines which state that oxygen can be used with elderly patients if it is indeed an appropriate treatment.

With substantial breakdown of communication and trust between regions and the state when it comes to this issue, it is no wonder the Health and Social Care Inspectorate is now also preparing to initiate an investigation of Swedish nursing homes in early June. In addition to examining the proper usage of oxygen with residents (or lack thereof), they will determine if residents received appropriate care based on their individual needs.

Latifa Löfvenberg, a nurse who worked in several nursing homes in Gävle, spoke with the BBC about her experience.

“They told us that we shouldn’t send anyone to the hospital, even if they may be 65 and have many years to live. We were told not to send them in,” she said.

“They suffocate to death. And it’s a lot of panic and it’s very hard to just stand by and watch.”

A physician at Karolinska University Hospital addresses the ethical dilemmas of using these opioid mixtures:

“when used in patients with oxygen deficiency, it definitely accelerates death for them. Because there is a ban on visitors, relatives often know nothing. Ethical aspects are not discussed, but I think this is illegal, and that some of these patients could have managed if they had been given oxygen therapy instead.” (translated from original Swedish)

Yngve Gustafson, professor of geriatrics, believes the elderly are exposed to a “cocktail of opioids”, which can be likened to active euthanasia.

“Living in a nursing home is not a diagnosis. That in itself can never be a medical basis for deciding whether to live or die. A doctor can prescribe palliative treatment over the phone [without ever seeing a patient]. It is a violation, a discrimination and a criminal offense not to make a medical assessment of what is best for the individual patient.” (translated from original Swedish)

Academics

In March, over 2,000 advanced degree researchers and academics signed an open letter emphasizing their lack of trust in the Swedish coronavirus response. Their basic request was for Sweden to begin adhering to the World Health Organization’s guidelines of testing, tracing and implementing increased social distancing measures.

Throughout April, there was more direct and ongoing criticism of the Swedish response by 22 experts in particular, some of whom were ridiculed by members of the press (here and here).

Their challenges were quickly dismissed by Anders Tegnell at the Public Health Agency. This, despite the fact the figures used by the 22 experts (obtained from the European CDC) were in retrospect far closer to the truth than the figures Anders Tegnell offered up at the time.

Conversely, Agnes Wold (a professor of clinical bacteriology who supports the current Swedish coronavirus response) holds regular coronavirus Q&A sessions for a national newspaper, during which she gives her personal opinion on hundreds of questions from the public.

Residents of immigrant descent

The following excerpt from an article written in early April illuminates the broken trust between the Swedish leadership and marginalized immigrant populations, many of whom did not receive appropriate public health guidance until it was too late:

“In Sweden there is a small diaspora community of Somali immigrants who fled war and poverty who make up just 0.69 percent of the total population. Normally, this diaspora group fades into the background, but now, suddenly, a chilling new statistic brings them to the fore, as 40 percent of the reported COVID-19 related deaths occurring in Stockholm involve the Somali diaspora communities. Other Swedish medical experts estimate 18 percent of the COVID-19 deaths country-wide are from the Somali community.”

Assyrian and Iraqi populations are also amongst those disproportionately affected by COVID-19 in Sweden.

In March, Morgan Olofsson, communications director at the Swedish Civil Contingencies Agency, admitted the agency had done poorly when it came to making health and safety information available to all residents in Sweden. There had been a significant delay in translating public health guidelines into minority languages, despite there being weeks to prepare.

Journalist Nuri Kino describes some of the confusion in Södertälje (a city south of Stockholm with a sizable community of Assyrian/Syriac descent):

“There is some kind of strange confusion at [the Swedish Civil Contingencies Agency]. In Södertälje, Assyrian/Syriac — the language spoken by most immigrants and their children — has been excluded from the brochures in which 22 other languages are featured. In the material, Somali was also wrongly translated, so some sentences have a completely different meaning.” (translated from original Swedish)

In mid-April, state epidemiologist Anders Tegnell reiterated that Sweden still had an overrepresentation of COVID-19 deaths from people born in other countries.

Speaking with The Associated Press, Akil Zahiri, who helps oversee a mosque on the outskirts of Stockholm says, “Many of our members have contracted the coronavirus. But you do the best you can.”

Historically-speaking, Sweden has been a world leader in the protection of equality for all.

As such, it should give at least some credence to the substantial part of the country which does not trust Swedish leadership during this pandemic.

In short, the “high trust” narrative, the backbone of the Swedish pandemic response, is certainly one that deserves a second and much more critical look.

Allyson Plumberg lives in Lund, Sweden. She can be reached at COVIDHumanRightsSweden@gmail.com

Get the Medium app

A button that says 'Download on the App Store', and if clicked it will lead you to the iOS App store
A button that says 'Get it on, Google Play', and if clicked it will lead you to the Google Play store