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Misinformation and de-contextualization: worldwide media reporting on Sweden and COVID-19 | Globalization and Well being

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Misinformation and de-contextualization: worldwide media reporting on Sweden and COVID-19 | Globalization and Well being

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I carried out a rapid review of mainstream Swedish and international news, focusing on the month following the WHO’s decision to characterize COVID-19 as a pandemic (11 March 2020) (Table 2).

Table 2 Media and internet sources reviewed

I started with the websites of three Swedish morning newspapers: Dagens Nyheter and Svenska Dagbladet are national papers, while Sydvenskan is a regional newspaper for Skåne. I also reviewed the websites of the two main national evening papers: Aftonbladet and Expressen, and that of The Local, which produces English-language news in Sweden.

I watched COVID-19 related news on Sweden’s public service television channels (Sveriges Television, SVT), using the online streaming service SVTPlay.se. I watched the WHO’s press briefings every other day and the Swedish Public Health Agency (Folkhälsomyndigheten, FHM)‘s daily press briefings, as well as press briefings with the Prime Minster and other government representatives. I took notes and used SVTPlay to go back and transcribe key passages.

The State Epidemiologist at FHM, Anders Tegnell, was one of the most visible faces of the official response and drew considerable ire online [7]. I used Twitter to follow discourse on the Swedish response and to identify which news articles were being shared. Hashtags I reviewed were: #Tegnell, #Coronasverige, #CoronaVirusSverige and #SwedenInDenial.

Through Swedish media and social media, I identified which international news articles were being discussed in Sweden and reviewed these. I also used Google Search to look for further articles, using the search string ‘Sweden’s COVID-19 Strategy.’ Additionally, I read The Guardian and BBC News online every day. Most of the international reporting I discuss here comes from English-language sources, but I also reviewed articles from Danish, German and Norwegian sources. I created an archive of 88 screenshots, primarily from Twitter, 248 news articles and transcriptions from press briefings, which I organized by date. Although many of the media outlets I reviewed print physical newspapers, I reviewed only the online versions.

My approach to studying the media was inspired by ethnography. As a process, ethnography is about immersing oneself in a community, whether online or in real life. This was not a properly ethnographic study because I did not interact with people; rather I took an ethnographer’s view while consuming online media. A good ethnographer approaches the field with an open mind, and uses inductive and iterative approaches, akin to grounded theory; that is one does not go into data collection with a hypothesis, rather the themes, concepts and narratives are identified through immersion in the setting [8,9,10]. In this case, I immersed myself in online news media and social media, primary Twitter. As part of the analysis I drew upon narrative approaches from the social sciences: I examined how media outlets created an understanding of the Swedish approach through the ways in which they organized and presented facts and interview data.

While much of the international reporting of Sweden was balanced and mostly accurate, misinformation and de-contextualized truths wove in and out of the coverage, giving rise to further misinterpretation on social media. In the sections that follow, I discuss six of the main narratives of media reporting about the Swedish response during the first month of the pandemic. This debate provides a snapshot; that is, as the pandemic progressed the dominance of certain narratives waxed and waned, and some of the content changed. However, the early reporting set the tone for later news stories, so it is worth exploring this first month in detail.

Narrative 1: life is normal in Sweden

While Sweden’s fellow Scandinavians and nearly all other Europeans are spending most of their time holed up at home under orders from their governments, Swedes last weekend still enjoyed the springtime sun sitting in cafés and munching pickled herrings in restaurants. Swedish borders are open (to EEA nationals), as are cinemas, gyms, pubs and schools for those under 16 [11].

International reporting painted a picture of Swedes eating at outdoor cafes and strolling in the sunshine, or even skiing [12, 13]. Trains and busses were ‘still shuttling people all over the country’ and cinemas were open [14]. ‘Sweden also keep domestic flights going, ‘despite the risk of spreading the coronavirus.’ [15] On the 9th of April, Vox reported that:

For months, the Scandinavian nation allowed large gatherings to form, schools for younger children to remain open, restaurants to serve late-night guests, and resorts to welcome thrill-seeking skiers [16].

The Vox article was striking, claiming that ‘for months’ Sweden had been acting normally. Yet, it was published less than a month after the WHO had characterised COVID-19 as a pandemic so most other countries had also been acting normal “for months.” One the first English-language articles to break the Swedish story was the aforementioned “Swedish PM warned over “Russian roulette-style’ COVID-19” strategy [5]. An early published version of the article stated that the Prime Minister, in a speech the night before had “urged Swedes to lunch at a local restaurant.” The text was later changed: Stefan Lövfen, in fact, had specified a “takeaway” lunch during a speech broadcast on the 22nd of March.

The narrative of Sweden as normal was misleading. The bulk of international media reporting focused on Stockholm, and most online videos showed the area around Kungsträdgården and Drottninggatan – the very city center. There was some truth to this narrative: during the second full week of April, it had been widely reported in national media that Stockholmers were pushing the limits of good advice, by sitting in crowded outdoor seating areas; the city of Stockholm responded by carrying out extra checks on restaurants and cafes over the Easter weekend [17]. However, central Stockholm is not representative of Sweden.

The main cinema chain in Sweden, Filmstaden, closed on the 17th of March so few people were attending the cinema when these articles were written [18]. After much discussion, SkiStar, the country’s main ski operator, decided to close its facilities on the 6th of April; ski gondolas were already closed on the 24th of March [ 19]. Sweden’s decision to keep a select few flights open was due to their designation as “societally important” routes: Visby is the main city on Gotland, an island. Kiruna is above the polar circle and the other cities: Luleå, Umeå, Östersund, Skellefteå, Örnsköldsvik, Sundsvall are also in the north and relatively remote. The government decided that flights needed to run not for tourists, but to ensure essential supplies and workers could reach these cities [20].

The wider picture – Sweden as normal – was misleading, because life was not normal. CNBC reported on a report released by Swedbank that forecast the economy would contract by 4% and that unemployment would reach 10% by the summer [21]. Already during the course of March 2020, the numbers of business going into administration (konkurs) had increased, with the hospitality industry seeing an increase of 1400% [22]. Stockholmers drinking in the sun should not symbolize the various Swedish COVID-19 experiences.

Narrative 2: Sweden has a herd immunity strategy

Now they talk about Sweden, but Sweden is suffering very greatly. You know that, right? Sweden did that, The herd. They call it the herd. Sweden is suffering very very badly, it’s a way of doing it. -Donald Trump [23]

During this month, several Swedish researchers who disagreed with the government’s approach stated, both in national and international media, that the governments was following a herd immunity strategy. The herd immunity theory also forms a large part of the “Russian Roulette” article, which served as a basis for much of the English-language reporting, and the concept came up in most international reporting [16]. On the 9th of April, Vox published an article with the title and subtitle:

Sweden’s government has tried a risky coronavirus strategy. It could backfire. Critics say the government seeks “herd immunity” from the coronavirus. That could lead to more deaths.

The author tweeted the article with the text: It sure looks like Sweden is trying to achieve #herd immunity.”

The government and FHM denied multiple times that they were following a herd immunity strategy, with the Foreign Minister Ann Linde discussing this on Swedish television and CNN [2]. The herd immunity rumor has a complicated history. Mathematician Marcus Carlsson forwarded this theory in a series of YouTube videos and Annika Linde, the former state epidemiologist also promoted the theory that FHM’s strategy was based on herd immunity; she did this in a Facebook post which was picked up in the media [5, 24, 25]. State epidemiologist Anders Tegnell also mentioned the term often on television which further led to public confusion [26]. At other times his quotes were taken out of context. In an article in Svenska Dagbladet, which was re-quoted in international media, Tegnell stated that the main strategy was to have a slow transmission of COVID-19 so that the healthcare system could manage, but that herd immunity was “not contradictory” with this. He also said that herd immunity was a “great concept.” [24]

Part of the herd immunity rumor had to do with how Swedish implementation was described in international media as being drastically different than other countries. Anders Tegnell argued that critics were emphasizing the differences, rather than similarities of the approach [27, 28]. That is, Sweden was also trying to flatten the curve but without draconian measures. The government took this line not in order to promote herd immunity but because they did not think it realistic or healthy “to keep people inside for 4 or 5 months.” [29] That is, the government and FHM considered the level of restrictions put in place in the first month of the pandemic to be sustainable over the long term. Similarly, schools remained open in part because of the negative impact of closure on mental and physical health, and also because it would create a childcare problem, not least for key workers [30].

There was no evidence that FHM had a “secret” herd immunity plan, and it was never the ‘deliberate strategy’ of the government to ‘let the virus spread its course and spread through the population [31].’It is more accurate to state that there was a hope that some level of herd immunity would be a side effect of the approach, but it was not the main strategy.

Narrative 3: Sweden is not listening to experts or data

At the end of March, a group of over 2000 individuals signed an open letter to the government asking for more measures. Time described them as ‘doctors, scientists and academics,” the Guardian as “doctors, scientists, and professors,” Vox as “academics and experts” and The Economist as ‘scientists and professors.” [11, 14, 16, 32] Both the Economist and the Guardian pointed out that Prof Carl-Henrik Heldin, chairman of the Nobel Foundation was on the list. To support this statement Time and Vox linked to The Guardian’s live reporting from 24 March in which Jon Henley had written that “More than 1,500 medical and other academics in Sweden ranging from full professors to post-doc researchers have signed a petition calling on the government to change its coronavirus strategy.”

There are several problems with this letter. Although there are a number of well-regarded public health experts on the list, the six main authors, while professors, did not work in public health. This was something pointed out by Dagens Nyheter, while international media ignored this [33]. Moreover, there were many masters and PhD students on the list, as well as a handful researchers outside of Sweden who signed the letter. These are hopefully the experts of the future, but not necessarily current experts.

The letter was not widely circulated. The copy of the letter and list I saw was tweeted by Sten Linnarsson on the 26th of March and then retweeted by Nils-Göran Larsson, both of whom were signatories. To my knowledge, the only media source which has shown the letter was Vice in a video [34]. The first paragraph of the English version, as displayed by Vice was:

The Swedish government must act not (sic) to step up the fight against COVID-19

We have signed this open letter to request the Sweden Government immediatley (sic) take measures to follow the recommendations of the World Health Organization (WHO) to their full extent, including interventions to reduce the mobility and contact in the population and to support and incorporate the latest technologies to increase our capacity to test for Covid-10 (sic) infections nationwide.

The letter’s starting point was that the Swedish government had not followed WHO Recommendations (I discuss this narrative in the following section). The second paragraph of letter also perpetuated the rumor that Sweden was following a herd immunity strategy.

A second example comes from media reporting of a piece in the Lancet. According to AFP and Euronews, respectively:

“A study published last week in the medical journal The Lancet, titled “COVID-19: Learning from Experience,“ said that the “initial slow response in countries such as the UK, the USA, and Sweden now looks increasingly poorly judged.” [35]

“A study published in the medical journal, The Lancet, indicated that “the initial slowness of reaction from countries such as the UK, the US and Sweden now appears to be increasingly unwelcome” [36].

The ‘study’ was in fact an editorial written by the Lancet’s editor-in-chief Richard Horton [37]. Richard Horton is immensely influential in global health and no doubt could be described as an expert. However, this was his opinion, not a study, even though it was reported as such.

These examples aside, there were other instances of researchers, including those with backgrounds in virology, epidemiology and public health who raised valid concerns about how FHM has handled the evidence. An interesting question revolved around modelling done by Imperial College. This included the infamous work that, according to media reports, pushed the United Kingdom to change its COVID-19 strategy, although Anders Tegnell has argued that the British media have overstated the importance of the research in its policy decisions [38]. Within the debate pages of Swedish newspapers, researchers discussed the strengths and weaknesses, scope and applicability of the Imperial College modelling to the Swedish context [39,40,41,42]. FHM also publicly discussed their consideration of the evidence [43].

Some Swedish researchers also accused the Swedish government of only looking at the economy, with one writing in a leaked email chain “How many lives are they prepared to sacrifice so as not to … risk greater impact on the economy? [5, 11] Another researcher was cited several times as stating that the government was not using scientific evidence in their decision making, stating: “We don’t have a choice, we have to close Stockholm right now.” [16, 32, 44, 45]

Modelling is not evidence, and models are only as good as the assumptions and data that is fed into them. Professor David McCoy discussed eloquently in The Guardian how the health and socioeconomic impacts of various lockdown measures had not been modelled [46]. I would suggest that the Swedish government and authorities did not take into account “the economy” but were cognizant that there are long and short term health effects of unemployment and underemployment. Additionally, the choice to ‘lockdown’ an entire community was also an experiment taken in the absence of definitive evidence, and many types of ‘lockdown’ measures, such as the quarantining of a whole city are not possible under Swedish law [47, 48]. Yet, international press focused on the conflict between FMH and other researchers, rather than fundamental questions about the limits and potential of mathematical modelling, and its role in policy-making. This was a missed opportunity to educate readers.

I return to the scope of evidence in the conclusion, but offer a further example here: On the 10th of March, FHM recommended against ‘unnecessary’ visits to care facilities (äldreboende) and the government implemented a ban on the 1st of April. Care facilities are run by local municipalities and in practice many municipalities had already banned visits before the 1st of April. In Norway, municipalities implemented different types of bans at different times, many later than in Swedish municipalities, with a national ban coming into force on the 7th of April. Yet, already by the 7th of April, FHM had reported that COVID-19 was present in half of the care homes in the city of Stockholm [49]. Undertaking serious analysis in the middle of a pandemic is challenging, but an initial comparison between care homes in Norway and Sweden suggest that simply banning visits is not an easy solution because it did not work in Sweden.

Narrative 4: Sweden is not following WHO recommendations

The argument that Sweden is not following WHO recommendations came up in several debate articles in Swedish news [42, 50]. Internationally, Time reported that “experts say the Swedish government is not following the World Health Organization.” [32] CNN included a quote from a spokesperson from the WHO Regional Office for Europe who had said “it’s imperative” that Sweden “increase measures to control spread of the virus, prepare and increase capacity of the health system to cope, ensure physical distancing and communicate the why and how of all measures to the population.” They also included a link to a Tweet by WHO/Europe from 8 April which read “There is a fresh surge [of cases] in Sweden.” It also found in the letter written by over 2000 individuals, as noted in the previous section. There are two issues with this line of argument. Firstly, there is a general misunderstanding about what WHO recommendations are and are not, and secondly, I argue that Sweden followed the WHO’s ‘recommendations’ regarding public health measures [51].

The WHO issues many types of documents, such as recommendations, advice, or technical guidance. Articles 19–23 of the WHO’s constitution cover the legal basis for recommendations, conventions, agreements and regulations. What people think of as “WHO recommendations” are usually a mosaic of binding and mostly non-binding policy, advice, technical guidance and even international law and commercial law. A ‘recommendation’ found in an Interim Guidance document is completely different than a ‘recommendation’ endorsed or adopted by the World Health Assembly. Many commentators took Dr. Tedros’s mantra “test, test, test” to be a WHO recommendation that all countries should test everyone. A more accurate interpretation of the WHO’s Interim Guidance is that testing needs to be carried out with regard to a county’s capacity, context and situation [52].

In general terms, the WHO provides guidance to 194 Member States, which means that WHO ‘recommendations’ are rather vague. Most of the time, the WHO provides a menu of policy options from which countries can adapt or implement measures to take based on their national and local contexts. In Interim Guidance issued on the 7th of March, the WHO provided recommendations for public health measures, writing the countries should ‘consider, based on local and/or global evaluation’ the following: avoid crowing, school closures, public transportation and workplace closures and public health quarantine [53]. FHM did consider these, and adapted WHO recommendations in line with the Swedish context.

Another example comes from the International Health Regulations (IHR). The WHO declared COVID-19 a public health emergency of international concern on the 30th of January and issued temporary recommendations under the IHR. Some temporary recommendations under the IHR are binding, such as the obligation to share information with WHO, but most are not binding. In general, the WHO prefers that countries avoid border closures, in part because the disruption they cause can prevent medical supplies from reaching populations in need; also border closures are not usually that effective. Specifically, under Article 43 of the IHR:

States Parties implementing additional health measures that significantly interfere with international traffic are obliged to send to WHO the public health rationale and justification within 48 h of their implementation. WHO will review the justification and may request countries to reconsider their measures. WHO is required to share with other States Parties the information about measures and the justification received [54].

Sweden did not close its borders on its own but was forced into the Schengen-wide border closure.

WHO advice, technical guidance and recommendations are extremely important, not least in a pandemic situation and countries should take seriously documents issued by the WHO. It is important to understand that most ‘recommendations’ are not universal but are written in a way which allows countries to adapt them to their own contexts. Whether or not Sweden’s interpretation of WHO ‘recommendations’ in this instance was effective or appropriate is a different question; but Sweden followed WHO ‘recommendations’ with regard to public health measures.

This distinction matters: on the 21st of May 2020, the sustainability rating company Standard Ethics, downgraded Sweden’s rating having assessed that: “during the first phase of the COVID-19 pandemic, Swedish health policy did not comply with World Health Organization recommendations.”

Narrative 5: the Swedish approach is not working; and Sweden has or will change course

On the 3rd of April, Reuters led with “Sweden’s liberal pandemic strategy questioned as Stockholm death toll mounts,” in which they wrote about a “spike in novel coronavirus infections and deaths.” [44] The Business Insider reported that “Sweden, which refused to implement a coronavirus lockdown, has so far avoided a mass outbreak. Now it’s bracing for a potential surge in deaths.” [55] On the 4th of April Bloomberg noted that the number of Swedish deaths rose to 373 on Saturday, up 12% from Friday [56]. On the 9th of April, Time Magazine reported that “Sweden’s relaxed approach to the Coronavirus could already be backfiring,” using the case fatality rate as part of the argument, although they recognized the challenges of this metric [32]. On the 4th of April, Deutsche Welle reported that “Sweden mulls U-turn on coronavirus restrictions.” [57]

Part of this reporting originated in a bill (proposition) proposed 7th of April (but which had been discussed in different forms during the previous days). This bill gave the government additional powers under the Communicable Diseases Act (Smittskyddslagen) to implement so-called ‘lockdown’ measures, such as closing harbors, train stations and shopping malls [58]. The interpretation in much of the international media was that Sweden was changing course. However, the Irish Times was one of the most accurate accounts:

“Sweden has reached cross-party agreement on sweeping emergency powers to close shops, restaurants and schools in response to the coronavirus crisis – but the government has no immediate plans to use them.” [59]

That is, during the course of the pandemic it became clear that existing legislation did not allow the government to act quickly in taking more ‘lockdown’-type restrictions, but there will be no immediate plans to use the measures [60]. In a press conference The Prime Minister referred to these new measures as ‘tools in a toolbox.’ The idea was not that Sweden was changing course but wanted to be prepared to face future uncertainties caused by COVID-19.

The effectiveness of the Swedish approach is difficult to fully assess at the time of writing, which I return to in the conclusion. Already after the first month of the pandemic, Sweden had seen a decrease of seasonal influenza and calicivirus disease (vinterkräksjukan) which indicated that voluntary social distance measures were working [61, 62] People’s behavior had also changed, although perhaps not as quickly as it could have [63]. Additionally, the pandemic curve in Stockholm was ahead of the rest of the country, making it difficult to draw conclusions on Sweden overall. It is also challenging to compare cross-country data, especially when journalists are not precise about what numbers are being reported: case fatality rates, total deaths, deaths per 100,000 or excess mortality. Other newspapers compared Sweden to the other Nordic countries, without noting that Sweden’s population is roughly twice as large as Norway, Denmark, or Finland. Although these countries later diverged in the number of deaths per 100,000, during the first month of reporting Denmark and Sweden had similar rates, so this omission distorted the early picture.

If more stringent measures are put in place, then they may be reported as ‘Sweden changing course’ or ‘the Swedish approach is failing.’ However, as early as the 22nd of March in an address to the nation, the Prime Minister was very clear that more measures should be expected; and the Public Health Agency stressed repeatedly that they were are taking a stepwise approach: “the right measure at the right time.” Similarly, when some travel restrictions for the summer were lifted in June, the government was clear that restrictions would be put back in place if the epidemiological situation changed [64]. If the government puts in more measures, it will be in line with their actions and the advice of FHM.

As a follow-up example, in June 2020 Anders Tegnell gave a short interview to Sveriges Radio in which he stated that there was ‘room for improvement’ in the Swedish approach and that, if the virus were encountered today, with the knowledge that we now have, that Sweden’s approach would have been between what the country did and what other countries did [65]. This was picked up in the international media with headlines such as “Sweden chose a looser lockdown. The scientist behind the strategy now says the death toll is too high” and “Architect of Sweden’s coronavirus strategy regrets not imposing tougher lockdown.” [66, 67] Tegnell clarified his statement the following day, as reported in The Local:

We still think that the strategy is good, but you can always make improvements, especially when looking back. I personally think it would be rather strange if anyone answered anything else to such a question. You can always do things better,” he said, adding that he did not necessarily think he had been misquoted, but that his comments had been overinterpreted [68].

Narrative 6: Swedes trust the government

The final narrative returns us to some of the points raised in Good Sweden, Bad Sweden. Much of the early international coverage focussed on high-levels of trust in Sweden [32]. Historian Lars Trägårdh explained it accurately for several papers, noting that citizens trust public institutions and the government, the government trusts the people to do the right thing, and there is social trust amongst citizens as well [11, 12, 69].

As part of this is the cultural code of recommendations and advice. The government expects that Swedes understand that recommendations are to be followed, they are “not just loose tips,” as the Prime Minister clarified in a speech. Representatives from FHM repeatedly noted that public health measures, including infectious disease control, are based on “voluntary measures, acceptance and understanding in the population – that the Swedes trust and follow recommendations from their authorities.” [70]

By most quantitative and qualitative measures, there are high levels of trust in Sweden. However, in describing the Swedish approach, national myths blend with truths. In addition to the “Swedes trust authority” discourse there are also a number of ideas circulating about how Swedes are. Writing for Politico Lisa Bjurwald, herself Swedish, argues that Swedes naturally socially isolate, writing “Skype-based relationships? No hugging? For Swedes, that’s not social distancing. That’s just life.” [71] Carl Bildt, a former prime minister joked to the Economist that, “Swedes, especially of the older generation, have a genetic disposition to social distancing anyway [11]. On social media, people have questioned whether or not Swedes are responsible, citing the existence of the state-owned liquor store Systembolaget as evidence. This is the narrative that Swedes cannot control their alcohol intake and must have alcohol sales restricted. Even the term ‘peace-damaged’ (fredsskadat) was discussed in national media [72]. Simplified, this is the idea that, because Sweden has not been at war for over 200 years, it is difficult for people to imagine bad things happening on a large scale on Swedish soil, and that is why Sweden did not act as forcefully as other countries.

A related narrative, found more in social media than in the news, is that Swedes blindly trust authority, or that “trust seems to be equated with not questioning.” [73] Some of this has come from foreign residents, who are not used to the Sweden system or feel that Swedes are dismissive of their concerns [74]. Similarly, Swedes have been described as arrogant or even post-colonialist in their approach to non-Swedes living in Sweden [74, 75].

Yet, a country cannot be reduced to a few cultural stereotypes, and distilling an entire country into a set of traits and values also ignores complexity. It is not simply the Swedes have high levels of trust and ‘know’ how to follow recommendations. Much of the government and authority’s response also has to do with the legal system and history of Swedish administration, the latter of which gives a great deal of independence to agencies such as FHM [12, 47, 48, 76]. There are other contextual factors that impact the spread of disease, which have been noted by some articles. Sweden has a low population density compared to most other European countries and more than half of households are single-person (https://ec.europa.eu/eurostat/web/products-eurostat-news/-/DDN-20170905-1?inheritRedirect=true).

Focusing on culture also leads to constrained thinking, in which commentators find it difficult to explain ‘Stockholmers drinking beer in the sun’ or people ignoring recommendations, without concluding that assumptions of ‘Swedish responsibility’ are false. One can also become stuck in a cycle of criticizing Swedish ‘culture.’ In setting health policy, there is a fine line between taking context into account and reducing behavior to ‘culture,’ as if it is a fact or a variable to be plugged into a model. Rather, history, law, socioeconomic factors and tradition have created a tangled ‘web of significance’ – to borrow from anthropologist Clifford Geertz – in which different Swedes make decisions and live their lives.

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