What’s missing from Sweden’s coronavirus strategy? Clear communication

Sweden is now one of the only countries in Europe, and one of the only coronavirus-hit countries worldwide, where it is still possible to go the pub or to school, and to gather with dozens, even hundreds of other people. Several experts have told The Local that the country needs to be much clearer in communications with the public on the coronavirus outbreak.

What's missing from Sweden's coronavirus strategy? Clear communication
Representatives from Swedish authorities at the coronavirus press briefing on Monday. Photo: Claudio Bresciani / TT

The measures currently in place in Sweden focus on protecting the most vulnerable groups, with over-70s and other members of risk groups urged to stay in their homes as much as possible. Find information on how to give, or receive, help here.

Flattening the curve

Anyone displaying symptoms consistent with the coronavirus (such as a cough, sore throat, fever or runny nose) is also asked to stay at home and avoid all non-essential social contacts. But under the official recommendations of the Public Health Agency, healthy people who are not in any risk group need only practise good personal hygiene, work from home if it all possible, and avoid non-essential domestic travel.

Events for more than 500 people have been banned, and organisers of smaller events asked to keep up-to-date on recommendations and carry out risk assessment. Schools and ski resorts remain open, as do cafes and restaurants, although new restrictions were introduced on Tuesday.

A sunny weekend brought crowds to Malmö's outdoor cafe terraces. Photo: Johan Nilsson / TT

In neighbouring Denmark, which currently has a similar number of deaths caused by the virus, there has been drastic action in the form of a lockdown. Meetings of more than ten people are banned, and schools, kindergartens, restaurants and cafes are closed.

The Danish health agency has shared an evaluation in which it estimated that these measures could cut the rate the coronavirus pandemic spreads in the country by as much as half.

That's because each person with the coronavirus is thought to infect on average another 2-3 people. By reducing the number of contacts each person in society has with others, this number (called the transmission rate) is reduced, which means fewer people will be infected by the virus at any one time.

Such a result would help to avoid overloading hospitals and healthcare, which it is hoped would give each patient a better chance of survival.

This is known as flattening the curve. 

Sweden's national epidemiologist, Anders Tegnell, has also called on people in Sweden to flatten the curve, but has said in press conferences that the agency believes the best way to do this is by following the measures currently in place rather than the draconian measures introduced in much of the rest of Europe and many countries further afield – although stricter measures are not ruled out.

'Keep your distance'

Social distancing is a general term which refers to limiting your social contacts, and encompasses things like avoiding busy places and large groups of people, avoiding public transport at rush hour, and working from home. 

The World Health Organisation has recommended standing at least one metre distant from other people, as one of five ways to reduce the risk of catching the coronavirus. 

Public Health Agency director Johan Carlson and Health Minister Lena Hallengren at Tuesday's press conference. Photo: Anders Wiklund / TT

Sweden's Minister for Health and Social Affairs, Lena Hallengren, also urged Swedes to practice social distancing in Tuesday's coronavirus press conference. “Keep your distance, we normally say in traffic. But that also applies to social life now. In the first instance, use telephone, video chat, or other tech, to keep in touch with relatives and friends,” she said.

However, when The Local contacted The Public Health Agency's press office to ask if keeping one metre away from people outside your household was recommended in Sweden, we were told “there are no such recommendations” and referred to advice on the agency's website.

That advice tells readers to protect themselves and others by washing their hands, covering coughs and sneezes with their elbow, and staying at home when they are sick. The agency has also asked people to avoid in-person visits to vulnerable groups.

How the decisions are made

The decision-making process works differently in Sweden compared to many other countries.

In Denmark, for example, the government has taken the lead on coronavirus measures. On some occasions, Danish government recommendations have conflicted with agency recommendations, including the decision to close the country's borders. The Danish public health agency (Sundhedsstyrelsen) has called this a “political decision” that would likely have little impact on infection spread.

Explaining why that country's lockdown has been so strict, Prime Minister Mette Frederiksen has said: “If we have to wait for full evidence to fight the corona, then it is my clear conviction that we will be too late.”

In Sweden, most of the decisions come directly from the Public Health Agency, which has a lot of independence.

When the recommendations do come, in Sweden there tends to be an emphasis on individual responsibility, which could leave people unsure exactly what that responsibility entails.

Danes were told by their government on Monday: “Cancel Easter lunch. Postpone family visits. Don't go sightseeing around the country,”. The Swedish Public Health Agency's corresponding recommendation is: “Ahead of the breaks and Easter, it is important to consider whether planned travel in Sweden is necessary to carry out.”

'With freedom comes responsibility'

Orla Vigsö, a professor who studies crisis communications at Gothenburg University, told The Local that the different political structures may be one reason for this contrasting wording.

“In Denmark, you can be fined if you don't do as the new laws say, so the authorities have backing to impose this on the public,” he noted. “There are no laws yet in Sweden so there may be a legal side; they don't want to say people should do something and be held responsible for economic losses – that's a possibility. There's also a general tendency not to use harsh imperatives in Sweden. We supply people with the facts they need to make an informed decision and we hope that decision is the right one.”

Epidemiologist and science writer Emma Frans had a similar view, saying that this different wording highlights the role of the individual in preventing the spread.

“In Sweden we are letting people use their own judgment,” she said. “We should all think not only about our own risk, but also the risk of transmitting the disease, especially young people who think they're not at risk of becoming critically ill or dying and aren't being as careful as they should. We are getting this freedom of not being locked down, but with this freedom comes responsibility.”

Emma Frans is an expert in epidemiology. Photo: Malin Hoelstad / SvD / TT

But is that strategy sufficient?

“No, I don't think so,” said Vigsö. “I think they need to tell people exactly what to do and not to do, to maintain their status as being reliable and concerned for the safety of Sweden's inhabitants.”

“It's better they say 'don't do this' and then afterwards let people do it once we know it doesn't pose a problem. But people need to know that they are risking the lives or at least the health of other people.”

Conflicting opinions

The coronavirus is new, so there's a lack of scientific evidence of the impact of different measures. In other words, not even the experts know exactly what is the best path to follow.

Some experts within the scientific community are confused about the discrepancy in approach between Sweden and its neighbours.

“We can't really understand why [the measures in Sweden] differ so much from other countries,” said Björn Olsen, a professor in infectious diseases at Uppsala University who has been among the open critics of the Swedish government's strategy and communication methods. 

He added that Swedish authorities “aren't very talkative to us scientists either, there's not much communication between them and us, and that's a bit of a problem I think.”

“It's fair to tell people 'we are making this decision because of this or that', and that's very important when you see this big difference between other countries. People aren't stupid, they know exactly what's happening in the rest of Europe, so it's very confusing for us scientists, for Swedish people and I imagine very much so for foreigners here. And they need to communicate with us, because we also have a voice in the media, so it's extremely confusing for people when we say one thing and they say something else.”

Empty streets in Berlin following Germany's ban on gatherings of more than two. Photo: AP Photo/Markus Schreiber/TT

The Local contacted the Public Health Agency for an interview for this article, but had not received a response by the time of publication, although the agency did respond quickly to some individual questions, directing us to their latest recommendations and Q&A.

Various articles written by researchers in infectious diseases have called for Sweden to change its strategy, including a recent opinion piece in Dagens Nyheter where two professors said the Swedish advice deviated from World Health Organisation recommendations. 

An open letter was launched by several researchers in Sweden to take measures immediately such as “interventions to reduce the mobility and contact in the population” and an increase in testing capacity.

That doesn't mean that the entire Swedish scientific community disagrees with the measures.

Sweden's former state epidemiologist, infectious disease expert Johan Giesecke, called on researchers to “stay within their area of expertise” in an opinion piece for Svenska Dagbladet, in which he highlighted the lack of knowledge about the virus. Giesecke stated: “The lack of reliable knowledge explains why countries choose to do things differently: nobody knows what really works, and you choose actions either on the basis of shaky data or for political reasons.”

And science journalist and epidemiologist Emma Frans said that journalists often look for conflicts, but that this can be problematic in the current situation.

“It's a different issue compared to other kinds of news reporting. You have to be very responsible and it's very important to get things right,” she says. “In a democracy you should always be able to question authorities, but with disease outbreaks, it's also important that people trust the authorities and listen to their advice otherwise we get problems.

“We saw this in central Africa with the ebola outbreak; the process of vaccination was slowed down because people didn't believe the vaccinations are safe. People's behaviour can be affected in a way that makes it more difficult to slow down the spread of the disease.”

Following developments

Frans was positive towards the efforts of both the World Health Organisation (WHO) and Swedish authorities to hold daily press briefings on the state of the outbreak.

But she added: “WHO have been very good at recognising the importance of handling communications. The Swedish authorities have been very focused on handling the disease, and not so much on handling press and communications. That's starting to change, which is good because there is such an abundance of information and self-proclaimed experts out there.”

Vigsö suggested that Swedish authorities could go further in ensuring that information and up-to-date guidelines reach the public.

“The state is relying on media to transmit the information to people, but perhaps they should consider other ways. I used to live in Denmark, so I get their official communications and received a mail from the health authorities about things I should take into consideration. There's been nothing like that in Sweden, and there's absolutely a need for something that has not been filtered through the media.”

One reason that keeping the population informed is so crucial is that the coronavirus is a slow-working virus. 

There is an incubation period between a person getting infected and getting sick, and typically patients show symptoms for around a week before needing hospitalisation. This means that the results of any measures will not be visible until between two weeks to a month after their introduction – something which, if the public aren't aware of it, might lead them to lose trust in the measures and their authorities.

A seriously ill coronavirus patient is admitted to intensive care in Germany. Photo: Hendrik Schmidt/dpa via AP/TT

“Downplaying the potential dangers and potential development was not a very good beginning when there were already signs from the WHO and international experts that this was getting very serious,” said Vigsö.

“They have stressed too little the importance of trying to avoid social contact; people haven't realised this is one of the most important ways of limiting the spread of the disease. People know what authorities in other countries say, so it's very peculiar for people to hear that in England, Germany, France, you should keep a six-foot distance, but not in Sweden,” he added.

“If the situation doesn't get better, the authorities will likely go out and say 'now you should keep that distance', and people will say 'why the hell didn't you say this two weeks ago'. I'm not saying it's wrong, but it arouses questions in the public. The authorities refer to different assessments in different countries, but that's not an answer.”

Infectious disease professor Björn Olsen shared this view. When asked what he thought was missing from Sweden's strategy, Olsen's answer was either a stricter suppression or lockdown, “or at least an explanation of why that's not an option”.

“Folkhälsomyndigheten keeps saying it's not an option,” he told The Local. “If you don't have a suppression strategy, I think you'll see the curve going up and up and stressing healthcare. It will then be necessary to take more aggressive measures later, but it's better to do this sooner, before you have stressed the system too much.”

Olsen also suggests that media should look at examples of how other countries have succeeded in battling the virus. South Korea has been praised for a dramatic turnaround in numbers of cases and deaths, without the draconian lockdowns seen in China, and this has been put down to factors such as the most widespread testing of any country, and swift action based on the experience with Sars. 

But he sees another factor, one which could more easily be replicated in Sweden.

“What they did in South Korea was inform, inform, inform. There were daily meetings where they really walked people through the material, saying 'this is what you need to do, this is the result you can expect in the short term and long term if you do this', and being extremely clear.”

Member comments

  1. Madness that they aren’t being stricter and locking down things more. They are playing with fire. At least close the ski hills, my god! If everyone goes up there for Påsklov we’re in real trouble.

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EXPLAINED: What to do if you face a long wait for healthcare in Sweden

Sweden theoretically has a "healthcare guarantee" limiting your wait to see a GP to three days, and to see a consultant to three months. The reality is somewhat different. Here's what you can do if you face a long wait.

EXPLAINED: What to do if you face a long wait for healthcare in Sweden

What is Sweden’s ‘healthcare guarantee’? 

Sweden’s “National Guaranteed Access to Healthcare” or vårdgaranti, is a right to care, protected by law, that has applied in Sweden since 2005. You can see the latest version of the relevant laws here and here. Here is a summary of the guarantee on the website of the Swedish Association of Local Authorities and Regions (SKR).

Under the system, all patients are guaranteed:

  • contact with a primary care centre by phone, in-person, or by video-link on the day they seek care 
  • an appointment with a doctor, nurse, physio, or psychotherapist within three days of seeking help 
  • an appointment with a specialist doctor or consultant within 90 days of seeking help 
  • treatment or operation within 90 days, if the specialist considers this necessary 

Does the guarantee mean I have a right to treatment? 

No. If the doctor at the primary care centre, after examining you and questioning you, decides that there is no reason to refer you to a specialist doctor, they do not need to do so. 

Similarly, if the specialist doctor, after examining you, decides that no treatment is necessary, then your case is considered completed.  

Can the waiting times to see a specialist or to get treatment be longer than 90 days? 

Absolutely. In fact, they very often are. 

According to the Swedish Association of Local Authorities and Regions (SKR), in February, 32 percent of patients had been waiting 90 days or more to see a specialist, and 43 percent of those who had seen a specialist had been waiting for treatment for more than 90 days.  

The situation in primary care was a little better, with 80 percent of those seeking care in contact with their primary care centre on the same day, and 83 percent having their case assessed by a doctor or nurse within three days. 

In addition, if you agree with your specialist doctor that you are willing to wait longer for an operation, then that wait doesn’t get counted in the statistics. 

So what can I do if I’ve been waiting longer than the guaranteed time? 

In reality, it’s actually less a guarantee than a target.

In primary care, there is no way for individual patients to complain that they have had to wait too long to see a doctor or nurse, or to cut their waiting times by citing the guarantee. 

“There’s no system for enforcing that guarantee,” says Emma Spak, the primary care doctor who doubles as section chief for SKR’s healthcare division. 

It would make no sense to set up a complaints line for those who have had to wait too long for phone contact with their primary care centre, she points out, when they could instead talk to patients seeking a primary care appointment in the first place. 

“It’s more of an incentive system for the regions,” she explains.

Every primary care unit and every region reports their waiting times to the national waiting time register, and then as part of the access agreement between SKR and the government, the regional health authorities receive a bonus if they meet their waiting times goal, or if they improve their waiting times. “That’s one way of sort of enforcing this guarantee,” she says. 

When it comes to specialist treatment, though, patients do have the right to demand to be examined or treated by an alternative specialist or hospital if they’ve had to wait longer than 90 days.

If your primary care centre issues you a referral to a specialist, and the specialist cannot then offer you an appointment within 90 days, the specialist, at the same time as offering you a later appointment, will often put you in contact with a unit at the regional health authority who will offer to find you an alternative specialist, either within the region or elsewhere in Sweden. 

The regional health authority will then have to reimburse any extra travel or hotel costs incurred by the patient.  

Similarly, if after examining you, a specialist cannot offer you treatment within 90 days, they will normally put you in contact with the same unit. 

Some regions have a phone line for people who have been waiting too long, or else you can contact your specialist or primary care centre and ask for information on seeking an alternative specialist. 

What happens if I don’t want to travel to see a specialist or get treatment? 

If your regional health authority offers you an alternative specialist, either within your region or in another region, so that you can get treated within the 90 day period, and you are unwilling to travel, then you lose your rights under the guarantee. . 

“If you’re in Gothenburg, and they say you have to go to Stockholm to get your treatment, and you say, ‘no, I want to go here, then then you’ve sort of forfeited your right, and you have to take what’s on offer,” Spak says. 

What happens if I agree with my specialist to wait longer? 

If your specialist says that they can treat you in four months, but also offers you treatment elsewhere within the guaranteed 90 days, and you choose to be treated by your specialist, then that counts as a patient choice, which will not then be counted in the statistics. 

“The specialist might say, ‘I don’t think you will get any worse for waiting two months extra, and if you wait five months, then I can make sure that you get your surgery done here, and we can make sure that you get all the aftercare and everything here as well,” Spak says. 

But these patient decisions are also counted in the statistics, and if a region sees a sharp rise in patients choosing to wait, SKR will tend to investigate. 

“If some region all of a sudden has a lot of patients choosing a longer waiting time, then we will call them and ask what’s going on here, because patients don’t tend to want to wait extra,” Spak says.  

Can I get financial compensation if I’ve been waiting too long? 


What other ways are there of speeding up the wait for treatment? 

Don’t underplay your symptoms

When drawing up their timetable for treatment and assessment, specialists will tend to give different patients different wait times depending on the urgency of their case.

For this reason, it’s important not to underplay your symptoms when visiting a primary care doctor, as they will tend to include a few lines on the urgency of your case when they write their referral. 

Stress your flexibility 

If you are unemployed, a student, retired, or have a very flexible job, it is worth telling your primary care doctor about this, because they may write in your referral that you are able to make appointments at very short notice. The specialist may then put you on their list of people to ring if one of their patients cancels. 

“Sometimes I write in my referrals that this patient could easily come at short notice, so please put the patient on the list for people you can call if there’s a time slot available,” Spak says. 

If you haven’t told your primary care doctor this, it’s not too late. You can ring the specialist yourself and tell their receptionist that you are very flexible, and ask to be put on the back-up list. This is particularly useful if you’re waiting for a scan, but you could also potentially work even if you’re waiting for heart surgery or a hip replacement. 

“If they’ve accepted you as a patient, and they’ve made sure that you fulfil the criteria for having that scan or whatever, then you can call them and say, ‘I have a really flexible job, I can come anytime if you have a gap,'” Spak says.

“A lot of people do that, because they can have [back-up] waiting lists. If you tell them ‘I work around the corner and I only need 15 minutes to be there’, then they might call you if someone doesn’t show up.” 

Ring up your specialist 

The queue system tends to be quite ad hoc, with no strict rules over who should be treated first, so it is often possible to reduce your wait by ringing up your specialist a few times a month, just to bring your case to their attention. Sometimes the receptionist will remember a slot that has just come free and bring forward your treatment while you are still on the telephone.