Migrant-focused inequity, distrust and an erosion of care within Sweden's healthcare and media discourses during COVID-19

Strange, Michael; Askanius, Tina

doi:10.3389/fhumd.2023.1243289

CONCEPTUAL ANALYSIS article

Front. Hum. Dyn., 29 September 2023

Sec. Migration and Society

Volume 5 - 2023 | https://doi.org/10.3389/fhumd.2023.1243289

This article is part of the Research Topic Exploring the Links between Social Connections, Care and Integration View all 12 articles

Migrant-focused inequity, distrust and an erosion of care within Sweden's healthcare and media discourses during COVID-19

$\r\nMichael Strange$ Michael Strange¹^*

Tina Askanius^2,3

¹Department of Global Political Studies, Malmö University, Malmö, Sweden
²School of Arts and Communication, Malmö University, Malmö, Sweden
³Institute for Futures Studies, Stockholm, Sweden

Despite initial suggestions that the COVID-19 pandemic affected everyone equally, it quickly became clear that some were much worse affected than others. Marginalization—including poverty, substandard accommodation, precarious or no employment, reduced access to healthcare and other key public goods—was clearly correlated with higher rates of both contagion and fatality. For Sweden, COVID-19 inequality could be seen along clear racial and socio-economic lines, with some of the first high death rates seen amongst Somali communities, where individuals had contracted the virus through unsafe employment as taxi drivers transporting wealthier Swedes home from their winter holidays. At the same time, actors on the extra parliamentarian far-right in Sweden were quick to blame the country's relatively high per-capita fatality rate on persons born outside Sweden working in the healthcare and care home sector. Media frames affirming racial stereotypes grounded in cultural racism circulated across the ecosystem of alternative media in the country. In both healthcare and the media, we see growing forms of exclusion disproportionately affecting migrants. Such intertwined exclusions in Sweden, as the article argues, are a sign of a wider disintegration of Swedish society in which individuals lose trust in both the core institutions as well as across different parts of society. Drawing on Davina Cooper's understanding of the relationship between the state and other public institutions with individuals as based on “touch,” the article explores how exclusionary practices impact this relationship. Our key argument is that, whilst ostensibly such practices often most materially hurt minority groups (e.g., migrants), they are indicative of—and accelerate—a broader disintegration of society through undermining a logic of “care” necessary to sustain social bonds.

1. Introduction

Trust serves as the core indicator of a politically stable society, with Scandinavian countries such as Sweden scoring highest within comparable studies attempting to measure public trust levels (Rothstein and Uslaner, 2005; Freitag and Bühlmann, 2009; Bergh and Bjørnskov, 2011). Yet, today in Sweden, the pandemic provided evidence that trust is declining as a small but growing part of the population has started questioning the credibility of health guidance advising them to vaccinate (Fahlquist, 2018; Kokkinakis and Hammarlin, 2023). Vaccine hesitancy in Sweden, as elsewhere, intersects with other polarizing issues that drive a series of political cleavages undermining broader trust (Lazarus et al., 2021; Raffetti et al., 2022; Steinert et al., 2022). At the start of the pandemic in early 2020 commentators referred to COVID-19 as a “leveler,” threatening every human regardless of wealth and power with media stories reporting examples of politicians and wealthy celebrities contracting the virus (Ali et al., 2020). As lockdowns were enforced and the virus played out, however, the narrative of equality unraveled as it became clear contagion and fatality rates were significantly higher amongst groups living on the margins of society (Cheshmehzangi, 2022). Poverty, substandard accommodation, precarious or no employment, and reduced access to healthcare and other key public goods were clearly correlated with higher rates of both contagion and fatality (Bentley and Baker, 2020; Orcutt et al., 2020). The effects of COVID were also very different depending on an individual's social status and precarity (Smout et al., 2022). Rather than being a leveler, COVID acted as a catalyst accelerating the effects of societal inequities normally experienced at a much slower and less visible state.

COVID emerged not in a vacuum but, rather, a period already experiencing excessive polarization with noted politicization of policy processes and knowledge formation in many parts of the world (Boräng et al., 2018). Where vaccine hesitancy coalesced in the form of social movements these mobilisations often contained a mix of demands and activists placed at opposite ends of the “Left-Right” political spectrum (Dubé et al., 2021; Sorell and Butler, 2022). Not only have anti-vaccine movements connected the so-called “Far-Right” and “Far-Left,” but they have also hosted a range of lifestyle cultures on the fringes of the mainstream, including survivalist, spiritualist, and alternative healing (Halafoff et al., 2022). Rather than being focused exclusively on vaccines, therefore, anti-vaccine movements provided a vehicle by which those perspectives that had come to perceive themselves as outside the political and cultural mainstream could link their otherwise diverse and often opposed identities. Public denouncements of those individuals as “ignorant” or “selfish” risk being counterproductive when made by figures they perceive as part of an “elite” associated with the source of their self-perceived “oppression.”

The World Health Organization (WHO) came to see the politicization of the vaccines roll-out as the greatest threat to preventing further deaths from COVID, emphasizing the urgency to develop communication strategies able to rebuild societal trust (WHO, 2020). The challenge for health bodies like the WHO, however, is that they have little capacity to handle phenomena like anti-vaccine movements when the grievances at play embody far more than just a debate about how best to respond to a health crisis. Where expert knowledge is questioned not for the veracity of its methods but for its perceived association with an “elite,” the value of the main currency used by medical practitioners and policy designers—expert knowledge—to legitimate their public role declines (Dib et al., 2022). Competing ideas of how both to interpret the pandemic and its unequal effects upon individuals play out in the Swedish case. In this article, we therefore use the case of Sweden as a window onto understanding inequity and distrust as factors to consider in the broader context of the role of institutional and societal care relations. The ambition of our contribution is to bring attention to some of the exclusion mechanisms and processes of cultural and racial Othering in public discourse in Sweden, which might provide a useful backdrop for addressing the broader political and discursive struggles in the region, today and historically (see Deland, 1997; Ter Wal, 2003). Our reflections are based on ongoing work and preliminary results of case studies conducted within the framework of the Precision Health and Everyday Democracy (PHED) project and its Commission on the Future of Healthcare Post COVID-19 as well as ongoing research on the production of extremist discourse in response to the pandemic by far-right actors and its projection into the digital mainstream and mainstream political discourse conducted at the Institute for Futures Studies in Stockholm in collaboration with TSAS.¹

Sweden was an outlier during the height of the pandemic as an advanced European economy that, in contrast to other Western states, opted for a voluntarist approach toward social distancing and other controls elsewhere imposed by the state. At the same time, Sweden initially experienced higher per capita deaths than comparable welfare states, particularly amongst elderly populations within nursing homes (Mishra et al., 2021; Rizzi et al., 2021). For many engaging with Swedish public institutions there was a sense that the pandemic did not exist (Strange et al., 2021). For example, foreign students faced legal precarity where universities moved teaching online and the Swedish Migration Agency reacted by seeing any failure by those students to attend on-campus as a violation of their residency conditions and therefore grounds for deportation (Gemma, 2020). COVID fatalities in Sweden followed societal cleavages most with respect to migration history, with a high prevalence of deaths amongst Somali communities in Sweden early in the pandemic's first wave (Rostila et al., 2021). Such deaths were followed by media speculation as to the causes, with some public commentators blaming the “culture” of the affected individuals. In this narrative, their death, albeit tragic, is nontheless related to a failure on their part to comply with consensus culture, and seemlessly adapt to a society of cultural homogeneity and high trust in authorities. As such, the immigrant or the refugee is, “an essentially ambiguous figure suspended between victimhood and malevolence,” and one who is at one and the same time in need of protection and threatening to the community to which they have been accepted (Chouliaraki and Zaborowski, 2017, p. 616). Whilst popular in the media, cultural explanations overlooked the prevalence of precarious employment within areas with high immigrant populations of non-Europeans. For example, those affected neighborhoods included a disproportionate number of taxi drivers who contracted the virus driving wealthy holiday-makers home from their ski trips (Kjøllesdal and Magnusson, 2021). Those same residential areas also included the poorly paid professional carers working in nursing homes. Nevertheless, nursing home workers and other carers born outside Sweden were soon identified as the main culprit by far-right actors who blamed and demonized immigrants for causing the abnormalities in the country's high per-capita fatality rate just as a series of culturally coded conspiracy theories emerged among actors in the same far-right media milieu in which the high death rates in Swedish nursing homes were presented as an intentional “geronticide” or “senicide” (the intentional killing of the elderly) committed by migrant workers (MSB, 2021). In this sense, national discourse both echoed and exacerbated the extensive international media attention Sweden reveived in which immigrants were predominantly made invisible or irrelevant (Irwin, 2020). As pointed out by Christensen (2022) international news pieces about Sweden and its lax or “light touch strategy” (both positive and negative) fixated on the relative openness of society using accompanying images from central city areas, often showing crowded restaurants and cafes or shopping areas full of young people, “while rarely (if ever) noting how this ‘openness' was reliant upon lower-paid workers such as cleaners or kitchen staff, often with immigrant background, who lived and commuted from parts of the city never shown or discussed in the articles” (Christensen, 2022).

Media discourse at large but most prominently that produced within the country's extensive online ecosystem of alternative news media, thus tended to erase or co-opt the inequitable impact of COVID in Sweden by subsuming it within a growing anti-migrant discourse in which the individuals' suffering was framed as being a consequence of their migration into Sweden and bringing a “culture” from abroad, as the article will discuss. To draw out the processes through which inequity revealed by COVID has emerged and been co-opted for a regressive politics explicitly intent on further inequity in Sweden, the article is structured as follows. It begins with an outline of inequity within Swedish healthcare during the pandemic, with emphasis on problems within health communication as well as healthcare access that disproportionately affected individuals along racial lines. Drawing upon secondary data and a synthesis of literature emerging on this issue, this section points to the experiences of regional health carers working with migrant populations and their feeling of being ignored by higher-level decision-makers who pushed for a “one-size-fits-all” model for healthcare ignorant of the barriers that prevented people with poor housing and precarious employment to follow health guidance for avoiding COVID.

The article then synthetises the emerging body of research on media and the pandemic to examine how COVID-19 was narrated as a highly mediated event within social media and framed in alternative and mainstream news media. Social media achieved new prominence globally during the pandemic due to social isolation and, in Sweden like elsewhere in Europe and the States, can be seen to have been important to conveying racialised narratives of otherness stigmatizing migrants as “dangerous” due to their lack of trust in public authorities or having a flawed and “culturally specific” response to the pandemic. Paradoxical and racialised media frames in which migrants who became victims of the pandemic were reframed as “aggressors” and “foreign bodies” failing to follow the guidelines of health authorities, obscured the inequities migrants faced whilst creating political obstacles for any government attempts to support those who were most vulnerable to the pandemic or working hard to maintain the Swedish healthcare system within nursing homes. Whilst these exclusionary practices will have most materially hurt those minority groups immediately impacted, the article considers them in a broader political context through drawing on Cooper (2019) understanding of the relationship between the state and other public institutions with individuals as based on “touch.” The authority of the state can be felt in a myriad of ways, as elaborated below, with consequences for the social bonds constitutive of society. Our approach posits that health systems and media systems, and the structural and discursive exclusions they may produce, are intricately linked even as they represent distinct ways of being “touched” and as such of being included (or excluded) in a broader horizon of care. Our key argument is that the practices evidenced in Sweden during COVID-19 are indicative of—and accelerate—a broader disintegration of society through undermining a logic of “care” necessary to sustain social bonds and in which there was a shift in how individuals felt touched by the State.

2. Being touched by the Swedish state

The below analysis draws heavily upon the work of critical political and legal scholar Davina Cooper for her reconceptualization of the State and its relationship to individuals as based on “touch.” That is because the state is never a fixed or physical entity but, rather, a concept that has material meaning based on how it is felt (Cooper, 2014, p. 65–66). The notion of touch does not necessarily equate to one of care but, nevertheless, highlights the various ways in which individuals feel the impact of the state on their lives that can take many different forms. The state can touch individuals in many different ways, as reflected in the variety of regime-types with stable democracies felt to be distinct from highly restrictive authoritarian states. At the same time, neoliberal states have a much more diffuse and thinned touch where individuals experience the provision of public goods as being dependent on a much more ad hoc and unpredictable network of agencies and non-state actors. Whatever form the state's touch may take, touch is the baseline for individuals' experience of the state and its societal role. Drawing on Cooper (2014) three aspects of touch were most visible in Sweden during the pandemic: (1) touch is reciprocal, impacting both parties even if in different ways; (2) touch can be both emotional and physical; and (3) touch is imbued with power and, whilst it may sometimes subvert relations, typically it reinforces existing structures. Since touch is a dynamic process that is never fixed, the same can be said as regards the relationship between the State and individuals. Relating back to the role of trust in society, touch provides an overall way of thinking through both how individuals experience the state but also the dynamic within that relationship. In Cooper's perspective, the state needs to be seen as an assemblage of institutional mechanisms, forms of political representation, public goods provision, rights protection, policing, and many other aspects that vary over time. It is also something highly mundane in which touch is felt largely as an everyday phenomenon through “jobs, membership, leisure activities, festive spaces, schoolbooks, accreditation, and recognition” (Cooper's, 2019, p. 15). Touch is often material but, also, for Cooper the dynamic in which the state can be experienced in alternate ways points to the role of imagination in thinking the state differently. Writing on the role of prefiguration in politics—the political significance of acting “as if” things were different—Cooper asks:

[W]hat if state actors take up and manifest conceptions of the state as caring, responsible, solidaristic and activist? What can imagining the state in these ways, and acting as if these ways were true ways, do? (Cooper, 2020, p. 898).

Her 2019 book “Feeling like a state” tackled this question directly by relating to examples where the state has been imagined differently to be at the center of progressive politics. She also relates to examples where the state withdraws its touch by refusing to provide care, resources, services to individuals. Importantly, the state is not taken as a reified concept but, rather, as “a way to orient our discussion of public governance toward questions of form, scale, and ethos” (2019, p. 23). The notion of the state is therefore not necessarily limited to one side of the traditional “state/non-state” binary but, rather, may embody a much wider series of relations and actors that as an assemblage touch individuals. The state works as a nexus of authority by which individuals are touched, which goes beyond just a one directional impact since, for Cooper, touch is reciprocal in that the one touching is also impacted by that contact. In welfare states like Sweden a touch of “care” has been central to the social bonds constituting society, coming from a historically two-way relationship in which labor movements were key alongside top-down policy implementation in establishing certain principles around provision of healthcare as well as solidarity within societal discourse. Yet, how the Swedish state touches individuals has shifted. In what follows, the article considers how Sweden's healthcare and media touched migrants during the pandemic. Whilst much of the media is private and the majority of Sweden's healthcare system is state-funded, from the conceptual lens we borrow from Cooper it can be seen that individuals feel both as part of the “State” touching their lives as they impact how it feels to be living in Sweden.

3. The structural basis of inequity within Swedish healthcare

Sweden's healthcare system offers a generous provision of medical care to those with legal residency on an equal basis to national citizens, though for asylum seekers coverage is limited to urgent treatment only (Mangrio et al., 2018, 2020; Mona et al., 2021). Varying levels of healthcare access mean that, on an experiential basis, Sweden as a state takes multiple forms, in which citizenship status is perhaps the most obvious way in which some are denied care. Healthcare access for migrants continued during the pandemic, comparing favorably to other European countries such as the United Kingdom where, for example, during the first wave of the pandemic asylum seekers were forced into prison-like accommodation with poor sanitation and no possibility to socially distance with the result that many caught COVID (Dalingwater et al., 2022). When compared to other countries Sweden has historically stood out for having taken a humanitarian perspective toward migrants but it has undergone a political shift since the 2014 election when an anti-immigration party first won considerable mandates in the general elections (Rydgren and van der Meiden, 2018). As already established, early in the pandemic there was evidence of higher contagion and fatality rates in Sweden amongst those born outside the country compared to native born individuals. Based on an inquiry we organized with healthcare practitioners, activists, and researchers—the PHED Commission on the Future of Healthcare Post COVID-19—in Autumn 2020 (Strange et al., 2021), the pandemic period identified two significant areas of inequity within the Swedish healthcare model that detrimentally impacted those with a migrant background.

The first aspect was the temporal delay in communicating essential health information—such as how to socially distance—to those outside the middle-class mainstream of Swedish life. Like many countries, Sweden was slow to make information available in languages beyond the official native tongue. This was despite the easy availability of translation resources within a rich country with a linguistically diverse population capable of providing that translation. More crucially, those familiar with the healthcare needs of migrants criticized the central health authority's approach as based on a narrow conception of life in Sweden that ignored the practical obstacles faced by individuals living in substandard accommodation and with economic precarity. Poor health communication is one of the main barriers to achieving universal health coverage, limiting not only access to healthcare services but also undermining individuals' understanding of their own health needs (Maibach and Holtgrave, 1995; Dutta, 2007; Maldonado et al., 2020).

Sweden is noted for having taken an exceptionalist approach to the pandemic, relying on voluntary compliance with guidelines rather than imposing social distancing and self-isolation via punitive measures due to the perceived long-term costs compared to the effects of the immediate pandemic. Sweden stands out as unusual, though, not just for taking a long time to impose restrictions but also a much less risk-averse approach toward pandemic-related health guidance. This was seen in the comparatively low use of face masks, for example. Health carers working with migrants experienced difficulties where there were significant disparities between Sweden's national healthcare guidance and the stricter approach advocated in the international media followed by their patients. This has been shown in a study by Mangrio et al. (2022) drawing on interviews with health and social care workers serving migrant populations. One such example was changing guidance regarding the at-risk status of someone being pregnant. Swedish health guidance was slow at defining pregnancy as a factor impacting at-risk status. Health carers working with migrants faced a contradiction between the national guidance they were required to convey to patients with the more risk-averse information those individuals received from the non-Swedish media on which they often relied for their understanding of the pandemic. The situation was made especially challenging where national guidance shifted over time and health carers appeared uncertain and ignorant in front of migrant patients. For health carers this undermined their authority with those patients, who turned even more to non-Swedish sources of information. More problematically, divergent perspectives on how to respond to COVID meant that some migrants chose to keep their children out of school despite Swedish guidance not to do so. By following what they saw as increasingly more credible non-Swedish guidance, migrant parents became stigmatized as “deviant” and “bad parents” for undermining their children's education and acting contrary to the national approach (Mangrio et al., 2022).

In the Scania region of Southern Sweden with a relatively high proportion of newly arrived migrants, the regional healthcare system was actively working to improve translation of health information for different migrant groups (Strange et al., 2021). A common theme expressed by those working with migrants and primary healthcare in the region, however, was that the national level was disinterested in the needs of a diverse population. There were very few opportunities to report problems back to the central level such that, despite Sweden's regional system for healthcare, the pandemic was managed centrally top-down with the region left to try and make-up for errors and holes in the system, such as an initial lack of interest in reaching out to migrant groups. The centralized structure of Sweden's response to the pandemic disproportionately impacted individuals with a recent migration background due to being most likely to be living outside the mainstream of an otherwise affluent society.

Sweden is a highly digitized society with a strong reliance on e-governance systems, including for healthcare, which can be accessed through having a Swedish “Bank-ID.” To have such an identity requires a Swedish bank account (Holmberg et al., 2022). As Sweden adopted an increasingly restrictive approach to the pandemic as the first wave matured and adopted some of the lockdown policies already implemented elsewhere, primary healthcare services including general practitioner consultations moved over to digital systems. The rapid shift was highly problematic for some of the most vulnerable groups in society, particularly non-European migrants, who were not only less likely to possess a Swedish Bank-ID but due to having come from authoritarian regimes were reluctant to communicate sensitive information via digital technologies susceptible to surveillance (Strange et al., 2021).

The mix of poor health communication, centralized top-down decision-making, and digitalisation of healthcare with no accommodation for a diverse population constitute a form of structural inequity. For those migrants directly affected structural inequity was felt with reduced healthcare access and options to maintain their wellbeing. The disproportionate impacts of the pandemic on migrants were seen across Europe and globally (WHO, 2022). In Sweden, rapidly changing health guidance that shifted from contradicting to belatedly supporting international media challenged societal trust overall. However, migrants who relied heavily on non-Swedish news sources are likely to have been impacted more significantly by finding themselves positioned as “deviant” if they followed guidance that differed from that provided by the national health authorities. Whilst trust relations between society and state were challenged globally with disproportionately negative effects on migrant populations, the Swedish case stands out for the effect this had within a country in which, whether supportive of those policies or not, many viewed their government as “migrant-friendly.” Where those structural inequities were largely hidden from the broader population, and migrants felt a heightened sense of distrust in authorities, the higher fatality and contagion rates amongst some migrant populations were hard to understand for those living within the affluent mainstream. Not seeing the structural inequities that made it harder for those migrants to protect themselves from COVID, it was easier to turn to explanations around the behavior of those individuals.

For more than a decade, Swedish politics has been dominated by a fear that the far-right anti-immigrant Swedish Democrats would enter government. As seen elsewhere, that fear has empowered a shift of the Social Democrats—traditionally Sweden's dominant party and in government during the pandemic up until September 2022—toward an increasingly anti-immigrant stance within its own policies (Oxford Analytica, 2022). That context was significant for the vaccine rollout where initial plans to prioritize some migrant groups due to having been most affected by the virus were dropped due to public outcry by the Swedish Democrats. Vaccine rollout in Sweden has been affected by the same structural problems and forms of exclusion described more generally within the healthcare system. Booking of vaccine appointments involved use of multiple apps, several of which were available in only Swedish and English or, sometimes, only the former. Non-European migrants were also less likely to vaccinate due to having developed lower trust in Swedish healthcare guidance (Tankwanchi et al., 2021). A study focused on Sweden identified a strong correlation between being a victim of racial discrimination and heightened vaccine hesitancy (Savoia et al., 2021). The complex character of racial discrimination and vaccine hesitancy means we should be wary of suggested direct causation, but nevertheless such studies underline the importance of examining the potential links between forms of societal violence and trust levels. The pattern of limited healthcare access and well-being for some migrant populations in Sweden has accelerated where combined with societal distrust. Reduced capacity to comply with health guidance amongst those vulnerable groups has furthered not only their own distrust in the healthcare system, increasing their likelihood to choose to ignore guidance, but also marked them out as “deviant” and subject to distrust from other groups in Swedish society. As an extreme event, the pandemic does not in itself provide evidence of a decline in general healthcare access for migrants in Sweden. The pandemic does not provide evidence of an overall decline of the Swedish state's “care” role since there is no directly comparable event. However, in the struggle over how much the Swedish state should adapt to individuals' needs, we do see a shift in which the Swedish state withdrew from that form of attentive and adaptive care within its touch. Equally, as the next section outlines, we see other aspects of its touch having strengthened through actively marking individuals out as different to the majority population—not by acknowledging their needs, but rather seeing their “difference” as a problem. A vicious circle has accelerated and spilled over into media discourses, as discussed in the next section.

4. Mediated touch and the cultural and racial othering of media discourse

The COVID-19 pandemic has been described as the first truly global, digitally mediated event felt everywhere. Not only is it one of the most reported news stories ever, it is also “the first epidemic in history in which people around the world have been collectively expressing their thoughts and concerns on social media” (Aiello et al., 2021, p. 1). For people in quarantined societies, social media turned into the prime channel of information and interaction and “a rigid and noxious polarization” has dominated much of public discourse (Bisiada, 2021, p. 2). Throughout the pandemic, media discourse was driving polarization and reproducing existing structures of social injustice, including racial inequities unearthed and aggravated by the pandemic. Across the world, we saw an uptick in online hate speech during the pandemic (United Nations, 2020) along with a surge in media discourse stigmatizing migrant communities (see e.g., Caiani et al., 2021; Poole and Williamson, 2021; Avraamidou and Eftychiou, 2022). Sweden was no exception to these tendencies. Albeit media provided community and support for many people during long periods of social isolation, it was also a source of divisive and stigmatizing discourse which framed the pandemic along ethnic and cultural lines. Such discourse was propelled not only by the country's extensive web of alternative far-right media but also, even in less blatant ways, by mainstream news media.

Given the media's role as an authoritative entity in society in general, and even more so during the pandemic, from the perspective of Cooper we may consider it one of the crucial ways in which individuals and communities were “touched” by the “state.” This was particularily evident in the early phases of the pandemic in which information and guideline transmitted directly from state authorities via public service media or sponsored content pushed into social media feeds were paramount. During the first waves of the pandemic in particular, as people found themselves confined to their homes and spending considerable time in front of screens, the individual-state encounter was largely mediated. Public service media served as the primary source of information and recommendations from the state communicated to the general public through daily live-transmitted press conferences, short videos with expert advice and other educational content on SVT, extensive news coverage etc. In this sense, public service institutions seeking to nudge people's behavior in a certain direction were one of the main ways people were “touched” by the state and its attempts to reduce mobility, encourage social distancing and promote vaccination campaigns. Indeed, research shows that news coverage played an important role in shaping public opinion, social norms and ultimately individuals' health-related actions in a context where Swedish authorities relied on voluntary compliance with public health recommendations (Garz and Zhuang, 2022).

But beyond public service institutions disseminating up-to-date and accurate information, promoting public health measures etc, news media more generally also framed the pandemic in important ways by providing the public with schematic interpretive packages (Gamson and Modigliani, 1989) with which to understand the nature of the public health crisis, its scale, causes, effects and potential solutions. COVID-19 spread unevenly in particular residential areas and disproportionately affected communities with a high number of residents with migrant backgrounds. These facts were widely reported across Swedish news media early on and fervently discussed in social media. In some of this media discourse, groups with migrant backgrounds were blamed and framed as “problems” in ways that testify to the discursive boundary-work of them/us along racial lines produced by media (Titley, 2019). In the initial waves of the pandemic, discursive processes of Othering that centered the racialised “migrant body” surfaced in Swedish news media and social media commentary. This too has been the case in international press about Sweden's controversial and hotly debated approach to the pandemic, framing immigrants as “the hidden flaw in Sweden's anti-lockdown strategy” (see e.g., Rotchild, 2020) often part of a more general framing of Sweden as the “worlds cautionary tale” (Goodman, 2020). Such discourse matters. Previous research indicates that media play a central role in the processes of stigmatization of residents in the “vulnerable neighborhoods” (Ericsson et al., 2000; Backvall, 2019) that became portrayed as hotbeds for COVID-19 transmission. As a proxy for the state in many people's lives, by touching individuals in ways that they feel differently recognized it has accelerated fragmentation.

A wealth of previous research has demonstrated how media tend to frame people with migrant backgrounds as causes for various social problems, for example by construing entire neighborhoods as “problem-places” and no-go Zones (Titley, 2019). The pandemic certainly provided ample opportunity for such scapegoating and Othering discourses to be perpetuated. Across various national contexts, media coverage of the pandemic has been characterized by problematic language that is consistent with racialization of illness and color-blind racial frames constructing COVID-19 as a highly racialized virus (Lyons et al., 2020). In some countries, public debates and media discourse about COVID-19 negatively racialised Asian communities and perpetuated Sinophobia (Zhang and Xu, 2020; Li and Nicholson, 2021; Wu and Wall, 2021). Research coming out of the US is showing how news media tended to report on racial disparities related to COVID-19 as an outcome of the “bad” health behaviors on the part of Black individuals thus ignoring the structural inequities and mechanism of exclusion behind the high numbers of morbidity and mortality affecting Black communities (Turchi and Melton-Fant, 2022). Similarly focusing on the US, Bonilla-Silva (2022) argues that the media framing of racial disparities in the early phases of the pandemic perpetuated public perceptions of Black individuals as unhealthy by nature or because of personal lifestyle choice. In a study of UK news coverage, Poole and Williamson (2021) show how the UK press often took “a culturalist position signaling overt religiosity and cultural practices as evidence of the social (and so health) threat that Muslims posed, and through constant attentiveness to their potentially regressive behavior,” they were portrayed as not only a danger to themselves and their communities but as threats to national security (p. 273). In doing so the media reinforced hegemonic discourse that has developed since 9/11 by drawing on and reworking longstanding tropes in which “marginalized groups are ‘othered,' subject to moral panics, and accused of refusing to integrate” (p. 275).

In the Swedish context, the racialised media discourse around the pandemic also invoked the figure of “disobedient” migrant bodies in the suburbs (on far-right media framed as “No Go Zones”) focusing on the failure of the Somali community in particular to follow public health guidelines, rather than treating them as a group in need of care. We see an early example of this frame in a widely circulated debate article by MP and leader of the Christian Democrats, Busch in the Swedish Daily Aftonbladet published in April 2020 in which she encourages the country to have the courage to speak plainly about “the problems of the suburbs” (Busch, 2020). With a focus on the seemingly insurmountable cultural differences, lack of trust and illiteracy of this particular black and Muslim minority population, the article echoes historical scripts about a lack of integration and adherence to the (formal and informal) rules and norms of Swedish society. In an op-ed published in the same news paper, also in the early days of the pandemic, three members of the far-right party the Sweden Democrats cautions that elderly care is being turned into an “integration-experiment” arguing that the health of elderly people was put at risk for the sake of integrating uneducated immigrants with poor Swedish language skills (From Utterstedt et al., 2020, see also Gustavsson, 2020).

The more general framing patterns, which these examples epitomize should be understood in the broader context of an increasingly hostile social and political climate toward immigration and the “Muslim Other” since the 2015/16 European border crisis (Askanius, 2021; Ekman and Krzyzanowski, 2021) and the last years' perpetual campaigns of far-right parties and groups promoting ethnonationalism and repatriation rather than integration, and policies actively working to disrupt possibilities for social connection and belonging for migrant minorities. Another important factor is the growing mistrust in traditional media among the Swedish population in particular with regards to reporting on issues related to migration which has provided a breeding ground for a flourishing scene of alternative “immigration critical” media in the country (Holt, 2016)—by far the biggest in Scandinavian comparisons (Ihlebæk and Nygaard, 2021). And indeed, the disobedient or infected “migrant body” took center stage in Swedish media discourse on the pandemic, most blatantly in the hyper partisan news coverage produced by this extensive network of alternative media but such ideas were also to some extent reproduced by mainstream media perpetuating culturalist explanations to first mortality rates and later vaccine hesitancy. Examining conspiracist and racist narra-tives circulating across the Nordic countries, Dyrendal (2023) found that migrant workers and ethnic minori-ties were among those most often presented as spreading the disease, and that these groups were represented either as part of a concerted malign effort to spread the virus or as spreading the virus “because of their culture” (p. 270).

These observations are in line with previous studies showing how historically infectious diseases are often represented as a threat from “outside” and construed around ideas of the mobile body as a threat to the larger social body (Kraut, 1994). The significance of such constructions is clear when contrasted against an imagined alternative in which, rather, the mobile body was seen as something to care for and preserve. Previous research tells us that when a pandemic threatens a global population, “the new fear of a floating population that moves as mobile migrants, passing mobile germs, fuels the media practices of boundary building of nation-states” (Kaur-Gill, 2020, p. 3). For example, a discourse analysis of the Canadian media coverage of the H1N1 outbreak, reveals that contamination “risk space” was centered around “mobile citizens” as particularly dangerous “pandemic subjects” (Maunula, 2017). Similarly, a study of media framing of the H1N1 pandemic in the UK context reveals the role of the traveling body as a central actor in media discourse (Warren et al., 2010). The blame game and scapegoating we saw unfolding in discussions on social media and in both mainstream and hyper partisan alternative media linked to the far-right is therefore best understood as a continuation of a set of longstanding mechanisms of exclusions—material as well as ideational. These are processes which extend beyond the case of Sweden and the current pandemic, but which in the specific context of Sweden and the COVID-19 pandemic had particularly damaging consequences.

The media framing and broader public discourse of the pandemic might not be formally part of the Swedish state, but in Cooper's broader understanding of the state such discourses are crucial to how people feel their relationship to the state. In this case, that media has been central in thinning the state's caring role. The stigmatizing or hateful discourse circulating online along with the more general and less blatant forms of scapegoating in mainstream media reporting provide an important backdrop to understanding a sense of being undeserving of care by the healthcare system and excluded by society at large. The role of the media—whether legacy or alternative online media—impacts how it is to experience living in Sweden and what to value in society such that, keeping with Cooper's approach to the “state,” we see the media as in some cases part of the Swedish state in other cases. Crucially, these aspects play into and amplify the more structural mechanisms of exclusion in Sweden today and alter how the state touches individuals.

5. Declining trust and a Swedish political crisis

At the time of writing Sweden is undergoing a seismic shift in its politics as the far-right party Sweden Democrats capitalize on their position as the second largest party in Sweden's parliament after the September 2022 national elections. Whatever legislative changes occur, the most immediate change is in Sweden's self-perception, the norms of political behavior deemed appropriate within the country's mainstream discourse, and how individuals feel touched by the state. In the first year of the pandemic there was evidence that trust amongst the Swedish public remained high (Helsingen et al., 2020), though it was becoming polarized along ideological Left-Right lines (Hassing Nielsen and Lindvall, 2021).

At the start of the so-called “refugee crisis”—a European Union political crisis as its Member-states failed to coordinate a measured response to the Syrian civil war—in 2015, Sweden stood out for its initially open-arms approach toward welcoming those fleeing the conflict. However, within a few months the governing Social Democrat-Green coalition made a very public “U-turn” toward the path pushed by the anti-immigrant Swedish Democrats and for the first time in many people's living memory imposed strict border controls on the Öresund bridge. The Öresund bridge had been a symbol of regional unity for both the EU and Scandinavia, linking Denmark and Sweden in what many in Southern Swedish municipalities had labeled the “Greater Copenhagen” economic zone that had helped spur significant innovation and growth within an area of Sweden often overlooked nationally (Hansen and Serin, 2007; Hansen, 2013). Sweden's radical policy shift in late 2015 came at a high economic price for its Southern regions which had most benefitted from the closer economies ties with the Danish capital as new border controls came into effect and disrupted cross border commuters and the ability of its growing technology sector to retain and attract employees (CPH Post, 2017).

Media reporting on the 2015 policy shift has presented it as an “emergency solution” to a “crisis” as Sweden's social services were overwhelmed by the influx of refugees that followed the government's initial welcome. Yet, at the time there was a debate as to whether the crisis was less to do with whether Sweden could afford to host refugees and, rather, more to do with a worsening fear that in welcoming refugees the then government risked greater political support for the anti-immigrant Swedish Democrats. For example, at events in Southern Sweden where most refugees arrived there was substantial mobilization by civil society and a claim heard at public meetings that the “crisis” was rather to do with Stockholm's perception rather than the reality of the situation.

The summary of these events provides part of the context to understand how health inequity in Sweden has become viewed within mainstream discourse. Another part of that context has been declining public trust due to reforms dated to the mid-1990s. Despite Sweden's self-image as a social-democratic country with a strong welfare system a series of both Left and Right-wing controlled governments have successively restructured public policy decision-making along market-oriented lines. New Public Management (NPM) models were adopted in Sweden and Denmark, for example, but whereas public servants in the latter often implemented such policies only superficially, their Swedish colleagues followed them much more directly (Hall, 2013). This can be seen in many areas of Swedish society and has restructured public policy to be increasingly technocratic and removed from political oversight or accountability with the result that Swedes have slowly lost trust in the systems once seen as key to making their country distinct (Hall, 2013). Such reforms mark a significant shift in the social bonds constituting Swedish society. The events of 2020 marked what Elander et al. (2021) describe as a “perfect storm” as policy uncertainties grew around not only COVID but also migration and climate change. Although none of those three policy crises are unique to Sweden, how they are positioned in Swedish political debates is arguably unique given how all three have historically been areas where Sweden's political elite have marked themselves as international pioneers and the country as “exceptionalist” compared to other states (Schierup and Ålund, 2011). We might even consider the September 2022 elections in which the issue of migration was largely blamed in media debates as a cause of growing gun violence as a reflection and an extension of this broader long term governance crisis in the country.

That individuals experience the state differently is, of course, not surprising, and certainly not unique to Sweden. What does make the Swedish state notable, however, is the shift it has undertaken in the last 10 years from an outwardly welfare-oriented and migrant-welcoming state to become something new as became evident in the pandemic and has been reinforced by its new government. If read superficially, these developments largely concern only migrants and their integration within Swedish society. Yet, drawing on Cooper, the overview of both healthcare and media discourses in Sweden during the pandemic indicates that how the Swedish state touches individuals has moved away from care. By marking an increasingly larger part of the resident population as subject to withdrawal from care and, in some cases, a “threat” to be managed the Swedish state has taken on an entirely new form of touch toward individuals. The social bonds making Sweden have shifted and, consequently, what it is to live within Sweden has altered. Not only did the Swedish state withdraw by refusing to acknowledge a diverse population impacted by the pandemic differently than an privileged elite with secure employment and safe housing, but also vulnerabilities were treated as threats and the fault of those worst affected by the pandemic rather than justification for enhanced care. Cooper's perspective allows us to look beyond individuals' citizenship status to, rather, understand what otherwise look like exclusions affecting only migrants as part of a broader shift in the social bonds constituting Swedish society in which individuals are now touched differently by the state. Although these exclusions may not be directly felt by those with formal Swedish citizenship, the pandemic period in Sweden evidenced an exercise of different ways by which the state touches individuals, including a general withdrawal from trying to understand how people live different lives.

6. Conclusion

Globally, despite high-level warnings that migrants living in precarious life conditions were both particularly vulnerable to COVID and political stigmatization that might worsen pandemic control measures (UNHCR, 2020), the pandemic has disproportionately impacted migrants with citizenship status playing a significant role in determining health outcomes (Shaw, 2021). Although in many cases the disproportionate impact on migrants has been due to explicit obstacles to health access, the Swedish case demonstrates how exclusion can often be much more passive but no less dangerous. In practice, structural inequities might be seen as more detrimental through being much harder to challenge as well as link to its consequences. Being harder to see, structural inequities in Sweden have been ignored within mainstream debates that have instead been dominated by cultural explanations of migrant deaths. Vaccine hesitancy as a symptom of societal distrust places migrants in a doubly dangerous situation through being both less likely to vaccinate but also vulnerable to stigmatization as being socially irresponsible and a “threat.” There is urgent need to understand the exclusions that lead to societal distrust, as well as levels of trust between different groups in society, that undermine health equity. Through Cooper, relations of care both within the public healthcare system and the media are understood as mechanisms by which the state and society touch individuals. That touch can take place in many forms, leading to varying levels of exclusion or inclusion with consequences for the overall level of trust and sense of belonging within the territory. The Swedish case evidences a disproportionately negative impact on migrants lacking formal Swedish citizenship, yet by considering it in the context of the broader social connections and importance of care in constituting “Sweden” as a societal entity, the shift in how the state touches individuals in Sweden impacts all of society. The approach developed here helps us understand the role of everyday micro-violences and their role in restructuring the relationship between individuals and the state, a shift that goes beyond any specific form of exclusion, in contributing to social disintegration.

Author contributions

TA wrote the section on Sweden's media discourse. MS wrote the section on healthcare. All authors contributed equally to the research presented in the final text.

Funding

The collaboration was made possible through the authors engagement within the Rethinking Democracy (REDEM) research platform supported by the Faculty of Culture & Society, Malmö University. In addition, the research builds on work supported by two external grants. One came from the Swedish Civil Contingencies Agency, Institute for Future Studies, Stockholm—Violent threats and internal security (1-MS-002 MSB). The other came from the Swedish Foundation for International Cooperation in Research and Higher Education (STINT)—Precision Health and Everyday Democracy.

Acknowledgments

We thank the numerous colleagues with whom we have discussed the ideas feeding into this paper. Any remaining errors or faults remain the responsibility of the authors.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Footnotes

1. ^The Canadian Network for Research on Terrorism, Security and Society, 1-MS-002: Violent threats and internal security, Swedish Civil Contingencies Agency (MSB).

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