Recently, the local authorities of Halmstad, Sweden, forced a teacher to remove her mask. In fact, they banned the use of masks in all schools, including all variants of PPE. Halmstad authorities stated that there was no scientific evidence to support the use of masks, and for this they were referred to the Swedish Public Health Agency. And it is that, at that time, said agency alerted about the “huge risk“which assumed that the masks were used incorrectly. These guidelines have since been withdrawn, however.
For anyone unfamiliar with the response the Swedish Government has given to COVID-19, this ban can be shocking. At the end of the day, and despite the fact that masks are not infallible, there are scientific evidence that these contribute to reducing the transmission of the disease, especially in those situations in which it is not possible to maintain social distance (as, for example, in schools).
Halmstad authorities finally rectified, but across the country there are many new cases of banning the use of masks. Librarians in the prosperous town of Kungsbacka, for example, have been given instructions not to use them.
How the hell did we get into this situation? Well, at the end of the day, everything that the municipal authorities of Halmstad and Kungsbacka ordered was in line with what was marked by the Public Health Agency. Therefore, these bans are the logical consequence of nine months of constant messages against the use of masks by the Swedish Government, and which in our opinion are a clear example of a poor risk communication strategy.
Outside of Sweden, by now most Europeans are used to wearing a mask when they are indoors, be it a supermarket, public transport or a doctor’s office. It has become such an ingrained practice that it could easily make us forget the fact that, during the first months of the pandemic, most of us did not wear any type of mask. In that early period, the main messages were “wash your hands” (simple to comply with) and “don’t touch your face” (much more complicated).
The European Center for Disease Control and Prevention recommended the use of the mask from the beginning, and as early as April. But it was not until June that the World Health Organization (WHO) joined this recommendation. England waited until July, while Norway, Denmark Y Finland they resisted until August to implement the use of the mask.
Sweden, as we have seen, decided to take a different path. The Public Health Agency has argued many times that masks are inefficient and that wearing them could favor the spread of COVID-19 (an opinion that was common at the beginning of the pandemic, but is now rare to hear).
In July, Health Minister Lena Hallegren explained that the Swedish Government had no neither culture nor custom to make decisions on protective clothing such as masks, and that therefore its Executive would not overrule the Public Health Agency.
Sweden’s anti-mask policy went beyond Swedish borders and fueled anti-mask activism on an international scale. In April, the country’s chief epidemiologist, Anders Tegnell, wrote an email to the European Center for Disease Control and Prevention (which happens to be in Stockholm) in which he warned this body about the dangers of his recommendation that people wear a mask. His reasoning was that such use “implies that the transmission is through the air”, which in his opinion could “seriously damage the confidence and therefore the effectiveness of future recommendations on the pandemic.”
How did we get there? If we go back to the spring of 2020, when SARS-CoV-2 was still a very unknown virus, the messages from the Swedish Government on COVID-19 consisted of a triple mantra, simple and logical: wash your hands, maintain social distance and stay home if you are sick. This will sound familiar to the citizens of many other countries, and in fact it is a book example of effective risk communication; a communication that must be clear, direct and promote actions that are easy to carry out.
The guidelines of the WHO for effective risk communication in public health crises emphasize three factors: that uncertainties must be explicitly named, that the information transferred must be robust and easy to understand, and that the contents of The messages should recommend the realization of concrete and realistic actions.
During its initial phases, the risk communication carried out by the Swedish Government met two of these conditions, but failed to cope with the uncertainties. This is something that many other countries did manage to do, where they also opted for very simple messages.
Although scientific knowledge about the virus continued to increase, the Swedish Government’s risk communication on the use of masks did not change. In August, for example, when wearing a mask became very common in other European countries, Tegnell stated that the scientific evidence supporting the use of masks was “surprisingly weak“, and that its use could even increase virus spread.
A confusing rule about the use of the mask
The Swedish authorities maintained their anti-mask stance until December, when Prime Minister Stefan Lofven announced a 180 degree turn regarding the use of these in public transport.
But Lofven’s new policy on masks didn’t just make them mandatory on transportation. Instead, he recommended wearing them between seven and nine in the morning and between four and six in the afternoon; and not for everyone, but only for those born “in 2004 and before”, and who also did not have a reserved seat. If this sounds too complicated to you, it really is because it is.
It is not surprising, therefore, that compliance with this standard has been poor and that only half of public transport users actually wear a mask during rush hours.
But it is not just ordinary citizens. Two weeks after the recommendation was approved, the director of the country’s Public Health Agency, Johan Carlson, was seen without a mask on a bus during rush hour. When asked about his inability to comply with his own recommendations, he affirmed that “I just didn’t realize that rush hour had come.” This case illustrates well the problem of overly complicated risk communication.
Confusing and complex
If the director of the Public Safety Agency is unable to follow his own rules, it will be difficult to blame people for their poor level of compliance.
At the beginning of the pandemic, the Swedish Government’s risk communication policy (the triple mantra) was straightforward and easy to understand. But until December the authorities were warning for months about the risks of wearing a mask. Thus, the public transport announcement was not only confusing due to how complicated it was, but also due to the fact that its content was directly contradictory to the mask guidelines that had been in effect between March and December.
In this context, it is not surprising that there are libraries and schools in Sweden that are sending mixed messages about whether or not to wear a mask.
It is the result of months of poor risk communication around a simple public health measure; a measure that has also been widely adopted in the rest of the countries. And this failure in communication policy could have really worrying consequences, such as the possibility of increasing the number of infections in a country that is already on the verge of suffering a third wave.