While the Nordic countries have long been champions of equality, the Covid-19 pandemic has put a new light on structural injustices inherent in our societies. In Copenhagen, Oslo, Helsinki, Stockholm, and Malmö, districts with a high share of residents with an immigrant background and a low socio-economic status stand out with high infection and mortality rates of Covid-19. The pandemic thus reveals and reminds us about the serious effects of segregation and unequal living conditions on citizens’ health status and ability to cope with and survive a pandemic.
This extended Executive summary is based on a quantitative and qualitative study aiming to identify structural barriers impacting residents’ ability to follow Covid-19 recommendations and guidelines, especially in low-income areas in major Nordic cities. Learning about these barriers - and effective measures taken to mitigate them - will help Nordic authorities and communities be better prepared for future challenges and crises.
About the study: Through a quantitative mapping at city district level in Oslo, Helsinki, Copenhagen, Stockholm, and Malmö, we aimed to outline relevant indicators relating to the increased risk of Covid-19 infection. Included indicators are annual income, share of residents with foreign background, share of inhabitants working in exposed occupations, and overcrowded housing conditions. Stockholm and Malmö were selected for an in-depth, qualitative study on the sub-district level with more indicators, such as household sizes, educational level, car ownership, and spatial density.
In Denmark, individuals from non-western countries make up 9% of the population but accounted for 26% of all confirmed Covid cases by 2 October 2020 (Statens Serum Institut, 2020b). In Norway, despite making up 18.5% of the population, individuals with immigrant background accounted for 30% of confirmed cases by 18 October (Indseth et al., 2021), and 47% of hospitalised cases were born abroad (Skogheim et al., 2020). In Finland, the National Institute for Health and Welfare (THL) reported that 25% of all confirmed infections in the country had been among individuals with foreign background, representing about 8% of the population. In Sweden, 32% of Covid-19 cases during most of the first wave (13 March to 7 May) were found in the immigrant community, while foreign-born make up 19,7% of the population (SCB, 2021).
The role of genetic or ethnic factors on human susceptibility to viruses have long been suspected, but so far there is no conclusive evidence (Zhao et al., 2015). In the context of Covid-19, characteristics of the residential area have been found to increase the risk of being infected, even when controlling for individual factors such as income, education, and occupation (Bartelink et al., 2020). Aspects that increase vulnerability to infection and mortality include poor housing conditions (OECD, 2020), overcrowding, and living in a multi-generational household (Florida and Mellander, 2020; Folkhälsomyndigheten; 2020a). The city district maps presented in the full Nordregio report show how these aspects accumulate in the same areas where the share of immigrants is high.
The Nordic Covid-19 prevention strategies shifted early on from containment to mitigation. Sweden responded somewhat later than its Nordic neighbours and took a less invasive approach based on guidelines and recommendations rather than imposing restrictions and lockdowns. The overall measures that were taken or advised to the public, however, did not differ much between the Nordic nations. The focus was on social distancing, frequent handwash, avoiding public gatherings, self-isolation, working from home, and avoiding public transport systems.
Building on the mapping exercise and our qualitative study, we identified the following, structural barriers at play in segregated, low-income areas. Barriers that made it difficult for residents to follow key recommendations or guidelines from the Public Health Authorities.
Findings from the qualitative part of the study in Rinkeby (Stockholm) and Rosengård (Malmö), do not support the claims that language barriers and lack of integration are the main reasons for the higher spread of infections among ethnic minorities. Interviewees argue that this is a too simplified explanation. Even though not all residents follow local media, the risks inherent in Covid-19 and the main measures to protect oneself are similar worldwide. However, the softer approach in Sweden could have made some residents feel that the situation was less severe in Sweden than in many other places.
Skogheim et al. (2020) who investigated dissemination of information in Oslo found that using already established, local channels and working with local ‘ambassadors’ were successful ways to share information in diverse districts with diverse needs. The surge in Covid-19 among Somalis was brought to a halt in early April 2020, conceivably due to a joint effort by the government and the Somali-Norwegian community (Indseth et al., 2021).
Two fundamental Covid-19 recommendations have been to stay home if you are feeling sick and work from home if you can. These recommendations are considered essential to minimise the risk of getting infected and to protect others. The home has been central in this context, but the privilege involved has gained little attention in the political debate. Those living in cramped housing might not have the ability to work from home, isolate if sick, and prevent infecting other household members. Recent data from Sweden estimates that almost 30% of immigrants who arrived less than 10 years ago live under cramped conditions (Grander & Salonen, 2020).
In theory, ‘evakueringsboende’ (evacuation housing) could be a powerful public tool to temporarily equalise people’s housing status in low-income areas, where many have crucial jobs that keep the society running. It was attempted in Rinkeby but proved unsuccessful. One month’s stay cost 5,000 SEK, and the offered reimbursement was retroactive. Residents were also hesitant to avoid all social contact with families during the stay. The experience from Rinkeby prevented authorities in Malmö from trying the same arrangement. A similar solution also seems to have failed in Norway, according to Skogheim et al. (2020), who state that “quarantine hotels seem a well-preserved secret” since local organisations interviewed did not know about this possibility.
Moving forward, solutions for more accurate registration and monitoring of tenants are needed to understand how extensive the problem of overcrowding is, even though it is a difficult task. Then actions are needed to meet the problem without leaving those in the most disadvantaged position out in the cold.
The recommendations to stay home with the slightest symptoms and work from home if you can, do not apply to many jobs, especially not in health care, elderly care, and the service sector. They also do not apply to all kinds of contracts. Evidence shows that some jobs are more exposed to Covid-19 and even linked to higher mortality rates, like transport (Billingsley et al., 2020; Folkhälsomyndigheten, 2020d). In all the Nordic cities investigated in this study, more disadvantaged urban areas, with a high share of foreign-born population, also have a relatively high share of the workforce in exposed occupations, such as health care, services, and transport. Recommendations such as work from home if you can or avoid using public transport do not work for employees in these occupations. Furthermore, the nature of these jobs involves many social contacts that further increase the exposure.
Measures taken to enable people to stay home with the slightest symptoms, such as abolishing sick-day deductions, do not cover workers on hourly contracts, gig workers, and others in an insecure working situation. According to Forte (2020), foreign-born are over-represented in the gig economy. Our data shows that residents in Rinkeby and Rosengård are over-represented in for example the health care sector that have a comparably high share of hourly or short-term contracts.
Last but not least, the policy of staying home with the slightest symptoms, was not accepted by all employers. This was highlighted in an interview with a health-care professional referring to patients showing text messages from their managers, pushing them to come back to work when not feeling well. In an insecure work situation, when the fear of losing one’s job is imminent, such pressure can prevent people from staying home.
The recommendation to avoid public transport, especially during rush hour, is not feasible for everyone. To avoid public transportation, people need access to cars, bikes, or the opportunity to avoid travelling by working from home. Car ownership is less common in the studied districts than in many other districts, and biking is not common – especially not in remote suburbs. Public health authorities have emphasised that those who can avoid public transport should do so for the sake of those who cannot. However, many interviewees described crowded buses and even cancelled trips instead of extra buses to meet these neighbourhoods’ needs. This was especially noticed in Rinkeby.
According to our findings, the heavy focus on digital platforms and systems to manage the Covid-19 situation, information, and care, have proven to be an excluding factor. The system requires users to have access to internet, digital devices, and a mobile bank ID. This is not always the case. Undocumented and homeless people are also left outside the system. The local health-care centres in Rinkeby and Rosengård, where the nurses know their clients, responded to this by opening special reception rooms to ensure easy access for Covid testing and consultations. Other local civil society initiatives emerged in the communities as well – with limited support from local authorities. At a later stage, access to testing was increased through mobile drop-in units in various neighbourhoods across Stockholm and Malmö/Rosengård.
In all the Nordic cities included in this study, higher spread of Covid-19 has been noted in areas with a high share of population with foreign background. The maps in the full report visualise how socio-economic factors accumulate in these areas and create barriers which undermine residents’ ability to protect themselves and others against Covid-19. Our findings signal a need for special attention and proactive measures targeting vulnerable groups in times of crisis such as the Corona pandemic.
As many of the interviewees stated, all though everyone has responsibility to follow the public recommendations, a greater responsibility falls on social groups with more resources. It is challenging for most people to adjust their lives to align with Covid restrictions. But it is even more so for those already facing multiple challenges in their daily lives. The overall picture is that most people want to adapt and protect themselves and others, but some face more structural barriers. Perhaps what we have seen is a ‘white-collar quarantine’, in which the wealthy can more easily work from their spacious homes, avoid public transport, and afford to stay at home when sick. Simultaneously, low-income groups are left on the front-line, in essential occupations, and struggling to isolate the sick in large and cramped households, leaving them excessively vulnerable to infection.
These inequalities are likely to be further exaggerated in the post-pandemic period. Firstly, the unprecedented unemployment rate in certain service sectors makes it tougher for immigrants and youth to find a first job. Secondly, Blundell et al. (2020) highlighted how the rise of digital work might not result in any benefits for low-income groups given that their occupations tend to be less suitable for remote working.
The civil society actors have played an important role in the case study areas by disseminating information and providing support to residents despite limited resources. Their potential to bridge the gap between residents and authorities, with their local knowledge and abilities to meet people, could have been utilised earlier and better to meet the varied needs of different groups in society. This issue was raised specifically in Malmö, where the Citizen Office (Medborgarkontoret) in Rosengård was closed two years ago.
The district director in Rinkeby-Kista conveyed that mistrust towards authorities did once again prove to be an essential factor standing in the way of success in Covid prevention. Public Health Authorities’ recommendations have been easier to follow for ‘white-collar’ workers. A learning from this pandemic could be to take different groups in society into account when creating policies and recommendations to curb a pandemic – and when deciding on measures and channels to engage with citizens and supply health care.
This Executive Summary is based on the report Who is left behind? The impact of place on the ability to follow Covid-19 restrictions on behalf of the Nordic Integration Programme.
Report authors: Hjördís Rut Sigurjónsdóttir, Dan Sigvardsson, Sandra Oliveira e Costa
Summary editor: Åsa Ström Hildestrand
Contact person: Åsa Ström Hildestrand, Nordregio
Cover and other pictures: Hjördis Rut Sigurjonsdottir, Nordregio
Layout: Marija Zelenkauskė, Nordregio
Nordregio Executive Summary
© Nordregio 2021