Fighting for public health

How a Swedish rural community confronted neoliberal cutbacks
19 January 2018
Paper

The rural communities in the Västernorrland county of Northern Sweden are not used to being in the national spotlight, but in 2017 their struggle to stop cutbacks in maternity and emergency care made national news. What are the lessons for all those involved in building counter-power in rural areas of the Global North?

In January 2017, two midwives in the town of Sollefteå, in Västernorrland County in northern Sweden, decided to organize a course teaching parents how to prepare for delivering a baby in their car. The maternity ward and emergency care capacity at the local public hospital was due to close on 1 February and in these sparsely populated areas the cutbacks would lead to some women having to travel up to 200 km to the nearest hospital with such facilities. When the media reported on the course the issue attracted national interest. But it had been preceded by several demonstrations in the region over the course of 18 months, gathering ever more participants every time. The third demonstration drew 20,000 people in Härnösand,i slightly more than the entire population of the town or almost 10% of the regional population. Two weeks after the planned course, citizens occupied the entrance to Sollefteå Hospital before the planned closure.

How far is too far from emergency care when you really need it? How much can you be taxed without getting that much back? And how could women be forced to deliver their babies outside a hospital in a welfare state such as Sweden’s? These questions captured the public imagination and turned the media spotlight on this previously marginalized issue. In this essay, I address what made the people around Sollefteå make public protests against their diminishing public health services, how they are doing it, and why they have been successful.

Let the protests begin

After 18 months of citizens protesting the cutbacks by writing letters to local newspapers, mobilizing in Facebook groups and organizing several demonstrations after the first news of the cutbacks was revealed in the local press, the occupation started on the evening of 30 January 2017. Hundreds of people gathered in the entrance of the public emergency hospital in Sollefteå in the County District of Västernorrland, northern Sweden. Many spent the night there and the hospital is still occupied day and night one year later. At the centre of this political dispute were the planned cutbacks in the emergency care and women’s access to public maternity care.

The protests concerned both the uneven nature of the cutbacks, which would mostly affect the northern area of the County District by closing the maternity ward and so disproportionally affecting women, while the southern area remains almost untouched, as well as legitimacy as the estimated savings represented only a small fraction of the budget deficit. The smaller southern part of the county is more densely populated while the northern part, where the cutbacks were planned, is larger but more sparsely populated.

The vast majority of births in Sweden take place in a hospital, so the women in the northern area of the county would need to travel long distances to give birth. The county politicians met some criticisms by promising to buy one or two more ambulances, but the delivery course organized by the midwives hit home since ambulances are not intended to pick up women in labour and the personnel have no specialist training in delivering a baby. On the contrary, women are expected to go to hospital when they are already in established labour.

One of the arguments that gave rise to the most anger and ridicule was made by the head of the county council, claiming that if you seldom need access to health care you can travel further to receive it, and was seen by many citizens as completely ignoring the reality of both childbirth and conditions such as strokes, where time is critical.

During this time, citizens started mobilizing in a variety of ways across the county, including public discussions in the local media and street demonstrations in both the coastal and the smaller inland towns. Despite the size of these demonstrations and the number of protests that were taking place across the county, these events received little attention outside the county and Northern Sweden.

After many confusing twists and turns, in November 2016 the County Council made the final decision to close down the maternity ward in Sollefteå within three months. The cutbacks no longer included Örnsköldsvik, but focused solely on maternity and emergency care in Sollefteå. This is when citizens occupied the Sollefteå hospital entrance, one day before the maternity ward was due to close on 1 February 2017.

Though squatting has been a marginal movement in Sweden, occupations have often been used to achieve political goals.[1] In this case, it was inspired by the occupation of the public health facilities in Dorotea a few years earlier, also to protest cutbacks in the emergency care, and showed that occupations could be a political lever in a country where political conflict and direct action has mostly taken other forms. The Dorotea occupation became one of the longest in Swedish history and ended in the county restoring emergency care after the protesters had forced through a county-wide referendum on the issue.

The media attention that had initially focused on the course offered by the two midwives was maintained by the activists occupying the entrance at Sollefteå hospital. This continued throughout the spring, and became a popular venue for national politicians to position themselves on issues of health care. As the occupation approaches its one-year celebration it has managed to turn a previously non-issue into an urgent political question to be addressed at the national level.

 

Neoliberalizing Sweden

Why is Sweden, known for its social democratic welfare state, at the heart of major protests for basic maternity services? Universal access to a long list of social rights ensure that even those who fare badly in life still can have a decent living. Though the image of the Swedish welfare state persists abroad, the reality is that Sweden long ago took a neoliberal turn, as did most other European countries. This ideological shift has been the driving force behind the development of the Swedish welfare state over the last 30 years. This is seen in areas from the increasingly deregulated housing market to restrictions on the right to personal assistance for people with disabilities, diminishing many people’s ability to live their lives as before. Most public companies are now operating according to market principles and the public welfare sector has vigorously implemented ideas usually referred to as New Public Management (NPM).

Public health care is organized at the county level in Sweden, which means that the implementation of a governing rationale such as NPM has not been imposed by the national government, but by the many democratically elected regional bodies. This has resulted in different outcomes across the country, but overall it has changed the operation of the public health sector in profound ways. [2]

Important in this change has been the prioritization of budget controls and a shift of power from the health professionals to middle management, which lacks practical knowledge of the day-to-day realities of health care. This change has affected diverse groups of workers in the health sector who have been caught between the demands of the budget and management on one side and the needs of the patients on the other. The consequences of this squeeze have affected groups in different ways, but nurses have been particularly hard hit by the intensification of their workload given their high level of responsibility. This is now resulting in the rise in sick leave among nurses along with a general shortage of nurses wanting to work in such poor conditions, forcing hospitals across the country to close down wards. These changes are thus particularly affecting a traditionally gendered line of work such as nursing, of whom most are women. [3]

That the closure of the maternity ward in Sollefteå caused such outrage arose from the medicalized model of maternity care in Sweden, where hospital delivery is the norm. In the entire country, only some 100 women each year deliver at home. There are no national guidelines for home deliveries but only two counties pay for it and in the other 19 the parents have to pay for it themselves. At the hospitals’ maternity wards midwives are responsible for normal, uncomplicated pregnancy and childbirth and an obstetrician will only be involved in an emergency. After having given birth, a first-time mother can stay in the postnatal ward staffed by midwives and assistant nurses for up to 48 hours, while for the others it is up to 24 hours. After that, mothers are referred to primary health clinics attended by nurses since there are no domiciliary postnatal check-ups.

The protests and particularly the occupation of Sollefteå Hospital managed to highlight several of the problems that welfare retrenchment is causing within the public health sector, helping to put them on the political agenda. One such is the application of austerity policies in public health care and their effects on the work environment and the ability to employ qualified personnel in sparsely populated areas. Another was the importance of demographics and distance in a country with highly uneven spatial distribution of jobs, services and health care, and people started asking themselves why they should pay taxes if they benefit far less than the urban population. Sometimes in the shadow of these questions were how the cutbacks would affect women’s health and increased vulnerability in sparsely populated areas.

An entire county on the move

While the first demonstration in Örnsköldsvik was more or less a spontaneous event called for by a group of midwives and spurred by the anger at widespread cutbacks in health care in the northern part of the county, resulting in all maternity wards in the entire northern area being closed down. It was a surprisingly large street demonstration, as people marched to the sound of a drum with the slogan ‘Without maternity ward, Ö-vik stops!’ on a windy September day. By the time of the demonstration the politicians had already changed the cutbacks plan to affect only Sollefteå Hospital, but the organizers carried it out anyway.

With time the mobilization became more organized. The second demonstration in Kramfors a few weeks later attracted even more people, and took an hour to pass outside the hotel where the district’s Social Democrats, who had just proposed the cutbacks, were holding a meeting. The last demonstration in April 2016 was the largest, at some 20,000, and also embraced by the local business community. These were organized by the newly forming groups called Sollefteå Framtidens Akutsjukhus (Sollefteå, The Emergency Hospital of the Future) and Föreningen Ådalen Reser Sig (the Ådalen Rises association). Here the theme of survival on which the debate had centred became apparent when the business representatives, trying to safeguard the economic life of the region, walked alongside families with children in pushchairs, trying to sustain their survival.

While these demonstrations were going on, a small group of dedicated people started reviewing the background and basis of the decision to cut back in certain parts of the county and not others, as well as the functioning of the elected assembly administering the region’s health care. This ‘citizen review’ gave rise to a speaking tour of several towns explaining the various episodes of bad management within the County District, ‘the Saga of the County District’. Several Facebook groups in different ways informed about and discussed the politics of the county and functioned as channels for mobilizing people to join the demonstrations and other protest events. The local newspapers were another important forum for long debates in the extensive correspondence regarding different aspects of the debate.

Some months after the third demonstration two main directions started to be seen in the movement. Sollefteå Framtidens Akutsjukhus continued to focus on influencing politicians to shift direction by using similar means as before. One demonstration was organized in September 2016 as part of the first national demonstration by the ‘Another healthcare is possible’- network that mobilized across 26 cities within a short time, but not like the large earlier demonstrations.

The Föreningen Ådalen Reser Sig started talking about what they called ‘Manifestation 3.0’. They had a research working group and in November 2016 started presenting the results and their ideas to the public in a series of talks across the affected towns. The plan was to take over parts of the health care from the County District, first in the form of a health station in Sollefteå and later extending this to Kramfors and ultimately taking over the entire hospital in Sollefteå to safeguard the provision of health care in the northern part of the district. To this end they started an economic association, a business form that is intended to be run democratically and benefit its members, called Vård och Omsorg i Norrland (Voon) (Healthcare and Care in Norrland). Their talks were the basis for recruiting members who would be interested in participating in the new health care provision they were planning for the area.

The occupation seems to have its own organization that overlaps with these two groups. By setting up its own Facebook group, where some organization is done but also lots of discussions, they have now been able to fill the hospital entrance with four shifts per day of occupiers.

Healthcare personnel are the ones having the hardest time to strike, partly because they are forced by law to work if the employer demands it and partly because they often are people that are there for others all the way. The occupation becomes an inverted strike, citizens that go into the workplace when the personnel can’t walk out. [4]

Throughout the occupation, the occupiers have been posting photos to its Facebook group. These photos, together with their record of occupiers, shows their diversity. After six months more than 1,700 people had taken shifts in occupying the hospital entrance, of whom 1,200 (68%) were women. Most are working people (48%), but many were also pensioners and some students, the average age being 53 years. While most have occupied the entrance only once, some have done so up to 40 times.

There is also quite a geographical spread, with 15% coming from other parts of Sweden, though the clear majority, some two thirds, comes from municipality of Sollefteå and the rest from the County of Västernorrland. [5] Though there has been a large variety of forms of protests and organizing, as seen above, the occupation was what really triggered the interest of the national media. From the photos, it is also evident that the occupation continues to appeal to the public imagination even a year later. Every so often a celebrity drops in showing their support and photos are taken.

The occupation, together with other collective actions across the country such as the two national demonstrations in September 2016 and 2017 called ‘Another healthcare is possible’ and demonstrations for improved maternity care in August 2017, women’s health is now becoming a national political issue because of problems in maternity wards all over the country.

Today the occupation and the planning of the private non-profit health station continue side by side, appearing not to be in contradiction with each other. The occupation is approaching the end of its first year and the first member-owned health station in the county opened on 20 December 2017.

‘It’s the same struggle now as then’

Part of explaining the success of the protests have been the linking of today’s struggles and resistance to the history of struggles and victories in the area. This has connected struggles against injustices 85 years apart. Throughout the mobilizations, the name ‘Ådalen’ started appearing more frequently. There are many spatial scales dividing the County of Västernorrland that one could talk about in this case. These range from the two regions Medelpad and Ångermanland (the region affected by the cutbacks) making up the County of Västernorrland itself, to the three different cities (Örnsköldsvik, Kramfors and Sollefteå) that were all being affected by the cutbacks to the County in itself, which is the regional public health administration deciding on the cutbacks.

Another scale could be the region of the High Coast where these cities are located, the best-known name on the tourist circuits, which has mainly been developed for marketing the area as a tourist destination, declared a World Heritage Site by UNESCO in 2000. But the older name, Ådalen, was becoming more common when talking about who was affected by the cutbacks. Ådalen no longer features on maps or traffic signs, nowadays a seldom used name for the region comprising the northern part of Västernorrland County and the three affected cities. Ådalen has been deliberately forgotten and hidden in the shadows of history. [6] So why pick it up from history’s dustbin and start talking about Ådalen again?

Ådalen has since 1931 been politically charged by events that played out in the area. In order to understand the power of invoking Ådalen we have to go back to the time of Sweden’s industrialization. In the 1920s Sweden had one of the highest rates of labour conflict in the world. [7] Strikes were still illegal but increasingly common until the 1930s, when several events changed this conflictual situation and put Sweden on the path of compromise and consensus between the trade unions and the employers’ association. One of these events was the deal at Saltsjöbaden, which laid the foundation for the following decades of peaceful labour relations.

Another event preceding this was the labour conflict in Ådalen in 1931, the location of some of the largest industrial developments during the period of Sweden’s industrialization in which forestry was an important part. It was the home of a huge number of sawmills and a shipping industry supplying the products to the rest of Europe. Just before the start of the First World War, Västernorrland’s sawmill exports accounted for over 25% of the country’s , and half of export revenues in northern Sweden’s forested region. It was also the arena of frequent and sometimes violent labour struggles during the same period, [8] peaking with the infamous conflict in 1931 when the military shot dead four workers and one bystander. [9]

This struggle was between stevedores in the harbour servicing the forest industry. When they went on strike for better working conditions, strike-breakers were called in by the harbour management, intensifying the already high tension. The workers organized a demonstration and in this situation, the military was called in to restore public order. In the aftermath of this conflict, the Social Democrat Party (SAP) won the general elections the following year. In their efforts to build what later became the famous Swedish welfare state, the image of Ådalen and the conflicts that had played out there was portrayed as an ideal of compromise as the means to create a modern country. This made the conflicts in Ådalen and other places that led to the creation of the welfare state appear as a remnant of the past that was either wilfully forgotten or the antithesis of the welfare state as what was left behind and to which we never want to return.

Several things linked the previous injustices to the current ones. After the second demonstration, the Facebook group ‘Ådalen rises’ started to safeguard the histories from the event, another Facebook group for the occupation is called ‘Ådalen 2017’. In the local newspapers, the connections seemed clear:

I was born in Ådalen in the late 40s and I saw the sawmill closures, unemployment, and more in the 50s. My dad marched in Ådalen in 1931, where five of his comrades were killed. They marched for their living conditions. I marched in Lunde in 1981 to honor my father and those involved. Last Sunday, I marched in Härnösand for OUR living conditions!

Margaretha Bodén, Sollefteå, Tidningen Ångermanland, 28 April 2016, Letters to the Editor

When the national media started to get interested in the protests around the start of the occupation, but also in a few earlier reports, the articles were framed around the idea that Ådalen was rising up again. One of the biggest national evening papers, Expressen, stated that ‘Ådalen has been forced to rise up again’, and continued that ‘every depopulating part of the country will need to bring out their inner Ådalen’ since the politicians seem unable to solve the problem of welfare services outside the urban areas [10]. The other major evening paper Aftonbladet followed the same line when they published a comic strip about the conflict named ‘Ådalen rises again’, written by a well-known author and publisher from the area. [11]

The use of the name Ådalen creates a link between injustices today and those of previous times and proved an efficient way of engaging and mobilizing people to attend the protests. The choice of this name seems to have been a conscious strategy by the activists and the creation of a counter-power was formulated through the constant references in traditional and social media to the cutbacks specifically targeting Ådalen. The activists’ use of the area’s history of workers’ struggles, which had a huge impact on Sweden’s development into a welfare state, became important in defining who ‘we’ are who are protesting, once again unjustly treated. In the aftermath of 1931 the Ådalen population was seen to be particularly rebellious and prone to rise up against injustices, even though doing so came at a high price. This imagined historical subversive identity of the people living in Ådalen is useful today when facing new injustices, including the welfare retrenchment that they need to resist today.

Where are the feminists?

With industry being so important for northern Sweden the deindustrialization from the 1960s onwards gave rise to several labour conflicts and wildcat strikes in the following decades. There was the miners’ strike in four mining towns in 1969 followed by the cleaners’ strike in 1974-75 that spread across the country and several of the same mining towns. One of the solutions to the deindustrialization pushed by the national government was to replace lost industry jobs with jobs in the public sector, employing many more women than the industry had done.

The rolling-back of welfare services today is a blow to precisely that previous solution to an earlier crisis. This moves the conflict over welfare retrenchment into new fields outside the urban areas and it particularly affects women, both by the loss of their health care services and their main labour market in public-sector service jobs. This was seen in the protests, as the statistics from the first six months of the occupation showed that women made up the backbone of the day-to-day work of continuing the protests. At the core is the issue of women’s health care and how unequal access to it can have particularly alarming effects in sparsely populated areas, coupled with the emergency care capacity, also a fight over time and space, life and death.

The question of equal access to maternity health care has from the start of the protests become a question of national political importance, but it is the counties that are set to solve it. And while the occupiers say they will not leave the hospital entrance in Sollefteå until they have their maternity ward back, one question has been lost – that of women’s jobs in an increasingly strained public health sector with extremely bad working conditions. How can women’s lives as workers be included in what is worth protecting and protesting for, not only women’s reproductive function? Women have been a driving force in much of the mobilizing around Sollefteå Hospital, but still it seems hard to mobilize around women’s work in the same way as happens when another factory closes down and men are laid off.

Lessons to be learned

The process of economic restructuring has different effects in distinct places. In Sweden, this has mostly been an object of debate and study from an urban perspective. In the sparsely populated areas of Sweden other types of restructuring, both old and new, the recent relocation of the welfare jobs that were the solution to the earlier industrial restructuring, different lines of conflict than the urban context, become important. At the moment one of the most urgent and the basis for diverse mobilization of counter-power is the fair provision of public health care across the country. Lessons that we can draw from the protesters in Ådalen are several.

One is the common idea that it is in the city that everything happens, that the sheer number of people will somehow in itself facilitate collective action. This might be true, but it might also be that when the very the possibilities to live in a certain place are threatened, when key services that make it liveable are taken away, people will mobilize counter-powers to fight for their right to keep on living in the place they were born in or chose to move to. Such seems to be the case in the outskirts of the Swedish welfare state, where services are scarce and unevenly spread.

One could talk about service deserts where living is becoming increasingly difficult to manage on a day-to-day basis. An overview by SVT (Swedish public television) showed that around 10% of the country is without services today, a consequence of closures over the last 50 years but especially the last 10 years. [12] Before it becomes a service desert, the Ådalen population has chosen to start fighting back showing that the countryside can also be the basis for the formation of progressive counter-power, at odds with how rural mobilization is often portrayed.

In this quest to formulate a counter-power, they have invoked history, a very infamous history of struggles in this case. Nevertheless, histories do not need to be so spectacular in order to connect current struggles with those of earlier periods. Histories of struggles, and preferably including victories, can aid in forming counter-powers that can resist increasing inequalities. These histories do not necessarily need to be in perfect harmony with today, as the workers’ struggles in poor Ådalen in 1931 are far away from the current situation of dismantling women’s access to public health care in a rich welfare state. It might, however, help us in reconnecting to collective forms of action in a time when problems are often seen as particular and responsibility lies with individuals to solve their own problems.

In this sense, public health care slides from being a right of all citizens, to becoming an individual problem where good customers move to where services are better. This individualization of problems [13] is contrary to the idea that many problems are shared by larger groups and turn our solutions away from lying in collective action. If we cannot think in terms of collective problems, how will we find collective solutions? Using histories of collective actions might help us reconnect through the inequalities we often share, and reconnect us to earlier successes of collective actions from which we have become detached. [14]

In the case of the Sollefteå hospital protests, the history of previous struggles and victories, though concerning different types of inequalities, were used to protest inequalities created by welfare retrenchment today. The connection of these struggles established a counter-power, which mobilized a large part of the population in diverse protest actions. Ådalen as a politically charged area with a national political trauma in the background makes it a very useful name to pick up in times of struggle. Every country has its own histories of struggles and victories and reconnecting with them might prove one way of engaging in current struggles.

Endnote
i. Though this number has been contested.

References
1. Polanska, D.V. (2017) Reclaiming Inclusive Politics: Squatting in Sweden 1968-2016, Trespass: a journal about squatting 1(1):36-72.
2. Hasselbladh, H., E. Bejerot, and R.Å. Gustafsson (2008) Bortom new public management. Institutionell transformation i svensk sjukvård. Lund: Academica Adacta.
3. Selberg, R. (2012) Femininity at Work-Gender, Labour, and Changing Relations of Power in a Swedish Hospital.
4. Fredriksson, K. (2017) 'BB-ockupanterna svar på pinsförbudet: "Gratis pins till vårdanställda!"', Aktuellt Fokus. 27 June.
5. Sundqvist, B., BB Ockupationen i Sollefteå - första halvåret. 2017, Facebook: Ådalen 2017 (Sollefteå BB Ockupationen).
6. af Geijerstam, J.S., Sörlin (2000) Det glömda Ådalen. Stockholm: Dagens Nyheter.
7. Nyzell, S. (2011) 'Det kollektiva våldets gränser: Möllevångskravallerna i Malmö 1926', Arbetarhistoria 2-3: 138-139.
8. Björklund, J. (1976) Strejk-förhandling-avtal: facklig aktivitet, arbets-och levnadsvillkor bland sågverksarbetare i Västernorrland 1875-1914. Avd. för ekonomisk historia, Umeå university.
9. Johansson, R. (2011) Kampen om historien-Ådalen 1931-Sociala konflikter, historiemedvetande och historiebruk 1931-2000. Stockholm: Hjalmarson & Högberg Bokförlag AB, Kammakargatan 11, 111 40.
10. Barr, B. (2015) 'Snart behövs Ådalen i varenda landsände', Expressen. 12 October.
11. Jonsson, M. (2015) 'Ådalen reser sig igen - serie av Mats Jonsson', Aftonbladet. 15 October.
12. Müller, A. (2017) En tiondel av Sverige saknar lokal service, in Sveriges Television. SVT: svt.se.
13. Brown, W. (2015) Undoing the Demos. Durham, NC: Duke University Press.
14. Tsing, A. (2009) 'Supply chains and the human condition', Rethinking Marxism 21(2): 148-176.

Re-Asserting Control: Voluntary Return, Restitution and the Right to Land for IDPs and Refugees in Myanmar - cover