Administration and Leadership, Exclusives, International, Top Story

Swedish EMS Rises to the Challenge of Multiculturalism

“A young man might throw stones at a fire truck or an ambulance,” says Janina Sabra, 31, as she strides into her office at a youth center in rough-and-tumble east Gothenburg, Sweden. “But he won’t throw them at his friend—he won’t throw them at ‘Uncle Daniel.’”

Sabra should know. The managing director of Person Behind the Uniform (PBU)—an innovative community outreach program designed to bring young people and first responders together—she has undeniable street cred.

Forward thinking: Janina Sabra, managing director of the Person Behind the Uniform. Photo Mark S. Weiner

After all, she grew up in one of the score of districts that police authorities here deem “especially vulnerable areas”—the Swedish equivalent of the hood. Jobs are scarce, and alienation runs high in these outlying suburbs, the majority of whose residents are non-European immigrants and their children.

The child of immigrants herself, Sabra understands why teenagers, especially second-generation boys, might throw stones at an emergency vehicle. In the logic of the street, mischief can create honor.

She’s just out to set them straight.

For EMS in Sweden, treating patients in the face of sporadic anti-social behavior—or worse, gang violence—can pose a challenge. Ambulances are sometimes forced to wait for police escort before entering vulnerable areas. This lengthens response times. It also  erodes public trust—the same dynamic that in the United States gave rise to the 1990 hit single by the group Public Enemy “911 Is a Joke.”

In addition, while some emergency caregivers have a special calling to serve immigrant populations, and report few challenges doing so, others say that intimidation from bystanders and the fear of violence in vulnerable areas has diminished their desire to serve at all.

But psychological strain and service delays are just the most dramatic, headline-grabbing tests that EMS is facing in a country undergoing a demographic revolution.

Long known for its ethnic homogeneity—in 1930, only 1% of the population was foreign born, half from neighboring Nordic countries—Sweden has become a coveted destination for economic migrants and asylum seekers, who are drawn to the country’s political stability and strong social support system.1

Today the foreign-born population stands at nearly 19% out of 10.1 million inhabitants, not including asylum seekers—of whom there were over 160,000 in 2015. From outside Europe, their most common points of origin are Syria, Iraq, Iran, Somalia, Turkey and Afghanistan.2

Social and cultural differences between these migrants and ethnic Swedes—as well as the personal experience of repression and trauma that many refugees have endured—can create obstacles to emergency care that are at least as significant as physical threats, and more pervasive.

Police officer Ulf Böstrom of Gothenburg discusses social diversity in contemporary Sweden: “Culture matters.” Photo Mark S. Weiner

“Cultural differences matter,” asserts Ulf Boström, a police inspector and integration officer in Gothenburg. “They matter for all men and women in uniform.”

For example, traditional Swedish households are centered on the nuclear family. But EMS personnel indicate that when entering immigrant homes, they often encounter crowds of extended family members—clans. Family members’ eagerness to help their kin while responders try to focus can require sensitive management to avoid friction.

Likewise, ambulance nurses routinely report that immigrants have different, generally lower, thresholds for expressing physical pain than ethnic Swedes, who surveys show view themselves as stoical. Both the perception and the reality of that difference creates a risk of under- and over-diagnosis.

Ambulance nurses also occasionally recount that some immigrants are wary of being treated by caregivers of the opposite sex, while Sweden ranks at the top of global gender equality indexes.

How Sweden addresses these and other challenges in cross-cultural emergency care—how EMS meets the test of demographic change—may provide lessons for nations undergoing similar transformations.

In the case of PBU, it also may help shape policy discussions about integration well beyond emergency medicine.

No Shortcuts

PBU is a systematic, caring response to a rash and dramatic act. In 2009, some young men standing on a bridge in Gothenburg pushed a breadbox-sized rock off the bridge and onto a passing fire truck below, smashing the front window. One firefighter was hospitalized and soon left the service in frustration.

The event was singular in its deadly potential, but less serious confrontations between young people and public authorities were common. The city also was living in the shadow of a nightclub fire in 1998 that killed 63 young men and women, most of them with migrant backgrounds. The fire was set by four young men who had been denied entrance to a Halloween party.

Firefighters felt that something needed to be done.

In line with Sweden’s consensus-oriented society, they chose a constructive path: they decided that young people and first responders should get to know each other face-to-face. However, the program they created to achieve this goal, Människan Bakom Uniformen in Swedish, goes well beyond the usual meet-and-greet.

Instead, it’s an extended, focused seminar that—again characteristically Swedish—requires significant time and resources from everyone involved.

Each PBU “class” runs for 10 weeks and includes about 20 participants between the ages of 15–25. Applicants undergo a careful screening process for suitability (no active criminality is permitted).

Attendance at all sessions is mandatory to earn a certificate of completion, which adds value to school and job applications.

The program begins in an intentionally gentle manner, with participants and first responders playing games and “shooting the breeze”; simply enjoying each other’s company. There’s lots of comfort food and each student receives a stylish black T-shirt bearing the PBU logo.

The meetings that follow—each at night, lasting three hours—are more dramatic and intense. Half of them feature first responders talking in a heartfelt way about their lives and work.

On other nights, participants learn practical skills and are led through a series of simulation exercises, culminating in a collective response to a multi-casualty traffic accident that doesn’t skimp on realism.

Firefighters, police, EMS, the private firm Securitas, and even tram operators are now all part of the effort.

There’s an undeniable magic about what results.

On a dark winter evening just north of Stockholm, a dozen young men and women gather in an EMS training facility and listen intently as two ambulance nurses dressed in green-and-yellow uniforms teach them CPR. A local firefighter looks on, as does a member of the Stockholm police department and a representative of youth social services.

Everyone has just eaten their fill of sandwiches, and this being Sweden, there is plenty of pastry and cake on offer, too.

“Press here, like this,” instructs paramedic Micke Aronsson, 49, as he kneels beside a manikin. “Remember [the beat of the song], ‘Stayin’ Alive.’”

Aronsson’s students have a lot to live up to. Two years ago, a former PBU graduate performed CPR in downtown Stockholm on a stranger in cardiac arrest, successfully resuscitating him.

Fifteen-year-old Adeeb, whose parents hail from Palestine, leans into the task. He aspires to become a police officer.

What did he think of the experience? “[I thought it was] good! It’s hard!” He later reports, speaking in English. “It hurts your hands!”

Paramedic Madeleine Matiasson teaches infant first aid at an PBU session in Stockholm. Photo Mark S. Weiner

Next, Aronsson’s colleague, paramedic Madeleine Matiasson, 36, shows how to clear an infant’s airway.

Following her instructions, a long-haired boy from East Africa, wearing a large silver crucifix, whacks a Baby Anne between the shoulder blades and nearly fumbles her to the floor. A teenage girl wearing a headscarf rolls her eyes, but then smiles sympathetically, catching his laughing look.

Soon the participants move to the ambulance bay and simulation zone in the basement, where specialist ambulance nurse Daniel Björsson, 43, demonstrates how to carefully roll a patient onto a backboard.

The mood throughout the night is classic PBU: earnest, good-humored and thoroughly group-oriented.

It’s no surprise that many of the organization’s graduates go on to become its official ambassadors and refer to the program as a kind of “family.” Wearing chic black PBU hoodies, they create a ripple effect of good will in their communities.

PBU has now spread to fifteen cities throughout the country—a signal of its success. Yet the costs of such pioneering community outreach are significant.

For one, the program puts a drain on resources and places personnel out of service. Every ambulance, fire truck and police vehicle utilized is not on the street.

“It’s fun and opens your eyes”: Daniel Björsson, a specialized ambulance nurse in Stockholm, is an enthusiastic supporter of PBU. Photo Mark S. Weiner

Finding leaders and volunteers is also a major undertaking. Sabra is one of those rare people who can be at once a stern disciplinarian and the coolest friend a teenager could ever have—and she takes pride when her graduates go on to join blue light services. Someone like her doesn’t come around often.

One of the program’s Stockholm volunteers was in the infamous Gothenburg club fire of 1998. Born in Iran, specialist ambulance nurse Parastou Erik, 35, lost many friends that night, and the experience led her into the profession—and PBU.

“It’s not for everyone,” counsels nurse Björsson. “If you’re not willing to spend an evening playing ping pong with teenagers, you shouldn’t do it; but it’s essential that we do. There are no shortcuts to building relations, and from that comes community trust. Plus, it’s fun and it opens your eyes.”

Indeed, in important respects the program benefits first responders as directly as it does its young participants.

“Before I was part of PBU, I was a bit tense with crowds of teenagers,” reports paramedic Ellinor Sedenberg, 43. “But now I know them, and that’s helped me relax and have a more inclusive approach. I’m also better at enlisting the help of patients’s family and friends. That creates better care.”

Cross-Cultural EMS

As one piece of the puzzle of how EMS can chart its future in multicultural Sweden, community outreach programs like PBU will be essential. In recognition of their importance, the country will shortly increase its funded mandate to ambulance services to participate in them, effective February 2019.

But Swedish EMS is addressing its multicultural challenge in a host of other ways as well. Precisely because of its history of ethnic homogeneity, this home of advanced medical research is well positioned to become a laboratory for cross-cultural emergency care.

For instance, at the Karolinska Institute near Stockholm, Veronica Vicente, Ph.D., of the Department for Clinical Research is supervising masters students Ronja Josefsson and Helena Rentzhog as they document the cross-cultural experiences of ambulance nurses through in-depth interviews.

Participants at an PBU session in Gothenburg watch as their peers undertake an exercise staged by the firm Securitas. Photo Mark S. Weiner

Using the academic perspective of caring science, drawn from the work of nursing theorist Jean Watson, they hope to understand how EMS personnel are reacting to their new demographic environment, and how they view patients from different parts of the world.

The investigators have been heartened by what they’ve found. Swedish ambulance nurses have a profound desire to understand “the person behind the culture”—to enter into an authentic human relationship with patients in need of care across lines of difference.

Making this possible at the highest level will involve a variety of interventions to make a regionally organized service that’s widely acknowledged as very good even better. EMS education, public outreach, enhanced service protocols, technological developments (such as smart pocket translators), information campaigns and improved community policing all may play their part.

Some EMS leaders, like Henrik Johansson, 48, chief investigator and former national chairman of the Ambulance Association, a trade union, also advocate that ambulance personnel have greater access to safety gear and that vehicles be augmented with tactical protections.

None of these efforts will succeed, however, unless EMS and other first responders receive the full trust of minority communities.

In this respect, PBU stands out not only for its success with young people, like 15-year-old Adeeb, but also for its larger public significance.

By framing the relationship between immigrants and EMS in terms of kinship—by seeking to make first responders “aunts” and “uncles”—PBU bridges the distance between the traditional forms of political order that many migrants experienced in their home country, where extended family membership is paramount, and the modern, more bureaucratic view of public authority that reigns in Sweden.

By helping EMS and other first responders do their job better, the program may point to a new way of thinking about solidarity in a country that Swedes often refer to as “the people’s home.”


1. Byström M, Frohnert P, editors: Reaching a state of hope: Refugees, immigrants and the Swedish welfare state, 1930–2000. Nordic Academic Press: Lund, Sweden, p. 9, 2013.

2. Utrikes födda i Sverige (Foreign born in Sweden), Invandring till Sverige (Immigration to Sweden), and Asylsökande i Sverige (Asylum seekers in Sweden). (Nov. 6, 2018.) Statistics Sweden. Retrieved Jan. 1, 2019, from