Immigration and Access to Healthcare in Europe: An ongoing struggle
Minorities, and particularly immigrant populations, have less access to healthcare than the general population in Europe.
Both healthcare policies and the collective perceptions and definitions of who is and who is not a citizen, have consequences for the access to healthcare of minority groups.
While altering the public perception is important, more immediate and large-scale results can be achieved by making healthcare policies in Europe more inclusive towards immigrant populations.
With recent news on AstraZeneca vaccine bans in Europe, several headlines stated that ‘the political had won over the sanitary’ (Says, 2021) when countries decided to ban the AstraZeneca vaccine with the primary concern of avoiding social unrest rather than actual sanitary risks. What may seem like a new phenomenon arising from the coronavirus crisis is, in fact, a reality shared by most countries and which dates back to pre-pandemic times. As a matter of fact, more often than not, it is the political that shapes the sanitary, and not the other way around. All over the world, people’s health status is mostly determined by the healthcare policies of their countries, access to healthcare facilities, cost of healthcare, and a myriad of other factors that solely depend on political decisions.
If the coronavirus crisis has shed a light on the close link between politics and health, it has also highlighted the differences between countries’ approaches to healthcare by making the differences in reactions to the spread of the disease, speed of reaction, and efficiency in taking measures to tackle the pandemic more visible. Such disparities have even been seen within countries of the European Union regardless of geographic proximity, shared borders, economic advancement and population sizes, leading to a total lack of European coordinated response to the pandemic. As a result, people’s lives across Europe have been affected differently, with Sweden refusing to put its population under lockdown, Italy being the first country to install a strict confinement in Europe, and Germany having been particularly successful in managing contamination rates across its territory, to cite a few examples. Consequently, death and hospitalisation rates have also varied greatly between countries, and perhaps the most important lesson learned from this past year was the importance of a reliable and solid healthcare system.
The missing piece of the puzzle
At the same time, one segment of the population has been largely left-out of the pandemic responses all across Europe: immigrants, both undocumented and settled. Amidst sensational news of new restrictions, increasing infection rates and hospitalisations, immigrant populations have been suffering a double sentence: that of the pandemic, and that of marginalisation and exclusion. Several refugee camps saw, for instance, stricter lockdown rules imposed, leaving them at higher risk of infection within unsanitary living conditions and with virtually no access to masks or tests, not to mention any other form of healthcare (George et al., 2020). An equally significant aspect of the pandemic response was the fact that it highlighted not only how countries’ public health systems faced the spread of the virus, but also how it managed to include or exclude minorities and fragile populations such as immigrants.
Indeed, increased movement presents countries with new challenges regarding healthcare systems, and although the World Health Organisation’s Constitution (2021) states that “The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition”, real-life applications of this principle prove to be a challenge for most countries. Undocumented immigrants aside, several minority communities, including citizens with an immigration background who have lived in a country for at least two generations, or racial minorities, also show disproportionately higher rates of infection than the rest of the population, as is the case with black, indigenous, latin american and pacific communities in the United States (The Covid Tracking Project, 2021).
While this has given rise to a wide range of hypotheses on the links between ethnicity and likelihood of catching the virus based on blood types, cultural differences or simply lack of health awareness (source), an increasing number of studies show that socio-economic status and area of living affects population health status significantly more than genotype or personal efforts made towards greater health. The field of medical geography takes interest in studying how health inequalities are distributed across territory, and consequently, how they are influenced by local and national policies. Notably, one of the most common findings across the globe is that populations’ health in cities is worse than that of suburban or countryside inhabitants. While there are several factors that explain these disparities, we will focus on the implications that this has on minority groups.
Immigration and the city
It is no coincidence that most public health issues are made visible in urban settings: firstly, cities are more densely populated than rural or suburban areas. They tend to welcome more diverse populations, and offer more job opportunities, thus attracting more immigration. Secondly, urbanisation itself serves as a factor for creating, strengthening or worsening disparities in terms of access to social services in general, and healthcare in particular. In the case of immigrants, refugees, exiles and asylum seekers, this materialises in the emergence of what is considered to be “undesirable urban forms” (Hoyez et al., 2019) which prompts policymakers to convert the neighbourhoods in which these populations settle into secluded and marginalised areas that should not be made visible. As a result, food, medical and educational deserts are created, leaving their inhabitants deprived of basic human rights. To make matters worse, not only do these populations find themselves excluded from access to healthcare, but the sanitary argument is often used as a claim to legitimise their expulsion or the dismantlement of urban settlements in the eyes of authorities, as was the case last summer during the disputes between Greece and Turkey over border settlements (Valadares, 2020).
In order to respond to these challenges, several NGOs have taken it upon themselves to bring solutions to health exclusion. One such example is the PASS department of the Saint Louis University Hospital in Paris, through which medical volunteers and NGOs try to provide basic medical, psychological and social support to fragile populations including migrants. PASS refers to “ Permanences d’Accès aux Soins de Santé” (permanence for access to healthcare) which was put in place as part of December 1998’s law against exclusion (CNLE, 2008) in public health establishments in order to facilitate access to healthcare as well as networks of institutional and associative care to people in need (Saint Louis University Hospital, 2021). That being said, the experiences of migrants in such programs have shown the shortcomings of local, small-scale responses to a larger and more complex issue, as research shows (de Celeyran et al., 2013). The vulnerability of these populations, coupled with their financial issues, hazardous living conditions, psychological trauma, language barriers and a myriad of other difficulties makes it virtually impossible for them to have access to equal access to proper treatment and medical services. As was highlighted by researchers who took part in the PASS program, comprehensive policies are needed in order to tackle health inequalities, seeing as national health policies, budget cuts and immigration policies largely influence hospital services and determine the degree to which volunteers are able to make an impact on these issues (de Celeyran et al., 2013).
The need for collective action
To be able to understand why local responses alone are insufficient, it is necessary to grasp the wide array of factors that exclude immigrant populations from having proper access to healthcare. While the previously mentioned structural barriers such as geographical isolation, lack of resources and language barriers are easy to discern, migrants also face smaller, indiscernible and complex issues that pertain to preconceptions and discrimination. These factors are worth taking into account by policymakers and healthcare experts alike because they not only lead to healthcare providers denying healthcare to vulnerable populations, particularly undocumented immigrants, but they also deter fragile populations from seeking medical care when they need it (George et al., 2020). This can be explained with what social psychologists call “Status-based rejection”, which refers to the ways in which minority and vulnerable groups, especially racial minorities, are likely to feel rejected and unsafe despite the removal of structural barriers in fields and institutions that have marginalised them in the past (Mendoza-Denton et al., 2002).
In order to tackle the problem at its root, there is a dire need in Europe for more inclusive healthcare structures and policies to which immigrant populations have full access to, and feel safe attending. A few European countries have already started implementing such policies in an attempt to include different groups in state provided healthcare, however, they remain largely inefficient at tackling the issue. Taking the French and Dutch examples, two countries with highly ranked healthcare systems but two different approaches to minority integration, we can highlight the necessity of improving the accessibility and inclusiveness of healthcare.
In the early 2000s, France introduced Universal Health Cover for its citizens as well as State Medical Assistance (Aide Médicale de l’État) for undocumented migrants’ health protection scheme (André & Azzedine, 2016). Meanwhile the Netherlands has a private health insurance system that residents are required to purchase, excluding immigrants, who only have access to medical care that is deemed urgent or necessary. However, healthcare workers could seek reimbursement for the provided medical care from a special fund, thus not requiring immigrant patients to pay (André & Azzedine, 2016). In both countries, public and political skepticism around these schemes in recent years has pushed policymakers to adopt stricter measures towards immigrant populations, and to make healthcare more difficult to obtain for them. In the Dutch case, this took the form of making the scheme indirectly accessible starting in 2009 by requiring that healthcare providers prove that they have tried their best to get paid by the immigrant patient, thus making the payment mandatory for the patient unless they prove unable to afford it, and considering free access to health an exception rather than the norm (Biswas et al., 2012). Likewise, in the French case, access to free healthcare became dependent on conditions of residency and financial contributions in recent years. As a result, only 10.2% of migrants could have access to it in 2014 (André & Azzedine, 2016).
The past year has presented health experts and governments all throughout the world with an unprecedented challenge: a global pandemic in times of globalisation and increased mobility. Nevertheless, this challenge drew attention to a pre-existent and growing problem: that of access (or lack thereof) to healthcare for immigrant populations and minorities, as well as the impact that structural barriers, stigma and discrimination have on limiting the access to a universal human right for large portions of the population. In order to break these barriers, collective efforts towards implementing more inclusive healthcare policies and strengthening the existing ones are now more pressing than ever.
André, J., Azzedine, F. (2016) Access to healthcare for undocumented migrants in France: a critical examination of State Medical Assistance, Public Health Reviews, 37(5).
Biswas, D., Toebes, B., Hjern, A., Ascher, H., Norredam, M. (2012) Access to health care for undocumented migrants from a human rights perspective: A comparative study of Denmark, Sweden and the Netherlands, Health and Human rights, 14(2).
CNLE. (2020) Orientation law of July 29, 1998 on the fight against exclusion, Conseil national des politiques de lutte contre la pauvrete et l’exlusion sociale, 13 June. Available at: https://www.cnle.gouv.fr/loi-d-orientation-du-29-juillet.html [Accessed 24/03/21].
De Celeyran, F. T., Girardeau, Y., Khan, S., Morinet, F., Georges-Tarragano, C. (2013) Health-care access for migrants in France, Lancet, 382(9906).
George, M. S., Davey, R., Mohanty, I., Upton, P. (2020) “Everything is provided free, but they are still hesitant to access healthcare services”: why does the indigenous community in Attapadi, Kerala continue to experience poor access to healthcare? International Journal for Equity in Health, 19(105).
Hoyez, A., Bergeon, C., Gasquet, C. (2019) Health systems and immigrants – a focus on urban France. In: Vojnovic, I., Pearson, A. L., Asiki, G., DeVerteuil, G., Allen, A. (2019) Handbook of global urban health. Oxford: Routledge.
Mendoza-Denton, R., Downey, G., Purdie, V. J., Davis, A., Pietrzak, J. (2002) Sensitivity to status-based rejection: Implications for African American students’ college experience, Journal of Personality and Social Psychology, 83(4), pp. 896-918.
Saint Louis University Hospital. (2020) Permanences d’Accès aux Soins de Santé. Available at: http://hopital-saintlouis.aphp.fr/permanence-dacces-aux-soins-de-sante-pass/ [Accessed 24/03/21].
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