The migratory phenomenon is spiraling down and the international community is panicking looking for a solution. In the coming months, the expected good weather and calm sea will likely lead to an increase in the numbers of migrants arriving to the EU coasts and to a consequent exacerbation of the emergency.
Lesions, burns, dehydration and musculoskeletal disorders are just few of the consequences that migrants will endure as consequence of their desperate journey across land and sea in the hope for a better future. Migrants’ health is an important and problematic aspect of the migration challenge.
The precarious conditions of migrants and asylum seekers’ lives before and after the journey increase the risk of communicable and contagious diseases.
Special attention should be given to women. The hard trip may cause serious complications for pregnancies and in childbirths. In addition, women are much more exposed to the risk of physical and verbal aggressions and sexual abuses.
Health consequences may be not only physical but also psychological. The migration process, in all its stages – pre-migration, in transit and post-migration – is a hard and vexing experience, and the consequent stress can lead to mental illness.
Once rescued and arrived in Europe, the majority of migrants are in need for medical assistance.
Migrants’ health policies in the EU
According to the UN Committee on Economic, Social and Cultural Rights (E/C.12/2000/4) the right to health involves a notion of accessibility, which includes in the practice of non-discrimination, physical accessibility, economic accessibility and information accessibility.
This concept is at the core of a research conducted by the EU Journal of Public Health that divides EU member states into three clusters depending upon the level of entitlement of undocumented, adult migrants to healthcare. There are countries that ensure (1) less than minimum right, (2) minimum rights and (3) more than minimum rights.
In the first cluster we find member states in which the entitlement to healthcare is highly restricted and where even emergency care is inaccessible as it is not affordable. Finland and Ireland provide emergency assistance under unclear cost. Migrants may access urgent care in return for payment of the full cost in Sweden, Austria, Bulgaria, Latvia and Czech Republic (in the latter country emergency aid is alternatively accessible upon purchasing a private insurance).
Austria represents a peculiar case. This country provides emergency care under payment, however the hospitals are required to pay the costs if the patient is unable to pay or is not identified. This practice could be interpreted as a minimum right.
The second cluster includes EU members where undocumented migrants are entitled to urgent care free of charge, such as Germany and Hungary. In some cases, there is a moderate fee. This group also includes states where more extensive healthcare might be accessed under certain circumstances or in return for payment of the full cost. That is the case of Cyprus, Denmark, Estonia, Lithuania, Poland, UK, Slovak Republic and Slovenia.
States where the right to health includes services beyond emergency situations belong instead to the third cluster. Those countries guarantee migrants free access to primary and secondary care. However local legislation may require in some cases administrative procedures that could to a certain extent reduce access to medical assistance. Netherland, Portugal, France, Spain and Italy apply to this level of right.
Focus on Italy
Migrants’ healthcare policies in Italy are recent. The first legislative act dedicated to this subject dates back to 1998 with the so called Turco-Napolitano Law, merged into the Testo Unico (TU) sull’Immigrazione with legislative decree n. 286 of July 25th, 1998. The Presidential Decree (Decreto del Presidente della Repubblica) n. 394 of August 31st, 1999 provided for the practical implementation of the TU’s provision regarding migrants’ right to healthcare, according to Article 32 of the Italian Constitutional Chart.
While Article 34 of the TU is dedicated to foreign people regularly registered to the National Health Service (Servizio Sanitario Nazionale – SSN), Article 35 deals with “irregulars”’ healthcare, defined as Temporarily Present Foreigners (Stranieri Temporaneamente Presenti – STP).
Italy ensures to the latter category of migrants not only urgent and essential care but also medical preventive services. Moreover, in the TU Italy decided to remove the obligation for healthcare structures to alert the police in case of irregular migrants or refugees asking for medical help, thus ensuring that the right to health had priority over the legal condition of the patient. This concept is also boosted by the 2006 Resolution n. 1, 059 of the EU Parliament. Those regulations have not been emended by following laws on migrations, such as the Bossi-Fini n. 189/2002, and are still in effect.
Besides national legislation, migrant integration and support initiatives, also regarding healthcare, are promoted and implemented locally.
Additionally, voluntary groups and non-profit organizations play a very important role. In 1998 Rome’s Caritas established an observation unit on local policies for migrants’ healthcare, and every day doctors and volunteers all over Italy uphold the right to health of thousands of people.
The case of Lampedusa deserves a separate discussion, as a prime access point to Europe from Africa ever since the 1990s. On the island, which hosted during these years millions of migrants, a special protocol of intervention is enforced in agreement with the Italian Ministry of Health (Ministero della Sanità).
Once rescued and landed, migrants are first of all examined. If they present physical problems or diseases they are brought to emergency structures. Those who need special assistance are moved to the Hospital of Palermo by helicopter.
The central figure of this emergency medical action is doctor Pietro Bartolo, director of Lampedusa’s health centre, who has examined virtually all migrants and asylum seekers arriving on Italian territory. At the ceremony of the Golden Bear Award 2016, won by a documentary (Fuocoammare by Gianfranco Rosi) where he appears busy in his daily duty, dr. Bartolo explained how medical examinations are not only essential from a health perspective, but also from a personal and psychological one. A ten minutes ultrasound for a pregnant woman may represent a moment of happiness and tranquillity after the hardest day she has ever experienced. The same happens for the numerous kids who may find in the health centre a nice and safe place to play.
In 2015, the Italian Red Cross awarded the people of Lampedusa with a Gold Medal of Merit for their reception system, a model for all Europe.
Communicable diseases, is there a real risk?
The worsening of the migrant crisis has generated scaremongering. Quite often we hear that immigrants expose citizens of the hosting countries to infectious diseases that have been eradicated in Europe. Is the risk real?
First of all we should recognize that although migrants and refugees who arrive in Europe are naturally exhausted by the trip they usually do not present serious health problems.
The main pathologies migrants develop are generally linked to housing problems, economic and working conditions, and limited access to healthcare systems. Precarious housing and living situations raise the risks of disease and infections. The difficulties of irregular job-seeking often force migrants to accept unprotected employments, with considerable dangers to their health and safety. Other problems may be caused by insufficient and unbalanced alimentation. Additionally, the change in environment lowers immunity and increases the risk of illness.
Furthermore, the most infamous “foreign” diseases rarely endanger the host countries’ health system. For instance, Hepatitis B, that is frequent enough among migrants, does not result in a major risk for those vaccinated against the virus (in Italy vaccination against Hepatitis B is compulsory since 1991). Scabies instead is a skin infection already endemic all over the world and easy to cure. And Ebola? First, Ebola did not appeared in Syria or the Horn of Africa, from which the majority of immigrants come. Second, the incubation period is estimated around 7-10 days, hence, considering migrants’ journeys last for months, by the time they arrive on our shores the disease should have already manifested or they should be dead already.
Therefore it is possible to conclude that the risks of contagious diseases in Europe are minimal in the short run: migrants are generally healthy; the hosting countries have efficient health systems that minimizes the risks for locals; and pharmacology ensures effective prevention and control measures.
How to handle migrants’ health challenge
The World Health Organization insists that on the long term national health systems should be prepared to address the migrants’ health challenge.
The European Commission already allocated funds to support relevant healthcare projects across Europe and recently introduced the use of a personal health record (PHR), managed directly by migrants, to facilitate the understanding of their medical needs and intervene with the right measures in the sensitive areas of major migrants flows.
A relevant and highly discussed issue is the implementation of dedicated health structures, able to address the specific necessities of irregular migrants. These centres shall take into consideration the social and working conditions of this category of people, shall function as an epidemiological observatory conducting analysis and studies on the real needs of the foreign population, and help the institutions providing correct national and local policies. The staff shall be assisted by interpreters and cultural-linguistic mediators, and it shall be trained on “transcultural medicine” – defined by medical dictionaries as the psychosocial aspect of healthcare, in which cultural differences between doctor and patient are considered in respect to privacy issues, as well as religious and ethnic preferences.
The European Centre for Disease Prevention and Control (ECDPC) encourages the establishment of shelters that shall be on the one hand responsible for examinations immediately at the arrival and, on the other hand, able to ensure personal hygiene and appropriate alimentation and to avoid crowding inside the buildings. In fact, although migrants are unlikely to catch infectious disease on their journey to Europe and potentially start an epidemic once arrived, their appalling travelling conditions can weaken them to the point of making them extremely susceptible even to common European illnesses.
According to the ECDPC, authorities need to start a serious vaccination campaign, along with the creation of an international database monitoring migratory flows from a health-medical prospective.
Given their fundamental role, it is essential to involve into migrants’ health responses non-profit organizations and voluntary associations for migrants’ integration.
An example of their efforts is provided by the Italian AMSI – Associazioni Medici di origine Straniera in Italia (Association of Doctors of Foreign Origins in Italy), led by doctor Foad Aodi, who is also president of COMAI – the Arab community in Italy – and Uniti x Unire, a transnational and transcultural network for the integration between different peoples. AMSI, beyond managing foreign doctors’ integration, medical personnel adjournments and international cooperation, deals with healthcare assistance on the Italian territory through the creation of healthcare centres dedicated to foreign patients, including undocumented ones.
The association promotes three projects linked to each other: Good Immigration, Good Education and Good Health.
These three points, along with emergency interventions at the arrival and appropriate policies, could be the key to guarantee to migrants and refugees the right to health. Education generates information, knowledge of the law and of available services and structures supports illness prevention and prevention mean of course more health for everybody. Organizations, institutions and the whole community must work together toward this goal.
Master’s degree in International Relations (LUISS “Guido Carli”)
Aodi, F., Personal communication. 2016, March 1st.
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