European Healthcare for Sub-Saharan Migrants:
Access and Experiences
Migrations as a multi-faceted issue
Currently, there are more than 244 million international migrants, equating to about 3.3% of the global population (15). Most migration (three-quarters) occurs within national borders with only a quarter of global migrants actually crossing borders to another country. Migration is a component of the internationalisation of the world economy as the majority of international migrations occur from low income countries (LIC) to high income countries (HIC) thus creating somewhat of a cultural transformation in the past century (15). A key component of this transformation is globalisation which has increased labour movements from the global south to the global north.
With this, cultural identities have become even more dynamic, fluid and situationally constructed (23). But what is culture? There is no exact definition, and this haziness is how politicians often claim legitimacy for their discourses against migration in order to preserve national ‘culture’ (23). In more recent times, culture has become a symbol for different ways of life, evoking cultural relativism and emphasising diversity as a strength. This is predominant in the more cosmopolitan global north/Europe which hosts a large diversity of immigrants. Namely, more than 13 million immigrants that live in the European Union come from LIC (13).
Immigration is a process by which non-nationals move into a country for the purpose of settlement. While most immigration to Europe occurs legally, one of the greatest anxieties for migrants as well as an issue of huge public concern within the European Union is ‘illegal’ migrants (15). ‘Illegal’/irregular/undocumented migrants are “individuals who enter a country without the required documents/permits, or those who overstay the authorized length of stay in a country” (23). This article addresses African migrants’ experiences of infectious diseases and healthcare via a literature review of 5 epidemiological research papers.
It is important to discuss these experiences, as they are the ones that portray the power of colonial histories and migratory patterns of today. European colonial rule restructured African societies and introduced new forms of forced migration (via slavery) as people were taken to work in centres for European development. Also, voluntary migration to port cities as new jobs arose in the industry of extracting resources to European economies (12).
Furthermore, the focus on infectious diseases is due to Africa representing epicenters of newly emerging diseases like Ebola and HIV/AIDS in mainstream discourse, creating a huge political scare of diseases crossing borders which has resulted in the increased securitization of European borders. Hunt (1989), refers to the ‘AIDS belt’ in Africa consisting of Rwanda, Burundi, Congo, Zimbabwe, Botswana, Guinea, Zambia, Kenya and Uganda emphasizing how African countries have been profiled according to infectious diseases.
Looking at infectious diseases also helps create discussion around the ‘healthy migrant effect’, where those who choose to migrate tend to have better physical health and are more capable of enduring stress (14, 9). Lastly, by analysing policy responses (internationally, in the European Union and within European countries) one can understand broader structural determinants of infectious diseases in African migrants. As it is often the case, plans to improve migrants’ health may be tactical or opportunistic, rather than in response to humanitarian policies and strategies (2).
Research
When trying to understand more about the undocumented African migrants experience with diseases and healthcare in Europe, qualitative andinterpretive research on the topic would be ideal. However, due to the lack of such research, 5 epidemiological papers have been chosen to help us delve into the matter more thoroughly. Another struggle was finding papers focusing on the ‘illegal’ migrant as only Prestileo et al's paper actually focused on clandestine African migrants out of all the other ones being reviewed (17). Secondly, as Spain is the highest migrant receiving country in Europeand has thus received the most academic attention in terms of migration and infectious diseases, 3 studies on Spain will be reviewed. Finally, papers that focused on specific infectious diseases like HIV/AIDS (Fakoya et al, 2008), were also helpful and included.
Prestileo et al, looked at the prevalence of communicable diseases in irregular African migrants that landed in the cities Lampedusa and Sicily from 2011 to 2015 (17). Out of the 24,861 people who arrived at Sicily in 2011, 66 suffered from an infectious disease. 21 of the infected suffered from Tuberculosis, 13 from HBV, 8 from Scabies, 5 from Pneumonia, 5 from Malaria, 4 HCV infections, 4 acute gastroenteritis, 2 HIV infections and the remaining 4 suffered from various tropical diseases (17). Interventions for early screening for tuberculosis started for identification and expulsion of affected migrants out of Italy. One key finding was the prevalence of HBV infection in young African migrants with a 21% frequency of confection with HIV. Most of these were those who had stayed in the concentration camps in Libya for extended periods of time, en route to Italy.
This paper (Prestileo et al, 2015) amplifies how ‘illegal’ immigrants are prone to face increased social marginalisation, putting them at a higher risk of disease morbidity due to linguistic/economic difficulties and making them more naïve to misinformation, high mobility, greater barriers in accessing healthcare/preventative treatments and social exclusion. Irregular migrants remain invisible in health systems and thus unreached by health initiatives. This, mixed with overcrowded and promiscuous housing conditions and the constant fear of being caught out by judicial authorities, increases their need for medical attention whilst also making early screening, diagnosis and treatment more challenging. The migration route itself often creates environments ripe for transmission of diseases.
Moving on, health coverage in Spain is universal with the possession of a health card that is available for legal and ‘illegal’ immigrants. Lopez-Vélez et al (2003), studied 988 immigrants (where 72% were undocumented and 79.9% were sub-Saharan Africans) in a retrospective descriptive study at the Tropical Medicine Unit in Madrid between 1989-1999. They found the most significant factors increasing the impact of infectious diseases to be poor, overcrowded housing conditions and low accessibility to health care. Past and Active Hepatitis B and C, HIV infection, Active tuberculosis, Filariasis and Malaria were the most frequent infectious diseases in Africans. Conversely, Monge-Maillo et al (2009), looked at the prevalence of infectious diseases in the same unit in Madrid, Spain but for two decades (from 1989 to 2008). In both studies, the number of patients suffering from infectious diseases increased over time.The studies also show that most of the immigrants seen at the Unit migrated for economic reasons from underdeveloped areas of sub-Saharan Africa.
However, there were less undocumented migrants in the latter study as they found a huge rise in Latent Tuberculosis cases among the migrants was discovered. Latent Tuberculosis is normally triggered in times of stress and difficulty- suggesting that during this time, migrants may have been suffering from harsher immigration restrictions on top of the terrible socioeconomic conditions which arise for migrants when they first enter a foreign country. Issues such as illegality, inadequate housing, social isolation and difficulty in health access make them extremely vulnerable to transmissible infectious diseases, especially HIV which disproportionately affects immigrants. African migrants also tended to be diagnosed very late (with lower CD4 counts), which increased their risk of death from HIV.
The need for early screening as well as a cultural and social programme to help ensure earlier diagnosis of sub-Saharan Africans who may have HIV/AIDS was emphasised in this paper (Mongo-Maillo et al, 2009). Delcor et al (2016), undertook a retrospective review of 180 newly arrived Sub-Saharan immigrants at an International Health Centre in Barcelona more recently (from 2009-2012). They found the highest prevalence of infectious diseases to beLatent Tuberculosis (60.6%) followed by intestinal parasites (36.8%) and other tropical infections. HIV and Malaria had the lowest prevalence (1.2% each) out of all of the infectious diseases. They emphasised legality issues (which had tightened from 2000 onwards), as well as an “attitude of not seeking treatment held by many migrants” as exacerbating conditions for the high levels of Latent Tuberculosis.
Fakoya et al (2008), found that in 2005, 46% of HIV infections among heterosexuals in Europe were diagnosed predominantly among Sub-Saharan African migrants. In the UK, 38% of African men were unaware of their positive HIV status. Issues of unemployment, poverty, poor housing and stigma creates additional barriers. Concerns about being seen by other community members, when entering a sexual health clinic is a huge deterrent, with Africans being two times more likely to be worried about future discrimination after being diagnosed than white males in London. HIV transmission is associated with promiscuity and unsuitable sexual relations within African migrant communities.
Restrictive immigration policies, deficient political will and the under representation of Africans in decision making processes are the major legal and political barriers, preventing Africans from testing. Migrants are disproportionately prosecuted and exposed for HIV transmission in Europe. An estimate of a 25% decrease in HIV testing was found with criminal convictions of HIV transmission (8). Access to healthcare for migrants varies across Europe, from conditional to unconditional treatment leading to complex regulations on the issue. Many times, this has caused confusion and prejudice, where neither the “healthcare provider or client understand entitlement policies”. Due to this, uninsured and undocumented migrants are extremely deterred from testing. Prejudicial media attention linking HIV to immigrants and tighter immigration policies with entry into a country being conditional on a migrant’s HIV status increasing any social exclusion/fear of testing felt by these groups (8).
Policy Response
11 million ‘illegal’ people experience prejudicial attitudes and live under discriminatory policies, lacking access to critical health resources (3). In the UK, heightened immigration enforcement in recent years has led to increased deportations which have in turn decreased the health and wellbeing of many migrants, thus demonstrating how immigration policy can become synonymous with public health. A lot of immigration policies increase stress and obstruct access to healthcare. It is important to consider policies that shape the broader health landscapes in which immigrants live and to strive for a deeper understanding of a policy’s impact. This helps us avoid making broad generalisations of all immigrant populations (3).
Internationally, policy making on migration has been conducted as separate to the health sector as they often have incompatible goals. Migrant health policy making tends to focus on human rights and the associated service challenges. However, poor policy conditions and contradictory policy goals, such as increased foreign labour requirements, can exacerbate risk conditions related to migration health and pose extra challenges. For example, in the past 50 years there has been an increase in ‘illegal’ migrants who encounter more health risks than other migrant groups whilst also having the most restricted access to healthcare. Migration health insurance schemes are encumbered by restrictive immigration legislation or exclude ‘illegal’ migrants and their families from coverage. Even where multilateral agreements exist, their implementation isn’t universal (24).
The 61st World Health Assembly (WHO 2008), called upon member states to “promote equitable access to health promotion and care for migrants, to promote bilateral and multilateral cooperation on migrants’ health among countries involved in the whole migration process.” Furthermore, in 2010 the WHO came up with key elements of its migrant health policy and legal framework. The three pillars to this were: disease control elements, migration management and control, and norms which looked at wider human rights and international law perspectives (19). However, at an international level the document did not speak about legal/political issues at all. It showed a very Eurocentric focus with a complete neglect of the wider structural effects of current migration policy that is making people so vulnerable. Interestingly enough, on their official website the WHO denounces any systematic association between migrants and ‘imported’ communicable diseases (WHO 2018) and yet has a whole section on infectious disease control from migrants in the paper.
Disease control is being used as an excuse to control migration and as a scapegoat for tighter immigration restrictions. Jelinek et al (2002) found how Europeans travelling back from Malaria-endemic areas in Africa import just as much malaria as African immigrants. Other criticisms of these Global Policy processes in Migrants’ Health Rights say that it ignores migrants political, legal, labour, civil and sociocultural rights; there is a need for policy coherence across sectors and that migration policies often fail to achieve their objectives/have hidden or contradictory objectives (4). Rogaly (2008) adds that all these international processes are fundamentally in neoliberal interests which severely impacts the livelihoods of the world’s poor. “Depending on the regional impact of immigrants and the amount of travel in the local population, data from national sources in Europe can be heavily skewed toward one or another group” (11).
In the UK, the Immigration Act of 2014 changed the definition of a ‘deserving’ citizen in access to the National Health Services (NHS). NHS providers can only legally provide healthcare to ‘legal’ migrants who deserve it. Deservingness of immigrant populations has been a relatively neglected area in academia. In fact, there has been a lack of discussion on the role of discrimination (racism/anti-immigrant prejudices) and the importance of understanding migrants ‘deservingness’ of healthcare (3, 22). Migrants in the UK now have to pay surcharges for health care access and are forced into poorer living conditions which can trigger Latent Tuberculosis. Moreover, ‘illegal’ migrants will be denied care. On the other hand, Spain has one of the most liberal immigration policies in the EU. After realising the economic value of immigrants, Spain started to recruit legal workers from Sub-Saharan African countries. At the same time, it has attempted to forge many agreements with various African countries for increased repatriation in exchange for greater economic and financial support. In terms of illegality, Spain has a strict expulsion policy with no legalisation for ‘illegal’ immigrants possible. Namely, many of them are kept within detention centres at the Ceuta and Melilla borders for years (1, 5).
More needs to be done to support migrant’s health. Increased outreach and community mobilisation programmes, as well as health promotion, addressing fear of diagnosis, and the success of treatment, are key to increasing HIV testing among black migrants. Additionally the prioritisation of the health access rights of ‘illegal’ migrants once diagnosed or who are at risk of infection should be considered. More investment is needed to expand the presence of HIV testing facilities beyond just sexual health clinics, but all health clinics so less people will be deterred from being tested (8). The European Academic Science Advisory Council (EASAC, 2007) highlighted the importance of global coordination. Member states should not only work on assisting healthcare finances for migrants, but also prioritise tackling infectious diseases in LIC in the first place, so as to reduce the global burden of disease and risk of transmission into the country.
Call for Action
Engage with the community! Many may be at the unique position of belonging or having a close connection to the migrant community that can help promote community mobilisation. They can also inform the community of important health topics or their rights as migrants, as a way to address the fear of diagnosis, and the success of treatment.
Promote through social media advocacy! As a way to counteract prejudicial media attention given to the migrant community, we can take advantage of social networks to help prioritise health access rights of ‘illegal’ immigrants and connect with supporters. Evidence-based information about the realities that migrants face can help address the prejudice and stigmatisation that the community faces.
Promote the conversation! There is a need for investment to expand the presence of HIV testing facilities beyond just sexual health clinics, so that less people will be deterred from being tested. As organisations and policymakers may seem reluctant to touch on the subject, we must be willing to spark conversations related to migrants’ health.
By
Neelam Iqbal and Israel Herrera-Ramirez
Acknowledgements
We would also like to thank Joseph Blakemore and Andjela Timotijevic for their comments and support in reviewing and editing the original manuscript.
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