Illegality as risk factor: A survey of unauthorized migrant patients in a Berlin clinic
Introduction
Unauthorized migration is increasingly a low-cost, flexible, but vulnerable source of reserve labor for many wealthy nations. In much of Western Europe, unauthorized migration has provoked tensions between universal health care models for those entitled to well-established social welfare systems and humanitarian concerns of providing basic medical services for all residents, whether they are “legal” or not. Defined as “illegality” (Chavez, 2007, De Genova, 2002) or “undocumentedness” (McGuire & Georges, 2003), uncertain legal status represents an additional, seldom studied variable impacting health, illness, and convalescence.
The condition of illegality is an expression of juridical status and social relation to the state (De Genova, 2002, Inda, 2006, Ngai, 2004). In contemporary Germany, as in many other nations, illegality is produced via labor market demands and results in shifting practices of inclusion and exclusion. Although the term “undocumented” is commonly used, especially in the United States, the term “unauthorized” is utilized in this article. Typically, migrants have some form of documentation, but use them in unauthorized ways – such as overstaying tourist, student, or border-crossing visas, or taking on employment without a work permit (Heyman, Nuñez-Mchiri, & Talavera, 2009). This term is especially appropriate in the German context, where the vast majority of individuals enters the country legally but overstays visas, resulting in illegal residency status. This description is also useful because it can be extended to two specific subgroups in the German context: 1) asylum seekers whose claims have been denied but who remain in the country, as well as 2) individuals arriving from the new European Union (EU) member states who are technically legal residents but who fall under transitional restrictions on labor migration. In Germany, individuals lacking residency or work permits are not included in the comprehensive social health insurance system. While mandatory, the system rests on employment status (since it is partially funded through employer contributions) or eligibility for state welfare resources. For those working illegally or overstaying a visa, evidence for neither can be mustered.
This article explores how illegality influences experiences of health, illness, and convalescence using a study of a Berlin clinic that treats primarily unauthorized migrant patients. It constitutes the single largest source of medical aid for such migrants in Germany, serving many of the city's estimated 100,000 unauthorized migrants (Gross, 2005) with more than 3000 visits per year. In Germany, while limited access to medical care is technically guaranteed to unauthorized migrants, a complex web of laws makes the provision of care difficult and certainly inadequate. Furthermore, migrants avoid public facilities because they will be questioned about insurance coverage, which will inevitably expose their unauthorized status and may lead to deportation. As there are no systematic studies of unauthorized migrants in Germany, this study is an initial attempt to document their health needs and service utilization.
This article reports on the results of 183 case studies of unauthorized patients collected during the participant observation phase of the larger study. Basic demographic information is presented and followed by a discussion of four themes which highlight the impact of illegality on health: 1) limits to the overall quality and quantity of care for mothers and infants; 2) the difficulties associated with accessing a regular supply of medication for chronic illnesses; 3) the unpredictable nature of injuries and other acute health concerns requiring immediate medical attention; and 4) generalized stress, anxiety, and depression affecting health that has led some patients and physicians to refer to an “illegal syndrome.” These discussions are drawn from case examples gathered during the participant observation phase and supplemented with interviews to highlight how the condition of illegality influenced experiences of medical treatment and convalescence.
Section snippets
“Illegality” as health risk
Epidemiological data on unauthorized populations in any host nation are scarce. Attempts to infer morbidity patterns by examining legal migrants' health patterns result in complex and contradictory data, depending on indices, location, and population. Some studies conclude that migrants have lower overall morbidity rates compared to host country counterparts; this is often explained by the healthy migrant effect – a selection bias which occurs when only relatively healthy young people migrate
Setting: the Migrant Clinic
Despite this web of laws, local efforts ensure that some level of medical aid is available. Across Europe, nonprofit and nongovernmental organizations have responded to migrants' health needs by establishing networks of referral or by creating low-cost or free clinics (PICUM, 2002). Data were collected at one such organization, the Berlin Migrant Clinic (a pseudonym), as part of an ethnographic study on unauthorized migration and medical aid in Germany from 2004 to 2006 and supplemented by
Patient characteristics
The sample of 183 patients collected during this study can be considered “typical” in that it mirrored the existing statistics provided based on the Migrant Clinic's own internal record-keeping. While the patients who sought assistance at the Clinic were a heterogeneous group, it is possible to point to some key patterns (Table 1).
Effects of “illegality” on health
The data presented here stem from the largest single source of medical aid for unauthorized persons in Germany and provide a glimpse into patient background, types of illnesses, and major issues encountered during the study period. While the information sketches a picture of labor migrants at the height of their working years, other variables were less predictable. The diversity of countries of origin is particularly surprising. Among the 183 patients, 55 countries of origin were identified.
Acknowledgements
The author wishes to acknowledge Melissa Johnson for helping with manuscript preparation. Mark Nichter, Kate Goldade, and Namino Glantz provided helpful comments on earlier versions of this paper.
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