Illegality as risk factor: A survey of unauthorized migrant patients in a Berlin clinic

Abstract

Unauthorized migrants face health disadvantages in many receiving nations. However, few studies have explored precisely how the condition of “illegality” influences illness experiences, medical treatment, and convalescence. This article presents a case study from Germany (2004–2006 and 2008), where unauthorized migrants face limited access to health care and the threat of deportation results in avoidance of services and treatment delays. This is confounded by unique laws which essentially criminalize health care workers for aiding migrants. This article provides a snapshot of 183 patients who attended a Berlin clinic that functions as the single largest source of medical assistance for unauthorized persons in Germany. The demographic information sketches a picture of labor migrants with a mean age of approximately 29 years. More women than men presented at this clinic, a result of its ability to successfully arrange prenatal care and delivery as well as a reflection of local labor markets. The diversity of countries of origin (n = 55) is surprising, underscoring the utility of using illegal status as a unifying variable to highlight migrants' shared position in the global economy and the resulting barriers to basic medical services. Patients presented with a range of illnesses typical for their age group. However, the effects of illegal status resulted in four areas of disparities: 1) limits to the overall quality and quantity of care for mothers and infants; 2) delayed presentation and difficulties accessing a regular supply of medication for patients with chronic illnesses; 3) difficulties in accessing immediate medical attention for unpredictable injuries and other acute health concerns; and 4) a lack of mental health care options for generalized stress and anxiety affecting health. In Germany, an incoherent policy environment contributes to inadequate services and treatment delays. Solutions must address these legal ambiguities, which represent a primary barrier to equity in a nation with otherwise universal health coverage.

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.