By Ursula Trummer
Undocumented migrants are among the most vulnerable groups in society, their daily living is characterised by uncertainty and abuse. Exploited on black labour markets, they are widely excluded from welfare systems. Seeking help from authorities is dangerous as it might result in detention and deportation. Research in this field is challenging. The recent scoping review on health and access to care for undocumented migrants in the EU, by Woodward et al., reveals the weaknesses in methodological approaches, in sampling and the lack of valid data. Indeed, methodological standards are sometimes overruled by a struggle for the best available evidence, which often comes from stakeholders in the field who are biased.
Health and access to care for undocumented migrants – a paradox framework
What is evident from our own research on health policy approaches and related practices to undocumented migrants is the paradox that is created by conflicting demands at the policy level. While the European Convention on Human Rights defines the universal right to health for everyone, irrespective of legal status and/or financial means, national regulations of most EU member states deny access to health care for human beings lacking a legal status and economic means. Consequently, whatever happens is wrong according to one or the other frame of reference. This creates a vulnerable space where everybody who steps in becomes vulnerable as well.
This paradox cannot be solved by practice and of course not by research. Research can, however, describe and analyse the strategies in place to deal with this paradox.
Handling the paradox: functional ignorance and informal solidarity
Functional ignorance appears to be the main strategy designed to handle this paradox at policy and practice levels. This can be defined as handling problems by ignoring them in the first instance. Take the case of Austria, a small, rich country, in the centre of Europe. Austria is proud of its insurance-based health care system covering approximately 99% of the documented population. The number of undocumented migrants residing in the country is not known but they have no right to access health care – they are ignored by policy. In practice, access to health care for undocumented migrants may be opened through the back door by not denying emergency care and regulations on treatment for tuberculosis. While basic health care is provided by NGOs, who themselves participate in this ignorance by not asking for the legal status of their clients. Officially, NGOs provide treatment to the homeless or uninsured, but not to undocumented migrants.
The second strategy is informal solidarity, acting in favour of something without addressing it openly. Again, this can be observed at the policy and practice levels. To act as care providers, NGOs need support from health professionals (acting as volunteers) and stable funding. Neither is provided by helping undocumented migrants but by supporting the homeless and the uninsured, NGOs receive support and funding to relieve the strain on the public health system, whose mainstream institutions are not able to cope with clients of multiple vulnerabilities.
Both strategies make it possible to fulfil two contradictory demands at the same time: provide and deny access to health care.
Lessons to be learned for research?
Can research in a vulnerable space, where evidence is hard to get and methodological standards have reached their limits, learn from these strategies? I look forward to discussing this!
Dr Ursula Trummer is Head of the Centre for Health and Migration, Vienna