IMMIGRATION PHENOMENON
AND RIGHT TO HEALTH IN ITALY
Luigi Toma
Introduction
For several years, the World Health Organisation (WHO), has
used the term Human Mobile Population to
define immigrants, refugees, political asylum applicants, exiles, workers in
transit, travellers, tourists; therefore all persons that for various reasons
move from one country to another. According to WHO data, over 1 billion of
people left their national boarders at least once in 2001 alone. In particular,
135 million migrated in search of work. A reservoir of desperation on the rise
which in the eighties numbered 70 million.
Since a few years, Italy has been affected by the
reality of immigration and currently represents the fourth European Union
country, after Germany, France and Great Britain, in proportion to the number
of immigrants it hosts, with an incidence of 2.9% on the resident population,
compared to the European Union average of 5.1 %.
For over a century, our peninsula has experienced the
phenomenon of emigration, along with all the cultural, political and health
consequences that this entails. However, from the mid-seventies, the migratory
flux of Italy began to invert due to the substantial increase of immigrations
which, in the years that followed, took on permanent and structural traits.
How many immigrants are there in Italy?
Foreigners
regularly landed in Italy are now estimated to be around 1.6 million (with an
incidence of 2.9% on the resident population against the average EU incidence
of 5.1%). The immigrant population has increased by 240.000 units from
1.252.000 of last year to 1.490.000; broken-down represents approx. 10.000 born
in Italy of foreign parents, between 80-90.000 new arrivals with entry visas
and 146.000 of those persons already legalised.
The archives of the
Ministry of Interiors supplies only partial data since it does not record all
the foreigners regularly present in Italy, but only those who possess legal
permission of stay. Therefore minors usually escape the data system as they are
inserted in the "authorisation of stay" issued to the household
heads. Minors only become holders when they enter for motives of adoption,
fostering, whenever unaccompanied by their parents, or if already resident they
formally apply for permission of stay, after their 14th birthday, in order
obtain an official "employment-card".
The
foreigners recorded by the Ministry of Interiors on December 31st
2000, including those of the European Union, totalled 1.252.000 compared to
1.033.000 of the preceding year.
However, in order to reach a general estimate of all
the foreigners staying in Italy on a regular basis, it is necessary to increase
this number by at least 19% so as to include the minors, unrecorded for the
aforesaid motives, as well as those people whose permission of stay (newly
granted or renewed) has not yet been processed due to bureaucratic delays. This
method is proposed by the work-team of the Italian Caritas that elaborates the
Dossier on Immigration Statistics.
Migrations and
health
Migrations
are a predictable source of stress and health hazards because they involve a
new organisation of life-styles consequent to an eradication from their
original environment and personal security. For this reason, the health
protection of emigrants becomes one of strategic importance, also in view of
safeguarding the health of all persons at risk of emargination.
The problem of "emigration medicine"
consists in the duty to assist persons whose socio-sanitary conditions are in
the process of social and cultural transformation. As far as concerns the
relationship between illnesses, symptoms, culture and ethnic affinity, evident
correlations between specific pathologies and determined peoples, or ethnic
groups, have never been observed. These patients present a very different
attitude towards the experience of illness, pain, suffering and death. The
diverse perceptions of the symptoms in relation to the various cultures of
origin is valid for all populations. It is necessary to take into account that
immigrants often use "somatic metaphors" as the briefest and easiest means of
expressing otherwise non communicable emotions and feelings. Very often, they
accuse symptoms of cenestopathic type (head-aches, digestive troubles, vague
and diffused pains, itching, burning at urination, worries about their personal
and physical well- being), without there being somatic comparisons. The process
of change which immigrants have to face requires a continuous upheaval of their
personal, historical and cultural identity. It could be said that immigrants
know in advance that they will be required to adapt to completely different
situations and that this will involve a heavy price; the advance expectation of
suffering is not enough to eliminate it. It is necessary that we physicians, who
often run the risk diagnosing only by somatic metaphor, when examining patients
from foreign cultures, become capable of understanding the entire aspect and
deeper sense of their attempts to recovering a new identity (Frighi,1990).
An Italian Experience:
The Institute of San Gallicano (IRCCS)
Within the panorama of institutions committed to the
field of immigrant health, the experience of the Scientific Institute of San
Gallicano in Rome can supply useful elements for a broader comprehension of the
problem. In fact, the Preventive Medicine Unit for Migrations, Tourism and
Tropical Dermatology, active within the institute since the beginning of
January 1985, has for many years represented the only point of public reference
for the care, assistance, clinical-epidemiological and socio-anthropological
research concerning the immigrant, nomadic and homeless population.
The service, which is free of charge and open every
day, constitutes a valid observatory on the health conditions of these
particular sectors of the population and the risk of diseases they are subject
to.
From January 1st 1985 to December 31th
2000, irregular and clandestine immigrant patients admitted to the Preventive
Medicine Unit for Migrations for a first medical examination numbered 42,820 of
which: 16,227 (37.9%) were female and 26,593 (62.1%) were male. 10% were
constituted by children, who were much rarer in past and have become are more
frequent. (see Table A).
Table
A -Immigrant
Patients observed from January 1st 1985 to December 31th
2000.
San Gallicano Institute of Rome
-(IRCCS) Preventive Medicine Unit for Migrations, Tourism & Tropical
Medicine.
Currently
36% originate from Africa (compared to 73% in 1985-91 and 48% in 1992-94),18%
from Central & South America (compared to 7% in 1985-91 and 22% in
1992-94),22% from Asia (compared to 12%in 1985- 91 and 21% in 1992-94), and 24%
arriving from Eastern Europe (compared to 8% in 1985-91 and19% in 1992-94).
(see Table B)
Table B -Immigrant
Patients according to Continent of Origin
10.0%
belongs to 0-12 year old age group, while 69.0% belongs the 13- year old age
group; as a whole, 79% of the immigrants observed are under 40 years of age
(see Table C). It is interesting to note the gradual increase of elderly
immigrants, over sixty years old, that exceed 11% in our figures.
Table
C -Immigrant
Patients according to age
As
far as concerns the level of education, 11% possesses an elementary education,
23.2% have attended lower secondary school, 38% present a higher level of
secondary education, 9.8% a university level of education, while 18% have a
university degree; besides their mother tongue, 86% also speak fluent English,
French, Spanish or Italian.
The
emigrated person in general, does not use preventive strategies but addresses
the social-health services only in case of emergency or full-blown ness; when
not longer able to go without medical aid. In the past, we had defined this
phenomenon as the healthy migrant effect,
due to the self-selection of those who decide to emigrate, which today
instead is only partly true (Morrone, 1995). The health patrimony of immigrants, albeit they arrive safe and sound
in Italy, rapidly diminishes (well-being interval) due to a series of risk
factors: psychological discomfort related to the condition of being an
immigrant; lack of work and income; underemployment in risky unprotected jobs;
degraded housing in a different context from the country of origin; absence of
family support; different climate and
eating habits (which further compromise conditions of debilitated nutritional
status); discrimination in the access to health services. In the last 4 years
this interval period, spent from
arrival in Italy to the first request for medical treatment (in which
conditions defined as illnesses of unease or illnesses from degradation may manifest), has been drastically
reduced from 10-12 months in 1993-94 to 2-3 months in the 1995-1998 period.
Moreover,
some immigrants tend to take on illnesses that indicate a state of extreme
emargination, the diseases of poverty: tuberculosis, scabies,
pediculosis, mycosis, certain viral and venereal infections which characterise
the homeless population. According to the base-line data, collected on a very
broad range, a few years ago the average immigrant generally appeared as a
strong, young, psychologically more stable person with a greater spirit of
initiative. Therefore, healthier and aware that the strength of the body
together with one's working ability was the only initial means of exchange that
one had with the new society. A good state of health represented the only
certainty upon which to invest one's future. Today, due to a series of complex
factors, there are also people entering our territory who are no longer young,
less acculturated, with transitory and unspecific migratory projects. These
included criminals who take advantage of the desperate conditions of other
immigrants, while some manage the drugs traffic and prostitution, above all
from Eastern Europe; whereby the health profile of these persons has also been
modified.
In
fact, it is not just a work-force that arrives but persons, human beings, with
their emotions, fee1ings and health conditions ( often no longer that of
"superman").
The
main pathology observed in these patients is not far removed from that of the
Italians, except for some particular aspects which can be divided into: 52%
dermatological diseases, 10.7% respiratory illnesses, 9.2% diseases of the
digestive system, 8.6% orthopaedic and traumatic illnesses, 11% infectious illnesses.
The latter increased in the last two years from 7% to 11 % showing an increase
in viral hepatitis A, B & C, formerly rather rare together with various
cases of leprosy. Neuro-psychiatric troubles are also in slight increase
reaching 5% in 1997.
Although not particularly high, AIDS has increased in
number and assumes precociously terminal forms, along with the terrible
difficulty of living this dramatic experience in a foreign environment.
Substantially,
immigrants do not introduce particularly serious pathologies of tropical or
very different nature in comparison to the resident population, if not for the
frequent lack of basic health protection and therefore, the possibility of
diagnosis and therapies in brief and effective time consenting a more effective
course of improvement and complete recovery.
Main
Factors concerning the health of immigrants
Concerning the most frequent illnesses, it is
necessary to introduce the premise that up until 2-3 years ago immigrants
arriving in Italy somehow represented a select part of the population (i.e. the
youngest, healthiest and strongest, able to undertake long and dangerous
journeys and succeed in disembarking or crossing over boarders).
However,
various health risks can be under-lined:
1.
The origin from high risk zones of certain illnesses (parasitic, tuberculosis,
malaria, leprosy, Aids) could have exposed them to these infections and it is
necessary that it be possible to examine them immediately in order to consent
correct diagnosis and timely therapies.
2.
The journeys which have now become more and more inhuman often foster the
development of disease caused by lack of basic hygienic conditions. Being
crowded in 300 -400 persons for 30 -40 days in a boat that could accommodate a
maximum of 60-80 passengers, implies favouring the impressive development of
intestinal, pulmonary, liver and skin infections. Physiological processes
(urination, menstruation, pregnancy, etc.) often become health risks.
3.
When they succeed in arriving in Italy uninjured, during their stay in our
cities, often in miserable conditions of shelter coupled with the . noted
difficulty in accessing the National Health Service, the possibility of
remaining healthy, particularly for women and children, becomes a significant
problem.
4. A real pathology due to psycho-physical
impoverishment superimposes as time passes, thus increasing a predisposition to
inflammations of the upper and lower respiratory tracts, digestive system,
skin, genital-urinary tract as well as infections present in Italy.
5.
Persistent states of degradation can easily manifest the clinical symptoms of
latent infections such as hepatitis, particularly A, B & C, tuberculosis
and sexually transmitted disease.
6.
Many psychosomatic and anxiety-depressive syndromes have also recently been
observed particularly in immigrants arriving from war zones (Kosovo, Sierra
Leone and Kurdistan).
7.
The cases of refugees that have been subjected to torture in their countries of
origin are also on the increase.
8.
Many women still address our Service in an advanced state of pregnancy, in the
second or even the third trimester, without ever having undergone a specialised
examination.
9.
The health condition of woman and children needs particular attention because
the symptoms of some diseases can often be deceptive, therefore the
communication skills of a Cultural Mediator is required.
10.
Natural events like giving birth or the most banal inflammatory pathologies
often become preoccupying situations for these persons, at times seriously
life-threatening, due to the difficulty in accessing a health net-work capable
of receiving and understanding them.
Currently, at least six critical areas are important
to underline concerning the health of immigrants:
1. The increase of infectious disease bearing upon
various organs: skin, pu1monary, sexual, liver and neurological; very scarce in
past but now more frequent. Correct clinical diagnosis of these conditions is
often delayed due to deceptive clinical symptoms.
2.
The appearance of anxiety-depressive syndromes and psychic disorders. The risk
of not being able to adequately diagnose these conditions and the difficulty of
planning psychological support in a foreign language;
3.
The inadequacy of maternal-childcare interventions, expressed by the increased
rates of premature births, caesarean-cuts and pre-natal mortality in this
strata of the population in comparison to the Italian average;
4.
The risk of illnesses connected to prostitution such as HIV infection and
sexually transmitted diseases. The cases of AIDS among the foreign population
reported to the COA have increased from 1-2% in 1992 to 10% in 1999;
5.
Drug addiction, evidenced above all in the jails where immigrants, particularly
those without permission of stay, total one third of the entire prison
population in Italy;
6. The shortage of services devoted to the health of
woman: prevention of female tumours, contraception, voluntary termination of
pregnancy.
Health Legislation concerning Immigrants
The protection of the health of immigrants stationed
in Italy represents a very complex theme, in as much as the legal formalities
foreseen, allowing foreigners access to the National Health Service, are very
different.
The
subject of health assistance to foreigners has always been marginally faced in
health laws (see Law 833/78, LD 663/79, DPR December 24th 1992) and it is only
since Law 943/86 that " parity of treatment and fu1l equality of rights in
comparison to Italian workers " (Article. 1) has been recognised to "
non-European Union workers and their families legally resident ...".
The
implementation of such declaration (also on the basis of the updating
introduced by the successive Law 39/90), nevertheless left a series of
situations uncovered (the non-resident, unemployed) and the persistence of
obvious discriminatory treatment.
With
the Unified Code of Procedures concerning the discip1ine of immigration and
norms on the condition of the foreigner (Legislative Decree n. 286 of July 25th
1998) that incorporates Law 40/98, notable progress was made towards the health
protection rights of foreigners present on national territory. In particular,
tide V; heading I -Dispositions in health matters, moreover affirms:
-Article
34. Regularly landed foreigners are obliged to register on the national health
service and have parity of treatment and have full equality of rights and
duties in comparison to Italian citizens.
-Article
35. Foreign citizens present on national territory, who are not in compliance
with the relative norms of entry and stay, shall be assured urgent medical and
hospital treatment (or nevertheless essential) in public and accredited
structures, including continuous treatment for illness and accidents as well as
preventive medicine and collective health programs. Moreover, in paragraph 5,
the law establishes that access to health structures by the
"irregular" foreigner cannot involve any type of signa1ling to the
authorities except for cases, at parity of conditions with the Italian citizen,
in which a report would be compulsory.
To
grant health performances, by guaranteeing the prohibition of judicial
signalling, allows foreigners to emerge from "a clandestine state of
health" and approaches those who, for fear of being reported or expelled
from State territory, would never have been able to cure themselves.
With
the exception of EU foreigners and those covered by international social safety
conventions, two categories of immigrants are distinguished: those
"registered on the NHS" and those "not registered on the
NHS".
Foreigners registered on the National Health
Service
This category comprises two types:
-subjects that are recognised the obligation of NHS
registration;
-subjects that are covered by an insurance policy
against the risk of illness, maternity and accident.
1) The first category comprises regularly landed
foreigners that carry out subordinate or autonomous work activities or are
registered on the unemployment lists. The obligation of registration is also
valid for foreigners present for political asylum, humanitarian, family,
adoption and motives of acquiring citizenship. For all these subjects, equal
rights and duties at parity with the Italian citizen is recognised. Moreover,
there are two other novelties worth noting that should make access to the NHS
mare serviceable:
-a
residence permit is no longer required but "permission of stay" is
sufficient far registering on the NHS;
-for
these subjects, registration on the NHS comes into effect the moment permission
of stay is granted; it remains valid for the length of the permission of stay
and during the time required far its renewal. In other words, the registration
expires only in the case in which the permission of stay is withdrawn or no
longer renewed. The annual validity of the NHS registration, which foresaw the
automatic cancellation of all immigrants from the regional lists at the end of
every year obliging them to reapply to the Local Health Units far new
registration, has been eliminated. NHS registration is also valid far family dependants.
2)
The second category comprises all subjects that regularly sojourn in Italy,
with the exception of tourists, far reasons other than those described (i.e.
study, au pair jobs, religious motives) far which insurance coverage is
compulsory. For these, a specific insurance policy against the risk of illness,
maternity and accident, stipulated with private insurance companies (Italian or
otherwise) or directly with the NHS, is foreseen.
Foreigners not registered on the National
Health Service
This category comprises all foreigners temporarily
stationed on national territory, including those with legal entry and staying
permits as well as those that are irregular or clandestine. Before analysing
the current eligibility it is useful to specify some subject types included in
this category, namely non-legal subjects; those who entered the country
illegally and those who have not renewed their position at the expiry of their
visa or staying permit. The category is therefore much broader than thought to
be and many of these find themselves in such condition due to gaps or
arbitrariness of the normative. An example is the "de facto rejoining of
families".
As a formally recognised right, the rejoining of
families lacks a punctual normative that guarantees it. The muddled
bureaucratic procedures required and the high degree of discretion left to the
competent organs (in verifying the adequacy of shelter and income) create the
condition that the family members (prevalently women, children and the elderly)
"irregularly" join the nucleus while waiting to comply with the
procedures.
One of the paradoxes in this sector is that
"irregularly" present children of school-going age are recognised the
right to an education (and inserted in the compulsory school system) but not
that of health.
While waiting for a reply to the request for refugee
status or the result of a recourse after a first refusal, political asylum
applicants find themselves in a condition of "invisibility". They can
remain in Italian territory but in reality cannot work, nor obtain residence,
or access the health services. In this period, health assistance is available
only in special reception centres and the necessary treatment is supplied
"in relation to the health context of refugees" by the ASL or by
"other health structures of associations and religious bodies, the expense
of which is covered by the Department of Civil Protection".
The content of the article constitutes a very positive
signal within the logic that health protection is a fundamental right of the
individual, regard- less of their legal status, as stated in the
"International Human Rights Declaration " and the Italian
Constitution.
What now needs to be understood is how its application
will be translated; numerous points are still difficult to interpret. In
particular, the clarification of what is considered "urgent and essential
treatment" and which criteria shall be adopted for evaluating subjects
"without sufficient economic resources".
On the other hand, the issue of how the continuity of
treatment shall be guaranteed and by whom: if in fact is predictable that
medical emergencies and accidents shall be administered by the hospitals, will
the continuity of treatment or essential, but not urgent, problems be managed
within "ad hoc" spaces or assigned to basic medicine as for Italian
citizens?
On the other hand, if the law expressly defines a
clear-cut demarcation line between medical-health operators and police control
regarding "illegal status" how can signalling to the Prefecture be
avoided if it is the Prefecture that must refund the hospitals and therefore
require the particulars of the patient in order to do so?
The
reality of our health structure is a multiform galaxy that can give very
different answers to the treatment requests of citizens. Guaranteeing this
right, still too often depends on the ability and will of the single
individual, other than the condition of local health structures, while the
interpretation of the legal system remains uncertain.
A
long journey yet remains to be accomplished, that which transforms recognised
rights into acquired ones: the fact that only slightly over 50% of immigrants
who enjoy this right are registered on the NHS cannot simply be attributed to
disorientation or bureaucratic difficulties. A global problem of structural,
social and cultural accessibility exists which needs to be faced in order to
render the existing system more serviceable and improve the relation between
health demands and services offered.
Many good laws have remained inapplicable, or poorly
applied, due to lack of financial coverage: the rights recognised by law have
been effectively unconsidered. Health in general and many specialised fields
such as mental health, prevention, geriatrics are the concrete example of this
persistent discrepancy between word and fact.
The
President of the Republic Decree n. 394, August 31st 1999, (Ordinary Supplement
to the Official Gazette number 258 of the 3rd XI 1999): Regulation concerning the norms of realisation of the Unifìed Code
concerning the discipline of immigration and norms on the condition of the
foreigner, in compliance with Article I, Paragraph 6, of Legislative
Decree n. 286, July 25'h 1998; completes the reform and updating
of normative that allow foreign citizens, whether regularly or
"irregularly" stationed on national territory, ordinary access to the
preventive care, treatment and rehabilitation of the National Health
Service.
