Punjabi Migrants’ Risky Route To Health Care In Germany
By Rajiv Kunwar
13 January, 2011
Countercurrents.org
The following write-up is based on my research paper titled “Undocumented migrants’ access to health care in Germany: Limitations and strategies”
Undocumented migrants' human rights are in no way sufficiently protected in Germany where the access to healthcare is governed by highly restrictive regulations and where medical assistance to this population is being hampered as well as criminalised through the legal framework. Unfortunately, this dismal situation puts tremendous pressure on local actors like healthcare professionals and social workers who often work with limited resources to defend this population's fundamental rights to healthcare. Undocumented Punjabis, the single largest South Asian ethnic community in Germany, are also trapped in the morass of illegality where they have to bite the bullet to take a risky route to overcome various constraints in accessing medical care.
Last year, one Punjabi migrant with undocumented status near Hamburg who needed to follow up with a doctor for his deteriorating mental condition, lost touch with him due to monetary and legal constraints including the suspected police observation. The patient did manage to see another doctor near Berlin after some time and was diagnosed to be in a life-threatening condition. He was advised to come back to the doctor for a shock treatment therapy which was extremely important for his mental condition. However, his failure to show up due to fear of arrest and deportation led to his sad demise. There are many such unreported cases of undocumented Punjabi migrants languishing here in Germany who eventually perish due to lack of health care access.
This population comes across several stumbling blocks while making desperate efforts to avail of whatever limited options they have, to seek medical care during medical emergencies. However an illegal status proves to be the main hindrance with regard to seeking health care. The height of desperation can be gauged by the fact that 90 per cent of these Punjabis who are of the Sikh origin, have to endure the self-humiliation of shaving off their hair and beard to avoid being identified and caught by the police during the time of approaching a medical care giver. This also explains why most of the undocumented Sikh migrants enter Germany or other European Union countries after shaving off their hair and beard to minimise the risk of identification and deportation.
During my research about this population for the South Asia Institute, Ruprecht-Karls-Universität Heidelberg, none of these Sikh migrants interviewed could conceal his grimace with regard to shaving off their hair. After all having long hair and keeping the turban is an identity of Sikhism. However, most of them also accepted that such compromises were part and parcel of a life in illegality where real identity is an impediment in accessing medical care options during the time of illness. However, the most obvious handicap named by almost everyone during this study was their undocumented status. With a ‘no paper identity' - a term used by the respondents to describe their illegal status – these Punjabi migrants adopt a ‘once bitten, twice shy' kind of approach vis-à-vis seeking medical help.
Another important reason which often keeps this population from seeking medical care is their shortage of money. These financial straits stem from the fact that undocumented residents are legally not allowed to work in Germany . Illegal types of employment are limited and full of risks. Henceforth, financial constraints are a big hindrance in seeking medical care though during this research, some of the migrants also admitted that they could arrange funds for medical emergencies through some undisclosed sources. With the cost of treatment being so high in Germany, proper medical attention is usually beyond their reach. Dara, who recently went to see a practitioner because of severe chest pain reveals: “The doctor was kind enough to waive off his consultation fee, but I had to borrow an amount of 180 Euros from a friend to buy medicines”. Yet another migrant interviewed discloses that whatever little money he earns by taking the risk of doing some dirty and degrading work, it is hardly enough for his own meals and his small family back home in Punjab.
Anonymity is another interference factor in availing of health care. Since these people do not want to divulge any information about their identities and avoid giving any contact details for fear of jeopardising their stay, it sometimes becomes very difficult for healthcare centres and clinics to start the treatment because it is often not possible to stay in contact with such patients and therefore no proper record of their treatment can be maintained. In many cases, long-term therapies cannot be carried out successfully due to this problem.
For all those undocumented migrants who somehow manage to see a doctor, the lack of German language skills is no small issue. “If I can't speak German or even English and I am not accompanied by anyone who can help me with the communication, I feel like a deaf-and-dumb”, one of the immigrants expresses his helplessness. For someone like Dalbir, who speaks some German, understanding a German doctor is the toughest thing he has to encounter when he goes to a clinic. “For me, they speak too fast and I hardly understand anything. And whatever little German I can speak is not good enough for them to understand my health problem”, he explains his dilemma. So, he generally prefers Russian- or English-speaking doctors because he spent a long time in Russia and can understand English better than German.
Another equally important factor which discourages these Punjabi migrants from visiting a doctor is their general lack of trust in others. Even their everyday lives and relationships with closer acquaintances are marked by suspicion and distrust. Almost all undocumented migrants interviewed during this fieldwork agreed on the view that doctors in Germany are under some sort of obligation to report the presence of an illegally residing person to the police or to the Foreigners' Registration Office. This impression is even justified to an extent as there have been instances of undocumented migrants being caught at healthcare centres. Among undocumented migrants, German practitioners have a different image in comparison to doctors of other nationalities. Barring a few, most interviewees believed that, being very law-abiding by nature, German doctors were less reliable for them. This also explains why some of these immigrants prefer to see either a doctor of their own nationality or someone who is known to them through a person of confidence.
Undocumented migrant Sukhi speaks in defence of German doctors. According to him, even German physicians are not too happy about their restricted freedom in treating undocumented migrants. “If German doctors were too tough to deal with, they would not be part of several NGOs and private initiatives which are committed to treating people without papers”, he argues and further explains: “The undocumented migrants' lack of trust in German doctors is a result of their own fears and suspicious behaviour”.
Although in spite of above mentioned constraints and hurdles in accessing health care, these migrants do not refrain from resorting to certain methods, tactics and ploys to avail of medical facilities but not without certain precautions. During all those free-wheeling conversations with some migrants, one thing which was more than evident was the fact that all of them are extremely anxious to avoid hospitalisation at any rate. A hospital stay is considered an enormous risk. Therefore, these undocumented migrants try to find alternative options.
Self-medication obviously is the most realistic option whenever these people encounter any health problems. All the respondents confirmed that they have stocked up with various basic medicines and tablets which can be used to stabilise their condition. New supplies are commonly arranged through friends. Gurudwaras (Sikh temple) frequently serve as collecting points for these medicines. From there, they might be picked up or delivered to the buyer's home. There are also some pharmacy and medicine students who provide the Gurudwaras and other social organisations with medicines which they obtain for free through visiting medical representatives at their university clinics and hospitals. Paracetamol , Crocin , Combiflame , and several other pain killers and tranquilisers were adduced as instances of medications which are popularly used in case of body pains, fever, headaches and colds. The use of antidepressants is also quite common among this population.
A German researcher Jörg Alt in 1999 found that sometimes these undocumented migrants even see themselves forced to resort to rather harsh measures, such as tooth extractions at home. Even though none of the respondents during my fieldwork mentioned any methods of this type, it is well imaginable that, in an emergency, such things might be tried in order to avoid hospitalisation.
In case of serious physical injuries, mental issues, cardiac disorders or other grievous complaints where self-medication is not applicable or effective, these undocumented migrants desperately try to see a doctor who is known to them only through a person of confidence In this context, the importance of social networks such as community-based get-togethers at Gurudwaras is worth mentioning here as they enable their members, including undocumented migrants, to share useful information like recommendations regarding certain doctors.
The migrants interviewed revealed that using other people's health insurance cards is a common practice among undocumented residents. If cash payment is not possible, they in many cases choose to borrow a friend's insurance card, preferably without the picture of the original card holder. In reply to the question about how exactly misusing someone else's card at a medical practice or hospital works, one migrant gives an interesting explanation: “There are few clinics everywhere in Germany where doctors are hardly perturbed by the illegal status of their patients. These never suggest to you to resort to unfair or illegal means of accessing medical care options. However, if you are using a health insurance card, which they notice, does not belong to you, they prefer to overlook it.” Echoing similar experience, yet another undocumented Punjabi migrant quips,” at times, it seems that the whole staff in certain clinics and private health care centres is trained in such pretences, which makes it little easy for illegal migrants to seek medical care”.
One Punjabi migrant who lived in illegality for more than ten years before obtaining a legal status describes his own experiences regarding the misuse of health insurance cards: “The passport is actually never needed when you want to see a doctor and so, if there is no picture on the medical insurance card you are carrying… It worked eight out of ten times in my case”. And on the remaining two occasions, the lack of German-speaking skills (pretended or otherwise) usually covered up his failed ploy, he discloses.
In cities like Berlin, Cologne and Heidelberg illegal residents sometimes approach medicine and pharmacy students for medical help. Further, there are some South Asian Ayurvedic doctors that are frequently contacted by these people. NGOs and private initiatives like Medinetz , Café 104 etc. are also approached when the patients are sure about getting free treatment for their ailments, especially sexually transmitted diseases and other contagious diseases with the sole exception of HIV.
And then there are self-styled therapists like Jagjeet Singh from Frankenthal, who claims to provide a massage therapy which brings physical and mental relief. He especially attends to undocumented migrants to help them cope with depression, anxiety and emotional traumata. Jagjeet laments that his therapy remains ineffective for some migrants who cannot visit him regularly due to their illegality. He himself spent 15 years as an illegal immigrant in and around Germany before finally obtaining a legal status only recently. With no formal training in massage therapy, Jagjeet, who hails from the Indian state of Punjab, learnt the finer points of this technique by reading a book. Initially based on a hit-and-trial method of learning, he acquired some sort of expertise after five to seven years of hard work. He does not charge any service fee from his undocumented patients, but the ones with a legal status pay seven Euros for a session of 45 minutes.
My fieldwork research about these undocumented Punjabis amply confirmed that they heavily rely on illegal means and methods from embarking on a journey from India to entering a new country in the EU and eventually sneaking across to yet another destination like Germany. As they do not shy away from using fake documents to travel from one country to another, one might be inclined to assume that these people may as well have forged medical fitness certificates without actually undergoing the procedure. This is where undocumented migrants' access to healthcare in Germany needs to be facilitated in order counter the threat of contagious diseases spreading through this population to the host population and other immigrants with legal status. Besides, it is an open secret now that these undocumented migrants are unofficially being exploited by state-controlled private agencies as cheap and effective workforce, which definitely is no mean contribution in the economy of this country. Taking into consideration these important factors, a continuous denial of adequate health care privileges for these undocumented migrants seems unethical and inhumane.
P.S. Names of the all the migrants in the above text have been changed due to interviewees'request.
Rajiv Kunwar is an independent researcher and freelance journalist based in Germany
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