The Alma-Ata Declaration of 1978 was an important milestone in the 20th century in the field of public health. It identified Primary Health Care as the key to achieving the Health for All goal – the now outdated “Health for All by 2000” goal. We can thus say that this laid the foundation for a global concept of health in relation to a new international economic order called globalization. However, more than 40 years later, a unanimous agreement on the definition of global health has not yet been reached and it is particularly important in the light of the current global crises – climate change, economic, food and energy crises – which make global health efforts even more challenging (Fidler 2009).
There are several critical anthropological and sociological approaches to global society and its effects on global health: from Arthur Kleinman’s theory of social suffering (2010) to Ulrick Beck’s risk society and Bauman’s liquidity (2000). COVID-19, the largest and most serious pandemic of the last 100 years, challenges all our certainties: science, medical knowledge, health; health care systems. From Ulrich Beck’s theoretical framework, we can interpret the pandemic as a clear example of the “Risk Society” highlighting the uncertainties in science and its experts; insecurities in the welfare state (where there is one), increasingly oriented towards neo-liberalism; lack of safety in our lives and our health (Beck 2000). In this framework we have to ask ourselves what the condition of people is in a state of vulnerability: migrants, the poor, the homeless – people who often have multi-vulnerabilities. The lockdown in most European countries (especially in Italy, Spain, France) has imposed social distancing, hospitals involved in the fight against the virus closed many wards and severely limited access to emergency units. Therefore:
- How are the migrants and where are they living?
- How can they protect themselves from contagion?
- What about the most vulnerable migrants such as those who are homeless, sick, minors, women with children, asylum seekers, etc.?
In an ongoing effort to curb the spread of coronavirus disease in 2020, countries have strengthened borders and put in place travel restrictions. These actions have affected refugees and migrants worldwide (IOM 2020). At the moment, asylum seekers, refugees and migrants are at greater risk of contracting diseases including COVID-19 because they generally live in overcrowded conditions without access to basic health services. The possibility of accessing healthcare services in humanitarian settings is generally undermined by shortages of medicines and lack of health facilities. Vulnerable migrants generally face legal and language barriers in accessing the healthcare and finding reliable information to refer to services. The document sent by the WHO to Europe, addressed to health authorities – Interim guidance for refugee and migrant health in relation to COVID-19 in the WHO European Region – provides specific guidance on assistance to refugees and migrants during the coronavirus pandemic (WHO 2020).
Coronavirus, the spread of contagion among migrants. The Italian case
Since the beginning of the lockdown in Italy (8th March 2020) and until 8th May, no official data have been published on the impact of the epidemic on migrants. This is a significant lack despite the fact that an official bulletin on contagion and mortality was and is issued every day. It actually means that the ‘migrant issue’ was suspended for two months. Finally, on 8th May, the Istituto Superiore di Sanità (ISS) published some data on contagion amongst the migrant population, which was updated on 22nd April highlighting that 5.1% of the cases of COVID 19, notified by the ISS, concerned foreign citizens, for a total of 6,395 out of the 125,000 infected people in the country. The population of migrant residents in Italy is around 6,000,000.
In general, the rate of infection amongst foreign residents is lower (1.2 per thousand) than among the Italians (2.1 per thousand), both for the male and female groups. This difference could be due to the younger age group of the migrant population (30-64 years). In Italy, the only group of foreigners that exceeds the incidence of COVID-19 contagion of Italians is those living in the North-West regions. At the moment we do not have sufficient information to formulate a precise analysis of the data. It is however certain that Lombardy is part of that macro-area and this region comprises about 25% of the migrant population residing in Italy (both from countries with Strong Migratory Pressure and Advanced Developed Countries (ADC)) and this region has experienced 50% of coronavirus infections and deaths for the country as a whole. Two other factors could account for the higher rate of COVID-19 infections amongst the migrant population in the North-West area. The high presence in Lombardy of foreign citizens from ADCs who, according to the ISS, show higher rates of contagion, as well as the rate of COVID-19 infections among the Peruvian (8.1 per thousand) and Ecuadorian citizens (4.2%) whose presence in Lombardy represents 44% and 46% respectively of immigrants in Italy. This sub-group includes those originating from countries accounting for about 60% of all non-EU workers in the domestic work sector, mainly concentrated in the North-West (INPS, 2018).
Table 1 – Cases of COVID 19 infection among migrants, by country of origin, total infectious and infectious per 1000. Source: Istituto Superiore di Sanità 2020. www.iss.it
|Country %||Residents in Italy||% of Residents in Lombardy out of total returns of the same national group in Italy||Covid-19 total number||Covid-19 cases per 1,000 residents|
Among foreign citizens, there is a higher rate of infection among women than among men. This could be mainly due to women’s working environments such as in hospitals and care for the elderly, the disabled, the vulnerable people, etc. The high Covid infection rate among migrants from Peru (8.1 per thousand) and Ecuador (4.2 per thousand) (see Table) should be investigated. There could be gender-based reasons for these immigrants: 57% of immigrants from Peru and 55% from Ecuador are women. An important factor is the presence of health personnel of foreign origin working in Italy. The data show that in 2015-2016 in Italy there were 10,163 doctors and 41,935 nurses of foreign origin, although in the last decade there has been a slight decrease in the number of doctors born abroad (OECD 2019).
A definition of ‘global health’ must therefore address the complexity of the issue by incorporating research and practice aimed at improving and achieving equity in health for all people worldwide (Koplan et al. 2009). In order to prevent the outcome of the pandemic from becoming yet another black swan for the resident migrant population – already exposed to multiple vulnerabilities, there is a need for policy strategies aimed at “global health” for the reception and health promotion of migrants and to facilitate access to health care for people with social and economic hardship. From this perspective, adequate care can guarantee a better quality of life, although we are aware that the path towards the reduction of health inequalities is particularly complex. To the extent that it is possible to activate functional policies to combat inequalities, it is necessary to implement both strategies and actions aimed at promoting the health of migrants. Above all, we advocate for a European homogeneity in data collection and analysis of the health status of populations. When it comes action, there is the need for interventions dedicated to neglected people, those who have been excluded from health and epidemiological surveillance actions (e.g. irregular migrants, homeless people, people who are victims of slave labour). To these health actions, we could add the numerous studies of the Commission on Social Determinants of Health, to redirect care strategies, combat socio-educational inequalities, support social participation and health citizenship. To this end, it is essential to implement good practices to reduce access barriers to health services and to improve the health of migrants experiencing poverty and social exclusion (WHO 2017).
by Lia Lombardi – Fondazione ISMU, University of Milan and Alessandra Sannella – University of Cassino
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