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4. Settling in

© 2018 Marianne Jossen, CC BY 4.0 https://doi.org/10.11647/OBP.0139.04

This chapter describes the case of Suzanne, a young and healthy undocumented migrant whose core moment of inclusion was brought about by finding a job, a social circle and a place to live — in other words, by settling in. This case also tells us many things about the preconditions of inclusion in healthcare.

In any given year, about 2%-4% of the total population of the area under scrutiny attend the NGO. There are certainly undocumented migrants in the area who are in good health and never attend the NGO, perhaps not even knowing of its existence. Thus, the story in this chapter is probably common to other young and healthy undocumented migrants, who, as the head of the NGO confirms, make up a significant portion of the population. Over time though, a greater percentage of undocumented migrants might attend an NGO. Indeed, Achermann et al. (2006:147) state in their study that out of eighteen undocumented migrants, only six had never seen a doctor, those mostly being people who had only been undocumented for a short time.

As in the case of Suzanne, it is estimated that most (Bilger et al. 2011:51), meaning around 80%-90% of undocumented migrants, are uninsured (Rüefli & Hügli 2011:24). The explanation for this allows us to take a closer look at undocumented migrants’ economic and legal situations (see also Achermann et al. 2006).

In reference to their economic situation, the head of the NGO estimates that an undocumented migrant in the region might be able to earn around CHF 800 to 1500 a month, while some might have no income whatsoever. She therefore broadly confirms the estimates of those authors who suggest that undocumented migrants in various Swiss regions earn between CHF 600 and 2000 a month (Chiementi et al. 2003:38; Valli 2003:34; Anlaufstelle für Sans-Papiers 2004:11; Achermann et al. 2006:113).

In order to contextualise the affordability of health insurance on such an income, we can use the example of a hypothetical person living in Zurich. If we go to www.comparis.ch, a website that offers comparisons between insurance policies, and look for basic insurance with accident cover for a twenty-seven year old, we find that the cheapest plan and the lowest annual excess of CHF 300 will result in a premium of CHF 395 per month (as of 16 March 2017). This constitutes roughly 26% to 49% of an undocumented migrant’s monthly income. Furthermore, if care is needed, 10% of the cost, up to a limit of CHF 700 (the so-called ‘deductible’) has to be paid out of pocket.

Those living in reduced economic circumstances might have access to premium subsidies in Switzerland. For a moment, leave aside the question of whether and how such subsidies are obtainable for undocumented migrants (see Rüefli & Hügli 2011:30ff). As of 2017 a twenty-seven year old person in Zürich can claim a maximum subsidy of CHF 1,644 per annum (Sozialversicherungsanstalt des Kantons Zürich 2017). This would mean a monthly premium of CHF 258, which would still constitute 17% to 32% of the monthly income of an undocumented migrant in the area under discussion.

By comparison, Swiss citizens without children and a low to moderate monthly gross income of CHF 2,500 to 5,000 (a Swiss citizen in 2015 had a median monthly gross income of CHF 6,500) spend 8% to 11% of this on health insurance (Lampart et al. 2016). The goal set by the revision of the insurance law in 2012 was to freeze the proportion at 8% (Lampart et al. 2015). Of course, these limits apply to people who are otherwise included in basic legal and social security schemes, with employment contracts that factor in provision for sick pay or notice periods, unemployment insurance, maternity insurance and the like.

To choose an annual excess of CHF 2,500, which would result in a lower premium, is too great a risk for an undocumented migrant. A patient would have to put aside CHF 2,500 on top of CHF 700 deductible, which represents at least two and at worst four months’ salary. In case of non-payment, the patient risks being exposed as undocumented, a problem that also arises in the UK with the Memorandum of Understanding on Data-Sharing Inquiry that allows data sharing between the NHS and the Home Office (UK Parliament 2018).

Fear of deportation often prevents undocumented migrants from taking out insurance in the first place. Any contact whatsoever with an organization that might be related to the state is avoided. Consequently, it is highly improbable that undocumented migrants would give their address to an insurance company — but if a person does not hold a current Swiss health insurance policy, they must provide proof of residence when applying, which is usually handed out by the municipality. An undocumented migrant lacks this proof. As stated by Patricia, the insurance employee whom I interviewed:

A normal administrator just looks at the dossier, is it complete […] and is there a confirmation of registration from the municipality. If not, he checks with the municipality.

This cross-checking with the municipality actually violates data protection rules (KVG 84ff; see also Hüegli & Rüfli 2011:32). In most cases, if clients simply forget to enclose the confirmation, or postpone its submission, this violation has no negative consequences. In the case of undocumented migrants however it can lead to deportation. In addition, a bank account is needed in order to organize financial transactions related to the insurance policy. But to open a bank account, one needs proof of residency in Switzerland.

Given all these issues, insurance is not a reliable vehicle for inclusion and it is at this juncture in Suzanne’s case, as with many undocumented migrants, that the NGO enters the picture. We are about to be introduced to Julia, the head of the NGO whom I mentioned earlier, as well as a general physician called David, a gynaecologist named Patrick, and another general physician with a specialization in ultrasound who volunteers at the NGO.

Suzanne: ‘Now, it’s just fine’

The interview with Suzanne takes place as she attends the NGO on a drop-in morning. Suzanne is in her twenties and has been living as an undocumented migrant in Switzerland for about four years now. Generally, Suzanne seems to feel that she is in good health. During the interview, she mentions several times that she does not consider herself able to contribute much to my project: on the one hand, her linguistic skills in our common language are slightly limited, on the other, Suzanne repeatedly states that at the moment, she’s very well. However, it is precisely because of this latter circumstance that Suzanne can give valuable insights regarding the question of what health means to an undocumented migrant and how undocumented migrants try to care for their health, despite limited resources.

Asked about her story, she says of her first two years in Switzerland:

For me it was rather terrible and I missed my family a lot, and my daughter, and I cried a lot, almost every day.

The difficulty of leaving one’s family behind will also appear in other patients’ stories. Here, at the very beginning of Suzanne’s narrative, we encounter the idea that there might be specific conditions in the life of undocumented migrants that could bring out particular health issues, such as the risk of mental illness brought about or exacerbated by isolation. Julia says that many of the health problems suffered by undocumented migrants are related to poor living and housing conditions, risky jobs, fear of being caught, missing their family and dependency on the goodwill of others for most common necessities.

But Julia immediately contrasts these difficulties with the cleverness, good language skills and independence of some undocumented migrants and refers to them as ‘survival artists’. Similarly, David, the general practitioner volunteering at the NGO attests to their ‘virtuosity’ in handling daily life. In a similar vein, Suzanne states, just after talking about how she had cried almost every day: ‘And yes, now it’s just fine’.

With these statements, we can see that it is important for both caregivers and the patients themselves to see that their status as undocumented migrants does not mean they are simply victims, at the mercy of circumstance, but they are also as active agents, able to control their own lives. We will see on several occasions that it is important for undocumented migrants to have agency, and to achieve inclusion in healthcare themselves, rather than having to refer to and depend on others.

But then, how did things become ‘fine’ for Suzanne after two years of struggle? How did she overcome the pain of leaving her family and especially her daughter behind? She says:

And then I got to know other women here and, yes, these women helped me so much. With work and so on. [Interviewer: Other women from your home country?] Yes, yes. I know two or three women. But now they have become good friends of mine [laughs]. And these women also work here. And I also work a bit more as a cleaner and sometimes I mind children.

We can see here that getting in touch with the local diaspora and finding work are decisive in helping Suzanne to live a ‘fine’ life. Indeed, Suzanne came to Switzerland with another woman from her country. This connection, together with her relationships with other compatriots in the area, gave her opportunities to find work. In addition, Suzanne learned one of the Swiss national languages.

As a result of her employment, Suzanne is able to support her daughter back home. This also helps her to address the pressures that accompany her status as an undocumented migrant. Inclusion in healthcare often affects more people than just the individual concerned. For Suzanne, for instance, her inclusion also helps her to care for her relatives who stayed at home. As we will see, the ability to support those ‘back home’ is also important for other undocumented migrants.

Finally, the NGO provides Suzanne with a place that ‘I can come to when I have something’ and thus helps her to create the conditions for healthy living, most importantly stability. One of her friends told her about it and at first she did not attend, as she did not see any need. Then, her friend told her it would be good to have a gynaecological check-up so she dropped in for the first time, her friend translating. The day of the interview is her third visit. She is here because of a cough and also for her ear, in which she has been experiencing hearing loss for several years and which is now aching and oozes liquid. She will be sent to the NGO’s network for her ear to be examined, and we will hear more about this network later on. For her, inclusion in healthcare is the knowledge that should she have some more serious issues, she has a place to go to.

The gynaecologist volunteering at the Access Point, Patrick, offers the professional’s point of view concerning routine gynaecological check-ups. He states:

Here I don’t notice much about their background, except that there’s sometimes a language problem. Other than that, it’s like it was when I was working as a gynaecologist in [a Swiss hospital].

Both he and the ultrasound expert state that, among the patients they have seen so far, they would not have been able to tell an undocumented migrant from a citizen.

Knowing that the NGO exists and (more importantly) finding a few friends and some work all allowed Suzanne to secure and maintain good health.

It is important to her that she can help her daughter and thus address her loneliness and sadness, problems that arise from her undocumented status. Her inclusion in healthcare also enables her to care for those left behind. Health, and inclusion in healthcare, are thus embedded into, and dependent on, social relations.

Suzanne has made a life for herself. She has found a secure base and thus she can be an active agent in relation to her own health. This autonomy contributes to her wellbeing. According to the professionals whose experiences are related in this chapter, the inclusion of undocumented migrants in healthcare can be quite unproblematic and does not necessarily require specific skills.