Migration and health in social context
Many people choose to move for work, studies and relationships (eg, Case 1), and many others are displaced by economic hardship, political conflict, war, natural disasters and environmental change (eg, Case 2 and 3). Migration has been an important aspect of human experience throughout history, with approximately 3% of the world’s population now living outside their country of birth.12 13 While migration brings advantages to many,14 this movement causes hardship for many other migrants due to changing places of residence and social networks, precarious legal status and limited access to health and social services. Moreover, substantial evidence shows that racism has an impact on many migrant patients15–17 and fuels differential outcomes in care.14 Despite increasing recognition that medical training should prepare clinicians to care for a diverse range of patients, clinicians often experience challenges in caring for migrant patients, who may not fit pre-existing expectations regarding who constitutes a deserving patient.18 19
Case 1. Ms. N: Differential valuation of human lives in an Ebola treatment unit
After receiving an Ebola diagnosis, Ms N, a 27-year-old woman from South Eastern Sierra Leone, was transferred to a non-governmental organisation (NGO)-run Ebola treatment unit nearby. There, she was isolated and offered oral rehydration therapy. Despite persistent vomiting, she was not offered intravenous fluid resuscitation with repletion of electrolytes. Her condition rapidly declined. Like many other patients with Ebola treated based on isolation-focused protocols, Ms N died soon thereafter.
During the 2013-2016 Ebola outbreak in West Africa, large numbers of foreign clinicians travelled to assist in response efforts. Because NGOs sponsoring foreign clinicians feared that their staff might be infected with the Ebola virus while caring for West African patients, many instituted protocols of ‘no needle’ care (with no intravenous fluid resuscitation) for West African patients rather than offering patient-centred, ambitious clinical services for critically ill patients. Yet, when foreign clinicians were infected with Ebola, the same NGOs routinely treated them using distinct protocols including intravenous fluid resuscitation and evacuation to overseas hospitals.
In general, healthcare workers at Ebola treatment units were not constrained by resources. Intravenous lines, bags of lactated Ringer’s and frustrated foreign clinicians agitating to use them were omnipresent. Rather, substandard care was deemed pragmatic, and therefore ‘ethical’, in this context. While infected foreigners were given intravenous fluid resuscitation and evacuated to foreign hospitals with intensive care capacity as standard of care, this level of care was codified as too risky to provide for West African patients who were disproportionately affected by Ebola.
As a result, patients like Ms N and foreign clinical volunteers received systematically different care, contributing to an Ebola case fatality rate in West Africa of 64.3%. Although significantly fewer American health workers in West Africa were infected with Ebola, the case fatality rate was 0 among infected American citizens (for further discussion, see Richardson ET33).
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Case 2. Mr S: Rejected referrals for psychiatric distress of undocumented migrants
Mr S, an Afghan man in his 30s, visited the Health Center for Undocumented Migrants in Oslo, Norway, several times during the previous 6 months. At this visit, he presented with insomnia, lack of appetite and a general sense of worry. He was restless, irritable and tired. The primary care physician asked about his situation and Mr S explained he was unable to sleep, despite taking medication. He lacked energy and felt hopeless. He worried that something bad would happen to him. Mr S saw no future for himself in Afghanistan, yet his future in Norway was also uncertain since his asylum application had been rejected 7 years earlier. The primary care physician referred him to a psychiatrist because his mental health concerns had worsened over the previous months. Knowing that undocumented migrants have the right to be assessed by specialists by Norwegian Law, the physician submitted the appropriate referral documents.
Three weeks later, a rejection letter arrived indicating that the patient’s precarious situation as an undocumented migrant would limit the treatment effect and the possibility for improvement. Psychiatric treatment would fail, the letter asserted, because Mr S’s life conditions as a migrant would lead to a resurgence of symptoms once the treatment was over. The decision revealed no disagreement over diagnosis, and no arguments related to cost-effectiveness. Rather, it hinged on the view that his life circumstances in Norway as a rejected asylum seeker caused his mental illness—something that the medical system could not, or would not, treat. The rejection letter cited no evidence in evaluating the potential effect of treatment for the patient. The usual medical criteria for psychiatric treatment were suspended, and Mr S was denied care.
Case 3. Mr G: Anti-Roma racism and dental pain
Mr G, a 23-year-old Romani man from Romania, presented to a charity clinic in Berlin with extreme pain in a lower left molar. As the receptionist handed Mr G’s chart to the primary care physician, she rolled her eyes and muttered under her breath about ‘another one of these pushy Roma’. Even though he was from Romania, a country within the European Union (EU), Mr G did not have health insurance. While all member countries of the EU are required to provide health insurance coverage for their citizens, there have been systematic obstacles to health insurance registration for mobile EU citizens, including Romani people.34
Examining the man’s mouth, the evaluating physician said, ‘Nice to meet you. What are you doing here in Berlin?’ Mr G explained in basic German that he was working in construction, living with his cousin and three other Romanian men in a one-room apartment. Following the brief examination, the clinician gave him a slip of paper with a list of addresses. The first was a mobile van providing free dental care to the homeless. The clinician emphasised that he should not go there, repeating this instruction twice to make sure he understood. ‘They won’t take you because you are from Romania.’ This statement is layered with implications. First, the mobile van had a new policy to prioritise Germans rather than foreigners in order to preserve scarce resources. However, it also reveals the widespread assumption that Romani people are ‘traditionally’ mobile, and thus do not fit the category of housing instability (and thus are not deserving of free treatment35). Instead, the clinician pointed to the list of private dentists further down the page, who had agreed to lower their rates for self-pay referrals from the non-profit clinic.
Mr G immediately took the subway to the first private dentist, where the receptionist told him the office was too busy and could not see him. At the next office, he faced a locked door because it was closed on Fridays. Finally, the third office on the list agreed to see him 3 days later, telling him to bring €100. Mr G returned to relieve the now-excruciating molar ache. The dental clinic staff extracted the tooth because a root canal procedure was assumed to be too costly for Mr G. Dental treatment at the usual standard of care—root canal for someone in his age category—was considered too expensive for this patient, based on his migration history and ethnic standing as a Romani man. The new gap in his smile joined those from other teeth that had been pulled over the course of his 23 years.
First, we argue that often unstated assessments of deservingness influence decisions about what kind of treatment migrant patients should receive—or whether they should receive treatment at all. Such assessments of deservingness are at work in clinical encounters and in health and immigration policymaking. Assessments of deservingness are at play in the differential treatment in Case 1, where racialisation, class and nationality fundamentally position foreign migrants working amidst the Ebola outbreak as more deserving of medical treatment than local patients they were treating. This case shows how assessments of deservingness—including valuations of human lives—were instituted through differential clinical protocols with life and death consequences. Similar assessments of deservingness lead to negative health outcomes in Cases 2 and 3. These decisions made by clinicians and non-clinical staff have a significant impact on individual patient health outcomes as well as population-level health as seen in each of the cases presented. These cases are composites of multiple real, similar clinical cases, anonymised to protect confidentiality.
Second, interactions between patients and healthcare systems are often influenced by implicit assumptions that different social and demographic groups deserve distinct levels, kinds and qualities of care, as illustrated in Case 2. Despite undocumented migrants’ right to be assessed by specialists, the team responsible for prioritising admission to the limited public specialist healthcare services decided against Mr S being offered psychiatric care. In the assessment of Mr S’ deservingness of treatment, his status as a rejected asylum seeker, rather than his mental health condition, dominated their decision. On a different level, Case 3 demonstrates discrimination that prevented Mr G from receiving standard of care for fixing his molar, where front desk staff and clinicians made assumptions about his health insurance status as well as which treatment would be appropriate for his tooth pain. These assumptions stem from power differentials and sociocultural and economic differences between migrants and clinicians and often yield harmful—and avoidable—consequences.
Third, every clinical interaction involves subtle and often unspoken moral and ethical decisions that influence who does and does not access care. Many factors, from nationality, religion, education, class, ethnicity, gender, accent and sexuality to migration and legal status, can affect assessments of deservingness.20 In some contexts, unauthorised migrants may be perceived as less deserving than refugees.21–23 In addition, interpretations of migrant patients’ moral character and behaviour can affect their healthcare and health outcomes.8 These moral assumptions influencing access to and quality of care compound implicit bias and stereotyping about compliance and adherence, such as in the case of Mr G.
Fourth, assessments of certain populations as undeserving can exacerbate systemic inequities. Structural, institutional and interpersonal racism plays a role in the distribution and quality of healthcare,24 as highlighted during the COVID-19 pandemic.25 These inequalities are perpetuated in part by legal definitions and institutional practices that categorise migrants into groups with different legal rights and entitlements. Yet, each health professional—from front desk staff to infectious disease specialist developing triage protocols in times of pandemic—routinely exercises discretion in relation to the access and quality of care patients receive. Migrants who have experiences of being treated as undeserving of care may be less willing to engage with the healthcare system, with potentially serious consequences. For all these reasons, considering and confronting these multiple levels through which migrants face evaluations of deservingness is imperative for individual and collective global health and healthcare.
