January
2011

Vol. 10 - No. 7


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MIGRATION


 

Undocumented Punjabi Migrants 
Languish in Stringent German Health Care System

 

BY RAJIV KUMAR *

 

Although officially not allowed to work, undocumented migrants living in Germany provide a cheap labour force contributing to the economy of the country. However, what is shocking is that the state has a very lackadaisical approach towards the health status of this population. In fact, there are double standards on the issue of providing medical care to people with illegal status. On the one hand, these immigrants without a legal status are being used as effective workforce and on the other hand, the Government is reluctant to formulate a policy to examine or improve their health status. The Government refuses to accept that these illicit workers actually fill a gap in the system. Instead, undocumented migrants are being exploited, stigmatised and criminalised.

 

Germany’s immigration policies focus mainly on combating illegal immigration, without any attention to the rights of undocumented migrants. Technically, there are certain minimal rights available to undocumented immigrants in Germany, including a reduced level of medical treatment. Several studies, however, have shown that in practice these migrants are hardly in a position to make use of their right to seeking medical care. This exclusion from full social benefits stems from the Government’s fear of creating any additional pull factors which might encourage further immigration.

 

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 segment of the population is being hampered as well as criminalised through the legal framework, particularly §87 and §96 Aufenthaltsgesetz (Residence Act). 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.

 

The following text underlines the plight of undocumented Punjabi migrants from India, the single largest South Asian ethnic community in Germany, with regard to this their health problems, health-seeking behaviours and ploys and tactics used in accessing health care due to stringent health care regulations in Germany.

 

At the outset, I must mention that the findings of my research during the fieldwork in various parts of Germany in the year 2009 have clearly dispelled the popular view that security and protection of life are the primary reasons for this population to seek refuge in Germany. Instead, money, job and relationship were found to be the most common motives behind an illegal entry in Germany. In an often free-wheeling conversation with me, some of these Punjabi undocumented migrants volunteered to explain that getting any kind of job and ambition to earn quick money in Euros, even at the risk of having an illegal status, was the their main aim of entering Germany through different EU countries sharing border with Germany.

 

Common health problems and ailments

 

Since the focus of my research was on the health aspect of this population, I managed to get sufficient evidence about specific health problems by way of studying their lifestyles. After having all those one-to-one interviews with these undocumented Punjabi migrants, I found that their health disorders were primarily mental and psychological in nature. Of the total 25 migrants, almost everyone complained of deep depression and anxiety characterised by sleep disorders and alcohol abuse. It is not so difficult to comprehend that these mental disorders are result of an isolated lifestyle and dire living conditions, where the fear of being unmasked constantly hovers over the heads of these people.

 

“Maada shareer” (“vulnerable body”), “bhaari sar” (“heavy head”), “deemagi bukhar” (“fever in the mind”), “darr” (“fear”), “shareer dard” (“body pain”) and “feeling down” are some of the most common terms and expressions used by these undocumented migrants to describe their mental and physical condition. The respondents repeatedly and categorically pointed out that they are often faced with a poor psychological state marked by anxiety, fear, stress and even guilt.

 

The young undocumented migrants in the age group of 20-25 interviewed were more keen to talk about their psychological problems than in giving details on their bodily constitution. In fact, they strongly believe that their physical condition is largely determined by psychological factors. Hunger, strength and energy, which form the physical aspect of an individual´s  health, are primarily dependent on what they describe as “man” (mood).  Two such young  undocumented Punjabi migrants Jagtara and Gulshan admitted that happiness, which is key to sound health, is a rarity in their lives and so all they can do is to learn to deal with their stress and anxieties.

 

While agreeing on the statement that fear was a dominant feature of their lives, the migrants interviewed express varying views regarding the origin of their poor mental condition. In the opinion of Dalbir and Sikka from the Indian state of Punjab, the fear of being identified, unmasked and persecuted haunts them all the time, forcing them into an isolated life for an indefinite period of time.

 

Iqbal Singh, another undocumented migrant, contends that the problem of anxiety has also to do with a high level of jealousy among the housemates. He explains that every time someone from their group fancies his chances of finding an escape route from a life of illegality, the others go into their shells. Almost all interviewed migrants admit to some sort of rivalry among housemates as to who will be first to obtain a legal status.

 

There is always a conflict between suspicion and trust on the minds of these undocumented immigrants. They do not easily trust anyone, not even the people they are sharing a room with, and prefer to remain tight-lipped about their plans and personal matters due to the fear of identity disclosure. There have been a few instances where people from within the same group secretly informed the police about a specific hideout or an individual working illegally at a certain place.

 

In many cases, undocumented migrants are bothered by strong feelings of guilt. The constant self-stigmatisation stemming from their illegal status without fail leads to an increased level of emotional distress. This, coupled with a traumatic past, marked by a loss of self-esteem and deepening inferiority complexes, adversely damages their mental condition. “Sharam” (“shame”), “badnaami” (“stigmatisation”), “bay-izzati” (“insult”), and “pachchtava” (“regret”) were some other terms used by the interviewees to express their feelings about their stigmatised and tarnished image.

 

As regards physical discomfort, the most common problems, according to these Punjabi immigrants, are abdominal, lower back and chest pain, as well as skin infections. 29-year-old Sri Lankan undocumented migrant Rajan quickly contends that barring skin infections, which occurred basically due to rather unhygienic living conditions, bodily ailments were symptoms of a stressful lifestyle characterised by anxiety, fear and a prolonged isolation from the mainstream society. Sikka offers a somewhat different explanation especially for abdominal pain. He believes that alcohol abuse has been a major trigger of abdominal pain among his housemates. In fact, he discloses that one of his friends, who often complained of body pain especially in the abdominal area, was recently diagnosed with a liver infection. Sikka’s contention makes sense as the majority of these undocumented migrants have admitted a certain addiction to drink. Defying the common medical perception, one interviewee even believed that the alcohol intake usually helped him overcome his depression as well as sleep disorders. Almost vouching for others, a Punjabi immigrant from Pakistan, who has been witness to situations where alcohol was used to fight depression, sympathises with his Indian housemates: “What else can they do to shed their mental tensions and worries?”

 

The common view among this population is that, as none of them actually undergoes even basic-level medical examinations, leave aside proper treatment, there is only scope for deterioration in health due to traumatic and unhygienic living conditions. Dirty, dangerous and degrading (3 Ds) are the terms commonly and incessantly used by these people to describe their working conditions and they did not desist from using these terms during their interviews with me.

 

Facing a life full of depression and anxiety for several months and even years forces some of these undocumented immigrants to resort to what one of the interviewees describes as ‘laundebaazi’ (‘gayness’). Though claiming to have refrained from homosexuality, Dara of the Pathan community in Pakistan spills the beans regarding the practice of gayness among his  South Asian housemates mainly Punjabis. Gayness, he tries to explain, is seen as an ideal foil to man-woman sex especially when the latter is more risk-prone due to the migrants’ restricted mobility. However, he clarifies, gayness works for those who find it a feasible option by choice and not by force. With homosexuality having ceased to be a social taboo in European society, some of his South Asian housemates are also fast coming to terms with this practice.

 

Although most of the interviewed immigrants admit to have experienced long periods of sexual abstinence during their isolated lives, they do accept occasional indulgence in sexual practices which are not at all safe. Almost everyone confessed to having ignored the use of safe methods at least twice in situations when they were either in a state of inebriation or too frustrated to be part of a life worth anything.

 

In response to the obvious question about sexually transmitted diseases (STD), Sikka echoes the common perception that there could be a high prevalence of STD among their population group due to unsafe practices. Almost vindicating this view, one of the undocumented migrants, speaking in a hushed voice while winking at his mate, admits that the use of condoms sometimes becomes secondary to the use of libido-enhancing pills.

 

Another undocumented Punjabi migrant from the Indian state of Haryana discloses some startling details about the on-goings during his stay in a building near Eppingen, a small town in Baden-Württemberg state of Germany. One of his housemates managed to strike a deal with a foreign cleaning lady who volunteered to take care of their sexual needs for a paltry amount of five Euros per person. “It worked because the lady was as frustrated as most of the housemates living there, and the African immigrants’ reluctance to use condoms almost became a kind of norm there”, he reveals.

 

Constraints and hindrances in accessing health care

 

The interviewees confirmed that they encounter several constraints and hindrances while trying to access medical care in Germany. However, the most obvious handicap named by almost everyone during this research was their illegality. With a ‘no paper identity’, a term used by the respondents to describe their illegal status, they prefer a ‘once bitten, twice shy’ kind of approach while talking about their personal life.. Hailing from South Asian countries where the possession of papers is no necessity to attain medical care, these undocumented immigrants often find themselves in an unfamiliar situation where their status turnout to be a serious hindrance in accessing medical care in Germany.

 

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. 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 person 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 health care 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.

 

These undocumented migrants are extremely overcautious when it comes to choosing a physician during their illness. They want to be absolutely sure that the doctor they are going to see is either known to them through a reliable friend or is someone with a similar cultural background. Medical care givers of South Asian origin are easily approachable because of a certain cultural and linguistic affinity. They are usually preferred over other doctors so that the patient’s health problems can be addressed without any cultural barriers. However, there were also some interviewees who felt uncomfortable talking to physicians of their own nationality and ethnicity about venereal diseases and alcohol abuse. They admitted that they were not used to sharing such problems with South Asian practitioners openly due to cultural conservatism. One reason to avoid seeing doctors of one’s own nationality or cultural background is these people’s shame and embarrassment in facing such doctors due to the stigma associated with their illegal status. The preference of Russian doctors in this case, however, is noteworthy. Physicians of Russian origin are very popular among South Asian undocumented migrants and particularly Punjabis. This could be attributed to the fact that the majority of these undocumented migrants enter the European Union after spending a fair amount of time in Russia. Familiarity with Russian doctors and their language helps them enjoy a certain comfort level.

 

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 person”, 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 were 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 from Punjab speaks in defence of German doctors. According to him, even German physicians are not too happy about their restricted freedom in serving 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”.

 

Tactics, methods and ploys in seeking health care

 

While trying to study the’ health-seeking behaviours, methods and ploys of this population in accessing health care in Germany, one significant finding was that all these undocumented migrants avoid hospitalisation at any rate. A hospital stay is considered an enormous risk due to their illegal status. 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. According to the interviewees, 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 anti-depressants is also quite common among this population.

 

In case of serious physical injuries, mental issues, cardiac disorders or other grievous complaints where self-medication is not applicable, undocumented migrants prefer to see a doctor who is known to them through a person of confidence. In this context, the importance of social networks such as community-based get-togethers at Gurudwaras cannot be neglected as they enable their members, including undocumented migrants, to share useful information like recommendations regarding certain doctors.

 

The immigrants 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 who recently managed to get a legal status after toiling hard for more than 10 years in Germany,  gives an interesting explanation: “There are a few clinics everywhere in Germany where doctors are hardly perturbed by the illegal status pf their patients. They never suggest anyone to resort to any unfair means of accessing health care. However, if one is using a health insurance card, which they know, does not belong to you, they prefer to ignore this. In fact, at times, it seems that the whole staff in the clinic is trained in such pretences.”

 

Another immigrant who lived in illegality for more almost 15 years 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.

 

Consulting pharmacists, medicine students and traditional healers is another active option vis-à-vis this population’s health-seeking behaviours. 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 (STD)and other contagious diseases with the sole exception of HIV.

 

And then there are self-styled therapists like Jagjeet Singh, who claims to provide a massage therapy which leads to 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 patients 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.

 

One startling observation made during interviews of these undocumented migrants is the  growing tendency of the young undocumented migrants to regularly consume cheap versions of Viagra sold at certain South Asian stores in some cities of Baden-Württemberg and Hessen region. Initially sold as anti-depression pills under code names like Sardard ki Goli (Headache pills), Murga Chhaap Pathaka (a popular brand name for fireworks and crackers in India) and Pink City (the city of Jaipur from where originally the supplier of such pills hailed from), these local versions of Viagra arriving from India are playing havoc on the minds and bodies of a number of young Punjabi immigrants, who are getting used to such pills.

 

Paradoxical health care laws in Germany

 

Like most countries of the world, Germany also accepts the United Declaration of Human Rights ( Article 25:1) that includes an individual’s right to seeking medical care. However, the fact is that undocumented migrants in this country are far from exercising these rights for fear of having their identities revealed. §87 Aufenthaltsgesetz (Residence Act) which is commonly referred to as Denunziationsparagraph  requires public institutions to report illegal immigrants to the foreigners’ registration office. While hospitals and independent physicians are not obliged to do so, social welfare offices have to adhere to this law.

 

Like asylum seekers, foreigners who are under obligation to leave the country, and refugees holding a Duldung (temporary suspension of deportation) undocumented migrants are entitled to limited medical care according to Asylbewerberleistungsgesetz (German Social Law for asylum seekers) §1 Abs.1. This includes basic standard benefits as per §3 AsylbLG as well as certain benefits in case of illness, pregnancy and birth according to §4 AsylbLG. However, treatment is only granted in the event of acute pain and afflictions; regarding chronic diseases, the situation is not clear.

 

Another section of the Residence Act which is relevant in this context is §96 Aufenthaltsgesetz. The so-called Schlepperparagraph (referring to the facilitation of undocumented migration) states that anyone who aids a person without documents might be liable to prosecution. The degree of culpability depends however on certain criteria such as the question whether a prolongation of the patient’s illegal stay is encouraged through the medical treatment, whether the doctor gains any financial advantage, as well as the frequency of such acts (cf. §96 Abs. 1).

 

Health care professionals, particularly doctors I interviewed during this research were on the horns of a dilemma on providing healthcare to undocumented migrants. On the one hand, they have the professional obligation to help illegal immigrants following the principles of medical ethics and humanity, on the other hand they are confronted with unpaid medical bills and the risk of legal consequences.

 

49-year-old Dr. Andreas L. renders his voluntary medical care to people irrespective of their legal status at the behest of Medinetz, an NGO in Mainz. Speaking with an air of nonchalance, he shares the popular notion of the medical fraternity and other social organisations about healthcare rights of undocumented migrants. “Why should someone be deprived of his right to seek medical care due to his illegal status?” he questions and then emphasises in the same breath,” doctor’s primary task is to identify the ailment and cure the same.” Dr. Timo H. and his wife Anne, who are part of the Büro für Medizinsche Flüchtlingshilfe ( The office for medical assistance for refugees)  in Berlin, working under the slogan Kein Mensch ist illegal (no one is illegal) strongly advocate that it is for the Government to ascertain the legal status of an individual and that a patient’s illegal status should not have any bearing on a physician’s duty. Most of the doctors and social workers involved with NGOs and private initiatives committed to serving undocumented migrants argue that, when the Government knows that there is a certain population of such people residing in Germany, at least the access to medical care should be hassle-free. If this population is denied access to healthcare, the overall health of society is sooner or later bound to become vulnerable. “After all, don’t we know that these people provide a cheap labour force to the country in some or the other way?” says one Göttingen-based gynaecologist on the condition of anonymity. The argument regarding access to healthcare makes sense because most undocumented immigrants rarely undergo any medical examination before entering Germany. And in order to rule out the spreading of contagious diseases through them, it is imperative for the Government to let these people have access to medical care.

 

As clearly visible from various findings of my research, the level of medical care available to the population of undocumented migrants in Germany is highly unsatisfactory. Although illegal residents do have a theoretical right to minimum healthcare according to German law, the access to these healthcare services is not guaranteed as it is to a great extent blocked by the implications that come along with the regulations in the relevant sections of German health policies.

 

Note: All the names of undocumented migrants and health care professionals in this write-up have been changed due to interviewees’ request.

_________________

The writer is B.A. (Honours) in English Literature, University of Delhi, holds a Post-graduate Diploma in Journalism from Bharatiya Vidya Bhavan, New Delhi, and M.A. in Ethnology  from the University of Heidelberg, Germany. Formerly a print media and TV journalist in India for 13 years covering investigative nature of issues related to health and society in New Delhi, he has contributed write-ups, news stories and features for reputed  English dailies like The Times of India, The Hindustan Times, The Telegraph, and The Pioneer. Exclusively covered 9th and 10th Lok Sabha elections for Doordarshan National Network. Currently working as an independent researcher and interpreter of ethnographical data related to South Asian projects undertaken by Dr. Gabriele Alex, Professor of Social Anthropology, Eberhard Karls. University Tuebingen, Institute of Ethnology/ Social Anthropology, Germany. He is also also involved in two short-term projects pertaining to social dynamics of immigrants’ health status in Spain, France and Italy.

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