Dr Paquita de Zulueta fights for those on the margins of society

Dr Paquita de Zulueta

Paquita de Zulueta has been volunteering at Project:London as a doctor for over two years. She’s helped many vulnerable people who are unable to register with a GP. When she’s not volunteering she works as a locum doctor. She has been a GP for 26 years. 

Paquita is passionate about Project: London and supports Doctors of the World UK’s work in this area. Paquita feels an affinity with immigrants and asylum seekers having lived abroad and met many people from different cultures and backgrounds while she was growing up. Paquita has worked with many asylum seekers in different areas of London during her time as a GP.  


She says she enjoys the challenge that comes from working at Project:London and the feeling that her work makes a big difference.

Here Paquita’s documents her experiences at the clinic which featured in the BMJ in October 2011 in an article entitled: ‘Asylum seekers and undocumented migrants must retain access to primary care’.

"They come singly, or in huddled clusters, subdued, their eyes downcast, their shoulders stooped. They tell us tales of loss, of devastation, of living in the penumbra, always fearful of exposing themselves to bureaucratic scrutiny. They sleep, if lucky, on the sofas of friends or in hostels, otherwise in doorways, on park benches, in churches and bus stations. They are like Dante’s lost souls, shadows wafting in limbo, neither in heaven or hell, but in a cold and lifeless purgatory, a place the world refuses to acknowledge. They tell me their stories, their faces etched with suffering, their eyes reflecting dull despondency or despair. And yet, as I bear witness, I am humbled by their grace, dignity, and endurance.  Somehow they manage to look clean, orderly and well presented. The tell-tale sign may just be the tightly clutched plastic bag. That bag may hold all their possessions, including documents such as a dog-eared letter, years old, from the Home Office blandly reporting information regarding the status of their asylum appeal. Many of them have not sought medical help for several years despite serious medical problems - some brought on by the lives they lead or the trauma they have experienced.

A support worker assists a service user at the clinic

The stories are varied and at times harrowing. A woman flees her village and elopes with a man she has fallen in love with. But he brings her to the UK in order to sell her to other men, not to marry her. He steals her passport, drugs her, and forces her into sexual slavery. Now she is pregnant and too sad to care, yet she cares enough to refuse abortion. A couple have been refused asylum. Local gangs threatened his life and they cannot go back home. The pregnant wife is in the third trimester. A depressed young woman fled the house where she had been enslaved since she was 14 and is forced to sell her body to get some food. A teenager with severe post-traumatic stress disorder has difficulties controlling his anger and is at risk of harming himself or others (he has already made a serious suicide attempt). A woman in her forties has rheumatic heart disease and is breathless with heart failure. These individuals are all in clinical need yet have been unable to access primary healthcare in the UK. Despite pleas to my colleagues to take them on, and even when they undertake to do so, they still turn them away when they arrive on their doorstep. Secondary care, including antenatal care, may be available, but carries the threat of unpayable fees. Do healthcare professionals expect women to deliver their babies in the street? In fact, some women we see have delivered at home without any clinical supervision. What do they think happens to those who are suffering from severe mental health disorders and chronic untreated diseases? Have they at least considered the risks to public health? The litany of misery continues and I take note of the small acts of unkindness and indifference meted out by my peers. But there are shining exceptions, and some GPs do manage to overcome bureaucratic barriers and register patients irrespective of their residential status. 

Paquita seeing a patient in the clinic

I am a general practitioner and work, when time permits, as a clinical volunteer at Project:London, a health advocacy programme set up by Doctors of the World UK in the East End of London. Here I treat those who cannot access primary care. These include those accepted or refused by the asylum system and undocumented migrants. The BMA reminds doctors that there is no requirement to determine someone’s immigration status to access primary care services. The GMC’s Good Medical Practice requires that doctors do not discriminate unfairly, but provide care and treatment to meet the clinical needs of all patients. The Royal College of General Practitioners (RCGP) endorses this:  “Based on the principle that General Practitioners have a duty of care to all people seeking healthcare, the RCGP believes that GPs should not be expected to police access to healthcare and turn people away when they are at their most vulnerable.

When people evince a lack of compassion and callousness, they use various tricks to preserve their self-esteem. One of these is to comply with bureaucratic diktats and elide responsibility for the consequences of ones actions. Another is to dehumanise individuals and view them as dangerous and unworthy of normal human decency. In mitigation, I recognise that some Primary Care Trusts send officious and misleading guidance. Receptionists and practice managers are exhorted to reject individuals who do not present a range of documents such as utility bills and passports – not easy if you are homeless or someone else holds your passport. These impositions carry no valid legal or ethical authority, but some may believe they do.

A Support worker sees a service user

What does the future hold? Finances are tight. Consortia may be more draconian. The government seeks to expand its existing restrictions to free secondary care and include primary care. This does not augur well for the vulnerable and dispossessed in need of humane clinical care – particularly as compassion appears to be a dwindling resource in modern medicine. "

This article was originally published 18/10/11 on the BMJ blog at http://www.bmj.com/content/343/bmj.d6637

Joanna Kotcher Medical Evaluator in Dolo, Ethiopia

Joanna returned to work with Doctors of the World (DOW) in August 2011 as a medical evaluator in Dolo area of Ethiopia.  It is located on the border of Somalia.  Joanna was sent in response to the famine crisis to create a needs assessment plan.

“There are 4 camps in the Dolo area, including a transit (border) camp. When we first arrived in the region I focused on getting a broad public health picture of the situation. For the first days of the assessment, I spent time at the UN base, interviewing the field managers responsible for health, shelter, and nutrition. From there I moved onto the camps. After securing the permits, we held daily meetings with refugee families. I discovered quickly that there were many children and women who had not received any medical care. In the transit camp I started my assessment outside the official border of the camp, it was here that we found thousands of people living rough in the bush with no shelter. Although they were able to get into the camp twice a day, hot meals, the sanitation and water needs were enormous.

The water situation was critical. The problem was that the ground on which the camps have been developed is rock bed that requires special equipment for drilling, there was no alternative land. The agencies responsible for water worked very hard to supply the minimum needed for drinking and sanitation, but it was a difficult task. Many refugee families had less than 8 litres per day to live on. Everyday we met with refugees who had given up trying to get water from the tap stands and simply left their water containers in neat rows until the water might flow again. The most challenging situation is that there were simply not enough services to meet the needs. Everyone was working at their maximum but it was simply not enough.

After several weeks in the camps, we decided that the best use of our resources would be in establishing mobile health services in the larger camps, to try to shorten the distance between health care and those refugees who had scant access to services. We also made the decision to assist the Minister of Health together with the host population who were under great pressure to balance their own needs in the drought, and that of the refugees.

After returning to headquarters we put together a workable plan to put Doctors of the World’s resources where they can really work – in helping both the refugee and host populations. Aid equity is always an issue, but it is always surprising when a host population needs as much help as the refugees that arrive on their borders. My previous medical co-ordination work in Kosovo, Central Asia, and Darfur were almost identical. Whenever there is mass migration or people fleeing war and famine, the health and psycho-social problems are similar. But the worst situation, for me as a medic, is when we cannot get into the areas where the conflict is occurring. This is what happened in Kosovo and Tajikistan (Afghanistan).

I think the future of the famine crisis depends on continued response from the international community and on co-ordination from the ground. It’s always difficult to coordinate so many organisations and activities and this crisis is no different. I hope that we are able to get into Somalia itself as soon as possible to implement programmes for aid there. It is gratifying to know we are helping on the refugee side, but thousands are suffering on the Somalia side. In mass crises such as these, we have to look at options that involve the refugees and host populations too. We can’t work in a vacuum or ethically implement programmes that institutionalize refugee camps so that they become long term communities.”

Somalia: The Humanitarian trap

Pierre Salignon

Pierre Salignon, Director General of Doctors of the World France writes about the complex situation facing aid agencies who respond to crises such as the famine that is facing Somalia.

He highlights the difficulties of humanitarian relief in Somalia, particularly for workers on the ground that get caught up in politics, looters and the difficulty experienced in accessing those in need.

Pierre Salignon, a trained lawyer, has most recently worked with the World Health Organization (WHO) and with Doctors without Borders.  As an author Pierre has published numerous articles on relief and humanitarian issues. 

Over the past few days, Somalia has made a noticeable return to the front pages of the media. According to numerous observers (NGOs, UN agencies and journalists), several areas of the country are now ravaged by the worst food shortages in twenty years. The United Nations no longer hesitates to talk about famine in southern Somalia. The alarm is being raised by aid workers on the ground in Somalia, as well as in Kenya and Ethiopia, where several thousand refugees are arriving destitute and exhausted every day. Once again, shocking images of starving, skeletal children are to be seen everywhere in the media and are focusing the public’s attention on the fate of the deprived populations of the Horn of Africa. All the ‘benevolent multinationals’ are calling for an extraordinary funding effort to tackle the tragedy and to deliver food to the country without delay, in order to “avoid the worst” and to save several millions of people from hunger.

Even as a new international humanitarian operation gets under way to save the starving, it is worth looking to the past, especially as the scenario is a well-known and recurring one in this troubled region that suffers from regular cycles of malnutrition. The dilemmas and risks of such an aid operation are identified and particularly well described by Jean-Christophe Rufin in his book, Le piège humanitaire (The Humanitarian Trap), published in 1992.(1) The French doctor writes: “it took months of editorial campaigning, of unprecedented efforts at communicating, for Somalia, having reached the very depths of despair, to ‘make it’ into the media. When the humanitarian machine got underway, it did so in spectacular and inappropriate fashion. The grand operation entitled ‘Rice for Somalia’ (…) represented an ill-judged response to the real problems. The difficulties on the ground in Somalia did not arise from a lack of food or financial aid: the media campaigns finally succeeded in releasing significant resources for the country. The constraining factor was the operational capacity of those supplying the aid and, above all, the country’s extraordinary instability. The omnipresent armed groups and their habit of demanding ransoms from the population, and of misappropriating aid destined for it, made distribution ineffective.”

This analysis remains astonishingly pertinent, casting light on the tragedy unfolding before our eyes. It also serves as a reminder of the fact that if, as the United Nations states, famine is raging, the reason for it cannot solely be the drought and the current lack of rainfall, suffered by the majority of nomadic herding peoples. The food emergency that is blighting Somalia (and surrounding region) is the result of a lengthy and progressive deterioration arising from a combination of recurrent climatic stress and conflicts, which have ravaged the country since the beginning of the 1990s. Rufin emphasises that, “through successive schisms, political authority has blown apart like a grenade, and loose formations of rival groups divide the country”, with matters made worse by the absence of a government since 1991. A host of external political and military interventions should not be overlooked either, ranging from the US military operation, Restore Hope, to more recent intervention by the Ethiopian army and deployment of United Nations troops, as well as the setting up of foreign Islamist cells following the attacks in Nairobi and New York. A widespread and chronic state of anarchy has bolstered the predatory power of local chiefs and turned Somalia into a kingdom where every kind of shady activity, including that of Islamic militiamen, is engaged in. For civilians, survival becomes a daily challenge.

Faced with this insecurity, aid workers, despite repeated attempts, have found it impossible to maintain an effective and permanent presence in the field. Some have been killed or have become targets of criminal violence and kidnappings, forcing the monitoring of operations from a remote base in Nairobi, now the humanitarian platform for the region. This is the price paid for maintaining the drip feed of humanitarian assistance, but it is accompanied by a loss of control over aid.(2) As Islamic militias gradually took control of southern Somalia (3) and imposed their conservative vision of Islam, the World Food Programme (WFP) was forced to suspend food distribution, due to insecurity, large-scale misappropriation of international food aid and widespread corruption that was severely testing the United Nations food distribution system.(4) In other words, all the necessary conditions were in place to ensure that chronic poverty degenerated into a fresh disaster for populations particularly afflicted by deprivation and violence, and by the terrible drought that the war sometimes hid from view. The refugees currently arriving at the camps in Kenya and Ethiopia provide tangible proof of an historic but very real tragedy, even though it has been turned into something of a media event in recent years.

Recent statements calling for international aid (while refusing to talk of famine), issued by Islamic militia groups controlling the areas declared by the UN to be in a state of famine, are not particularly reassuring. Is there anyone who really believes that Somalia is now, as if by magic, going to open up to international aid without there being any quid pro quo or risk involved? The challenge is enormous for aid workers already striving to consolidate their efforts to contain a disaster that has been widely broadcast and warned of in the media. While they must act quickly, they are going to have to deploy their resources extremely carefully in a region where they are not welcome and where nothing will be made easy for them. In other words, there is a huge risk of food aid being misappropriated.

The recent history of humanitarian interventions in Somalia teaches us another important thing: the mobilizing of funds currently underway, necessary as it is, will not be enough to ensure the aid missions are successful and to get Somalia out of its present-day vicious circle. There will be no humanitarian resolution to this crisis as there has not been for others. While the humanitarian response is, at this stage, the only conceivable one, given the gravity of the situation, it is far from satisfactory. In the absence of other more politically focused options, it will doubtless make it possible to contain, but not assuage, the raging food crisis. The Somali government may be moribund, but the current tragedy also points to the collective failure of the international community and governments in the region. The drama of this country without resources or strategic value can be summed up in one word: abandoned. Nothing has changed in 20 years. In the absence of a long-term vision, the international community, in the form of the United Nations, is satisfied today, as it was yesterday, with temporary, humanitarian solutions to each fresh crisis, in the time it takes for attention to move away from the Horn of Africa and its starving populations deserted by their own governments. And why should tomorrow be any different? Without a change of approach and “long-term investment”, as the FAO is demanding (on the issue of agriculture in particular), it will be impossible to escape from the trap that a humanitarian response represents, and impossible to avoid this type of crisis reoccurring.

Endnotes

1 «Le piège humanitaire”, followed by “Humanitaire et Politique depuis la chute du Mur”, Jean-Christophe Rufin, Collection Pluriel, 1992 (“The Humanitarian Trap” followed by “Humanitarianism and Politics after the Wall Came Down”).

2 La Revue Humanitaire , 29th July 2011, see the article by Stéphane Berdoulet,” MDM en Somalie : l’art difficile du travail à distance” (DOW in Somalia: The tricky art of working remotely”), on the reasons which have led the organisation to close its programme a few months ago at Merka in southern Somalia, pointing out how difficult it is for foreign aid workers to intervene in this country.

3 Except for certain neighbourhoods in Mogadishu where the TFG – what remains of the government recognised by the UN – maintains a presence with the support of UN soldiers.

4 “L’aide alimentaire du PAM s’évapore en Somalie avant d’atteindre ses destinataires” (“WFP food aid vanishes into thin air in Somalia before reaching intended recipients”), LE MONDE.FR with AFP, 10.03.2010.

This article also featured in Humanitarian Practice Network here: http://www.odihpn.org/report.asp?ID=3220

Listen to Professor Chris Bulstrode and Dr Oda Mukkuaka discussing Haiti on BBC Radio Oxford and BBC Radio 4

Doctors of the World's Professor Chris Bulstrode, and Haitian surgeon Dr Oda Mukkuaka worked alongside each other in Haiti after the devastating earthquake that struck in January 2011.  Doctors of the World invited the surgeon over to the UK to help train him in surgical techniques, so that he in turn can help his colleagues back home.   The two explain their work with Doctors of the World's emergency mission and discuss how things are now in Haiti in these interviews.  Listen here to BBC Radio Oxford's interview and here to the Radio 4 interview.

Surgeon Chris Bulstrode on his work with Doctors of the World

Listen to surgeon, Professor Chris Bulstrode, as he talks to BBC Radio Oxford's Malcolm Boyden about his work with us in Haiti and his forthcoming project in Bangladesh.

 http://www.doctorsoftheworld.org.uk/resources/surgeonchrisbulstrodeonhisworkwithdowuk.asp

Access to Primary Health Care for migrants is a right worth defending by Wayne Farah

As the NHS faces up to the realities of the Government cuts, calls to restrict further migrants’ access to free NHS services, are growing. This is not something new, but the evidence suggests that excluding migrants would actually increase costs, leave all of us at greater risk of ill health, and undermine the integrity of the NHS.

Wayne Farah

Wayne Farah is one of Doctors of the World UK's highly esteemed Trustees. He is also Chair of the Migrants’ Rights Network, as well as Vice Chair for Newham Primary Care Trust. He has been a Visiting Lecturer at London Metropolitan University where he helped develop the Certificate in Education Partnership for refugee teachers. He is on the Board of the Mental Health Mentoring Project for the Migrant & Refugee Communities Forum as well as Vision Care.

KEY FACTS

•The rules on eligibility to primary and secondary health care are fundamentally different

•Nobody can lawfully be prevented from accessing GP services because of their immigration status

•Some migrants can be charged for some hospital treatments

JANE’S STORY

“You’re an illegal, so you are not entitled to NHS treatment. If you need treatment you’ll have to pay for it privately or go to Urgent Care Centre or A&E, and your details will be passed to our Counter-Fraud team and the Home Office.”

It was the third time that Jane, 26 weeks pregnant and feeling unwell, had received this response when she tried to register with a local GP . Jane returned to her sister’s flat, and her brother-in-law contacted the local Primary Care Trust (PCT). They said the GP surgery were right, Jane could not access primary care unless she had ‘leave to remain’ in the UK for more than 6 months. He explained to Jane that they could not afford to pay for private treatment during her pregnancy, but would try to secure a loan in order to pay for the delivery. Jane decided that she could not risk enforced removal from the UK to her war-torn country of origin, so she decided to avoid further contact with the authorities and give birth to her baby at home.

Will Jane end up in the A&E department suffering from complications that her GP could have identified during routine antenatal screening? Will her baby be born with a low birth weight, and therefore likely to suffer poor health later in life? Sadly, the answers may depend on whether Jane seeks legal advice, because the GP and PCT are acting unlawfully.

ELIGIBILITY FOR NHS CARE

The NHS is not a “public fund” as defined by the “recourse to public funds rules”. No law or regulation exists that restricts a patients’ right to access primary health care services because of their immigration status. Jane could therefore consider suing the GP and the PCT because, by linking residency status and eligibility to primary care, they are breaching their fundamental duty to provide NHS treatment free of charge unless otherwise legislated .

SECONDARY CARE REGULATIONS

The law on eligibility to primary and secondary care are different. Section 175 NHS Act 2006 empowers the Secretary of State for Health to make Regulations to charge some people who are not ordinarily resident in the UK for some hospital treatments. The rules on “6 or 12 months’ residence”, ‘lawful residence’, ‘settled status’ etc. follow from section 175 and only apply to secondary care. Eligibility for free primary care is unaffected by these regulations.

Primary Care Regulations

There is no law excluding anyone from primary care, and therefore immigration status and ‘ordinary residence’ are irrelevant when registering with a GP. There is no legislation, statutory guidance, or case law suggesting that people must be ‘resident’ for any length of time, or have a visa etc. The only relevant pieces of legislation are the GMS Contracts and PMS Services Regulations , which govern the delivery of NHS primary medical services.

Any attempt by the PCT to interfere with a GPs’ discretion to register Jane as a patient, would be a breach of the GMS/PMS Regulations. The PCT’s policy that GPs should refuse to register people because of their immigration status, is unlawful. Their advice to the public that eligibility depends on immigration status is also unlawful, and places the PCT in breach of its statutory duty to procure primary care services to all people in its area . Unfortunately, Jane’s PCT is not the only one providing delinquent advice to GPs. Over two thirds of PCT’s in London  have issued guidance to GPs that is incompatible with their legal obligations. Many PCT’s advise GP’s they should only register people living legally in the UK for  more than six months’, but this is wrong as the ‘ordinarily resident’ test applies only to hospital services. The rules are simple; GPs have complete discretion to register whomever they wish. The GMS\PMS regulations do allow GPs to refuse to register someone on reasonable grounds (e.g. the patient is not living in the GPs catchment area, or their list is closed). However, they must not discriminate by refusing to register on grounds of health status, race, gender, sexual orientation, social class etc.

Upholding the Law

Based on poor guidance from their PCT’s many GP practices demand proof of immigration status along with proof of residence before they will register some patients. As immigration status does not affect eligibility to primary care, GPs have no reason to establish immigration status. By refusing to register Jane as a patient because of her immigration status, the GP imposed arbitrary criteria that are unlawful, unethical, and probably in breach of the GMS/PMS Regulations. Moreover, by linking eligibility with immigration status, the GP is utilising administrative arrangements that probably breach the Equalities Act 2010 provisions on indirect discrimination. Jane could therefore seek redress, including compensation for any adverse impact the refusal of treatment has on her and her baby’s health, through the courts. She could also refer her GP to the General Medical Council (GMC), which regulates Doctor’s in the UK.

Data Protection

If the GP or PCT did pass Jane’s information to the home office, they would be in breach of the NHS Constitution and may have committed a criminal offence.The UK Border Agency (UKBA) has contacted PCT’s and GPs to inform them, incorrectly, that a specific patient is ‘not entitled to NHS treatment’. Some GPs have acted on this false information, wrongly removed people from their lists, and then had to reinstate them. 

In recent times, there have been a number of incidents where the UKBA have asked for patients’ details, citing an exemption to Data Protection Act that authorizes disclosure where it is necessary to prevent crime or apprehend offenders. A GP or PCT would have to be satisfied that the requested information was necessary for the prevention of a specified (and sufficiently serious) crime to justify disclosure. They are unlikely to be able to disclose information lawfully without seeing legal documents to support the UKBA request. Even then, they would need to consider the competing public interest of maintaining trust in the confidentiality of medical records and personal data, as specified in the NHS Constitution. Therefore, if the GP or PCT did pass on her personal details to the UKBA, Jane could probably sue them for breach of the Data Protection Act.

EXCLUSION IS A BAD IDEA

Like Jane, thousands of migrants across the UK are facing unlawful restrictions on their access to primary care. As the NHS faces up to the realities of having to find £20 billion efficiency savings, calls to further restrict migrants’ access to free NHS services, are growing. We can reduce costs to the taxpayer and improve services if we stop “illegal immigrants abusing our NHS”, is the claim.

Demands to exclude migrants from the NHS are not simply the result of the financial crisis; they have been around as long as the NHS has existed. As Nye Bevan explained when he created the NHS - “One of the consequences of the universality of the British Health Service is the free treatment of foreign visitors. This has given rise to a great deal of criticism, most of it ill informed and some of it deliberately mischievous… The whole agitation has a nasty taste. Instead of rejoicing at the opportunity to practice a civilized principle, Conservatives have tried to exploit the most disreputable emotions in this among many other attempts to discredit socialized medicine .” Moreover, the evidence suggests that excluding migrants will increase costs, leave all of us at greater risk of ill health, and undermine the integrity of the NHS .

Economics

Current estimates suggest there are up to 725,000 undocumented migrants in the UK , or just over 1% of the total population. If these migrants consume NHS resources like the rest of the population, then they would consume a little over £1% of the total NHS Budget of £120 Billion, or just over a £1 billion per year. However, we know that undocumented migrants do not consume NHS resources in same way as the rest of the population.

On average, over a quarter of all the health care someone consumes in their lifetime they will consume in the last year of their life . Most migrants are young, have good health , tend to make less use of NHS services , and have little impact on demand for health care . Moreover, all migrants face particular problems accessing health care due to language barriers, lack of knowledge of the NHS, institutional racism, and the lack of cultural competence of NHS systems and staff . These barriers are often insurmountable for undocumented migrants. Therefore, it is likely that the actual cost of treating undocumented migrants’ will be significantly less than the cost of missed NHS appointments. In 2008, patients failed to turn up for over six million hospital appointments, 911,000 GP consultations and 264,000 practice nurse appointments, at a cost to the NHS of almost three quarters of a Billion . If we want a more efficient and accessible NHS, we do not need to leave Jane and her baby without health care, we just need to turn up for our appointments.  There are also additional costs associated with clinicians' spending time explaining and assessing eligibility, and administrative costs of checking documents etc. The evidence shows that even in a very high migrant area, the numbers of undocumented migrants using primary care is low and the costs of administration will probably exceed the income derived from charges .

Whatever the cost of treating undocumented migrants, the cost of not treating them may be higher as there is a strong economic foundation to the medical adage that prevention is better than cure. The cost of treating a neglected condition in an emergency setting will usually exceed the cost of preventative or maintenance treatment. Poor access results in late presentation for many conditions, including cancer, that then require more expensive and often less effective treatments, resulting in increased costs and unnecessary deaths. A visit to A&E costs three times more than a visit to a GP. One admission to intensive care for a patient with HIV-related pneumonia costs as much as two years of antiretroviral treatment .

Public Health

By refusing to register Jane as a patient, the GP and PCT are preventing her from accessing a range of screening, immunization, and health promotion services, which will probably have severe consequences for Jane and her baby. They are also putting the wider community at risk, because public health surveillance and protection in the UK depends on the NHS to manage infectious and communicable diseases.

The MMR vaccine helps to protect our children, in part, by establishing herd immunity. The decline in the take-up of MMR following ill-founded concerns about possible links with autism resulted in a measles epidemic. An epidemic that illustrates the risks to everyone if there is a break down in universal health care. 

How can there be an effective emergency plan to combat a flu-pandemic, if we exclude hundreds of thousands of people from the arrangements? Excluding migrants from the NHS might satisfy prejudice, but as viruses do not discriminate, it will leave all of us at greater risk when the next measles epidemic or flu-pandemic strikes.

Restricting access to primary care will prevent the NHS from being able to diagnose and treat communicable diseases such as TB in a vulnerable section of the population. Limiting the availability of treatment to symptomatic patients in A&E departments, will mean that they will only receive treatment to stabilise rather than cure their condition. This will increase the probability of the evolution of drug resistant infections. In addition, it will help create backstreet health services outside the NHS regulatory framework, where unscrupulous practitioners will exploit a new market of vulnerable people. Unregulated health services will also help facilitate the evolution of drug resistant infections, and place additional demands on the NHS emergency services that will ultimately have to deal with the medical consequences when things go wrong. 

Social Cohesion

Restricting migrant’s access to health care, not only undermines the public health; it also undermines the social inclusion strategies needed to reduce health inequalities .

Our social environment is a powerful determinant of our health and on almost every index, there is a correlation between inequality and poor health and social problems, which is too strong to be attributable to chance. Relative poverty, low social status, and weak social affiliations explain most variations in health inequalities in industrialised countries and correlate with a range of social problems, from homicide to teenage pregnancy . Therefore, condemning thousands of people to absolute poverty, and then excluding them from the one of the few national institution most Briton’s still respect would be a folly of epic proportions.

PROTECTING THE NHS

Restricting migrants’ access to primary health care is unlawful, uneconomic, and unhealthy. Moreover, it could undermine the foundations of our NHS.

Privatisation

If GP’s have to identify and charge some patients for services, they will have an incentive and capacity to offer private treatments to other patients. GP Practices are businesses that want to maximise their income. If they have to invest in a system to charge some patients, why not use the system to offer additional services for patients able and willing to pay. Exclusion could prove to be yet another vehicle for the creeping privatisation of our NHS.

Increased Bureaucracy

If you want to separate the sheep from the goats both must be classified, and GP’s will need to recruit new model army of bureaucrats to administer the system. The creation of a new bureaucracy to check eligibility for free care will make accessing GP’s services a major inconvenience for everybody. The process for determining any individual’s immigration status is complex and time consuming. Any GP that requests proof of immigration status will need to demonstrate that their actions are not discriminatory. They would therefore need to check the immigration status of every patient seeking to register with their practice and every patient attending for an appointment. An NHS number or previous GP registration would not be sufficient, because an individual’s immigration status may change over time.

Institutional Racism

The new model bureaucracy will generate a culture of suspicion around eligibility that will inevitably focus on Mrs Patel rather than Mr Peters. There is substantial evidence that the poor health outcomes for established Black and Minority Ethnic (BME) communities are associated to the barriers to accessing health care they face, including institutional racism in the NHS . Suspicion of eligibility will intensify these barriers, making BME communities access to the NHS a continuous struggle with ‘institutional racism gone mad’.

Ethics

Excluding people because of their immigration status, establishes non-clinical criteria for rationing health care. Today we exclude the undocumented migrants, tomorrow the feckless welfare mother, or binge drinking child. The next day it is whomever else the Sun or Daily Mail decides is unworthy of our generosity. Such an approach is ethically bankrupt. There is no crime in UK law that is punishable by the denial of health care. Every day we ask our Doctors and nurses to care for mass murderers, paedophiles, and rapists. Is having the wrong passport or visa such a heinous crime that doctors should treat its perpetrators worse than they would a mass murderer?

Many GP leaders have expressed concerns about the ethical implications of refusing to treat people because of their immigration status and argue that the extension of internal immigration controls into primary care would be incompatible with the GMC code of professional ethics . It would certainly be incompatible with the World Medical Assembly Declaration on the Rights of the Patient, which states, "Every person is entitled without discrimination to appropriate medical care… (and) physicians and other persons or bodies involved in the provision of health care have a joint responsibility to recognize and uphold these rights. Whenever legislation, government action or any other administration or institution denies patients these rights, physicians should pursue appropriate means to assure or to restore them."

Resistance

Before the politicians and bureaucrats throw the NHS baby out with the anti-immigrant bathwater, let us remind them that Nye Bevan’s civilised principle of universal health care free at the point of need remains the best prescription for a healthy society.

Up-Hold the Law

Migrant’s rights campaigners and advocates need to make greater use of the law to ensure that GPs do not deny migrants access to primary care. The law is simple; immigration status is not a criterion for eligibility to primary care. Any GP or PCT that suggests that it is, are acting unlawfully and unethically. Challenging them in the courts, and where possible suing for damages, will help GPs’ understand that costs of unlawful discrimination can be very high. Although undocumented migrants may be reluctant to seek redress through the courts, legal action by any migrant or asylum seeker refused the right to register with a GP, will help reinforce the principle of universal access and discourage unlawful discrimination against undocumented migrants.

Advocacy Skills

To ensure you are able to represent migrants effectively when dealing with GP registrations, training and support are available from Doctors of the World UK

Campaign for the NHS

There are campaigns in opposition to the ConDem Governments proposals to restructure the NHS springing up across the UK. Migrants’ and refugee rights groups need to be active in support of these campaigns to ensure that the principle of universal access, including access for undocumented migrants, is part of the campaign agenda – www.nhscampaign.org

Build Alliances

Many GPs and other health care professionals are themselves migrants and the NHS could not function without them. Many more health professionals will try to maintain their ethical duty to their patients whatever the circumstances. Campaigners need to build alliances with these professionals. As a first step, campaigners could approach their local GPs and other clinicians to ask them to sign the European Declaration of Health Professionals – Towards non-discriminatory access to health care

This piece was co-authored with Fizza Qureshi (Doctors of the World UK) and Adam Hundt (Pierce Glynn Solicitor). It can also be viewed on the Migrants Rights Network

Photos © Tom Bradley

Haiti: 1 Year After the Earthquake

5th January 2011
To pull through this emergency, keep the promises made to the Haitians.

Since the earthquake on 12th January 2010, Haitians have been surviving essentially thanks to the mobilisation of international assistance. On the ground, conditions for survival remain extremely precarious and the UN & member states are far from meeting their commitments. Reconstruction work is stalling and the Haitian people continue to wait for promises to be fulfilled.

Mobilising the funds promised by the international community

For one year, the majority of donations received from all over the world - almost 3 billion dollars, much of which has come from private donors - have financed the massive humanitarian operation that is continuing today. The Haitian population has endured disasters, frustration and disillusionment for several months. It is therefore not surprising to see, during this extremely sensitive electoral period, an upsurge of sometimes fierce criticism of the United Nations, other states and, occasionally, humanitarian organisations.
While Haitian and international emergency teams have enabled vital needs to be addressed, states themselves are far from meeting their commitments in terms of reconstruction. Of the 10 billion dollars pledged in March 2010 during the international donor conference of the United Nations and Member States in New York, only a few hundred million dollars has been paid out. If the promises made to Haiti on reconstruction are not kept, the country risks another disaster: economically, socially and politically.

Medical action taken by Doctors of the World over the past year
The earthquake completely destroyed an already very fragile and inequitable health system. To deal with this, the Haitian Ministry of Health established an intermediate reconstruction plan. Yet one year later, in spite of efforts, the plan has made too little progress. It is principally the NGOs who are managing the cholera emergency. The Haitian government, paralysed by the lack of funds promised by Member States, is having trouble getting back on its feet and initiating a sustainable reconstruction of the heath system.
For the past year the Doctors of the World teams have been offering multidisciplinary access to healthcare: treatment of cholera cases, medical consultations, reproductive health, vaccinations, nutritional screening, specific follow-up of women and children, assistance to victims of violence and post-traumatic psychological follow-up:
* More than 580 000 medical consultations, including 800 surgical procedures, carried out since the earthquake. On average, about 9 250 medical consultations were carried out each week of which 20% were for children under 5 years and 12% were for pregnant women.
* To address the cholera epidemic: 5 Cholera Treatment Centres with a capacity of 40 to 50 beds each and 11 Cholera Treatment Units dedicated to oral and intravenous re-hydration.
* 4 operational areas: Port au Prince, the Goâvienne region Grande Anse and Nippes
In Port au Prince: 8 permanent tented clinics in the displaced persons camps and slums
: 4 mobile clinics operating on 16 sites of Cité-Soleil
In the Goâvienne region: Supporting the Petit Goâve hospital and 10 health care centres
In Grande Anse: Supporting the provincial hospital in Jérémie and 11 health care centres
* 1 268 staff working for Doctors of the World of whom 95% are Haitians.

To find out more read our Doctors of the World 1 Year After the Earthquake Press Kit