How Europe keeps migrants out of its health system, by Sophie Arie

BMJ 2015; 350 doi: (Published 24 April 2015) Cite this as: BMJ 2015;350:h2216

Sophie Arie, journalist, London

Europe may not want to rescue migrants crossing the Mediterranean from Africa to enter Europe illegally, but those who reach dry land do receive the healthcare they need. However, asks Sophie Arie, does it last after the cameras have stopped watching?

What healthcare are migrants given on arrival by boat?

On arrival by sea, migrants are usually sunburnt, dehydrated, and exhausted. Often, those who paid less than others or of nationalities considered inferior by the human traffickers who operate the boats are locked below deck throughout the journey and come close to suffocation.

All migrants are given water and a health check immediately. Those requiring emergency care are quickly identified and taken to the nearest hospital.

Some have injuries or trauma from earlier stages of their journey. For example, on one boat that was rescued off the Italian island of Lampedusa in April, there were 23 people, including children, with burns, many of them severe. They said that a gas canister had exploded in Libya while they were waiting to be loaded on to boats. They were taken to a burns unit at Palermo’s central hospital.1

Those who are relatively healthy are held in detention centres pending decisions on their migrant status. Those whose applications for asylum are rejected often appeal that decision and remain in limbo, as “undocumented migrants,” for many years.

How many undocumented migrants are there in Europe?

Between 1.9 and 3.8 million undocumented migrants are thought to be currently living in the European Union, some in detention centres but most living and working clandestinely for the long term. The vast majority did not take the most perilous route to enter fortress Europe. Most entered legally—on work, study, or spouse permits—and remained after their visas expired. Around 300 000 are those apprehended by border controls after attempting to cross illegally by land or sea.

What healthcare can they get?

The perilous boat journey across the Mediterranean is usually the last leg in a long and dangerous journey across Africa or the Middle East for people escaping war, persecution, and extreme poverty. Some research shows that precisely because of the difficulty of the journey, it is mostly young, fit people who make it. However, most have mental health problems caused by trauma, but they do not receive any support for that from European states.

Undocumented migrants who enter Europe legally and then remain without visas tend to have similar health needs to regular citizens, but they often allow their conditions to advance for longer before seeking help. They tend to live and work in poor conditions, which can increase their health problems. And many suffer from stress, anxiety, and depression related to their precarious status.

What are Europe’s obligations to undocumented migrants in terms of healthcare?

Most European countries have signed human rights treaties recognising the right to health of any person within their jurisdiction. But, in reality, most countries provide only emergency healthcare to undocumented migrants. Of the 18 countries that do that, 11 charge a fee that can be prohibitive, research by the Platform of International Cooperation on Undocumented Migrants (PICUM) has found.2 Five countries offer full access to their health services: Belgium, France, the Netherlands, Portugal, and Switzerland. The United Kingdom, Germany, Italy, Spain, and most northern European countries are somewhere in between, allowing undocumented migrants access to more than just emergency services.2

What happens in reality?

In reality, even in the countries that provide full access to health services, there are barriers that deter undocumented migrants from seeing a doctor. These include language barriers, lack of knowledge of the health system and how to access it, prohibitive charges, and fear of being deported. Often, undocumented migrants only present very late and with advanced conditions, and they approach non-governmental organisations such as Médecins du Monde. “Some people rely on NGOs [non-governmental organisations] that tend to pick up a lot of the care when it becomes acute because people still don’t want to go into the public system,” says Lilana Keith of PICUM. But non-governmental organisations do not want to create a parallel system, so they try to play a referral role, helping people to access the national services they are entitled to.

Is it getting harder for undocumented migrants to access healthcare?

Processes for granting asylum have been tightened in many countries in recent years, so fewer numbers of undocumented migrants are obtaining refugee status and the access to services that brings. Failed asylum seekers are rarely immediately repatriated as they have a right to appeal, and they find themselves in a limbo that can last for years. Some countries, including the UK and Spain, have in recent years announced policies that reduce the health services that undocumented migrants can access. But others, such as Sweden, have expanded those services. Spain’s announcement in 2011 that all undocumented migrants would only be allowed to access emergency care was largely ignored, with only one small region implementing the national policy and all other regions continuing to provide other services to different degrees. The Spanish government recently announced it was reintroducing primary care for all undocumented migrants because of public health concerns.

Do healthcare professionals know how to respond to undocumented migrants?

Most healthcare professionals follow their professional code of ethics and provide care to anyone who needs it. The dilemma for many is whether they should change the treatment they provide to undocumented migrants based on the regulations in their country. “When restrictive policies are brought in, there is inevitably a degree of confusion, and healthcare professionals do not always manage to provide the access that people are entitled to,” says Keith. “The most obvious solution would be equal provision of care to remove the administrative burden. At very least, administrative procedures need to be reduced. There should be one single registration which provides undocumented migrants with a health card.”

In 2009 Italy tried to impose a duty on citizens to denounce undocumented migrants, but it was strongly rejected, particularly by doctors. In Germany there is a duty on social workers but not on healthcare workers to denounce any undocumented migrants they encounter.


Cite this as: BMJ 2015;350:h2216


  • Competing interests: I have read and understood BMJ’s policy on declaration of interests and have no relevant interests to declare.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

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