Back to the UK

I’ve reached the end of my four-week trip and I’ve arrived back to Manchester with a month’s worth of laundry and a huge pile of notes to, at some point, decipher… After months of planning and organising (anyone that has worked with me knows I don’t tend to wing things!) it feels strange to be back to normal life without this project to ‘manage’. But whilst the travels might be over, I have heaps to think about and lots of learning to reflect on, both in terms of my research area and personally. I tagged a bit of holiday onto my trip and, for the last few days, I was based in Sorrento and after a busy few weeks it was great to have some time to reflect on the experience whilst exploring the coastline.

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View of Positano

But, the research isn’t over (I think ever drawing a line under it will be hard!) and I’ve already got a couple of Skype calls lined up with people and organisations I didn’t get chance to meet whilst I’m away. I am extremely grateful to the Winston Churchill Memorial Trust for the opportunity to travel to learn and I look forward to developing as a Churchill Fellow and continuing my learning. Thanks, too, to everyone who agreed to meet me and share their views and experiences with such honesty and enthusiasm for the project. I’ll be producing a report of my findings and looking for other opportunities to share what I found in Sweden, Germany, and Italy, too. Finally, thanks to my employers – the Care Quality Commission – that enabled me to take the time off from work to pursue this opportunity. Whilst the thought of getting through four weeks’ worth of emails is a bit daunting, I’m looking forward to returning to my team and reflecting on what I have found.

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GPs’ experiences in Florence

I have reached the final leg of my research and for the last few days I’ve been in Florence meeting GPs with experience of working with refugees and asylum seekers in the city and surrounding towns and suburbs. From my interviews I’ve learnt that, ostensibly, refugees and asylum seekers have full access to Italy’s State-funded national health system. Undocumented migrants are provided with a ‘Temporary Present Foreigner’ card (which must be reapplied for periodically) that also enables access to healthcare, in theory. However, in practice it can take months for an asylum request to be processed with one of the GPs I met suggesting that the authorities were deferring this process purposely to limit migrants’ rights for as long a period as is possible. Responsibility for health is devolved to the regional level so there are differences in how migration is managed across Italy. Whilst devolution could, as one GP reflected, provide the opportunity for responses tailored to local circumstances, it has only created inconsistencies between regions and a lack of data and information sharing between health services.

It was really interesting to hear about the challenges facing the GP sector in Italy and how they may act as a barrier to effective primary care for refugees and asylum seekers. The sector is ‘fragmented’, in part due to regional variations, but also because there are numerous bodies that ‘represent’ the sector (with in-fighting between them) meaning that there is no shared ‘voice’. The GPs I met also described general practice as being under-recognised and seen as being separate from the ‘core’ national health system. As in Germany, quality of care is not assessed or measured, and neither is asylum seekers’ and refugees’ access to health services specifically.

But despite these difficulties, I heard examples of excellent work. One of the GPs I met works in a recently established Casa della Salute (House of Health) located in a suburb of Florence with high levels of socio-economic deprivation. The service is also directly opposite a disused building which has become a squat for refugees, asylum seekers, and undocumented migrants. Recently established, the aim of this State-funded service is to provide comprehensive and holistic primary care. Like the National Institute for Health, Migration, and Poverty in Rome, multi-disciplinary working is a key feature of the service’s approach: there are a variety of health professionals on site. The service also tries to resolve other difficulties that patients are experiencing that might be affecting their health and well-being; in particular, housing. I was told that even State-run housing for asylum seekers and refugees is poor quality and often unsafe, let alone conditions in the squats.

Similar to the approach at the National Institute for Health, Migration, and Poverty, the House of Health has a pool of around 200 Cultural Mediators who play a key role in the delivery of the service. In addition to providing interpretation (every Cultural Mediator is at least bi-lingual) during patients’ appointments, they also help the patient to explain their problem to the health professional therefore helping to overcome some of the differences in cultural understanding about health and illness. The GP I met described the Cultural Mediators as being vital for working with highly-sensitive concerns amongst their most vulnerable patients, including trafficked women and women that have experienced or continue to experience sexual abuse and violence. The Cultural Mediators also provide patients with information about their rights to health.

Given the direction that government’s migration policy is taking, it seems a likely possibility that refugees’, asylum seekers’, and undocumented migrants’ access to healthcare will be restricted. The voluntary sector plays a key role in supporting refugees and asylum seekers in Italy, including in addressing their health problems; the demand for NGOs’ support is likely to grow. Sadly, I ran out of time in Florence to meet a local NGO I’d been introduced to via email but I’m looking forward to arranging a Skype call when I’m back in the UK. Whilst my time on my trip is almost up, there are lots of ideas and leads I look forward to pursuing when I’m home…

Anthropology in action: Italy’s National Institute for Health, Migration, and Poverty

It’s the last week of my four-week trip and my final stop: Italy. Data from the UN show that 20,885 migrants have arrived in Italy, via the Mediterranean Sea, since the beginning of the year; more one thousand migrants have died or are missing at sea. Migration is, of course, a contentious issue in Italy. The general election earlier this year resulted in a hung parliament with the populist League party emerging as the main political force. Matteo Salvini, Interior Minister and leader of the League, has had approved a series of hard-line measures to reduce the protection provided to migrants and make deportations easier, whilst ships rescuing migrants from the Mediterranean Sea have been blocked from Italy’s ports. Whilst Sweden and Germany are both, seemingly, experiencing a rise in far-right populism, the rhetoric and the reality of anti-migrant sentiment in Italy is perhaps the most extreme of the counties I have visited as part of my Fellowship. Arriving in Italy, I was interested in finding out what this context means for refugees’ and asylum seekers’ access to primary healthcare.

My first meeting of the week was at the National Institute for Health, Migration, and Poverty in Rome. The Institute was established 15 years by the Ministry of Health to support and respond to the needs of migrants. It does this both directly via a drop-in health clinic, and indirectly via training and support to a network of health professionals across the country. On a tour of the clinic, I soon realised how many specialisms were under one roof: dermatology, gynaecology, ENT, paediatrics, infectious diseases… and the list went on. All services are accessible without charge to refugees and asylum seekers.

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Headquarters of the National Institute for Health, Migration, and Poverty

But what is so fascinating about the Institute (at least to me, with a Social Science -background) is that alongside the wide-range of medical professionals, the Institute has employed – for many years – two Anthropologists. The role of the Anthropologist (one of whom I had the pleasure of meeting: Maria Concetta Segneri) is to negotiate the cross-cultural encounter between the patient and the medical professionals which so many of the health professionals I have met in Sweden and Germany so far have remarked upon; such as during my visit the Transcultural Centre in Stockholm.

The Anthropologists achieve this by talking in depth with the patients about their experience of, and attitudes towards, health and illnesses / diseases; from this, the Anthropologists communicate their findings to the medical professionals, enabling them to better understand their patients’ needs and perspectives. The Anthropologists are also supported by 20 Cultural Mediators, directly employed by the Institute, who provide interpretation; both during the clinical consultations and during the Anthropologists’ in-depth conversations with patients, if needed. The Institute also employs Social Workers and has links with services and NGOs across the city; the Anthropologists explore each patient’s particular circumstances (including housing, social relationships, and practical problems – such as inability to contact relatives) and draw on the Institute’s network to try and improve the patient’s well-being beyond just their physical and mental health.

It was so inspiring to hear how anthropology was embedded in the Institute’s work and, as Maria explained, a key feature of the Institute is the way in which professionals from such a wide range of disciplines work together as part of a truly multi-disciplinary team. She described how each professional’s individual skills and knowledge are valued and drawn upon with the shared aim of improving the health and well-being of refugees and asylum seekers. Looking to the future, Maria, Angelo, and Cecilia were unsure what the future held regarding refugees’ and asylum seekers’ access to primary healthcare, given the current political climate, but I left the meeting with a great deal of optimism: it was really inspirational to hear about the Institute’s work. Thank you to Maria and Angelo Barbato (the Institute’s Health Care and Preventive Medicine Director) and Cecilia Fazioli (who leads the Institute’s external communications) for their time in meeting me.

GPs’ experiences in Leipzig

It’s my penultimate day in Leipzig and the fourth city I’ve visited so far on my Churchill Fellowship. It is a great place; it has a young population, thanks to the reasonable rents and relatively cheap cost of living, and a growing economy. There is a strong sense of history here (including the city’s links to Bach and, much more recently, the protests against the GDR in October 1989 which some say led to the fall of the Berlin wall), but it feels like the city is looking to the future with optimism.
IMG_20180924_151621367Thanks to the support of Prof. Thomas Frese from Halle University (and a representative of the European General Practice Research Network) in accessing interviewees, this week I have met with GPs from across the city that have experience of working with refugees and asylum seekers. It is noteworthy, though, that none of the practices I visited had a remit to focus on these patient populations specifically, and most of their patients were born in Germany (in contrast to the Hjällbo Health Centre in Gothenburg, for example).

There is a lot for me to reflect on from my interviews but two key things have struck me. Firstly, the pragmatism that GPs have demonstrated in overcoming some of the challenges they face; most pertinently, the lack of interpreters for their consultations with refugees and asylum seekers. The GPs I have met have described a complete lack of interpreters, meaning that they rely on Google translate, the family and friends of patients, and sometimes other patients or contacts that offer informal help over the phone. This is unacceptable and I was surprised that, three years on from 2015’s influx of refugees, there isn’t better infrastructure here in Leipzig to enable GPs to treat asylum seekers and refugees effectively.

Secondly, I have been struck by the lack of oversight of the GP sector here in Germany. There is no formal regulation, so I’m told, and the body that administers practices’ funding and the State of Saxony take a hands-off approach. On the one hand, this affords GPs a degree of freedom (that no doubt many GPs in England would envy); but on the other, there seems to be a lack of any strategy or assistance for GPs, including in meeting the needs of refugees and asylum seekers. With the exception of only one GP I spoke to, nobody could cite any support they had received to enable them to best support the refugees and asylum seekers they treat. If I had more time here in Leipzig it would be great to hear from NGOs and voluntary groups that work with refugees and asylum seekers to hear their perspective on these groups’ access to primary care. With a week left to go of my trip, I’m already thinking of Skype calls I’d like to set up once I’m home…

Berlin: Researchers’ perspectives on Germany’s migration response

After Gothenburg, my next stop was Berlin for a few days. A few days in Berlin was never going to be enough: the city has so much to offer (both in terms of contacts for my project, and sightseeing!) I’m already thinking about when I can next go back. Despite being short on time, I managed to fit in some really thought-provoking meetings with academics and researchers involved in refugees’ and asylum seekers’ access to healthcare. Whist many of the people I spoke to had a clinical background, their involvement in academia and research gave them an ‘outsider’s’ perspective, in some ways, and it was fascinating to hear their thoughts on how Germany is (or isn’t) meeting the needs of these patient groups. It was also great to spend time with fellow researchers and hear their experiences of recruitment strategies, ethics, and methods.

The starting point for most of my conversations in Berlin was the refugee crisis: back in 2015, Germany accepted over 1 million asylum seekers, many of whom were seeking refuge having fled Syria. There was a feeling amongst those I spoke to that Germany, and the health system in particular, hadn’t been prepared. In the void that was created, bands of enthusiastic volunteers stepped in and a host of groups and organisations emerged to try and meet the health needs of Germany’s new arrivals.

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Close-up of the East Side Gallery, Berlin

Three years on, the numbers of asylum seekers entering Germany has subsided considerably. And there have been other changes, too. The academics and researchers I met with in Berlin described how, in immediate response to the crisis, the government had invested significant funds in research relating to refugee and asylum seeker issues (for example, this study into refugee women’s experiences). But this is no longer the case: some of those I met felt that the government is now less willing to fund refugee-focused research and projects due to a change in public mood towards refugees. At the extreme, this has manifested as xenophobic rioting in Chemnitz.

I also heard how there was a risk of fatigue amongst the voluntary groups that sprung up in response to the crisis. Furthermore, many groups had been formed so quickly that not much thought had been given to their sustainability; for example, the need to recruit new volunteers. In response to this, two of the people I met in Berlin, Prof. Sabine Oretelt-Prigione and Jenny Jesuthasan, are involved in developing a tool-kit for voluntary groups working with refugees.

Given this context (the lack of government funding / appetite for refugee-focused projects, and the recognition that the voluntary sector can only do so much), the role of local health systems, including General Practice, in meeting the needs of refugees and asylum seekers seems vital. I’m looking forward to seeing how this challenge is being responded to in my next stop: Leipzig.

 

 

Exploring Gothenburg

Despite the rainy start to my time in Gothenburg, by the time Saturday came and my meetings were complete for the week, the sun was out! It is a handsome city with distinctive architecture. But despite the often grand buildings, it has a pretty laid-back feel and a little less ‘polished’ than Stockholm. IMG_20180915_111748548_HDRGothenburg is an easy city to explore thanks to the handy tram network which extends all the way out to Saltholmen: the departure point for ferries to the archipelago. Having visited one of Stockholm’s islands, I had to see how Gothenburg’s compared… so I took a ferry to Brännö, just a 20 minute journey from the mainland (and all included on my public transport travel pass: bonus!) It was a beautiful day to be on the island: bright, breezy, and warm. Despite a ferry-load of people arriving on the island, the crowds soon dispersed and I had a peaceful couple of hours exploring the island.IMG_20180915_131742775On my last day in Gothenburg, I spent some time at the Röda Sten Konsthall: a modern art gallery in a renovated boiler plant. Quite a contrast to the quaint summer houses and fisherman’s shacks on Brännö! The theme of the exhibition was ‘Shout Fire!’ with all of the artworks intending to spark discussion about democracy, activism, and cultural autonomy: fitting given the current political context here in SwedenIMG_20180916_122629300_HDR

 

 

Reflections from Gothenburg

I arrived in Gothenburg on Tuesday; in contrast to Stockholm, where I had been lucky to catch some lovely September sunshine, I was met by grey skies and wet weather. It felt like home! With three days of interviewing ahead of me, though, the weather was a good excuse to spend time settling into my accommodation (a flat in the suburb of Majorna) and do some reading up on the organisations I’d be meeting. My interviewees in Gothenburg spanned three organisations: the state-funded Refugee Health Clinic; an NGO, the Rosengrenska Foundation; and a GP clinic in Hjällbo. All of my interviews were arranged with the help of retired GP, Dr Kristian Svenberg. Kristian now works at the Refugee Health Clinic; formerly, he was a GP at the Hjällbo Vårdcentral (Health Centre) for 20 years.

My first meetings of the week were at the Refugee Health Clinic which Gothenburg offers specialised therapy and treatment for trauma caused by the effects of war and torture. I learnt from Dr Eva Theunis, a GP at the clinic, that the clinic achieves this through a multidisciplinary approach: the clinic brings together a team of psychologists, physiotherapists, counsellors, and GPs. Like the Transcultural Centre I visited in Stockholm, the clinic also provides a health communication programme to increase patients’ ‘health literacy’, covering themes such as diet, dental health, sleeping problems, and sexual health. The clinic is also trying to raise awareness of refugees’ and asylum seekers’ health needs and rights amongst doctors in ‘mainstream’ services, through education such as talks and lectures.

I was interested to find out more about the role the voluntary sector plays in supporting migrants’ health needs in Gothenburg. The Rosengrenska Foundation was established in 1998 by a small group of health professionals, including Anne Sjögren who I had the opportunity to interview along with Dr Kjell Reichenberg, a psychotherapist. Staffed by volunteers, Rosengrenska provides healthcare to undocumented, or papperslösa, migrants in Gothenburg: those that are most likely to encounter problems in accessing primary healthcare. Rosengrenska provide a weekly clinic, situated in a church, providing treatment for physical and mental health problems. Rosengrenska have successfully campaigned to improve undocumented migrants’ access to health. Since 2013, undocumented migrants in Sweden have been entitled to ‘care that cannot wait’: a subjective classification, open to doctors’ interpretation. All the interviewees I spoke to in Gothenburg noted the continuing challenges that undocumented migrants face in accessing primary healthcare; it feels like it will be a long time before Rosengrenska will be able to achieve its aim of ‘abolishing itself’ due to it no longer being needed.

My last meeting of the week was at a GP clinic in Hjällbo, a district to the north east of the city. Here, I interviewed a GP, Dr Emma Dahlgren-Mensah, about her experience of providing primary healthcare to Hjällbo’s diverse population. Like the Trauma and Crisis Clinic, the Hjällbo Health Centre is characterised by a diverse team of professions, all working under one roof, including physiotherapists, GPs, a dietician, a diabetes nurse, a lung disease nurse, and a paediatric nurse. The centre also works proactively with other agencies, such as employment and social services. Like the staff I had met in the Refugee Health Clinic and Rosengrenska, it was clear that staff at the Hjällbo Health Centre were passionate about their work with refugees, asylum seekers, and undocumented migrants. For Emma, part of the appeal was the opportunity to work ‘internationally’ from a clinic in Sweden; she told me she has a map of the word in her consulting room with a new pin added for every patient she treats that has migrated to the country from elsewhere.

Looking to the future, many I spoke to in Gothenburg were worried about the impact that the election results would have on their work and the patients they serve; in particular, the Swedish Democrats achieving their highest ever share of the votes, albeit fewer than had been predicted earlier in the summer. The Refugee Health Clinic described having received threatening letters from objectors to their work, whilst interviewees from across the services I visited commented on the levels of stress and anxiety being experienced by their patients, especially the papperslösa, due to the social and political climate. But it is clear that, within Gothenburg, there exists a community of enthusiastic health professionals committed to reducing health inequalities, whatever shape the new Swedish government takes whenever it is formed…