Discussion
Undertaking research on paperless migrants is a challenging task. They are afraid, live in hiding, do not appear in any statistics and often have poor Norwegian language skills. If we as doctors wish to improve the provision of health services to this marginalised patient group, we need better knowledge about it. Previous studies have largely been based on mapping studies undertaken in non-public health clinics that are frequented by paperless migrants (10) – (12).
With the aid of the membership register of the Association of General Practitioners we were able to reach virtually all Norwegian GPs to ask them about their experience of paperless migrants. This approach has provided us with new insight into the contact that Norwegian GPs have had with this group, but the method has weaknesses. Although nearly 100 % of all Norwegian GPs are members of the Association of General Practitioners, we had no functioning email address for 10 % of them, and another 20 % were temporarily absent from their practice and could thus not be invited to participate in this study.
Paperless migrants seek health assistance all over Norway. In our study, GPs in all health regions report to have had contact with paperless migrants. This finding contrasts with the findings made by a Dutch study from 1997, which indicated that GPs in poor regions in the major cities are those who primarily have contact with this patient group (13). One practical outcome is that Norwegian GPs all over the country must expect to encounter this patient group, not only those in urban regions. The mapping also encompassed the GPs’ use of interpreters. The results from the questions pertaining to the use of interpreters have been published in a previous article (9).
In light of this study, Norwegian GPs seem to encounter the same health problems in paperless migrants as those faced by doctors in other parts of the world (11, 12). These primarily include mental problems, to which a stressful life situation before the arrival in Norway, the stay in a reception centre and life as a paperless migrant may be contributing factors. In our study, the doctors reported that 50 % of those whose asylum application had been rejected contacted them due to mental issues, compared to 29 % for the group as a whole, but these figures are fraught with considerable uncertainty. In a Swedish study, the prevalence of anxiety, depression and suicidal thoughts was ten times higher among paperless migrants than in the Swedish population in general (10). An overview of migration and mental health in Europe indicates that when compared to the general population, there is an elevated prevalence of schizophrenia among migrants and refugees, and among paperless migrants in particular. Anxiety, depression and post-traumatic stress disorder are common diagnoses (11).
In 2007, Doctors of the World (Médecins du Monde) conducted a mapping study in which 835 doctors from nine European countries participated (12). Digestive disorders, «general and unspecified» and musculoskeletal afflictions were the problems with which paperless migrants were diagnosed. This indicates that this group suffers from many of the same health disorders as the general population (14).
Regulations adopted in 2012 stipulated the rights of paperless migrants to health assistance (15). These were later replaced by the Regulations on the right to health and care services for persons not permanently resident in the realm, which grants the right to emergency care and necessary health care that cannot be delayed, as well as health assistance for pregnant women, children and people with serious mental disorders. The patients must pay for these health services themselves.
As we see it, there is no political will today to grant this group of people regular access to health services. There are national and local guidelines for handling of asylum seekers, refugees and those who have been granted family reunification, but none for how paperless migrants should be addressed. As a member of the Schengen Agreement, Norway’s commitments with regard to asylum seekers remain unchanged, meaning that the results of this mapping study are still relevant. At the time of mapping, our neighbouring countries maintained similar restrictions, whereas other countries, including Spain and Italy, granted more rights to documented migrants (2).
The response rate in this study was low, at 28 %, but approximately as expected for an electronic survey (16, 17). Altogether 23 % of the respondents reported to have treated patients who were illegally resident in Norway. In our study in 2007 (5), the response rate was 37 %. The higher response rate on that occasion may have come as the result of a shorter questionnaire. Then, 43 % reported to have treated patients who were not legally resident.
We may reasonably assume that GPs who have a positive attitude to treating paperless migrants have been more inclined to respond to the survey than doctors who do not share this positive view. The study is retrospective, and thus involves a possibility of recall bias. These factors and the relatively low response rate indicate caution in drawing any general conclusions from our findings. We nevertheless believe that they provide useful information about this patient group.
The paperless migrants’ right to health services is also a political topic. Many politicians find it unacceptable that this group is denied health services on an equal footing with Norwegian residents (18). The political parties, including the government coalition parties, do not share this view and use limited health rights as an instrument in immigration policy (19) – (21).
Norwegian doctors are bound by their medical oath and the Codes of Ethics of the Norwegian Medical Association and the World Medical Association (22). The rules affirm that doctors shall provide health services according to need, irrespective of the patient’s civil or political status. In our study, altogether 70 % of the doctors who had treated paperless migrants indicated that they would continue to receive this patient group, irrespective of the health problems they present with. The remaining 30 % would only treat this group in accordance with the prevailing guidelines. We did not pose this question to those who had not treated any paperless migrants, so we have no knowledge of their attitudes in this respect.
At the time of the mapping, the legislation and regulations were open to interpretation. Whether or not paperless migrants will receive general medical help will often depend on the attitudes of each individual doctor with regard to Norwegian immigration policy and his or her assessment of medical ethics – a situation that frequently presents the doctor with a moral dilemma (23). A qualitative study conducted in Norway corroborates this view (24). The way in which the doctor-patient relationship is handled depends on the doctor’s ethical considerations, set alongside the commitments laid down in international conventions.
The fact that health services for paperless migrants have been established by non-governmental organisations must also be regarded as indicating that this group’s need for health services is not being met by the public providers. When this study was conducted, a low-threshold clinic had opened in Oslo under the auspices of the Church City Mission and the Red Cross. In Bergen, a clinic opened in 2014. In other regions of the country, however, this group remains reliant on contacting GPs or emergency rooms to access normal health services.