Health policy and care for foreigners: a temporary employment agenda
From the mid-1950s up until the mid-1970s, people from various countries, including Italy, Spain, Portugal, Turkey, Greece, Morocco, former Yugoslavia, Tunisia, and the former Dutch Antilles were recruited to come to work in the Netherlands [
18,
19]. This period also saw the migration of people from Suriname, a former Dutch colony, as well as ‘repatriates’
1 from the former Dutch East Indies during the 1950s, Mollukens, and refugees from Eastern-Europe, Vietnam, and Latin-America to the Netherlands [
19]. Despite this influx of people migrating to the Netherlands, those in political power during this time did not view the Netherlands as a country of immigration [
18]. For instance, in the ministerial
Memorandum on Foreign Workers of 1970 [
18] it is unequivocally stated that the Netherlands was ‘not an immigration country’, and thus foreign workers were expected to eventually return to their countries of origin. Regarding the preservation of ‘own identity’, the
Memorandum on Foreign Workers of 1970 states:
Regarding foreign employees who generally will only remain in our country for a short period, the emphasis will be placed on the maintenance of own identity. Readjustment difficulties upon return to their own country will this way remain as minimal as possible [
18]. (authors’ translation; see
Appendix 2. item A. for the original Dutch text)
What the political discourse and policies during this first period embed is the production of a specific category of foreign workers who are recognised as being culturally and linguistically different; however, these differences were at the time not seen as being problematical because the maintenance of ‘own identity’ was deemed to be important in order for the foreign worker to eventually return home. This narrative of the Netherlands not being an immigration country had implications for the management of primary health care for these foreign employees.
Initially, the occupational doctors first came in contact with the new foreign employees, and soon various professional publications appeared on the specificities of treating employees who came from outside the Netherlands [
20]. Taking stock of these concerns, in 1972 the then Minister of Public Health and Environmental Hygiene established the
Overlegorgaan Medische Verzorging Buitenlandse Werknemers (OMVBW) [Consultation Body Medical Care Foreign Employees] in order to accomplish the following: to find solutions to the problems which occur in the medical care of foreign employees, to help implement these solutions, and finally, to advise the Minister concerned as to how to proceed. In 1974, in their first advisory document, the OMVBW reached four specific conclusions about the problems which occur in the medical care of foreign employees; of these, language and communication problems were described as the ‘biggest problem’ in the medical care of foreign employees [
20]. Subsequently, based on this finding that language and communication are the primary cause of problems in providing care for foreign employees, the OMVBM initiated and set up in 1976 the
Bureau Voorlichting Gezondheidszorg Buitenlanders (BVGB) [Bureau Health Education Healthcare for Foreigners].
In 1980, the BVGB published one of its first booklets entitled
De buitenlandse patient [The foreign patient] for healthcare professionals who came into contact with foreign employees as their patients [
21]. The booklet aimed to increase a care provider’s background information of their foreign patients to ‘prevent unnecessary irritation’ and ‘increase understanding about their foreign patients’ [
21]. As such, the booklet provides information that gives the care professional insights that will ‘breed more sympathy and understanding for their foreign patients’ [
21]. Additionally, the booklet provides suggestions as to how care providers can better communicate with foreign patients, on how they should respond to particular situations, and encourages them to use bilingual materials available from the BVGB [
21‐
23].
The diagnosis which emerged during this time identified the problem as the unfamiliarity of the Dutch care provider with their foreign patients and the communication problems that exist due to linguistic and cultural differences. It follows that the prognosis (the proposed solution to the problem) was, as with all public provisions produced for these groups during this time [
16] to accommodate and guide foreigners through the healthcare system during their time in the Netherlands—which was deemed achievable through the education of care professionals. Because migrants were expected to eventually return to their countries of origin, ‘maintenance of culture’ and preservation of ‘own identity’ was considered desirable, as this would facilitate the eventual return of foreign employees to their homelands. For this reason, the focus of the diagnosis and prognosis during this period was on changes to be made by Dutch care providers and not by the foreign patients themselves.
Health policy and care for ethnic minorities: a multicultural agenda
By the early 1980s expectations regarding the return of foreign workers to their homelands had changed drastically, and along with it, the political discourse had shifted. An important 1979 report entitled
Etnische minderheden [Ethnic minorities] from the Scientific Council for Government Policy was the first significant acknowledgement of the fact that persons who migrated to the Netherlands as temporary foreigners were now permanent residents, and the report served as a catalyst into a new period of ethnic minority politics [
17,
19]. This new political period would come to focus on the need for the structural improvement of minorities’ social and economic position within the newly conceptualised multi-ethnic Dutch society [
24]. What emerges from the political discourse and policies during this period is the production of the specific category labelled
ethnic minorities, which refers to people who are socially and economically disadvantaged and culturally and linguistically different. This difference was, again, however, not problematised per se in the policies of this period, as the prevailing view was that it was important to aid ethnic minorities to find their way to public services in order to have equal access to public provisions [
25].
Reflecting the shift in government policy, two primary institutions, which had been originally created to facilitate the provision of medical care for patients who were previously called foreigners, were renamed, replacing the word ‘foreigners’ in their titles with the word ‘minorities’. Thus, the
Bureau Voorlichting Gezondheidszorg Buitenlanders became the
Bureau Voorlichting Gezondheidszorg Minderheden [Bureau Health Education Healthcare for Minorities], and the
Overlegorgaan Medische Verzorging Buitenlandse Werknemers became the
Overlegorgaan Medische Verzorging Minderheden [Consultation Body for Medical Care of Minorities]. Their new primary task was to increase the
accessibility of Dutch healthcare services and to ensure equal access to public service for all minority groups [
25]. The
Minority Policy Memorandum of 1982 states:
Also with regard to healthcare, the starting point is that members of ethnic minority groups should have equal access to provisions […]. The means that for the accessibility of services, it is desirable that the expertise of the care providers in relation to this patient group is increased. For this purpose the Ministry of Wellbeing, Health and Culture has developed a programme containing the following elements: Firstly, in 1982, 35,000 copies of the bulletin
Gezondheidszorg voor de buitenlandse patiënt [Healthcare for the foreign patient] were distributed among doctors, midwives, community nurses, and healthcare facilities [
25]. (authors’ translation, see
Appendix 2. item B. for original Dutch text)
Thus, while the political discourse shifted significantly—from a discourse about (temporary) foreign workers to a discourse about (permanent) ethnic minorities in Dutch society—the prognoses and calls to action did not. Firstly, the diagnosis continued to focus on communication problems caused by linguistic and cultural differences; secondly, the responsibility and call for action to improve these issues was again placed on the healthcare provider, for whom ‘expertise needed to be increased’ [
25].
Two central themes can be identified in the area of primary care related to ethnic minorities: firstly, the necessity to provide general information and training for all healthcare providers (what today would be known as the interculturalisation of health care); and secondly, the development of group and individual health education in minority groups’ own language and culture. Light can be shed on the interculturalisation of healthcare by examining the bulletin
Gezondheidszorg voor de buitenlandse patiënt [Healthcare for the foreign patient] distributed among physicians, nurses, midwives, and health centres in the Netherlands, as this was one of the first elements introduced to ensure equal access to healthcare for ethnic minorities in the first Minority Policy Memorandum in 1982 [
25,
26].
The bulletin starts with a definition of foreign patients and states that this term is used to describe patients who belong to ethnic minorities; it then provides a table with the key statistics in regard to this population organised by country of origin, namely Greece, Italy, (former) Yugoslavia, Portugal, Spain, Turkey, Morocco, and Indonesia [
26]. The introduction states that while ‘in principal every employee of the Dutch healthcare system can encounter the responsibility of caring for a foreign patients’ many care providers consider themselves ‘ill-equipped to care for these patients whose language, culture, habits, and health problems they are barely or not at all familiar with’ [
26]. And so, the bulletin offers information on these cultures, habits, and health problems in order to better equip care providers to care for their ethnic minority patients. Similarly, further materials developed by the BVGM in subsequent years were formulated with the explicit aims of complying with the discourse about multiculturalism. For example, the workbook
Voorlichting voor migranten, een methodisch werkboek [Health education for migrants, a methods workbook], is a workbook designed for instructors working with Dutch care providers who are being trained to offer health education to migrants [
27]. This workbook states that it aims to ‘create acceptance of a multi-cultural society, with all of its advantages and disadvantages’, and seeks to achieve this aim by providing information on ethnic minorities’ culture, on the effects of migration, and by discussing the willingness to ‘recognise multiculturalism’—the acceptance of which can be tested by practising respectful and non-judgmental communication skills included in the book [
27]. In addition to the information provided to healthcare providers, during this political period we also see the further development of group and individual health education programmes in the migrant groups’ own language and culture [‘voorlichting eigen taal en cultuur’].
Thus, while the political discourse changes from the 1970s to the 1980s, the focus and responsibilities of the interventions (prognosis and call for action) in health services provided for foreign employees in the 1970s and ethnic minorities and migrants in the 1980s did not differ much: Health providers formed the primary targets of these educational interventions prescribed by policy during both periods. Furthermore we see similarities, among the first and second political discourses with regard to the populations considered to be the object of these concerns. Although these populations were first produced as temporary foreign employees, and later as permanent ethnic minorities, the actual countries of origin of the persons deemed to belong to these categories were similar—mostly Turkey, Morocco, China, Portugal, Italy, Spain, Greece, [former] Yugoslavia, Suriname, and the Dutch Antilles.
Health policy and care for ‘allochtoons’: an integration agenda
Towards the late 1980s and early 1990s, ethnic minority policies and multicultural discourse experienced significant and increasing criticism from within politics, as well as from academia in the Netherlands [
16,
17,
28,
29]. These criticisms pointed to the continued social and economic deprivation of minorities, and called for a revision of current policies. In 1994, the government responded to these concerns in the
Contourennota Integratiebeleid Etnische Minderheden [integration policy ethnic minorities], in which it is stated that, although the government had achieved some significant improvements through the implementation of its minority policies (especially in regard to specific areas such as housing, education, and work), too little progress had been made under the minority policies [
30]. For this reason, the government adopted a ‘new vision on the presence of persons from diverse cultures in the Netherlands’. The
Contourennota Integratiebeleid Etnische Minderheden of 1994 states:
As a guiding principle for a new vision on the presence of persons from diverse cultures in the Netherlands—regardless whether they are newcomers or have been in the Netherlands longer—the cabinet adheres to the concept of citizenship […]. Citizenship implies for all those involved in the integration process a choice for sustained participation in Dutch society, with all the associated right and obligations [
30]. (Authors’ translation, see
Appendix 2. item C. for original Dutch text)
During this political period there is a shift in the language used to describe ethnic minorities in national healthcare policy, namely the word allochtoons is now used to describe those groups previously referred to as foreign workers and ethnic minorities. In English, the word allochthonous is used in the field of geology and literally means that something originated or was formed somewhere other than where it is found. In the Netherlands the word allochtoon is used to describe and categorize individuals and groups who are considered of foreign heritage, and its antonym autochtoon is used to describe and categorize individuals and groups who are considered native to the Netherlands. Furthermore, during this political period, with its focus on citizenship, integration, and participation, a shift took place from a diagnosis that stated that communication problems between foreign workers and Dutch care professionals and unequal access for ethnic minorities were the source of the problems, towards a focus on the cultural problems allochtoons brought to the health and healthcare situation.
In 1995, the then Minister of Health, Welfare, and Sport (VWS), Mrs Borst-Eilers, addressed the form in which the new integration policies would take with regard to healthcare for allochtoons. In this policy letter, the Minister states that the health situation of allochtoons gives reason for concern, and defines these differences, when compared to the Dutch population, as resulting from ‘socio-economic and, specifically, cultural-adjustment problems’ [
31]. This shift in discourse, diagnosis, and language, with the use of this specific term allochtoons, is critical as it indicates a shift in how the population which these health policies seek to target is constructed in the discourse of this new period. Namely, whereas in the previous two discourses, we observed policies and programmes geared towards foreign employees and later towards ethnic minorities from Turkey, Morocco, Portugal, Italy, Spain, Greece, (former) Yugoslavia, China, Indonesia, Suriname, and the (former) Dutch Antilles, the category allochtoons (as included in the health policy letter of 1995) only mentions the categories Turkish, Moroccan, Surinamese, and Antillean. In 1999, this demarcation and differentiation was formalised by the Central Bureau of Statistics (CBS), when certain countries of origin, such as Turkey, Morocco, China, Suriname, and the (former) Dutch Antilles, were defined as
non-Western, and other countries of origin, such as Italy, Japan, Spain, Portugal, Greece, and Indonesia, were referred to as
Western [
32]. This led to whole populations being labelled as either Western allochtoons or non-Western allochtoons. The justification for this distinction and division was based on perceived socioeconomic and cultural
similarities and
differences, where people originating from Europe (excluding Turkey), North-America, Oceania, Japan and Indonesia were considered to be similar to the Dutch with regard to ‘socioeconomic and cultural position in Dutch society’, and those with origins in Africa, Asia (excluding Japan and Indonesia), Latin-America, and Turkey were considered to be decidedly different from Dutch society and other Western groups [
32]. This discourse had implications for the management of primary healthcare for these so called non-Western allochtoons.
During this period, the diagnosis of the problem and the prognosis shifted from the accommodation of minorities in a multi-ethnic society and in the healthcare system, to a problem definition that pointed to the lack of integration and participation of minorities, which included cultural problems as a focal determinant of health inequalities. Particularly, this shift can be seen in the categories produced in these representations, from foreign employees and ethnic minorities to non-Western allochtoons, with a specific characterisation of this category as having specific cultural problems affecting health and healthcare. As such, it follows that specific interventions were deemed necessary for this particular group to address the cultural and integration-related problems affecting their health; one such widely employed intervention is the allochtone zorgconsulent [allochtonous care consultant].
By the late 1990s and early 2000s the BVGM had trained and certified health educators to give health education to minority groups in their own language and culture [voorlichting eigen taal en cultuur] (VETC), and by 2002, twenty regional and local support centres had been set up to assist VETC programmes across the country. By the late 1990s and early 2000s, VETC consultants were increasingly referred to as allochtone zorgconsulenten [allochthonous care consultants], and in 2002, this shift in terminology was solidified with the publication of the handbook
De allochtone zorgconsulent [
33]. The handbook was produced in a collaboration between various national organisations, including Forum Instituut voor Multiculturele Vraagstukken [institute for multicultural affairs], The Netherlands Organisation for Health Research and Development, and National Institute for Health Promotion and Disease Prevention (NIGZ). The NIGZ was founded in 1996, when the Bureau Health Education Healthcare for Minorities merged with four other organisations in order to become a national institute. In the first chapter of this handbook, in the paragraph titled ‘Een interactief antwoord op huidige knelpunten’ [An interactive answer to current bottlenecks], problematic ‘bottlenecks’ were identified as all relating to the reciprocal lack of information on the part of ‘allochtone patients’ and healthcare providers, and ‘cultural and languages difference’ [
33]. Specifically, it is stated that allochtone patients ‘often know little about the anatomy of the body, the relationship between anxiety and physical complaints, and the structure of the Dutch healthcare system’ and that ‘allochtoons very often present somatic and psychosocial problems’; care providers in turn ‘often lack the necessary knowledge of opinions and expectations of allochtone patients regarding health, (illness-related) behaviour, and treatment’ [
33]. The allochthonous care consultant is perceived to be an interactive answer to these described problems, as the allochthonous care consultants can ‘bridge the differences’ between patients and care providers and ‘better inform each other about the other party’ [
33].
What emerges from the political discourse, policies, and programmes during this period is thus the production of a category, non-Western allochtoons, who are deemed to be culturally and linguistically different, and this difference is problematised, in that it is considered to have negative implications for health and healthcare. For this reason, not only health professionals (as previously seen), but also allochtonous patients became the targets of behavioural change interventions and programming.
‘New style’ health policy and care: an agenda for genetics in care and research
During the analysis of the previous period, it has been demonstrated that perceived cultural and linguistic difference of non-Western allochtoons, compared to Western allochtoons and autochtoons, has emerged as a problematic issue in healthcare. Nevertheless, public services and projects were funded by the national government during this period, and special services for the so-called non-Western allochtoons were available. During the next period, from the mid-2000s to present, we see two new directions in the healthcare policy related to ethnic minorities and migrants—namely, the Integratiebeleid Nieuwe Stijl [New Style Integration Policy] and health-related policies that take into consideration the genetic and biological relevance of ethnicity for research and care.
With its onset during the early and mid-2000s, the New Style Integration Policy (as the policy makers who authored the policy named it) continues the previous discourse and focuses on active
citizenship and individual
responsibility, yet with an even stronger emphasis on cultural adaptation to Dutch society. During this change in discourse, the coordination of integration policies moved from the Ministry of Home Affairs, where it had been for 22 years, to the Ministry of Justice under a new Minister for Alien Affairs and Integration [
17]. Within this new period, intercultural care services, such as health education in a group’s own language and culture and the allochthonous care consultant were increasingly seen as obstructing integration. For instance, in 2011, the current Minister of Health (VWS) Mrs Schippers was asked the following question by parliament member Gerbrands from the Party for Freedom (a right-wing political party):
‘Do you share the opinion that appointing allochthonous care consultants send the wrong signal, namely that the medical world needs to adapt to allochthoons instead of the other way round?’ [
34] (authors’ translation, see
Appendix 2. item D. for original Dutch text).
Health Minister Schipper’ reply exemplifies the political discourse of the New Style period: She states:
‘I am of the opinion that healthcare contributions [premiums] should be spent providing care. Making yourself understandable is the responsibility of people who locate themselves here. If the government and institutions keep providing solutions which reduce the necessity to learn the language, in the long-run the position of the allochthoon will even be damaged’ [
34] (authors’ translation, see
Appendix 2. item E. for original Dutch text)
And indeed, with the onset and development of the New Style Integration Policies and the general retreat of the welfare state in the Netherlands, many institutions, projects, and programmes involved in intercultural care lost their subsidies and so, many closed.
2
What continues to emerge from the current political discourse and policies is the image of the highly problematised non-Western allochtoons, who are culturally and linguistically different and in urgent need of integrating and adapting, as their cultural and linguistic differences are represented as having negative (and one might add, self-inflicted) consequences for their health and their access to healthcare. What is interesting, however, is that while current ‘New Style’ political discourse discourages policies and practices geared toward making healthcare more accessible and intercultural (because cultural and social integration and assimilation into Dutch society are desired), ethnicity is, however, being taken into account in other areas related to health policies and practices. What has emerged is a second shift in focus, away from attending to cultural and linguistic differences towards taking into consideration biological and genetic factors.
Registering ‘ethnicity’ for healthcare and public health research
From 2007 to 2011, the possible registration of ethnicity for healthcare and research purposes was the subject of political and public debate in the Netherlands. This discussion formally started in 2007 when the
Trendanalyse Biotechnologie
3 [Trend analysis Biotechnology] was published, in which ethnicity is named a possible relevant factor in scientific research, genetic diagnosis, and genetic public health research. Based on this report, the then State Secretary of Health (VWS) requested the Organisation for Clinical Genetics Netherlands (VKGN) to inform her whether there was a relationship between ethnicity and genetics and, if so, what the possible consequences on health of this relationship would be [
35] In their reply, the VKGN concluded that ethnicity can be seen as a relevant factor in scientific research, genetics diagnostics, and genetic public health research, because these groups are subject to migration, isolation, selection, and ‘cultural influences’, and thus genetic differences in ‘disease-causing mutations’ among ethnic groups do exist [
36]. However, the VKGN authors also warn that, in practice, it is difficult to deal with ethnicity accurately as there exists no ‘generally accepted division of ethnic groups’ [
36]. In 2008, upon receiving this reply from the VKGN, the then State Secretary of Health (VWS) again sent a letter to the Dutch parliament, in which she stated:
I have informed myself, by the Vereniging van Klinische Genetica Nederland (VKGN) among others, regarding the possible relevance, as presumed in the Trendanalyse, of a possible relationship between genetics and ethnicity for healthcare. The VKGN has come to the conclusion that ethnicity can be a factor in scientific research, genetics diagnostics, and genetics public health research [
37]. (authors’ translation, see
Appendix 2. item F. for original Dutch text).
This letter establishes the genetic relevance of ethnicity, while the ambiguity of categorising ethnicity, as put forth by the VKGN when stating that no ‘generally accepted division of ethnic groups’ exists, is lost. And so, in November of 2011 after receiving additional advice about the legal aspects of registering ethnicity in care and research from the Netherlands Centre for Ethics and Health and the Council for Public Health and Health Care [
37], the Minister of Health pens her final letter on this topic to the Dutch parliament, concluding that it is legally possible to register ethnicity for health research and care when using the existing municipal registration system and electronic patient files [
38]. It is interesting that, during this entire time, exactly what ethnicity actually
is is never defined. However, the use of these particular systems (i.e. the existing municipal registration system and electronic patient files) to conduct scientific health research and for clinical care is crucial to the manner in which ethnicity is defined and co-produced as a
genetic entity deemed scientifically and clinically relevant through these practices.
Namely, when using the existing municipal registration to conduct epidemiological and health research, researchers can link their own data and all kinds of health data available from the Central Bureau of Statistics’ StatLine database to ethnicity by matching (patient) social security numbers to the Dutch municipal registration system. In this municipal registration system, ethnicity is categorised by country-of-origin; it is further subcategorised by the Central Bureau of Statistics into the three categories: autochtoon, Western allochtoon, and non-Western allochtoon [
39]. Thus, the establishment of ethnicity as a genetically relevant entity through policy formation, the subsequent possibilities for registering ethnicity in research and care, and the municipal registration system operative during the process when this policy was formulated resulted in the scientific reproduction of politically produced categories and worked in tandem to co-produce the particular categories autochtoon, Western allochtoon, and non-Western allochtoon as genetically relevant categories applicable to certain groups of people.