Characteristics of undocumented migrant participants and their health complaints
The undocumented migrant participants had a mean age of 30 years for 'overstayers' and 38 years for 'failed asylum seekers'. The group of 'overstayers' had been in Denmark as undocumented migrants for a mean duration of 1.5 years compared with 4.5 years for the group of 'failed asylum seekers'. Table
1 gives an overview of the characteristics of the undocumented migrant participants, including health complaints and received treatments while undocumented in Denmark.
Table 1
Characteristics of undocumented migrant participants
P01 | Bangladeshi | Male | 31-40 | Failed asylum seeker | Dental problems, mental health problems | None |
P02 | Bangladeshi | Male | 31-40 | Failed asylum seeker | Superficial wounds after assault, asthma | Prescription for medication from general practitioner |
P03 | Bangladeshi | Male | 21-30 | Failed asylum seeker | Psoriasis, mental health problems | Treatment for psoriasis through informal networks of healthcare professionals and at a hospital dermatology department |
P04 | Bangladeshi | Male | 41-50 | Failed asylum seeker | Leg fracture, mental health problems, cancer suspicion | Treatment for a leg fracture at hospital ER, check-up at hospital oncology department |
P05 | Indian | Male | 41-50 | Failed asylum seeker | Diabetes, high blood pressure, heart disease, mental health problems | Treatment for depression through informal networks of healthcare professionals. Medical supplies through personal networks |
P06 | Indian | Male | 31-40 | Overstayer | Dental problems, ulcer, sprained foot, mental health problems | Treatment for a sprained foot at hospital ER |
P07 | Nepali | Male | 21-30 | Overstayer | None | None |
P08 | Nepali | Male | 31-40 | Overstayer | Dental problems, mental health problems | None |
P09 | Nepali | Male | 21-30 | Overstayer | Sprained hand, skin allergy | None |
P10 | Nepali | Male | 21-30 | Overstayer | Mental health problems | None |
Participants reported a variety of acute and chronic illnesses and health needs while living as undocumented migrants in Denmark. Mental health issues were predominant and the majority of undocumented migrant participants reported that the conditions of living with an irregular migratory status induced mental health problems, including generalised stress, anxiety and depression:
"You don't even have your identity. You've lost your home, you've lost your relatives, you've lost your mother tongue, you've lost your culture and friends ... so if you speak about stress, this is also stress. If you think about pain ... what is pain? I cannot explain what pain is." (Participant 5)
Participants also experienced stress from the insecurity of not having regular employment, not knowing what do to in the case of severe illness or if caught by the police as well as pressure from relatives in home countries who expected regular supplies of money.
Undocumented migrants' experiences of access to the Danish healthcare system and alternative health-seeking strategies
Four undocumented migrants had experienced accessing the Danish healthcare system for a variety of health complaints. In all cases they were accompanied by Danish citizens, whom they mentioned as a key factor in obtaining healthcare. In the following quote, the participant describes an episode where he went to a Danish friend's general practitioner and obtained a prescription for asthma medication:
"No, that was not a problem [to obtain treatment], because one of my friends was with me. It was not a problem, by a coincidence it was his personal doctor." (Participant 2)
Participant 2 explained how they told the general practitioner that he was a tourist who therefore did not have a health insurance card, and thereby obtained a medical examination.
In the following quote, a Bangladeshi participant describes an episode where he received treatment at a hospital emergency room after he had an accident at work, where an industrial food mixer had fallen and fractured his leg:
"[my Danish friend] did all the talking with the doctor, then I got the bandage on and I got crutches ... These doctors and nurses are not only human beings, they are like Gods. Within five minutes I was taken in and then X-rayed. The doctor gave me all the instructions I needed: that I had to stay in bed for 14 days and then it would be all right." (Participant 4)
Undocumented migrants who obtained treatment expressed deep gratitude towards those healthcare professionals who would treat them despite their irregular migratory status. Participant 4, who does not speak Danish and only poor English, emphasised the necessity of the Danish friend who played a central role as a mediator in both explaining needs and negotiating the terms of care.
Factors influencing access to healthcare
Some undocumented migrant participants expressed uncertainty about their possibilities of obtaining healthcare in Denmark, including the right to emergency treatment, while others knew of ways of obtaining treatment. The following shows two participants' replies when questioned about the possibilities of medical treatment for undocumented migrants in Denmark:
"After I'm out of the [asylum] system, where can I go? It's not possible in Denmark to go to a doctor or hospital." (Participant 1)
This participant also said that undocumented migrants have no right to healthcare in Denmark and they would therefore not seek any treatment within the Danish healthcare system. Moreover, this participant did not know of any informal networks of healthcare professionals from which he could seek treatment; he would rely solely on staff from the 'Copenhagen NGO'.
Another participant said that it was not possible for undocumented migrants to access the Danish healthcare system but, contrary to Participant 1, he knew of informal networks of doctors which he had made use of once:
"No way, not when you are blacklisted, when you are underground you cannot, but I know that some organisations are working." (Participant 5)
This participant considered himself a 'fortunate person' because he knew of informal networks of doctors, which he said might not be the case for other undocumented migrants.
We found that fear of being reported to the police was the primary barrier to undocumented migrants seeking healthcare:
"If I go to the doctor and the doctor is a very good Danish person, a good citizen, then maybe he will call the police. And then I would be handed over to the police and then I would have a great problem. Then my life is risky." (Participant 5)
This quote reveals a contradiction in how migrants view 'good Danish citizens', who on the one hand are 'good' if they uphold their civic duty by not aiding undocumented migrants and reporting irregularities to the authorities, but on the other hand are viewed as 'good' if they defy these duties and do provide care.
The perceived severity and urgency of the illness condition appears to be a decisive factor as to whether undocumented migrants choose to seek medical attention:
"I think that if they [healthcare professionals] think it [my health problem] is not so serious, then maybe they will contact the police because I have no ID card and then I will get into more trouble." (Participant 4)
This participant was under the impression that the likelihood of receiving care was proportional to the severity of the condition, and that healthcare professionals take this into account when considering whether to provide care. In the following quote, another participant replies as to whether he would seek medical attention for conditions that are not urgent:
"Normal problem you mean? Like fever or something else ... You don't bother to go to a doctor. You just buy some panodil [paracetamol] from the supermarket and then eat it ... Only thing is if they [undocumented migrants] don't have anything to do [any other option] they need to go to a doctor and that is the doctors' decision what they are going to call police or not. That is totally up to them actually." (Participant 2)
The undocumented migrant participants underlined that any contact with the authorities could ultimately result in deportation. Accordingly participants were wary of situations that could compromise their safety, for example, they would carefully consider whether any illness was sufficiently severe to warrant medical attention. Likewise participants stated that they were reluctant to seek attention for conditions which they in their home countries normally would not hesitate to be examined for.
Another barrier may be arbitrariness in healthcare professionals' attitudes towards treatment of undocumented migrants. This is illustrated by a participant who contacted a dermatology department to enquire about the possibilities of medical treatment for psoriasis:
"He was quite an important doctor. He said: If you don't show the card then you do not get a file. He said: Okay, I can treat you today, but next [time] the doctor will change, and he may not be willing to treat you." (Participant 3)
When such experiences are spread around within the undocumented migrant community, it contributes to the perception that visits to the healthcare system may not always result in treatment, and further emphasises the need for alternative health-seeking strategies.
One participant described how language and cultural differences may place undocumented migrants in a more vulnerable position and obstruct access to healthcare:
"Most of the illegal immigrants can't speak the language [Danish] and not even English. They need to have some person with them who can explain about them or else they will be in a big trap down there. Language miscommunication; maybe the doctor wants to ask something and he can't answer and everything will be ... It will not work in that way." (Participant 2)
In addition language and cultural differences may be connected to low health literacy, where the lack of ability to navigate and negotiate in a complex healthcare system may construct barriers of access for undocumented migrants.
Thus, the participants reported different factors influencing access to healthcare and affecting how they responded to illness and health needs.
Alternative health-seeking strategies
Problems in accessing healthcare may give rise to alternative health-seeking strategies.
The majority of undocumented migrant participants recounted situations where they had postponed or avoided contact with healthcare professionals and instead had used alternative treatment methods:
"They [undocumented migrants] are just their own doctors. They just take the medicine. Perhaps they have just called Bangladesh or their own country and have called their doctor or their parents and have explained the problem to that doctor, and perhaps that doctor told them that you should take this kind of medicine." (Participant 2)
Participants said that it was common for undocumented migrants to contact doctors in their home countries for medical advice and for persons in their network to bring medicine from their home countries. None of the participants expressed concern in regard to receiving long-distance examinations, but viewed it as safe and easy way to gain medical advice.
Participant 5, who had high blood pressure and a heart disease, explained how fear prevented him from entering the healthcare system for a check-up and how instead he made use of an old prescription for heart medicine:
"I need regular treatment, but I did not have regular treatment. So I used the prescription from when I was an asylum seeker, which is not so good for the health, because you know, the prescription has to change [...] So from the beginning, if I get the same medicine for a long time it is like a poison. So in that way I was taking poison, but I did not have any other way." (Participant 5)
This participant was able to procure the necessary medicine through persons in his network who had contact with heart patients with extra tablets or buy them on the illegal drug marked in Copenhagen. He was fully aware that it could be potentially harmful to use an old prescription without receiving any medical follow-up or adjustments, but yet he did not see any other options.
In the following quote, the participant recounted how he had noticed a growth and had suspected it to be cancer but waited eight months before finding a way to get an examination:
"I had kind of a growth here. It took eight months for me to get in. Some experts looked at me. I was afraid that it was cancer, but the doctor said it is not cancer." (Participant 4)
Likewise, other undocumented migrant participants reported being aware of all symptoms, even minor symptoms. They emphasised the importance of good self-care when healthcare is not easily available. This quote also illustrates the stress which undocumented migrants may experience when not being able to obtain certainty about medical conditions. Again, in this case, the delay of treatment was influenced by this participants' inability to procure a Danish citizen that could help him seek medical attention.
ER nurses' experiences in encounters with undocumented migrants
ER nurses from three out of four hospitals had either themselves or knew of colleagues who had provided healthcare for undocumented migrants or for persons whom they suspected were undocumented migrants. The nurses reported that undocumented migrants seldom appeared in the ER; nevertheless, they could be characterised by a treatment-seeking pattern that differed from that of most other patients. It was found that undocumented migrants sometimes delayed treatment and that they appeared insecure and preferred quick treatment to being hospitalised:
"A couple of months ago a person [undocumented migrant] came in with a really nasty, infected wound. I am guessing that it was from a dog bite. It was on the right thigh and it was badly infected. He was reddish and had a fever, so we recommended that he was hospitalised and treated with intravenous antibiotics. But he didn't want that. So in the end we patched up his wounds and then sent him away with a prescription for penicillin." (ER nurse 2)
All interviewed ER nurses expressed that nurses have a duty to treat all patients in need of medical care regardless of whether the patient is an undocumented migrant. Thus it was underlined that non-discriminatory care and patient confidentiality is a matter of professional integrity:
"Those who come here have the right to be treated. And whether they are here legally or not, that must be up to some other authorities to decide. That is not up to us to decide." (ER nurse 5)
Similarly, another ER nurse said:
"The moment I put on my nurse's coat I am a nurse and have a duty to treat whoever comes." (ER nurse 7)
However, arbitrariness in healthcare professionals' attitudes towards treatment of undocumented migrants was described in one interview where the nurse recounted an episode where the police were contacted:
"This colleague of mine, I don't know if she was afraid or felt insecure or just thought that he [undocumented migrant] shouldn't be allowed to be here. In any case she called the police and they came. And the end of it was that he got the medical treatment and was then subsequently arrested and taken away." (ER nurse 2)
This episode gave rise to internal discussions among the nurses about whether it was acceptable that the police had been contacted. ER nurse 2 described how opposing opinions clashed in later discussions between the nurses and how the matter remained unresolved, which she imputed to the lack of internal guidelines:
"Our heads of departments have not issued any common guidelines on how to act in such a situation. But I also think the problem is that they have just as much difficulty in giving out any common guidelines, because you can say that it is an area where legally we stand very weak. And it is because, according to the law, that somewhere we have an obligation to contact the police and say: well, this is a violation of the law. And then we have the oath of confidentiality which does not permit us to contact the police, and then you can discuss what weighs heaviest." (ER nurse 2)
This quote shows the contradiction between the conception of being loyal to law, implying that it is a civic duty to notify the authorities of persons residing illegally in the country, and then the professional obligation to always act in the patients' best interest. This nurse touched upon the discrepancy between the law and codes of medical ethics which may create uncertainty about their position when encountering undocumented migrants. Furthermore, these uncertainties are amplified by nonexistent policies and guidelines within the organisation, which may make it difficult for the healthcare professionals to navigate.
Challenges for ER nurses in treating undocumented migrants
ER nurses reported possible challenges in treating undocumented migrants, including language barriers and undocumented migrants' lack of trust in the healthcare system, which may cause them to be less informative about their situation and illness. One nurse mentioned insecurities regarding the correct standard procedures and expressed a need for guidelines on how to respond to undocumented migrants, while the remaining nurses expressed that they considered guidelines were already implicitly included in codes of medical ethics. Another challenge concerned undocumented migrants who in an attempt to obtain healthcare professed a false identity by using another person's health insurance card:
"If you are scanned for pain in the abdomen and the person you have borrowed the health insurance card from has had his appendix removed, then we might say to ourselves: well, then it is not appendicitis and then you could die from a perforated appendix. So, of course it is dangerous. But it is also really, really foolish ... then it is better to say that you do not have any [health insurance card]." (ER nurse 3)
The nurses explained that this practice may ultimately have fatal consequences, and they underlined the importance of explaining to those patients that they could be treated anonymously.