Talking about public health in Europe today also means talking about migration. Nowadays, according to the World Health Organization (WHO), 73 million migrants are estimated to be living in the European Region, accounting for nearly 8 percent of the total population, and 11 million immigrants have arrived in Europe in 2013. The point is that the word immigration has several meanings: it means people who choose to come and live in Europe for study and work; it means the difficult stories of those who have to leave their families to come to work as a domestic worker; last but not least, it means fleets of people crammed into small boats putting their lives in the hands of luck. This last phenomenon represents one of the biggest challenge for European health policy.
Although involving the whole of Europe, the problem of the ongoing management of migration flows does not affect all countries equally. Since the beginning of the crisis in North Africa in 2011, the Mediterranean countries have been experiencing a continuous state of emergency, due to the uncontrolled arrival of migrants fleeing from their countries, and the weakness of the infrastructure, often incapable to stem such a phenomenon. Although some places in the Mediterranean area are at the centre of the migratory routes, Italy was not the country with the largest number of immigrants in 2013.
In fact, according to WHO, France, Germany, the UK and Sweden have welcomed many more immigrants in 2013 than Italy. And even if we consider the totality of migration worldwide, Italy is not on the top of the rank.
Three types of migration throughout Europe
“We see a particular phenomenon, which is the presence of three Europe, depending on the type of migration that we consider,” says Santino Severoni, Public Health and Migration Coordinator of the WHO European Office for Investment for Health and Development. The whole area of the former Soviet Union is substantially affected by a migration triggered by economic reasons and people usually speaks the same language of the receiving country. On the other hand, in Northern Europe the majority of migrants is made up by asylum seekers and people aiming to stay there. Instead, Southern Europe is facing a difficult humanitarian situation. Severoni explains that the challenge is to plan a series of infrastructure that allow to cope with the humanitarian situation without needing a permanent state of emergency.
The chart below tells another facet of the differences in immigration that characterize the different European states. We observe, for example, that in Italy 85 percent of the 92,000 immigrants are refugees, while only the remaining 15 percent is made up of asylum seekers. The difference is substantial, even with respect to the issue of health. Refugee status is applied in cases where there is a fear that a person may be persecuted in his country of origin. It implies a residence permit that lasts for two years and is renewable, and it obligates foreigners to subscribe to the national health service. Instead, asylum seekers have the right of staying in Italy for a long time if fundamental freedoms are denied in their country of origin. At the same time, however, the protection afforded by the state is more restricted.
Concerning the differences between countries, data highlight that, in Greece, only 5 percent of the immigrants – which were 73,000 in 2013 – are refugees, with the big chunk being represented by asylum seekers. In Germany and Spain the situation is very different compared to our country, which is why – as it is clear from Severoni’s words – an international coordination seems necessary in order to take into account the structural diversity of different countries in terms of health policies.
WHO: Italy leads a European pilot project
Beyond numbers and comparisons, in Italy, in recent years, immigration is a problem, even for public health.
There is a widespread call for international aid coordination at the European level that can help to meet the demand of those fleeing war without bringing down entire islands, as often happens in Lampedusa. Our country has promoted and entirely funded a special office within the World Health Organization, for a total of 1.8 million Euros over three years, since 2011. Unfortunately, few words have been dedicated to such an initiative by Italian media and the existence of the project is little known. "The office was created in 2011, when we realized that the North African crisis that was emerging in Europe, would soon be translated into immigration crisis," Severoni says.
The project is implemented under the new policy framework for the WHO European Health for Health 2020. The goal? To identify success stories that could be achieved in other countries, making accurate information about the actual likelihood that immigration brings to the public health of the host country and address the different legal scenarios that determine access to health services by migrants, in order to stem the spread of infections.
Not emergency, but planning
"What I think is the crucial point,” continues Severoni, “is that the immigration issue is treated as an emergency, when in fact it should be handled as a part of public planning. It’s just a different view of the problem and we intend to work on that. This happens because declaring an emergency means having instant access to extra funding without resorting to bureaucracy. In Sicily we are doing an amazing job. Other European countries like Malta and Portugal, with Spain being the next one, are taking inspiration from the Italian program."
The case of tuberculosis
“Lastly, another important point is represented by the Health Information System, for instance concerning communicable diseases,” explains Severoni. “Perhaps the most significant example in this sense is the case of tuberculosis.”
It is true that tuberculosis continues to be a major public health problem, but it is equally true that the real problem for Europe. is represented by the poor hygienic and sanitary conditions in which migrants have to live as soon as they hit the ground. “Regarding tuberculosis, we register only two cases over 10 thousand migrants,” Severoni says. “Furthermore, with regard to infectious diseases, it is not easy to have a clear overview of the situation since data are often not comparable. Although TBC among migrants is occasionally highlighted as problematic by political or populist movements, actually there is a lack of data to indicate significant TBC transmission from migrants to the native population; the majority of the studies indicates that the transmission of TBC occurs within migrant communities themselves.“For this reason, the aim is to involve all the stakeholders: the Ministry of the Internal Affairs, prefectures, the army abroad. The impact of migration on public health depends on decisions made by different sectors that need to communicate” Severoni says.
“For example, in some countries regulations require that migrants who have done research for asylum should be kept closed in shelters, some with only one hour of exercise per day, so make them unable to escape. In cases like these, WHO has reported the development of mental illnesses related to these stringent conditions.”