Elsevier

Social Science & Medicine

Volume 120, November 2014, Pages 352-359
Social Science & Medicine

Performing deservingness. Humanitarian health care provision for migrants in Germany

https://doi.org/10.1016/j.socscimed.2014.04.046Get rights and content

Highlights

  • Humanitarian aid for migrant patients can have unintended negative side-effects.

  • Humanitarian aid differentiates between deserving and undeserving patients.

  • Physicians may deny treatments to patients who do not match their expectations.

  • Migrants learn to perform the role of the docile, thankful and undemanding patient.

  • Patient autonomy and shared decision-making are significantly restricted.

Abstract

In this paper, I critically investigate humanitarian aid for migrant populations in Germany. I aim to enhance the existing literature on migrant deservingness and humanitarian aid by focusing on the performative aspects of concrete face-to-face interactions between physicians/volunteers and patients. I argue that despite efforts of volunteers to provide non-discriminatory care, the encounters between patients as aid-receivers and volunteers/physicians as aid-providers are inevitably shaped by power inequalities. These immanent power inequalities may lead patients to perform their deservingness, that is, to present themselves as helpless sufferers rather than empowered subjects. Simultaneously, patient-solicitants are prevented from feeling and enacting a sense of entitlement. Those patients who do not heed to the social mechanisms of humanitarian aid, such as being thankful and humble, cause disenchantment on the side of some medical professionals who provide care as part of humanitarian networks and subsequently, they may be turned away.

The research project focused on the migration trajectories and illness experiences of undocumented Latin American migrants and their access to healthcare. The analysis draws on my long-term ethnographic fieldwork with 35 Latin American migrants in Berlin (2008–2011), 22 interviews with healthcare providers, and my experience as an activist/volunteer for a Berlin-based humanitarian NGO (2008–2012).

Introduction

In this paper, I critically investigate humanitarian aid for migrant populations in Germany. My analysis builds on the literature on the health-related deservingness of migrants, which has been defined as “migrants” shifting and historically produced experiences of socio-political exclusion from their countries of residence, often leading them to be portrayed as unwanted, undesirable, and unworthy of services” (Castañeda, 2012: 830). Despite a growing scholarly interest in this topic, the academic literature is still relatively sparse (cf. Willen, 2012). Recent ethnographic studies have documented the construction and treatment of undocumented migrants as undeserving of public health services for example in France (Larchanché, 2012), Israel (Willen, 2012, Rosenthal, 2007), the U.S. (Heyman et al., 2009), Costa Rica (Goldade, 2009) and Germany (Castañeda, 2009, Huschke, 2013). In the literature, the process of constructing deservingness is contrasted with entitlement, the formal and legal stipulation of a right to receive medical care (Fassin, 2001, Willen, 2012: 813–4). This juxtaposition of deservingness and entitlement is central for analysis of the interactions between volunteers/physicians and patients in humanitarian encounters developed in this paper.

In my analysis, I focus on the performative aspects of giving and receiving humanitarian aid to highlight the intersubjective, dynamic ways in which deservingness is enacted in the encounter between patient-solicitants and physician-patrons or volunteer-patrons. The role of the patient's performance and the enactment of deservingness have not yet received much attention within social science and medical research. I therefore draw on literature regarding welfare distribution more generally which shows that docile, passive and shameful clients receive preferential treatment compared to demanding ones (e.g. de Swaan, 1988, Will, 1993, Yoo, 2008). By using the terms patient-solicitant and physician-patron (or volunteer-patron, depending on the context) in my discussion I aim to stress the relevance of the power inequality between patients and physicians/volunteers that is codified in the humanitarian healthcare provided to migrants: the patient presents a plea for help which is assessed by the volunteer and/or physician and that can be granted or denied in any given interaction. Humanitarianism is founded on an inequality of lives (Fassin, 2010) and inevitably implies the discursive and interactional construction of deservingness. Humanitarian practice constitutes a “voluntary expression of human decency and solidarity in the face of suffering” (Stellmach, 2010: 2, emphasis added), and thus, the question of who should receive what kind of care is continuously negotiated and defined in the concrete humanitarian encounter. Consequently, humanitarianism – as a form of charity – “is always discretionary” (Fassin, 2001: 469).

The importance of a solicitant's performance in humanitarian spaces of care and control has been addressed for example by Ticktin in her analysis of undocumented migrants' struggle to obtain legal status based on their illness in France. Ticktin points out that “a face-to-face encounter allows for performances on both sides, and if one does not perform in the desired manner, one may be penalized and excluded” (Ticktin, 2006: 43). Furthermore, Larchanché (2012) investigated undocumented migrants' access to health care in France, and draws out how “intangible factors” such as social stigmatization and an atmosphere of fear created by restrictive migration regimes contribute significantly to migrants' self-perception and their (lack of a) sense of entitlement on one hand, and on the other hand, lead government officials in charge of handling migrants' claims to perceive them as undeserving. Although these authors mention the importance of a solicitant's performance, they are predominantly concerned with the question of how socio-political constructions – or categorizations – of more or less deserving migrants as well as predominant stereotypes about different migrant groups shape clinical practice (cf. Jubany, 2011, Grove and Zwi, 2006, Fox, 2001: 282). Their focus lies on the discursive construction of deservingness prior to or outside of the actual interaction between a state official or a physician and the patient.

In this paper, I aim to expand these investigations of humanitarian encounters and analyses of migrant deservingness by focusing on the concrete face-to-face interactions between physicians/volunteers and patients, thereby providing an in-depth discussion of how a patient's performance in the humanitarian space of migrant health care contributes to her/his perception as deserving or undeserving. I argue that despite efforts of volunteer-activists to provide non-discriminatory care, the encounters between patients as aid-receivers and volunteers/physicians as aid-providers are inevitably shaped by power inequalities. These immanent power inequalities may lead patients to perform their deservingness, that is, to present themselves as helpless sufferers rather than empowered subjects. Simultaneously, patient-solicitants are prevented from feeling and enacting a sense of entitlement. Those patients who do not heed to these social mechanisms of humanitarian aid cause disenchantment on the side of some aid-providers and subsequently, they may be turned away by medical professionals or hospital staff collaborating with humanitarian NGOs.

My analysis is grounded in ethnographic fieldwork on healthcare for undocumented Latin American migrants in Berlin as well as in my experience as a volunteer for one of the humanitarian organizations providing medical assistance to migrants. The implications of the dual role are discussed in more detail below. First, however, I will describe the humanitarian organizations working in the field of migrant health and the migrant groups they attend to.

Section snippets

Research background

The vast majority of people living in Germany are covered by health insurance (Statistisches Bundesamt, 2008), which in turn facilitates access to comprehensive medical care. When seeking medical assistance in a private practice or a hospital, patients are asked for their insurance card before seeing the physician. Everyone residing in Germany is legally required to be insured, and social benefits for legal residents with low or no income include statutory health insurance. Out-of-pocket

Methods

This paper is based, first, on ethnographic fieldwork (2008–2010) with undocumented Latin American migrants in Berlin. The aim of the research project was to understand undocumented migrants' illness experiences and health-seeking practices in the context of their everyday lives and their marginal position within German society. In total, 35 (currently as well as previously undocumented) Latin American migrants took part in my research project. The Latin American community in Berlin is

Real pain and trivial concerns

During office hours, Medibüro volunteers would usually see between 10 and 20 patients. On our arrival at the office, several people would already be sitting outside in the hallway, hoping to be one of the first people allowed in. One after another, we would then ask patients into the small, crammed office that fits no more than a table with a phone, a few chairs, and a shelf for our documents. The only question we would then ask patients is: “How can we help?” or “What's the issue?” Patients

Deportability and migrants' sense of entitlement

The cases presented above of patients who are deemed too demanding by medical professionals and the voices of undocumented Latin American migrants who are worried about being viewed as too demanding and being turned away as a consequence constitute two sides of the same coin: in both cases, the actors involved refer to the concept of making (or not making) demands and feeling (or not feeling) entitled to receive a certain kind of care as a crucial aspect of the interaction between the

Conclusion

In this paper, I have provided an analysis of the concrete interactions between volunteers/physicians and patients in one of the humanitarian organizations providing healthcare to undocumented and uninsured migrants in Germany, thus enhancing the existing literature on deservingness in the context of healthcare provision by focusing on the performative aspects of humanitarian practices. I have discussed interactions between patrons and solicitants, aid-providers and aid-receivers in

Acknowledgements

The research was funded by a doctoral grant (2008–2011) from Hans-Böckler-Stiftung. Earlier versions of this paper were discussed with the participants of the Working Group Medical Anthropology at the Institute of Social and Cultural Anthropology, Freie Universität Berlin, and presented at a workshop with Miriam Ticktin and Heide Castañeda, entitled “The Double Face of Humanitarian Aid” at the Institute of European Ethnology, Humboldt-Universität Berlin, in 2012. I thank Ruari McBride, Claire

References (36)

  • R. D'Andrade

    Moral models in anthropology

    Curr. Anthropol.

    (1995)
  • N. De Genova

    Migrant “illegality” and deportability in everyday life

    Annu. Rev. Anthropol.

    (2002)
  • A. de Swaan

    In Care of the State

    (1988)
  • D. Fassin

    Charité bien ordonnée: principes de justice et pratiques de jugement dans l'attribution des aides d'urgence

    Rev. Fr. Sociol.

    (2001)
  • D. Fassin

    Social illegitimacy as a foundation of health inequality. How the political treatment of immigrants illuminates a French paradox

  • D. Fassin

    Inequality of lives, hierarchies of humanity. moral commitments and ethical dilemmas of humanitarianism

  • F. Fox

    New humanitarianism: does it provide a moral banner for the 21st century?

    Disasters

    (2001)
  • L. Goldade

    “Health is hard here” or “health for all”? The politics of blame, gender, and healthcare for undocumented Nicaraguan migrants in Costa Rica

    Med. Anthropol. Q.

    (2009)
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