October, 2017
Michael Knipper| University of Giessen and Vivian Mannheimer | HCSM blog
Dr. Michael Knipper, researcher at the Institute for the History of Medicine, University of Giessen, is an expert in the relationship between migration and health.
On September 24th, Angela Merkel has won four more years as chancellor after her center CDU/CSU alliance got a 33% of the vote in federal elections. This was her party’s worst performance with her as leader and for the first time since 1945 a far-right party, the AfD, could enter German parliament, becoming the third force in the Bundestag.
Some may say that the conservative rise is related to Merkel’s decision in 2015 to open the German border to refugees.
To shed some light on the country’s immigration policies, mainly those related to health, we invited Dr. Michel Knipper, of the Institute of the History of Medicine at the University of Giessen, Germany.
Knipper talked about the contradictions of the current immigration policies, the intercultural health programs and how the rise of conservative forces can affect the new German government on these issues.
Nowadays, health is a largely neglected dimension of immigration and integration policy in Germany. Generally speaking, the priority is still on public health in a somewhat old-fashioned way: to safeguard population health with major concern for infectious disease control and rather little attention to individual health needs beyond emergency care.
Due to limited legal entitlements and severe bureaucratic barriers, access to health care for refugees and asylum seekers is restricted for the first 15 months of stay in Germany.[1] [2] This leads to avoidable harm and suffering, but also to higher economic costs for the taxpayer, as research has shown recently.[3] However, the government of chancellor Angela Merkel has not shown real interest in improving this situation. [4]
Even worse: recent reforms of federal migration policies explicitly lowered the standard of health protection for refugees in case of deportation: mental health issues, like Post-Traumatic Stress Disorder (PTSD), are no longer considered as impediments for deportation. The most vulnerable have to bear the consequences of a migration policy committed first and foremost to deter refugees and asylum seekers from entering Germany and to increase the number of deportations – at all costs.
Do you believe the policy towards immigrants will change in Germany after the election?
Some weeks after the elections, the situation remains unclear: A paradigm shift would be needed to align migrant health policies with human rights standards instead of subordinating health of migrants – and their prospects for a healthy future and integration – to shortsighted political goals.
But will a new government be willing and able to develop – finally – a coherent migration policy, based on fundamental values, international law and a candid analysis of migration and human mobility in the past, present, and future?
Some weeks after the elections, the situation remains unclear: A paradigm shift would be needed to align migrant health policies with human rights standards instead of subordinating health of migrants – and their prospects for a healthy future and integration – to shortsighted political goals.
But will a new government be willing to develop – finally – a coherent migration policy, based on fundamental values and a candid analysis of migration and human mobility in the past, present, and future?
Personally, I’m pretty sure that in Merkel’s Christian Democratic Party (CDU) and even in its Bavarian sister-party CSU (supposed to be particularly traditional and conservative), many would be ready to embrace this perspective. Moreover, both Liberals and Greens – the two parties in process to prepare the new coalition government with chancellor Merkel – are committed to a progressive migration policy.
Berlin, 20 June 2015. A demonstration marking the World Refugee Day. Der Spiegel
I’m afraid, however, that the self-proclaimed “conservatives” in Merkel’s party and the CSU will oppose any improvement. Under the leadership of Bavarian’s prime minister Horst Seehofer, conservatives heavily attacked Merkel’s decision to keep Germany receptive to refugees in 2015, encouraging adverse attitudes towards migrants and refugees, as well as against Angela Merkel herself.
The chancellor, however, did little to oppose these activities and to defend her initially receptive position with arguments and explanations. There is reason to believe that Merkel’s elusiveness coupled with the populist discourse of her fellow conservatives made for the great losses of CDU and CSU in the elections, and pushed the radical-right, neo-fascist “Alternative für Deutschland” (AfD) to earn 12.6 percentage points.
For the creation of the new government, the desperate attempts of German conservatives to keep up with AfD-populism and to push Merkel’s party even more to the “right” is truly the biggest obstacle.
What I think is missing, actually, is chancellor Merkel and the moderate voices in her party challenging Seehofer and his anxious followers with arguments and with the one basic question: What does “being conservative” actually mean today, at the beginning of the 21st century, and in one of the most powerful and wealthy European democracies?
The inconsistency of the conservative’s position behind the clamor and strong rhetoric is embarrassing, for its destructive and harmful consequences for German politics and the real lives of real people.
Conservatives claim to set high value on the “family” as the nucleus of society, yet at the same time reject family unification of Syrian refugees – ignoring humanitarian and human rights standards and all evidence regarding the positive impact of family reunification for social integration (and the detrimental effects for men, woman and children of being separated from their families).
Conservatives advocate for the “rule of law”, yet largely ignoring severe shortcomings in the asylum application process, and the fact that German migration policy – e.g. in the field of health – does not comply with international human rights standards like anti-discrimination and the “human right to health”.
Do they really think that global conflicts and global migration will bypass German or European borders because of the unease of German voters and provincial politicians? Do they really think that populism, parochialism, and an only selective adoption of human rights and international legal standards will provide for a peaceful future in Germany and globally?
A serious discussion is overdue in Merkel’s two sister parties, whether “conservative” is identical to backwardness, crude nationalism, and xenophobia – or not. Unfortunately, the future policy towards immigrants depends on these unsolved problems within CDU and CSU.
What was the difference between Germany and other European countries regarding immigrants?
The current situation in Germany is probably even more contradictory than in other European countries, although they all show a painful inconsistency between rhetoric commitments to human rights and “European values” on the one hand, and real politics on the other.
In Germany, we have the huge contrast between receiving and welcoming more than a million refugees since 2015, with long lasting support and commitment by large parts of civil society until now, and a very restrictive policy and legal framework. Receiving and integrating such a large number of refugees is actually not an easy task. Yet German laws and current policies, as well as the structures build upon these laws, make the lives of asylum seekers (and the work of volunteers, supporters and health professionals) unnecessarily difficult.
Both dimensions of this contradictory situation have their roots, I think, in the historical experience of the early 1990s: In the years after the unification, large numbers of refugees from East Europe and former Yugoslavia entered Germany, about 430.000 only in 1992. In response, the previously liberal asylum laws were transformed into the far more restrictive framework that we are having today.
In the same years of the early 1990s, open violence and hate crimes against refugees horrified the German society, just as the ascension of a new party at the radical-right. When in 2014 and early 2015, a new wave of incidents against refugees occurred, including arson attacks on reception centers, large parts of the German population decided to take a stand and to prevent this from happening again.
In my eyes, the German “welcome culture” and receptiveness for refugees since 2015 was not only a humanitarian gesture, but also a response to the historical experience of the Nazi period (when large numbers of Jews and other Germans had to flee oppression, persecution and terror), of post-war displacements (also affecting huge numbers of German families), and of the more recent incidents in the 1990s.
Independent of all right-wing clamors of the last years, the humanitarian support and activism for refugees by civil society is still strong. What is lacking, though, is to transfer the humanitarian impulse and volunteer’s activism into a coherent and solid, rights-based policy. It will be interesting to see if the new government will actually pursue this task.
What is the relevance of intercultural health programs in Germany today?
Independent of the recent migratory movements, more than 20% of the German population is considered having a “migration background”. Social and cultural diversity are topics of high relevance in Germany, and so are intercultural health programs.
The situation in hospitals and health services, however, does not correspond to the needs. At some places and in some institutions, intercultural health programs are well established, with good availability of linguistic and cultural mediators, for example.
At other places, in contrast, this is not the case. There is no systematic policy in place, like for example in Switzerland. It’s a highly fragmented situation. [1] The responsiveness of health services to the social reality of our society still relies on local or individual initiatives, engaged public authorities or companies.
The pattern is the same as described above: The lack of political leadership and of a systematic and coherent institutional response is partly compensated by civil society. A comprehensive strategy is needed for preparing the health system to better serve all inhabitants of Germany today and in future – without discrimination and avoidable harm.
“Health for All in the 21st Century” is not only an issue for countries in the global south! And different to 1978, Germany should not ignore this proposition again.
[1] Knipper M, Razum O, Brenne S, Borde T, Kluge U, Markus I. MIPEX Health Strand: Country Report Germany. 2017. http://equi-health.eea.iom.int/images/MIPEX/GERMANY_MIPEX_Health.pdf
[2] Razum O, Wenner J, Bozorgmehr K (2016) Wenn Zufall uber den Zugang zur Ge-sundheitsversorgung bestimmt: Gefluchtete in Deutschland. Gesundheitswesen. doi:10.1055/s-0042-116231
[3] Bozorgmehr K, Razum O (2015) Effect of Restricting Access to Health Care on Health Expenditures among Asylum-Seekers and Refugees: A Quasi-Experimental Study in Germany, 1994-2013. PLoS One 10(7):e0131483. doi:10.1371/journal.pone.0131483
[4] Kickbusch I, Franz C, Holzscheiter A, Hunger I, Jahn A, Köhler C, Razum O, Schmidt J-O (2017) Germany’s expanding role in global health. The Lancet 2017; 390: 898–912
How to cite this interview:
Knipper, M; Mannheimer, V. The new Bundestag: refugees and health. História, Ciências, Saúde – Manguinhos blog, 2017. http://www.revistahcsm.coc.fiocruz.br/english/the-new-bundestag-refugees-and-health/
Related papers in HCS-Manguinhos:
Santos, Fabiane Vinente dos. The inclusion of international migrants in Brazilian healthcare system policies: the case of Haitians in the state of Amazonas. Hist. cienc. saude-Manguinhos, Jun 2016, vol.23, no.2, p.477-494. ISSN 0104-5970
Global Public health and National Security: an historical perspective – Patrick Zylberman analyzes the impact of war, religion and migration in global health.
