Complex entanglements: migration and health in Austria (AT)
Written by Agnes Raschauer
Text reference: Kutalek, Ruth (2009): Migration und Gesundheit: Strukturelle, soziale und kulturelle Faktoren. (translation: Migration and health: structural, social and cultural elements.) In: Maria Six-Hohenbalken / Jelena Tošic´, eds. Anthropologie der Migration. Theoretische Grundlagen und interdisziplinäre Aspekte, p302-321. Vienna: facultas wuv.
Introduction: Migration experience and questions of health care
How might an experience of migration prove relevant for health related issues? Migration and health are connected in various complex ways. Drawing on a multitude of studies (her own research as well as secondary data), Ruth Kutalek tries to specify how cultural barriers may affect medical care. She demonstrates the importance of being attentive to cultural factors in administering health care, yet also puts forth an argument for interrogating structural constellations. Challenges associated with migrants accessing healthcare institutions are often attributed to cultural differences, while they actually stem from general problems on a structural level. For example, difficulties in physician-patient-communication are regularly ascribed to poor language competences on the side of the migrants. Yet, lack of communication due to time constraints is a reality in hospitals. It is not only testament to “migrant-specific” issues, but a general problem, which might be made more visible in cases where language differences come into play. Departing from a perspective of migrants as a special interest group, the author claims there are changes needed on a structural level, which the general public would benefit from and not only migrant patients.
Even though public debate often suggests otherwise, migration does not constitute a recent development in Europe. Rather, migration is a constitutive element of European history, leading to what the author calls a “multi-ethnic reality” (p. 302, transl. AR).[1] In the text, Kutalek problematises the common preconception of “migrants” as a homogenous entity. She explains that the label “migrant”, whatever system of classification is used – according to national, social or ethnic background, according to time of migration etc. – always denotes a diverse set of people, many of whom the only thing they have in common is that they are considered a minority. Furthermore, experience of migration often interacts with other social dimensions, such as gender or age, thereby differentiating what is commonly perceived as problems related to migration.
Access to health care institutions
According to Bollini and Siem (1995), the approach to migrants by the Austrian health care system can be described as “passive”. [2] That is to say that migrants are expected to make use of services and access healthcare institutions, but this process is not thought to change the services and institutions themselves. Thus, there are no systemic answers to “multi-ethnic reality”, such as services tailored to migrants’ needs or efforts trying to reduce barriers migrants face. Kutalek proposes that insurance carriers as well as migrant communities and their representatives engage in common dialogue in order to find solutions for structural issues. To date migrant communities are seldom invited to such debates.
In Austria, people with experience of migration, who are trying to access health care institutions, are confronted with social, economic, communicative and cultural barriers. First of all, migrants are seldom specifically targeted by health care initiatives, preventive actions, rehabilitation measures or psychiatric-psychotherapeutic services. Many migrants experience a higher bar when accessing health care institutions. One reason is that they may lack information on how the institutions work and where to turn to with a specific ailment. Secondly, the general deprecation of migrants, which in many European countries is a social fact, translates to the healthcare system, leading to both direct and indirect forms of discrimination.
Knowledge about migration and health: lacking data – complex explanations
Many European countries, Austria amongst them, produce very little data assessing migrants’ health status, their access to health care institutions and health related behaviour. The same is true for many ethnic minorities living in Austria. What complicates the situation further is that individuals’ health and state of well-being is dependent on a multitude of factors, interacting in complex ways. For example, poverty is a crucial factor influencing a person’s health status. Risk of poverty is higher for migrants than for the Austrian population at large. Yet even when migrants and Austrian nationals from the same socioeconomic background are compared, migrants’ health condition is found to be poorer.
Analysing diverse studies on migrants from different national backgrounds now living in Austria and Germany, the author reports inconsistent findings, making it difficult to extrapolate general statements regarding “migrants’ health condition”. In order to resolve these contradictions she pleads for specifically addressing migrants in health surveys and breaking down statistical results according to migrant status, which is not a common practice in all European countries.
Not relying on statistical data but on interactive accounts, Kutalek highlights the potential of anthropology for uncovering areas of conflict among different actors in the healthcare sector. Anthropological material lends itself to analysing the specific barriers migrants face in the healthcare system, but also helps with assessing whether challenges can be attributed to cultural, social or structural issues.
Notions of the body: Norms of physical contact, expression of pain
On the basis of research the author conducted on Turkish migrants’ access to healthcare services in Vienna,[3] Kutalek states that cultural and religious ideas are commonly omitted from clinician-patient interactions and from the management of healthcare institutions. Yet, these ideas are highly relevant for medical practice. One need only think about norms regulating physical contact, which impact how the touching of a stranger – which is usually part of medical examination – is experienced. For example, shaking hands is a common way of greeting a strangers in Austria. While medical staff might try to reduce barriers by shaking the hands of their patients, this greeting ritual could increase discomfort among some patients. Devout female Muslims might feel uncomfortable touching a male stranger. Norms of physical contact bear on concepts of prudency and images of the body. Medical practice touches these norms and images in various ways: having an examination, being touched by a physician in the course of treatment (during anaesthesia, during surgery, during wound care), undressing etc. Moreover, ideas of the body and its inner workings influence how we describe and express pain and suffering.
During the study on access of Turkish migrants to healthcare services, Kutalek and her team observed the following encounter in a Viennese hospital:
“A female patient who migrated to Vienna from Turkey goes to the hospital’s drop-in clinic. She points to her heart and explains to the physician: ‘There is fire.’ The physician misunderstands at first and thinks she is having heart trouble. When it becomes obvious that the patient feels misunderstood and she suddenly starts to cry, the physician proves to be very astonished and asks the project interpreter to translate. It turns out, the patient wanted to express she had a ‘broken heart’, which she is suffering from quite badly.” (p. 309, transl. AR).
Kutalek explains that the expression of pain differs from person to person, yet at the same time it is subject to culturally specific ways of expressing oneself. Communicating pain and suffering epitomises cultural values and ways of interpreting the world. Viennese healthcare professionals are trained from a Western medicine point of view, thinking of pain as a local phenomenon. Other cultural traditions approach pain from a more holistic perspective, viewing pain as something that affects the entire body. Expressing and communicating pain hinges on fundamental cultural ideas, but also on things like language competence and opportunities a patient has to convey what is going on.
This is exemplified by a different account Kutalek portrays. She talks of a woman suffering from rheumatism, who is confronted with a different doctor each time she comes in for treatment. She experiences great difficulty in communicating her specific form of pain, starting from scratch each time, never being able to build on previous encounters and personal knowledge of her case by the doctor.
In a different qualitative study conducted in Vienna focusing on female Turkish migrants and their access to healthcare institutions, lack of verbal communication possibilities, what Kutalek calls “speechlessness” (transl. AR), between patients and staff has been identified as a major concern.[4] Not feeling able to adequately communicate is perceived as problematic not only by patients, but also by staff administering care. Differences in concepts of pain, norms of physical contact or indecency prove to be especially problematic, when patients and professionals find no appropriate way of communicating them. This lack of mutual understanding causes frustration on both sides.
Conclusion: Disentangling social, cultural and structural barriers
Kutalek contends that within the complexity of migration, health issues are often perceived to be based in cultural differences, while actually they are primarily caused by structural problems, for example a lack of an interpreter. In line with this argument, the author states that things like an experience of discrimination, time constraints or hierarchical hospital structures are much more powerful in shaping interactions in the healthcare context than cultural barriers could ever be. Thus, she suggests to be wary of explanations that enforce cultural difference while neglecting the heterogeneity of migrant patients.
Furthermore, the author proposes facilitating the recruitment of second generation migrants living in Austria to work in health care institutions as a measure of mainstreaming diversity in these institutions. Also, institutions should tap into the existing competences of their increasingly transcultural staff. Moreover, healthcare professionals as well as their educators at universities and medical schools should be trained in cultural sensitivity.
On a system level, Kutalek pleads for a change to an active approach towards migrants. This may include service providers issuing multilingual information brochures, development and expansion of interpreting services and services with a low-threshold. Yet, it also entails improving the social conditions migrants living in Austria find themselves in.
[1] Nevertheless, migration is also subject to time-specific dynamics, i.e. the fostering of the European Union, giving way to specific patterns of migration at a specific point in time, leading also to distinct ways in which migration and health interact.
[2] Cf. Bollini, Paola and Harald Siem (1995): No Real Progress Towards Equity: Health of Migrants and Ethnic Minorities on the Eve of the Year 2000. In: Social Science and Medicine 41/6, 825f.
[3] Kutalek, Ruth (2009): Türkische MigrantInnen und ihr Zugang zum Gesundheitssystem in Wien. Unpublished project report. Österreichische Hochschuljubiläumsstiftung.
[4] Cakan, Nursen (2007): Türkische Migrantinnen und ihr Zugang zum Gesundheitssystem. Master Thesis. Medical University of Vienna.