Friday, August 12, 2016

Germany and the Refugees

More than 1·1 million refugees entered Germany in 2015, and more than 442 000 new asylum applications were filed that year—more than in any other country in Europe (authorities also estimate an unregistered 200 000–600 000 refugees are already living there.)  But many thousands of those refugees cannot access adequate health care, say local doctors.

Winfried Huber is the former managing psychological psychotherapist at the Caritas Hospital in Stuttgart. Today he is using his home to provide free psychotherapeutic treatment to 30 of the city's refugees.

He explains, “One in two refugees in Germany has severe psychiatric needs. I have patients who've seen friends and family shot before their eyes, seen their own house bombed, or seen countless corpses. They have risked their lives crossing the sea to get here. Their very existence has been under threat non-stop for a long time. This psychological strain is unbearable.” He goes on, “At the moment all they have is the German Asylum Seeker's Medical Benefits Act (AsylbLG), which only guarantees emergency treatment, not psychiatric treatment—unless individual cases are deemed ‘acute’. Authorities are sending these trauma victims through endless hoops of paperwork just to receive emergency treatment. It's immoral.”

Huber refers to a young man from Iraq he recently treated. The patient had arrived severely traumatised after his father and brother murdered his aunt for having divorced her husband. Huber's patient had been so affected by this, and the ongoing political violence in Iraq, that he fled to Europe in desperation. When he found his way to Huber, the patient was suffering from extreme paranoid schizophrenia. Huber says the German health system failed him as a refugee, and, without his professional intervention, the consequences might have been fatal. “I telephoned a local hospital and told them my patient had to be admitted immediately. He was claiming he was a second prophet and he was becoming volatile, violent, and potentially suicidal. 2 months later, no action had been taken. I then wrote to the local council saying if he was not admitted immediately, I would file criminal charges for denying treatment to a patient in need. The next day he was admitted for a 21-day stay, although the international norm for these cases is 31 days. This must stop.”

One of Huber's patients is called Emran, a refugee from Afghanistan. Emran tells his tragic story. “My parents, four brothers, and three sisters paid smugglers. We walked for 4 days to escape the bombing, and reached the Iran–Pakistan border. There were about 150 of us. We were exhausted. It was midnight and dark, and we were about to cross. Then the Iranian police started firing shots. We started running, and there was chaos.”

“I made it over the border with about 20–30 others. In the confusion, I lost my family. I haven't heard from them since. I don't know if they are in prison in Iran, or even if they are still alive.” When Emran arrived in Germany, he was first officially registered in Munich, where he filed his asylum application. He was then moved to Saarbrücken, and later to Stuttgart. His first accommodation was a crowded village sports hall housing Syrian, Iraqi, and Afghan refugees. He was put with a group of Afghan men, with only medical screens for their privacy. Given the echoes from the wooden floor, no walls, and the fears for his family, Emran could not sleep for days on end. Things had got a little easier, but recently my uncle contacted me, telling me that the Taliban had killed his brother, my other uncle. He's sent me photos of his body by text. I feel wretched. I'm finding it hard to stay calm again. I panic about my family and my future.”

Stuttgart has traditionally been very open to foreigners. More than 40% of all residents are descended from immigrants, mainly Turkish, Italian, Greek, and Croatian. For those younger than 18 years, the rate is 60%—the highest in Germany. To avoid developing exclusive enclaves, in the 1970s, new arrivals were deliberately encouraged to live right across the city. Nowadays, voluntary organisations are applying the same “Stuttgarter Modell” when providing accommodation for refugees. Almost 9000 refugees now live in 124 facilities, which are deliberately spread across 22 districts. Support at group level is managed by 40 official refugee support centres (Freundeskreise für Flüchtlinge), run by 3500 volunteers. Here the groups provide activities such as sports, games, manual construction, and cooking. The small town of Böblingen, 20 km southwest of Stuttgart, has played an active part in helping to house, feed, and support refugees. A key part of which is the weekly drop-in centre, the Muhajer (“immigrant” in Arabic) Asylum Café, based in the local worker's centre. A mosaic on the wall outside reads “Justice Elevates The People”. Inside it feels like a cross between a modern café and a youth hostel. Jutta Jakaobi co-founded the café in 2005 told The Lancet. “We know that we can't really change anything on a political level, so we just do our bit by trying to brighten their day a little.”

 A refugee health card would at least improve refugees' access to treatment.

The German Medical Association (BÄK), which represents the country's more than 400 000 physicians. The organisation has publicly slammed the government's current organisation of treatment for refugees as unfair, and extremely time and cost ineffective. BÄK president Frank Ulrich Montgomery said refugees across the country should receive an electronic health insurance card like any other patient in Germany. “In front of physicians stands not a migrant, but a patient. We should not differentiate between a refugee and a German citizen. A nationwide health insurance card for refugees would achieve that. Currently, refugees must go to the welfare office to get a medical certificate, which only entitles them to a day's worth of treatment at only one doctor. Even with the exceptions made under the Refugee Medical Benefits Act to allow treatment for acute illness, acute pain, and for pregnancy, it is still insufficient. If a refugee woman has cystitis as a result of diabetes, which has not yet been discovered—what then? Here she has to wait for her diabetes to become acute for it to be treated”, said Montgomery.

Some organisations claim the electronic health card provides a quick and simple way to ensure these people get access to health care. These groups include the German Association of General Practitioners (Deutsche Hausärzteverband eV), which has more than 32 000 resident physicians as members. Federal chairman of the Association, Ulrich Weigeldt, told The Lancet that the bureaucratic hurdles are “still too high” for refugees. “A health card for refugees would be a sensible way to relieve this. I have not heard of a better suggestion for reducing bureaucracy in health care. The experiences from individual federal states show that the implementation of the card is wholly possible and sensible.” The refugee health card is currently in use in only six of Germany's 16 federal states.

Diana Golze, health secretary for Brandenburg, described to The Lancet what she sees as all-round benefits to the card. “For a long time now, the communal welfare offices have had to issue certificates for every visit to a doctor, and also decide how necessary the treatment is in each case. Through this the public health service suffers an additional burden. That health insurance providers, hospitals, and chemists here are all behind the heath card, is a clear signal.”

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