Migration and refuge: necessary topics for Nursing teaching in COVID-19 times

Migración y refugio: cuestiones necesarias para la enseñanza de la enfermería en tiempos del COVID-19

ABSTRACT

Objectives:

to present an overview of migratory processes and access to health care for immigrants in Brazil and reflect on the importance of training in Nursing from an interdisciplinary perspective, focused on the care of this population in the context of a pandemic.

Methods:

this is a theoretical-reflective study based on the authors’ experiences and anchored in the literature.

Results:

some particularities in the access to health services by migrants and refugees show how the pandemic’s advancement and continuity impacted them in different ways. Interdisciplinary research and teaching are essential to study and better understand the health needs of the migrant population in Brazil, especially in the context of a pandemic.

Final Considerations:

the training of health professionals, especially in Nursing, must include these people’s specificities so that future interventions are more sensitive and closer to their reality.

Descriptors:
COVID-19; International Migration; Refugee; Accessibility of Health Services; Nursing

RESUMEN

Objetivos:

presentar el panorama de los procesos migratorios junto al acceso a los cuidados de salud de los inmigrantes en Brasil y reflexionar sobre la importancia de la formación en Enfermería dirigida a la atención de esta población desde una perspectiva interdisciplinaria en el contexto de la pandemia.

Métodos:

se trata de un estudio teórico-reflexivo, pautado en las experiencias de los autores y también basado en la literatura.

Resultados:

algunas particularidades en el acceso a los servicios de salud de los migrantes y las personas refugiadas evidencian que éstas han sido impactadas de diferentes maneras con el avance y la continuidad de la pandemia. La investigación y la enseñanza con un enfoque interdisciplinario son importantes para estudiar y comprender mejor las necesidades sanitarias de la población migrante en el país, especialmente en el contexto de la pandemia.

Consideraciones Finales:

la formación de los profesionales sanitarios, especialmente en Enfermería, debe comprender las especificidades de estas personas para que las futuras intervenciones sean más sensibles y cercanas a la realidad que viven.

Descriptores:
COVID-19; Migración Internacional; Refugio; Accesibilidad a los Servicios de Salud; Enfermería

RESUMO

Objetivos:

apresentar o panorama dos processos migratórios e de acesso à saúde de imigrante no Brasil e refletir sobre a importância da formação em Enfermagem, numa perspectiva interdisciplinar, voltada ao cuidado dessa população, no contexto de pandemia.

Métodos:

trata-se de um estudo teórico-reflexivo, pautado nas experiências dos autores e ancorado na literatura.

Resultados:

algumas particularidades no acesso a serviços de saúde de migrantes e pessoas refugiadas evidenciam como elas têm sido impactadas de diferentes maneiras com o avanço e continuidade da pandemia. A pesquisa e ensino de abordagem interdisciplinar são importantes para estudar e melhor compreender as necessidades de saúde da população migrante no país, especialmente no contexto de pandemia.

Considerações Finais:

a formação de profissionais de saúde, especialmente em Enfermagem, deve compreender as especificidades destas pessoas para que futuras intervenções sejam mais sensíveis e próximas da realidade que vivem.

Descritores:
COVID19; Migração Internacional; Refúgio; Acesso a Serviços Saúde; Enfermagem

INTRODUCTION

This reflection is motivated by our experience as social scientists and nurses in undergraduate Nursing education. In general, we seek to sensitize students using Anthropology’s theoretical and methodological tools to think about the human body as a multiple reality constructed by different social actors and knowledge. From this reference, we aim to relativize the notions of health, illness and health care, discussing them as social and culturally constructed processes that entail diversity, even in contemporary society, in which the biomedical vision and practice prevail. To achieve these objectives, we seek a theoretical approach with different concepts, conceptions, and sociocultural processes of health/disease/care. We discuss the differences and similarities in thinking and acting on these processes. Among the topics covered in our curricular unit, the vulnerable groups that suffer the structural setbacks of inequalities were highlighted, emphasizing migrants and refugees, given that their invisibility in the context of the COVID-19 pandemic further accentuates inequities.

Moreover, an overview of transnational migratory processes in our country was presented, as well as the particularities of access to health services and how migrants have been impacted in different ways with the advancement and continuity of the pandemic. Finally, we discuss the importance of interdisciplinary research and teaching to study and better understand the health needs of international migrants in Brazil, especially in the context of a pandemic.

We intend to contribute to the training of health professionals, especially nurses, to understand the specificities of migrants and for their future health interventions to be more sensitive and closer to the reality of this population.

OBJECTIVES

To present an overview of migratory processes and access to health care for immigrants in Brazil and reflect on the importance of training in Nursing from an interdisciplinary perspective, focused on the care of this population in the context of a pandemic.

METHODS

It is a reflective theoretical study based on the critical thinking of its authors and supported by the scientific literature on migration and health. The text is structured around three thematic axes: transnational migrations and health inequities; experiences of access to health for migrants. And interdisciplinary nursing training: subsidizing health care for the migrant population.

RESULTS

Transnational migrations and health inequities

The COVID-19 pandemic advancement led the World Health Organization (WHO) to declare an international emergency in January 2020. In March of that same year, like other countries, Brazil declared a state of public calamity and adopted social isolation and mobility restriction measures to prevent contagion and the spread of the virus in the country. However, such actions were politically controversial in Brazil, requiring great regional and local mobilization in observing the restrictions on agglomerations and people’s mobility and movement conditions. Such measures demanded great individual and collective efforts that are conditioned by socioeconomic conditions, housing, access to health and education, among others, of each person and/or social group and, although necessary, produced significant socioeconomic impacts for the greater part of the population. The effects of these measures occur unevenly, fundamentally affecting people that live precariously on the margins of society, including international migrants and refugees(¹).

Thus, the pandemic exacerbated structural social inequalities, being more dramatic in the poorest and most vulnerable populations. Worldwide and in Brazil, mobile people, whether migrants or in a refugee situation, are undoubtedly one of the groups most severely affected by the crisis.

In recent decades, Brazil has been the destination of many migrants and refugees in a Global South-South migration trend, mainly from some South and Central American countries, such as Bolivia, Peru, Haiti, Syria, and more recently, Venezuela, as well as those from African countries such as Congo, Senegal, among others. As a result, the National Migration System (SISMIGRA) of the Ministry of Justice-Federal Police recorded, between 2000 and March 2020, the entry of 1,504,736 people into the country, coming from 227 different locations, most of them from the Global South(²).

According to the United Nations High Commissioner for Refugees (UNHCR-UN), people can move to improve their living conditions, for family reunions, or other reasons. They migrate to alleviate hardships caused by natural disasters, hunger, or extreme poverty. They leave their countries for these reasons and are generally not considered refugees. Refugees are migrants, but not all migrants have legal refugee status. In this case, they are specifically defined and protected by international law and characterized as persons outside their countries of origin because of well-founded fears of persecution, conflict, violence, or other severe circumstances. By the end of 2020, the Brazilian government had recognized 57,099 refugees(³).

Integrating migrants and refugees into the countries that receive them is complex. Health stands out as an essential component in this process since it is a crucial right in integration(⁴-⁵).

Analyses on the inclusion of international migrants by official health systems show that part of the cases occurs without the reference systems and codes specific to the societies of origin, including all traditions and values carried by individuals and families in the migratory process, being placed in dialogue within the receiving system(⁵). In this way, migratory flows give rise to several debates, such as public policies for access to health, work and income, education, and social welfare. In addition, attention to their singularities also demonstrates a more fruitful way to guarantee the Unified Health System (SUS) principles, such as universality, integrality, and equity.

This text thus aims to reflect, in an interdisciplinary perspective, on the health of the migrant population residing in Brazil facing the COVID-19 pandemic.

Migrants’ experiences of access to health

In general, health is a privileged topic for understanding how migrants and refugees enter the host country and organize their lives. The search for possible suffering and anguish in the migratory process and the local integration must consider how these people experience health and disease processes.

Basic Health Units (UBS), a primary care device in the context of the SUS, have become an essential point of contact with the immigrant population in the country, especially in the city of São Paulo. Several studies have detailed the experiences of migrants in the health system in Brazil. Successful experiences, such as the hiring of migrant Community Health Agents, can be faced with several situations in which health services cannot overcome obstacles that prevent access. Impediment of full communication caused by foreign national languages, or even dialects, or the distance caused by the different ways of conceiving and practicing health, can emerge in the most varied situations: in the apprehension of the complaint, in the communication of a therapeutic proposal, in the impediment caused by traditions that may prevent physical examination, among other examples(⁵).

The inclusion of migrants and refugees in the health system, at its various levels, highlights the complexity of transnational migratory processes. Examples in health services are migrants who face cultural, moral, and political barriers; previous experiences of emotional, physical, or sexual trauma that result in fear or apprehension concerning these services; problems of access to the new health system; or even racism, xenophobia or prejudice. Racism was identified in studies with Brazil refugees and mental health services(⁴).

In health practices developed with the migrant population, it is necessary to consider this diversity of experiences. Health professionals need to be aware of diseases, conditions, and injuries that different groups of migrants may suffer associated with working conditions or more frequent health problems in their country of origin. An example of a health problem for Bolivian migrants in Brazil, closely related to their working conditions in sewing workshops, is the incidence of tuberculosis in this group(⁵).

Thousands of migrants live in precarious housing conditions in large Brazilian cities: they live in tenements, squats, sewing workshops, or reception centers, in addition to those living on the streets. In this way, they are the target of social and racial discrimination, and their rights are often disrespected in public spaces, intensifying their vulnerability(⁴). Moreover, they are subject, in different ways, to places and circumstances that potentiate various health problems and other morbidities present in this population. Such as diseases prevalent in their countries of origin (Chagas disease among Bolivians), injuries and stress caused by excessive workloads like the workers in the meat cutting industry and sewing workshops, food insecurity among Haitians, violence against women in a domestic and work environment. These are some aspects that should be considered in the quarantine of most migrants in the metropolitan region of São Paulo(⁶).

As an example, in the central region of São Paulo, UBS Sé is a unit that serves many migrants and refugees. This health unit is geographically close to Missão Paz, a philanthropic institution managed by Scalabrian missionaries to support and welcome immigrants and refugees in the city of São Paulo.

According to field data of research carried out by our research group at UBS Sé in 2020, there are 1,271 registered migrants, 1,047 of which were adults, 469 men, and 578 women. There is a great diversity of nationalities: people from Bolivia, the Democratic Republic of Congo, Angola, China, Colombia, Paraguay, Peru, Ivory Coast, Senegal, Guinea Bissau, Nigeria, Haiti, Syria, and Venezuela. Preliminary research results show that health professionals know the complexity of care for these people. Among the challenges, we highlight the diversity of languages spoken, the difficulty understanding the functioning of the SUS, the different conceptions of disease, health, and care, and the structural vulnerability to which many are subjected. Health professionals know the specifics of people who attend the Unit and create strategies to improve communication and, consequently, care. An example in the pandemic was a nurse who communicated with a Chinese puerperal woman through WhatsApp using a translator into Mandarin. In this case, he followed the entire learning process about breastfeeding and could clear up doubts with the woman.

There is evidence that confinement has already impacted the lives of migrants and refugees, enhancing the precariousness of life and situations of domestic violence and in collective workspaces. The stoppage of work activities immediately affected these people’s lives, also generating the possibility of a large part of them remaining without work, further accentuating the instability of survival. Cavalcanti et al. (2020)(⁷) highlight that, in the dimension of the effects on the formal labor market, the impacts were uneven depending on the profile of the worker and, in particular, the sector of activity.

For example, the impediment of work for informal workers, such as street vendors and day workers in large urban centers. This reality has a severe impact on the satisfaction of the basic daily needs of families, especially in the maintenance of housing and accentuating food insecurity. In addition, the lack of information on the morbidity and mortality of the migrant and refugee population by, at least, nationality and ethnicity compromise the surveillance of cases and the possibility of preventive actions in the context of the pandemic.

The exclusion of immigrants was made explicit in the problems of their access to policies to minimize the damage of the pandemic, such as bill 1066/2020, which established the emergency benefit for vulnerable families. The absence of inclusive digital platforms, the requirement for Brazilian documents, and the lack of centralized information constitute obstacles to accessing assistance in Brazil. The situation is even worse for the undocumented or those who have recently arrived in the country. Proof of home address with the presentation of a recognized official document (bills and/or letters proving the authenticity of the signature) has also created enormous obstacles for migrants and refugees concerning vaccination against COVID-19.

On the other hand, it is worth mentioning the support of civil society networks (Non-Governmental Organizations, charities, among others) and public policies for migrants and refugees in some municipalities, seeking to alleviate the seriousness of the situation they currently face live. For example, specific cases of inclusive actions in health within the Unified Health System (SUS) in the city of São Paulo can be illustrated by the mobilization of community health agents visiting migrants and by the restructuring of actions more suited to the needs of this group, such as raising awareness among health workers or even encouraging them to learn the most prevalent languages in the services. In the case of São Paulo, these interventions were expanded from 2016 onwards, when the Municipal Law for Immigrants and Refugees was enacted, creating the Municipal Council of Immigrants and the Permanent Forum of Immigrants, a turning point in public actions (state and civil society) with migrants and refugees(⁸).

In parallel with public health policies aimed at protecting the population, one must question the challenges and limits of totalizing proposals that are distant from the particular experiences of each social group. For example, how is an official message of social isolation understood to contain the transmission of a virus that, for many, is still distant, mediatic, and competes with survival? How is the possibility of developing hand hygiene techniques, masks, and home isolation conditions for this population exercised? Is it possible to spend money on purchasing masks when there is food insecurity? In addition, there are specificities in the health care of migrants and refugees which go beyond the understanding of the national language, as previously stated.

In times of a pandemic, it is important to reflect on how socioeconomic conditions are articulated with the challenges of interculturality in health, as well as conceptions about illness and the different ways of dealing with the pandemic among the different groups of migrants and refugees. We observed, for example, reports from migrant leaders about the difficulty of understanding the existence and the logic of operation of the national vaccination system represented in Brazil by the National Immunization Program (PNI-Ministry of Health): no national immunization program exists in some countries; bureaucratic routines to access the health system often create obstacles, such as the requirement for documentation and/or proof of residence; in addition to the financial difficulties experienced by migrants in acquiring masks and rubbing alcohol, and even if they have access to these protective devices, care is not always understood and performed according to proven practical guidelines.

Mass vaccination and its most significant challenge, production and distribution globally, must dialogue with social inequalities, health inequities, and cultural differences. The exposure of the population to contagion by COVID-19, especially the most vulnerable segments, including migrants and refugees, minority groups, and millions of Brazilians who also suffer from neoliberal economic policies, mainly impacts the SUS. Consequently, there is an excessive number of deaths, ignoring individual and collective suffering.

Such a perspective evokes the interpretation of a necropolitics context whose logic of sacrifice, even the extermination of the weakest, explains the darkest face of neoliberalism. The regulation of life was transformed into death in extreme conditions produced by society. Death due to the impoverishment of minorities and the lack of right to life and health; these bodies were already exposed to physical exhaustion and toxic substances at work, now also exposed to the coronavirus(⁹).

The ethical expectation for the moment would be solidarity and cooperative actions. Paradoxically, one is witnessing the folly of political leaders from different nations, including Brazil, blaming each other for the pandemic. It is evident that we can and must contribute now and later with our theoretical-methodological contributions from the perspective of interdisciplinarity for a better understanding and contextualization of health, disease, and care processes. Thus, we wish to contribute to the development of more porous forms of care that consider the specificities and encompass the needs of the migrant and refugee population.

Interdisciplinary nursing training: subsidizing health care for the migrant population

The complexity involved in articulating different paradigms, values, beliefs, practices, and priorities of health professionals, specifically Nursing, is evident. This interdisciplinary stance needs to be exercised even during university/professional training.

In our experience in undergraduate Nursing, some conceptions were highlighted that might be valid for intervention actions with migrants and refugees, among several vulnerable groups that suffer from the pandemic. According to Menendez (2020)(¹⁰), the Covid-19 pandemic highlighted the structural and decisive importance of health/illness/care-prevention processes with consequences and reactions in all areas of collective and individual life.

Our pedagogical approaches involve conceptual and practical contact with international migration and health. Among the strategies carried out, we point out some for a more sensitive approach to the theme: theoretically introducing questions about refuge and migration, in the context of the Global South; understanding the health/disease/care-prevention processes considering the specific knowledge of each social group and the forms of self-care; understanding the challenges of acting in intercultural health. These topics have been addressed through specialized literature, lectures, debates, and interviews with migrants or refugees, handling conceptions of health, illness, and care in these groups. In addition, care aimed at the immigrant population can be experienced by nursing students in theoretical-practical classes, health care spaces, and extension projects.

Thus, discussing the issue of the sociocultural context of migrants and refugees in university spaces is essential to understanding the inequities and differences involved in the health/disease and care processes of these groups. Furthermore, with the intensification of this population’s vulnerabilities in the context of a pandemic, the Nursing professional must have a closer look at their specificities and demands. In this sense, training in Nursing must envisage a graduate with skills and abilities to act in the face of the health demands of migrant and refugee populations, in a logic of interdisciplinary and interprofessional work, seeking ways to prevent diseases, promote health and develop the social mandate of the profession.

FINAL CONSIDERATIONS

This reflection sought to highlight the importance of knowing and reflecting on transnational migratory processes in Brazil in training and research in the field of Nursing. SUS is an essential gateway for this population and needs to be aware of its specificities and demands. In addition to their different nationality and language, the difficulty of integrating this population into local and regional contexts is notorious. Studies show the existence of xenophobia, racism, the problem of accessing social and health rights, discrimination, and prejudice enhanced in the context of the pandemic. The stereotyped view of these people often boils down to observing cultural differences and, consequently, unfolds in explanations, justifications, and negative feelings(⁸). Therefore, one must broaden the debate on the processes of health, illness, and care of migrant and refugee populations. The role of Nursing is central in health services for identifying and caring for these people. In this sense, we point out there is a remarkable potential in the profession to make a more sensitive and culturally close approach to their health needs.

• FUNDING
  This study was funded by Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq). Grant number: 307120/2018-0.

REFERENCES

• ¹
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Edited by

EDITOR IN CHIEF: Antonio José de Almeida Filho

ASSOCIATE EDITOR: Fátima Helena Espírito Santo

Publication Dates

• Publication in this collection
  03 June 2022
• Date of issue
  2022

History

• Received
  26 Nov 2021
• Accepted
  20 Jan 2022