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HEALTH AND BOLIVIAN IMMIGRANTS IN ARGENTINA1. Introduction Disease-health-assistance processes are not only determined by biological and psychological factors but also by economic, social and cultural ones such as the international and national socio-economic and political context, the social position of individuals and groups and specific environmental circumstances (Breilh, 2003).
Immigrants are frequently exposed to several difficulties in societies of destine: bad working and living conditions, social vulnerability, sexual and labor violence and discrimination, among others.
As Cerrutti (2010) remarks, even though immigrants generally have a good health profile and their migratory social networks are frequently a significant contention, migration generates various risk situations that can affect their health: exposure to a new socio cultural environment, separation from close relatives and adaptation to a new world. Besides, when immigrants attend to health assistance services, they appear as an “unexpected” subject, whose otherness is not always understood (Carballeda, 2008).
There are three important issues regarding health and transnational migrations: health problems caused by migratory and integration processes, difficulties in accessing health services and problems that arise in the relations between immigrants and health effectors during the process of attention.
In this paper we will refer to the situation of Bolivian immigrants in Argentina regarding health problems, access to health services and the characteristics of the process of health-disease-assistance. There are few statistics useful for these analyses:
the National Census of Population 200112 and the Complementary Survey of International Migrations 2002-2003 since surveys and hospital registers lack of precisions about migratory condition13. This study also considers qualitative data coming from different case studies and our own ethnographic field work carried out since 2006.
2. Health vulnerability of Bolivian immigrants Bolivian immigrants in Argentina have less educational levels and minus incomes than native population. They usually live in marginal areas where basic infrastructure is scarce14. They are precariously employed in the lowest labor posiUnfortunately, the National Census of Population 2010 is still being processed.
Courtis, Liguori & Cerrutti (2010) remark that health statistics in Argentine are neither useful to determine immigrants mortality and morbidity rates nor to analyze death causes. Death certificates only include the final cause of death not considering the previous symptoms or diseases which might have led to it. Besides, those registers that do consider the place of birth are not useful to analyze the situation of particular groups of immigrants.
According to the Complementary Survey of International Migrations 2002-2003, recent Bolivian immigrants have increasingly directed to urban areas. Although they have the opportunity tions, thus lacking of legal work contracts as well as health and labor accident insurances. These circumstances, together with xenophobic discrimination, seriously affect their physical and psychological health.
Besides, they are prone to suffer some diseases because of excessive workload, hard labor, bad living and hygiene conditions, overcrowding15, lack of spaces of recreation and spreading, changes in their feeding practices and lack of orientation. Different labor contexts also influence their great risk of disease and disability:
a. Apparel manufacturing in sweatshops: infectious diseases (tuberculosis, venereal diseases, HIV), respiratory allergic diseases (rhinitis, sinusitis, bronchitis, etc.), deficiency diseases mainly in young people (anemia and malnutrition), skin diseases due to lack of hygiene and humid environment mainly in children (dermatitis, mycosis, estafilococcias), musculoskeletal diseases (lumbago, herniated discs), depression (melancholia, uprooting, sadness, etc.).
b. Agriculture: respiratory processes (pneumonia, bronchitis, asthma), allergic-toxic syndromes caused by the use of fertilizers and agrochemicals (skin, respiratory), rheumatic and osteoarticular diseases, skin infections, parasitosis.
c. Construction: musculoskeletal and osteoarticular diseases (bone deformities, rheumatism, osteo-arthritis), hepato-biliary diseases, cholecystitis, metabolic diseases (diabetes T1-T2).
d. Automotive driving: osteoarticular diseases, obesity, diabetes.
Women and young Bolivian immigrants have some specific problems regarding reproductive health and responsible parenthood, since this flow has progressively feminized and has a particular age structure. In 2001the stratus of young people within 15 and 29 years old was the widest and the rate of attendance to educational establishments of teen-agers was significantly lower than that of the total of the population of Argentina (Cerrutti, 2009). This author says that uprooting and difficulties to adapt to a new socio-cultural context may cause several tensions and anxieties to teen agers and young people, thus they may be reluctant to demand medical attention because of ignorance, modesty or fear. This situation is particularly worrying regarding reproductive health, especially in the case of recent Bolivian female immigrants who begin their maternity when they are rather younger than native women and whose rate of fecundity is also higher.
According to Cerrutti (2010), in 2008 Bolivian puerperals in the Metropolitan Area of the City of Buenos Aires had a similar number of previous births as native women, which contradicts the prejudices of some health effectors. Other paradoxes were that the proportion of puerperals younger than 20 years old was less among Bolivians and that their newborn babies were more robust and heavier than those of to access a variety of public services they generally live in inconvenient dwellings (tenement rooms, precarious dwellings or other types, excluding flats and ranches). Besides, immigrants who work in agriculture live in huts with poor sanitary conditions (Pizarro, 2011).
Courtis, Liguori & Cerrutti (2010 say that the average quantity of people living in homes with at least one Bolivian immigrant is higher than those were no Bolivian immigrants live (5.4 and 4. persons respectively). Housing conditions of those homes where at least on Bolivian immigrant live are also deficient. Critical overcrowding (three persons or more per room) in these homes is 16.7% while in those with no Bolivian members is 9.6%.
native ones, even though many Bolivian mothers suffered of tuberculosis and Chagas disease. But Bolivian puerperals were more reluctant to do prenatal controls than native ones and most of them declared having given birth without any company though they would have liked to.
Another important issue related to immigrants’ health is their psychological vulnerability due to factors such as discrimination, transculturation, uprooting and disorientation, which may cause low self-esteem, sadness, resignation and/or impotence. Achotegui (2005) says that their mental health is challenged by a high psycho-social stress known as the Ulysses Syndrome (immigrant syndrome with chronic and multiple stress) 16. Bolivian immigrants in Argentina have several symptoms of this disease: depression (sadness and crying), anxiety (excessive concerns, reiterated insomnia), headache, fatigue, musculoskeletal discomfort and dissociative signs such as temporo-spatial confusion, among others.
3. Access to health services Migratory policy in Argentina was very restrictive regarding Latin-American immigration until 2004. Pacecca & Courtis (2008) explain that the General Law of Migrations and Foment of Immigration N 22.439 sanctioned in 1981 under the last military dictatorship (1974-1982) defined immigrants with no regular migratory condition as illegal, so they could not access their fundamental rights nor they were allowed to be employed. Moreover, teachers, doctors, notaries, traders and entrepreneurs, among others, were obliged to denounce them.
Xenophobic discriminatory discourses and behaviors against certain immigrants seriously increased during the 1990s. Public servicers, political authorities and the mass media defined them as “unwanted” and suspected them of competing with local workers and of enlarging the number of beneficiaries of progressively scarce social services (Pizarro, 2009).
Argentine migratory policy radically changed in 2004 when the inclusive National Law of Migrations 25.876 was sanctioned. According to this law, citizens of those countries which are members of the MERCOSUR (Mercado Comn del Sur – South Commonwealth) and of the associated ones can obtain their legal residence in Argentina by only accrediting their nationality and the lack of penal antecedents. That is to say that immigrants coming from Brazil, Paraguay, Uruguay, Bolivia, Chile, Peru, Venezuela, Colombia and Ecuador find it easier to reside in Argentina. They are not asked for a visa neither a work permit and their social rights are guaranteed regardless their migratory condition (Pacecca & Courtis, 2008) 18.
This critical stress is caused by seven mourning processes: family and close relatives, language, culture, homeland, social status, group of pertinence and physical integrity risks.
Those coming from adjacent countries and Peru as well as Koreans and Chinese.
It must be remarked that comparisons between the migratory policies of Latin America, United States of America and Europe are difficult to make since the socio-political contexts are rather different. The regionalization of South Latin American countries and the interest in strengthening economic and political relations must be taken into account. Thus, facilitation of migration between those countries aims to achieve a regional citizenship.
So the right to migrate was consecrated as a human right and the right to familiar reunification was guaranteed. The State was made responsible of guaranteeing the rights to education and health in an unrestricted way to all foreigners, regardless their migratory situation. The obligation of denouncing irregular immigrants was overridden and the promotion and diffusion of immigrants’ obligations and rights were boosted. It was also recommended that the State should favor their integration.
Article N 8 says that access to the right to health, social assistance or health care cannot be denied or restricted in any case to those foreigners who require them regardless their migratory situation, and that authorities of health care institutions must orient and advice them about the bureaucratic process that must be undertaken in order to regularize their migratory condition.
Although the law is a great achievement and a very important legal framework, it has not necessarily led to an immediate change in the daily infringement of labor immmigrants’ rights, neither in their vulnerable work and living conditions nor in their public and private xenophobic discrimination, especially in the case of those coming from adjacent countries and Peru (Pizarro 2009).
It must also be considered that in Argentina, access to public health services is free for every person who does not have semi-public or private health coverage.
Pacecca & Courtis (2008) explain that registered wage earners have access to semi-public health coverage and public retirement since discounts and affiliation to semi-public health insurance are compulsive by law. Both natives and immigrants are included in these labor regulations.
Although access to health services might have improved in the last years, data of the National Population Census 2010 have not been processed yet. Nevertheless, as Cerrutti (2009) says, in 2001 Bolivian laborers had the minor access to semi-public or private health services among immigrants of adjacent countries and Peru. This may be due to the fact that many of them are unregistered workers (which limits their access to semi-public health insurance) or because their socioeconomic condition is not so good (thus they cannot afford private health insurance). The author remarks that those immigrants who arrived in the last 1990s were in the worst situation since only 11% had access to private or semi-private health services.
Thus, many Bolivian immigrants can only attend public health services, which is now a right legally guaranteed regardless their migratory condition. Nevertheless, they cannot always enjoy this right.
According to Cerrutti (2010), empirical based researches show that doctors, nurses, authorities and health administrative staff can favor or hinder assistance to certain “unwanted” immigrants such as Bolivians. This may be because they believe that immigrants might do an “undue” use of health resources. It is also common among certain authorities and the media to overestimate the number of immigrants that demand public health assistance19. Caggiano (2007), Cerrutti (2009), Cerrutti & Nevertheless, although most of these believes are not accurate, it is remarkable that budget and administrative resources in various public institutions are too scarce and that they lack of adequate infrastructure, human resources and other important inputs.
Freidin (2004), Karaskik (2006), Pizarro (2009 and 2011) among other authors, have registered situations in which health administrative staff, doctors and nurses mistreat foreigners, trammeling them with bureaucratic restrictions or even verbally mistreating them.
4. Processes of health-disease-assistance A crucial issue regarding patients’ health is the kind of treatment they receive from doctors, nurses and health administrative staff, which can be summarized in the claim of immigrants to “be treated as a human being” (Cerrutti, 2010). Thus, this author highlights that health effectors must be rather sensitive and reject discriminatory discourses in order to successfully interact with immigrants.
Jelin, Grimson & Zamberlin (2006) have registered that doctors have certain difficulties to interact with immigrants, being incomprehension of their codes and behaviors one of the most important. Based in our ethnographic research we can resume some of the discriminatory prejudices against Bolivian immigrants that are recreated by health effectors:
a. They are more resistant to pain and to hard work because of their phenotype.
b. Some diseases such as rheumatism are proper of their phenotype.
c. They are guilty of propagating in Argentina some infectious diseases such as dengue and cholera.
d. Their cultural feeding habits are inadequate and must be changed.
e. Their tendency to alcoholism is endemic and does not relate to social disaffiliation but to cultural costumes.
f. They compete with natives for scarce public health resources and they do not pay any taxes.
g. Their healing practices based in uses and customs are anachronistic.
h. They live in overcrowded dwellings and to be labor and sexual abused because of their culture.
i. They are dirty and ugly smell.
j. Parturients are reluctant to the hegemonic medical model because they live in a traditional and anachronistic way that must be modernized, being one of the most despised practices to give birth squatting.
k. Parturients cross the international border in order to use native health services and to obtain the Argentine citizenship for their sons and daughters.