“Health for All?” critically explores global moves towards Universal Health Coverage and its language of rights to health, equity, social justice and the public good. Highlighting emerging ethnographic and historical research by both young and established scholars, the series explores the translations and frictions surrounding aspirations for “health for all” as they move across the globe. The series is edited by Ruth Prince.
When large parts of Norway shut down to halt the outbreak of COVID-19, the Health Center for Undocumented Migrants in Oslo, co-run by the Red Cross and the Church City Mission, also had to close its doors.
“Now we see just how vulnerable it is to provide healthcare based on voluntary labor”, the manager of the health center Oslo noted to the media (Utrop, March 16th). Apart from a few permanent staff, the health center is operated by voluntary health personnel, many of them retired and hence in the risk group for severe illness from COVID-19, or working elsewhere in the health sector, and therefore urged, following public guidelines for health personnel under corona, to stop volunteering.
“What will you do?” I asked Eeda. The last time she lost access to her prescription drugs, after her application for asylum was rejected, she ended up in the hospital. Eeda explained that she had a stock of medicines for her chronic condition to last her a couple of weeks, but she did not know what she would do after that. At the moment, however, she was more anxious about getting infected with the coronavirus: where would she go? Through every channel, people were encouraged to stay inside, to not see other people. Libraries were closed, churches were closed, restaurants, bars, cafés and stores were mainly closed, and malls were deserted areas. On social media people urged everyone to #StayHome, or even #StayTheFuckHome. For Eeda, this was a lot easier said than done.
Eeda came to Norway, fleeing political persecution in a Middle Eastern country, more than a decade ago. She usually spends her days doing volunteer work and getting by on odd jobs cleaning and cooking for acquaintances. She does not have her own place to live, and before the outbreak, she would sleep on the couches of a small group of friends, staying a few nights here and there. Now she feared bringing the virus with her, and her friends worried too. Moreover, if she were to fall ill, she had nowhere she could go into quarantine – she had no one she could expect to take her in.
Insecurities in a comprehensive welfare state
As the number of confirmed COVID-19 cases began to rise in Norway during March 2020, tensions and insecurities grew among the population, as they did in other countries affected by the pandemic. Currently, the authorities consider the outbreak in Norway to be under control and restrictions are slowly being eased up; kindergartens, schools, hairdressers and restaurants have reopened, with the hope that society may slowly find a path back to certain normalcy. Yet the months when this small, wealthy country feared being faced with an acute lack of medical protection gear and the potential collapse of the healthcare system has left a tangible sense of insecurity, vulnerability, and bodily precarity in its citizens. An insecurity that to the majority is arguably a qualitatively new experience, due to Norway’s otherwise comprehensive health care system. Indeed, Norway is a country where the health care system is not too far from realizing WHO’s conception of Universal Health Coverage, where the state ensures access to a strong and resilient public health system, as well as systems of financial protection for all those living within its jurisdiction (Ngozi et al., 2018; Prince, 2020) – in short, comprehensive healthcare ‘for all’.
And yet, there are critical exceptions to whom these provisions include. Eeda is one such exception. As a rejected asylum seeker, her rights to public healthcare encompass access to some forms of specialist care beyond emergency care, but her access to primary care is restricted to “health services which are absolutely necessary and cannot wait without the danger of imminent death, permanent and seriously reduced functionality, serious injury, or severe pain” (Healthcare Regulation, 2011). Moreover, unlike other residents, she is expected to bear the full cost of care, regardless of the procedure or treatment. Hence, Eeda has come to rely on the Health Center for Undocumented Migrants for her healthcare needs – one of very few recourses that exist for people who are not included in the public healthcare system and do not have the means to access the private. In this lies the paradox of a strong welfare state like Norway: there is very little outside of the public system, and if not included, the exclusions may be more devastating and severe than in less comprehensive welfare states that have stronger traditions for ‘compensatory’ services (e.g. services to disadvantaged, vulnerable, and marginalized groups to compensate for shortcomings in the welfare system) provided by NGOs, private enterprises or religious societies.
To Eeda, then, the ramifications of COVID-19 merely highlighted a known and embodied experience, rather than something radically new in her life. Potentially devastating as the closure of the Health Center for Undocumented Migrants threatened to be for her, she was already living in a pervasive state of exception (Agamben, 1998, 2005; Kjærre, 2011).
Daniel is another such exception, and while the following events took place before COVID-19 came to Norway, they illustrate another shade of this (Norwegian) state of exception.
Daniel is a man from an Eastern European country. As a citizen of the European Economic Area (EEA), he is entitled to the same healthcare as Norwegian citizens so long as he is legally employed. Daniel has been in Norway for a number of years, working on and off in construction, sometimes through formal employment, while at other times making do with informal work under very poor conditions. When his health began deteriorating and he had trouble handling his different tasks at work, Daniel went to see a public general practitioner, who determined he needed an operation. He was placed on a waiting list for surgery at public hospital. During the waiting period, Daniel lost his job, and since he could no longer cover rent, he was homeless by the time he was admitted to the hospital.
The operation was successful, and after three days, Daniel was discharged and referred to the Norwegian Labour and Welfare Administration (NAV) for help with a place to sleep and emergency aid, such as money for his prescription painkillers and anti-coagulant medicines. However, NAV rejected his application, and referred him to the Social and Ambulant Emergency Aid (SAA), a municipal service that handles applications for emergency social aid (among other things). SAA concluded that Daniel did not qualify for assistance. Furthermore, since he did not have a permanent place to live, they also rejected his application for emergency funds to purchase medicine, as they would not be able to follow up on his treatment. After pleas and protests, Daniel was given a lump sum to buy the anti-coagulants, but no money for painkillers. As for sleeping, he was referred to the Red Cross Emergency Shelter – a dormitory of camp beds, open from 10pm to 7:30am, which, due to demand that often exceeds its capacity, allocates beds to the line of queuing persons by way of lottery. Hence, during his convalescence, Daniel was obliged to spend 14 hours a day outside, not knowing whether he would get a bed for the night.
The rejections from NAV and from SAA were most likely tied to the precariousness of Daniel’s employment and living arrangements in Norway, which raised doubts as to whether he had ‘legal residence’ (lovlig opphold) and ‘permanent residence’ (fast bopel), both of which are necessary in order to qualify for full rights to social assistance in Norway (Norwegain Labour and Welfare Administration, 2018; Social Services Act, 2009; Social Services Regulation, 2011), and which Eeda also lacked, although for different reasons.
Hence, despite having lived in Norway for many years, and despite being incorporated into labor relations, both Eeda and Daniel stand without the protection this inclusion normally entails. As anthropologist Marry-Anne Karlsen has suggested, they can be seen as “precariously included” in the welfare state, as they are (or can be) “accorded certain rights and access to services caring for their bodily survival [but this care] tends to be of a subordinate, arbitrary and unstable kind” (Karlsen, 2015, pp. 9-10). This inclusion runs a risk of becoming pathogenic as well, when healthcare is inadequate or delayed; when people refrain from seeking healthcare for fear of the cost; or when one’s employment is precarious and unprotected; and when, because of this precarity, access to treatment and welfare provisions is compromised.
The Janus face of the state
Eeda and Daniel’s situations suggest some of the characteristics of the “politics of precarious populations” (Fassin, 2012) as it is unfolding in Norway today, from the increasingly central role of various NGOs in tending to its effects, to the Janus-faced state in regulating and caring for populations in a world of increased mobility. It is a state offering a necessary operation, but not a bed to recover in; a state offering emergency health care, but neither the prescriptions nor the medicines to prevent a chronic condition from becoming life-threatening.
When the Health Center for Undocumented Migrants in Oslo had to cease activity on March 12th, the few staff that remained were left answering phone calls and trying to help patients access the public health system. They heard about people afraid to go out; people who, like Eeda, had difficulty finding a place to stay, but also people who had been taken in by friends for a longer period of time under the unusual circumstances. Several of their patients reported reduced access to food and basic supplies. A patient whose medical supplies had run out called the center, but as they had no doctor available, they could not prescribe new ones, knowing well that his condition could turn life-threatening without proper controls and medication. The health center’s dental service was also closed, and there was nowhere to refer patients with inflammations, caries and rotten teeth (Helsesenteret for papirløse migranter, koronadagbøkene).
By March 27th, the health center had managed to reassemble a limited service: a nurse in the backyard of the health center twice a week. “I am so sorry that we do not have a better service at the center now”, the manager emphasized to a local reporter. “We are in dialogue with the municipality on how to ensure a good health service to our patients” (Utrop, March 20th).
Meanwhile, Portugal decided that starting March 30th, foreign nationals with pending applications should be treated as permanent residents until at least July 1st, to ensure they have access to public services – health care and welfare provisions – during the Coronavirus outbreak. In the UK, hotels are turned into shelters for homeless people and rough sleepers to safely self-isolate. Italy has granted temporary residence permits to 600,000 people living in the country without authorization. During negotiations surrounding the ‘Corona packages’ in the Norwegian parliament the Socialist Left Party (SV) proposed granting full rights to healthcare for ‘undocumented migrants’, but this was not supported by the majority, despite the UN committee on Economic, Social and Cultural Rights having repeatedly voiced their concerns about this group’s restricted rights to primary healthcare. However, starting April 17th the municipality of Oslo has provided a GP to work one day a week at the Health Center for Undocumented Migrants and provided access to quarantine hotel. They also concede that the health center’s patients with acute dental care needs can be referred to the municipal dental service.
“Thank you for these nice words”
A few weeks later, I text Eeda again to see how she was holding up. She wrote that she was doing “fine” and that she hoped the virus crisis would pass so we could all meet again. “Take care”, she writes, with characteristic consideration. Trying to end on a positive note, I reply that perhaps this crisis can lead to more people understanding what it is like to have so little security and predictability in one’s lives; understanding what it is like to risk not receiving help when needed, and having their lives placed on hold. “Perhaps it can lead to something good”, I write, well aware of the naivety, but trying to find something encouraging to hang on to. “Thank you for these nice words”, she replies, the subtext thick with misgivings and experiences of living within a seemingly comprehensive and caring welfare state, but which appears to people like Eeda and Daniel as something quite different.
Vilde Fastvold Thorbjørnsen is a Norwegian author, completing a PhD in medical anthropology at the Institute of Health and Society, University of Oslo. Her research explores a nexus of material poverty, exclusions from welfare protection and vulnerabilities to labor exploitation, and how this affects health, well-being and psychosocial experiences. She has conducted research in Oslo and in Martinique. Her debut novel “Felt” was recently published, and is a critically acclaimed fictional exploration of colonial structures of power, exoticization, ecological disaster and anthropological research ethics.
Agamben, G. (1998). Homo sacer : sovereign power and bare life. Stanford, Calif: Stanford University Press.
Agamben, G. (2005). State of exception. Chicago: University of Chicago Press.
Fassin, D. (2012). Humanitarian reason : a moral history of the present. Berkeley, Calif: University of California Press.
Healthcare Regulation. (2011). Forskrift om rett til helse- og omsorgstjenester til personer uten fast opphold i riket [“Regulation concerning the right to health and care services to people without fixed abode in the country”]. (FOR-2011-12-16-1255). Retrieved from https://lovdata.no/dokument/SF/forskrift/2011-12-16-1255
Karlsen, M.-A. (2015). Precarious inclusion : irregular migration, practices of care, and state bordering in Norway. (Doctoral thesis) University of Bergen.
Kjærre, H. A. (2011). In a space of everyday exception – day-to-day life and illegality among rejected asylum seekers in Norway. (Master’s thesis) University of Oslo.
Ngozi, A. E., Martin, J., Marten, R., Ooms, G., Yates, R., & Heymann, D. L. (2018). Building the case for embedding global health security into universal health coverage: a proposal for a unified health system that includes public health. The Lancet, Health Policy, 392, 1482-1486.
Norwegin Labour and Welfare Administration. (2018). Veileder for NAV-kontoret ved vurdering av lovlig opphold for EØS-borgere.[“Guidelines for NAV offices regarding assesment of legal residence for EEA citizens”] Retrieved from https://www.fylkesmannen.no/contentassets/6407ac3b189b49bbab3965a1486c153e/veileder-for-nav-kontoret-ved-vurdering-av-lovlig-opphold-for-eos-borgere.pdf
Prince, R. J. (2020). Utopian aspirations in a dystopian world: “Health for all” and the Universal Health Coverage agenda – an Introduction. Somatosphere (April 20th). Retrieved from http://somatosphere.net/2020/universal-health-coverage.html/
Social Services Act. (2009). Lov om sosiale tjenester i arbeids- og velferdsforvaltningen (sosialtjenesteloven). (LOV-2018-12-20-98 ). Retrieved from https://lovdata.no/lov/2009-12-18-131
Social Services Regulation. (2011). Forskrift om sosiale tjenester for personer uten fast bopel i Norge (“Regulation concerning the right to social service for persons without fixed abode in the country”). (FOR-2011-12-16-1251). Retrieved from https://lovdata.no/dokument/SF/forskrift/2011-12-16-1251
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