Hiv & immigration: health care in an ethnically mixed society

Cristina Visiers Würth

Immigration is a question that, as is frequently repeated, is relatively new in a country that, like our own, is by tradition emigrant. Leaving the political use, which is being made of it, to one side, the tendency to turn immigration into a problem is also the fruit of ignorance and of the mistaken use of concepts.

Healthcare professionals who have been working with seropositive people for years well know the risks that confusion and lack of information generate. This experience should help us to be careful in our dealing with two delicate subjects surrounded by myths and contradictions, as are both immigration and HIV infection.

We are, indeed, accustomed to establishing the 'immigrant-problem' association with the mass media, schools, hospitals, social services etc. In fact, practically every time immigrants are discussed, problems that they have or that they generate are alluded to. Immigrants arrive from countries with exotic and threatening illnesses, many die on the way, they are poor, they cannot find work, they do not have identification papers and their cultures make their relationships with institutions and specialists difficult. Such a great concentration of conflicts makes us feel impotent in facing a battle, which is already, in advance, both costly and lost. One of the reasons why we see it this way is precisely because of mixing it all together, all tangled up as if it were a ball of wool. And it is impossible to answer a tangle of questions. This article aims to follow, at least, a few of these threads of wool and to turn the problems into more concrete questions for which one can at least look for some answers, if not solutions.

Let's follow up on the main thread first, that is to say, whom are we talking about when we talk of 'immigrants with HIV'? First of all, we try to establish the figures, starting with what should be most familiar to us, that is to say, with HIV infection. But here we run into the first difficulties. As far as the number of HIV infected people goes in our country, and despite the efforts being made to monitor the infection, there are no global statistics, given the fact that only AIDS diagnosis has to be declared obligatorily. This gives rise to the fact that, for example, every year we are offered optimistic figures on the decline in the number of AIDS cases and deaths, which could in turn mean a reduction in the perception of risk and of the corresponding preventive measures for many people.

If we go over to the area of immigration we find ourselves with another confusion. To begin with there are only figures on the immigrants with residence permits (5.05% in Catalonia in the year 2002) or those on the electoral register (6.96% in the same year). But from a healthcare viewpoint, and especially if we are talking about people with HIV or risk practices, this information is just not enough. All the people who have not managed to get through the residence permit application procedure labyrinth, or who have not managed to retain one, or all those who cannot register themselves due to a lack of documentation, to ignorance, or to mistrust (which will predictably increase when the new law comes into force; according to which the police can gain access to the electoral register to facilitate the task of expulsing people who are illegally registered) do not appear in the statistics, in spite of the fact that they could have deficiencies of a social and healthcare nature -or indeed as a consequence of their being illegally registered-.

The need to pay attention to the legal questions is justified, given that it is the electoral register certificate that guarantees the healthcare card and, as a result, access to public healthcare, with the exception of the case of minors, pregnant women and emergencies. That is to say that any treatment at all, including antiretroviral treatment and treatment with methadone, to give just two crucial examples in the care of people with HIV or with risk practices, is vetoed for people who do not hold this certificate. Another question is that the specialists and people in charge of the healthcare centres opt for following their own ethical principles instead of this norm.

In other words: we do not know how many people are infected with HIV, nor do we know how many immigrants there are in this country; it is logical, therefore, to say that nor do we know the number of seropositive immigrants. We do, however, have at our disposal some indicative figures on people born abroad with AIDS: 13.6% of the cases accumulated in 2002 and 23% of the cases diagnosed this year (CEESCAT* 2003). The data available on HIV infection reveal that 23.5% (CEESCAT* 2003) were people of foreign origin in the year 2002. Hidden behind these figures are all those seropositive people who do not appear in the statistics and who do not have access to antiretroviral treatment. Thus the most urgent and necessary response in facing the situation of immigrants with HIV is that of guaranteeing access to public healthcare for everyone, no matter what their situation is from an administrative point of view, as included in the 2001-2004 Interdepartmental Immigration Plan of the Generalitat de Catalunya (Catalan government)(1).

A second thread that needs to be followed up on is that of social deficiencies and marginalisation amongst immigrants. And here it is essential to distinguish between social problems and those deriving from the culture, which are mixed up far too often. Precarious or inexistent housing, insufficient hygiene, resorting to delinquency, the lack of family support are better explained by immigration and legal difficulties than by turning to the 'cultural differences', which are so useful to ignorant ethnocentrism. Even if it is necessary to place emphasis on those situations that demand more help, associating immigrants with marginalisation will prevent us from being able to see the resources that non-marginal immigrants have and which, from the perspective of their own cultures, can help to give us clues to finding escape routes.

Even if immigration itself does not always cause the problems, it is true that it tends to make the deficiencies of the system manifest. A system that is too rigid, too arbitrary, badly organised or plain insufficient will easily go over the top with the arrival of immigrants. Immigration could be seen as a magnifying glass of the defects (and, of course, of the virtues) and an opportunity to revise inefficient structures for a population as diverse as is our own society.

The last thread that I would like to cover is that of the challenge that looking after people with different cultures presupposes for healthcare specialists. And it is here that the concept of immigration, so heavily media influenced, most clearly becomes unusable. This fetish term that seems to be associated with delinquency, the dole, death, (in) security and illegality etc., is in reality not very accurate and cannot stand up to even the slightest of examinations. Whom are we talking about when we talk of immigrants? Are the Moroccans who have taken Spanish nationality and who hold DNIs (National Identity Documents), the Japanese who work here in our country, the Catalans who are the children of the Swiss or the Russians (non-community European countries) or the Canadians and the Argentine grandchildren of Spaniards also immigrants? And what about the rich foreigners who are Spanish residents? In reality it seems as if the term immigrant has a usage that is circumscribed to that which is uncomfortable, which is poor, which is dangerous. This term is not really rigorous in any context, not even in the figures given above (in general the figures on immigrants include the Europeans even though the imagination of the citizens excludes them). But it is in the area of attention to cultural diversity that the term immigrant is most definitely useless. Whereas if we talk about the transcultural approach (2) in healthcare, instead of showing a homogeneous society and culture and statistics in which the autochthons (or indigenous Catalans or Spaniards) witness the mass arrival of immigrants with different cultures that threaten their own national identity, we can imagine a society in which there are people with differing origins, with certain cultural aspects that they have in common and others that differentiate them. Instead of talking about immigration we could make reference to people born abroad, or new Catalans or Spaniards (instead of the children of immigrants or second generations), or gypsies (the oldest and most forgotten ethnic minority), who have their own culture and, at the same time, form part of this society which is as much theirs as ours.

Moreover, the term transculturality allows us to talk of not just the culture of the other, but of our own, given that we are talking about the relationship between the two cultures (my own and the other's). What angers us or makes us uncomfortable, what surprises or fascinates us about the other has as much to do with his/her culture as it has to do with our own. It is from comparison that we can understand what is cultural as related to ourselves, given that if we have something to compare it with, 'what is normal' becomes a synonym of 'what is ours'. Questions like the notion of space, time, identity or health form part of our way of understanding the world, but we do not see them as cultural until we meet people who (from our own viewpoint) are unpunctual, get too close when they speak to us, or who believe that in order to cure themselves, as well as taking medicines, they have to consult a witch doctor or (in transculturally correct language) a traditional therapist.

Even at the risk of seeming paradoxical, the best way to learn when dealing with patients in a transcultural situation is that of learning about our own culture. If we understand our own way of understanding the world, illness, cures, the profession -and we are capable of accepting our own contradictions and prejudices- we will know where the traps, that could make our care relationship with people from other cultures more difficult, are. For example: from the recognition of the fact that in our country the equality of rights between men and women continues to be a pending question and one which is charged with emotions and contradictions -as is the case of women who have entered the labour market and continue to be responsible for the household chores, to give but one example- the conflicts between specialists and patients generated by this question are explained; in spite of -or precisely because of- the fact that other people's sexist attitudes are well known to many professionals. Even so, instead of learning from our own sexist countrymen, it seems that in facing sexists from other cultures we take advantage of the excuse in order to vent our own frustration and (legitimate) rage against sexual inequalities.

In this way, the contradictions in the culture of the other are accepted a lot less than our own are. What we have just commented on is a frequent example, but religion is another common example. It very often seems as if the specialists "demand" a much more dogmatic religion from their Muslim patients than from their Catholic patients. If they drink alcohol then they should not request a pork-free diet, or what difference does it make if they do not respect Ramadan. On the other hand, it is understandable that a Catholic eat meat during Lent but should also wish to celebrate Christmas.

Added to all of this are the prejudices, the greatest danger of which for specialists is that of trying to ignore them. The principle is to know and recognise them, explore them and to be aware of how they make us vulnerable. In our own society it is common to have prejudices (even if they are kept hidden in the unconscious) against the Moroccans and the gypsies for example, these being the communities with which we have cohabited the most number of years. Recognising these prejudices and the effect that they have on us is fundamental in order for us to be able to care for these people better, in order to avoid the reactions or emotions, that these unconscious myths or images provoke in us, from making us fall into confrontation or into patronising attitudes; in short, in order to offer quality care, independent of the customs, ways of living or ideas, for all the people who make up our society.


Cristina Visiers Würth is a graduate in Humanities from the Pompeu Fabra University (Barcelona, Spain) and has followed up her studies with training in logotherapy and existential analysis in Tübingen, Germany. She has carried out a postgraduate course at the lCESB (Institut Catòlic d'Educació Social de Barcelona - Catholic Institute of Social Sciences of Barcelona) in Barcelona, Spain, on psychosocial intervention and chronic illness processes and holds a university diploma in transcultural psychiatry from the Paris-13 University (Paris, France). She has worked in the social area with drug addicts, seropositive people and prison internees developing direct care functions, teaching, management and research. She is currently in charge of the transculturality and immigration programmes for l'Òrgan Tècnic de Drogodependències de la Generalitat de Catalunya*.


*N. de la T
CEESCAT : Centre d'Estudis Epidemiologics Sobre la SIDA de Catalunya correspond to the Center for Epidemiological Studies on AIDS in Catalonia
l'Òrgan Tècnic de Drogodependències de la Generalitat de Catalunya corresponds to the Catalan government’s technical organ of the Department of Drug Dependency.

(1) Despite it being impossible to say with any exactitude the number of immigrants without a health card, according to the IMSERSO (Instituto de Migraciones y Servicios Sociales – Institute of Migrations and Social Services) study at the end of the year 2000, between 20 and 30% of the immigrants were not in possession of one.
Díez J, Ramírez MJ. La voz de los inmigrantes. (The Voice of the Immigrants) Madrid: IMSERSO; 2001.
(2) That is to say, that in which the patient and the specialist do not belong to the same culture but that the cultural dimension and its influence in the diagnosis and in the development of the care relationship is borne in mind.

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