Final Research Paper: Looking at Italy's Health Care Dilemma for Undocumented Migrants

           Imagine being a nine-year-old child in excruciating pain with no place to obtain medical treatment while in an unfamiliar country. This horrifying nightmare is a reality to many migrants living in Italy. Just two weeks ago at the Joel Nafuma Migrant Center on Via Nazionale in Rome, a young nine-year-old boy was faced with this exact situation. Hit by a car while crossing the street, he acquired numerous injuries to his left leg and was unable to walk. He was a refugee from Afghanistan making his way through various countries in Europe in hopes of reaching Norway, a place where migrants receive the best benefits. His friends hovered around him reassuring the many worried onlookers that he was fine and did not need medical attention. The young boy’s excruciating expression told otherwise. Without the proper papers in Italy, it becomes complicated to receive medical attention. His guardians were worried that their illegal status in Italy would be disclosed if they brought him to a doctor. Sandra, a volunteer at the migrant center, decided to take her chances and brought him to a hospital. She had to go to three different hospitals until medical professionals finally saw the young boy. As one can see, the Italian health care system is very complex, especially concerning health care of undocumented migrants.

            There are many complex regulations in Italy in terms of who can be covered by the country’s public health care. These regulations range from a person’s legal status in Italy to the severity of illness. In this paper, the state policy in Italy for migrants compared to legal residents will be examined in terms of their access to health care. In addition, the correlation between this policy and the realities of health care practices for migrants will be assessed. The term migrants, as used in this paper, means everyone who has moved to Italy whether their move was by choice such as for an immigrant or forced such as for a refugee. The term undocumented refers to those who are not registered with the Italian government and are illegally in the country. These terms will be used throughout to better understand the complex Italian health care system and how it pertains to undocumented migrants.

-METHODS-

            Information on this topic of Italian healthcare for undocumented migrants as well as legal residents was gathered from a variety of sources. The Joel Nafuma Migrant Center provided great insight on how these undocumented migrants receive care. Sandra, a volunteer for many years at the center, has a lot of personal experience dealing with these migrants at the center and was very gracious to share her experiences. In addition to Sandra, I was also able to speak with Sina who is a nursing student in Rome who volunteers his time at the Joel Nafuma Migrant Center. Sina, even with the language barrier, was able to provide a lot of valuable insight on how undocumented migrants get into contact with doctors to receive the care they need. The staff at CARITAS also provided valuable information, especially Anna Galdo who is the research and projects officer in the asylum and migration department. The internet also served as a valuable source. Such journals as The European Journal of Health Law and The Health Economics Journal provided information on the Italian health care system. Other internet websites were informative by providing statistics as well as the current health care issues in Italy.

-FINDINGS-

According to the World Health Organization (WHO), Italy has the second highest rated health care system in the world (Healthcare Economist). Italy guarantees the uniform provision of comprehensive care throughout the country (France). Italy’s national health system, called Sercizio Sanitario Nazionale or SSN for short, receives funding from a regressive payroll tax, social insurance contributions as well as co-payments. In-patient and primary care are free yet tests, diagnostic procedures and prescription drugs require co-payments as high as thirty percent. However, forty percent of the population, which includes the elderly, pregnant women as well as children, is exempt from these co-payments (Healthcare Economist). Emergency health provisions are available to all EU and non-EU visitors. No matter where one comes from, it is mandatory to have some form of health insurance upon arriving in Italy. A permesso di soggiorno, or residency permit, will not be issued without it (Healthcare Economist).

Despite the high rankings by the WHO, Italians are dissatisfied with the quality of their health care. Italians believe that patient choice will improve the quality of care, yet reform is unlikely to happen anytime soon. Waiting times are also a prevalent problem in the current health care system. For diagnostic tests, the average wait for a mammogram is seventy days and for endoscopy seventy-four days (Healthcare Economist). In addition to long waiting times, the sanitary condition of many hospitals is unacceptable. Overcrowded rooms often are filled with lice while patients are served uneatable foods (Health System in Italy). Many opt to pay for private health care as a result of these conditions. Also, the health care system is complicated by the fact that constitutionally, responsibility for health care is shared between the central government and the twenty regions. There are large disparities in regional health service organization and provision (France). In addition, coverage differs greatly depending on one’s legal status. As a result of all these impediments in the health care system, many within Italy are unsatisfied with the Italian health care system.

There are many ways for people to get insured and be covered under this health care system. These include working in Italy, being a EU citizen visiting Italy or simply being an Italian citizen. If you are working in Italy, the employer pays your health insurance. All you need to do is go to your local health authority and register with a doctor at the health convention. A health number is then created along with a health card, which can be used to have all visits to a family doctor be covered. If you are an EU citizen visiting Italy, you can take advantage of reciprocal health agreements. This can be done by simply going to the ufficio staniero (foreigner’s office) and filling out paperwork to cover your temporary stay (Health System in Italy).

Obtaining health care if you do not fit into these categories becomes a little more complicated. My talk with CARITAS’s Anna Galdo informed me that with the correct paperwork, immigrants are treated in the same manner as Italian citizens. The current legislative provisions concerning health care for illegal immigrants can be found in Article 35 of the Legislative Decree No. 286 in July 1998. The article is organized according to several principles including human dignity, health need and solidarity with the most vulnerable people (Romero- Ortuno). This includes having equal rights for everyone irrespective of personal or social characteristics. In addition, everyone in need is granted a right to health care. The article states how illegal immigrants in Italy have the right to receive urgent and essential primary care due to illness or accident, with guarantee of continuity of care (Romero-Ortuno). In addition, migrants are covered for pregnancy and maternity care, full health care for everyone under eighteen as well as vaccinations according to the rules and within the areas of intervention set by the regions. Their health care even extends to diagnosis and treatment of infectious diseases and prevention, treatment and rehabilitation of toxic dependencies (Romero-Ortuno).

In order to receive these benefits, illegal immigrants must fill an official form self-declaring that they lack sufficient economic resources (Dichiarazione di Indigenza). In return they will be given an anonymous ID regional code (Codice Staniero Temporaneamente Presente) which is valid for six months. With this code they can receive all of the benefits listed above and be treated under the same conditions as Italians. The regional health authority refunds the provider for all expenses. In addition, an illegal immigrant cannot be reported to the authorities (Romero-Ortuno).

Health care for undocumented migrants gets tricky when these migrants fail to obtain these documents. From my talk with Sandra, an avid volunteer from the Joel Nafuma Migrant Center, I have learned that even without documents it is possible for illegal immigrants and refugees to receive care, even if it is breaking laws. According to Sandra, there are certain hospitals in Rome that do not check for documents and turn their head in order to give care to those in need. Sandra mentioned the Ospedale Nuovo Regina Margherita in the Rione Trastevere as a good hospital for immigrants without documents to go and receive care. According to Sina, a nursing student who volunteers his time at the Joel Nafuma Migrant Center, these hospitals take the people’s name and number without contacting the police. In Sina’s words, “this is a way to break the law and do the right thing.”

Overall, migrants either documented or undocumented are able to get access to health care in Italy even if they do so illegally. Migrants who do not have their papers might come up against barriers to receiving care at certain hospitals, but there are places that are open to helping everyone. This type of information is important to pass along to all migrants in order to ensure good health for everyone.

-DISCUSSION-

            Many believe Italy has a very strong health care system in place. Their health care system is set up to offer care to the majority of Italy’s population with little or no copayment. As long as one has the correct paperwork, whether they are an Italian citizen, illegal migrant or legal migrant, they will be covered under the Italian health care system. Other than the bad conditions of long wait times and unsanitary hospitals, the health care system basically has been proven to be successful in ensuring good health for the majority of the population. However, a major problem this system sustains is its inability to provide coverage for undocumented migrants.

This issue of health care for undocumented migrants in Italy has become a pressing topic. There are those who believe that if one is not paying taxes, then they should not be entitled to health care. Aiding these undocumented migrants without papers only puts the Italian health care system further into debt. On the other side, others wonder if it is ethically right to deny someone health care. This is the current topic being debated.

Although some migrants might know these particular hospitals that do not check for paperwork, many others must simply go without help. Changes must be made to this current health care system in order to ensure good health for all. The Italian health care system needs to be prepared for Italy’s changing identity. According to Sylvia Poggioli’s film titled “Immigrants Forced to Margins of Italian Society,” Italy has the fastest growing immigrant population in the world.  This film states that immigrants constitute seven percent of the Italian population. Ever since the mid 1980’s, Italy has imported people from many vicinities including Northwest Africa, South and Southeast Asia as well as South America (Grillo). Italy’s identity is shifting to becoming a multi-cultural country (Wong).

With migration in Italy playing such a large role in today’s society, adaptions must be made to fully include all migrants, whether legal or illegal and with or without paperwork, into the health care system. Access to health care is an integral part of living long healthy lives. Opening the doors at hospitals across Italy for these undocumented migrants would promote good health. Making adaptions to the Article 35 to include ways undocumented migrants can receive care legally will in turn result in better health for all.

There are many problems precipitated by these illegal actions of providing migrant health care. Article 35 of the Legislative Decree No. 286 written in July 1998, relates that there are equal rights for everyone irrespective of personal or social characteristics. In addition, everyone in need is guaranteed a right to health care. According to the findings provided, this universal coverage does not seem to be the case. Undocumented migrants, who do not possess the correct paperwork, are not given equal opportunity to health care in Italy. They are forced to go to the select hospitals that break the law and do not check the migrants’ papers. These illegal practices are hotly debated in Italy since caring for these undocumented migrants puts the Italian health care system further into debt. The Italian health care system has an average deficit equal to $2.5 billion US dollars per year (Maio). These illegal migrants only further the situation. This question of whether these hospitals should care for these migrants given that this care comes at a price is a major issue at hand. Both sides cause issues for either the migrant or financially for the Italian health department.

-CONCLUSION-

            In the end, there is a very complex health care system set up in Italy. This system is designed to cover Italian citizens, EU visitors and documented migrants will little or no copayment. Undocumented migrants, on the other hand, are only covered under extreme circumstances. These include such circumstances as urgent and essential primary care. Although there are certain hospitals that turn their heads in order to help, more needs to be done to enable all hospitals to treat these undocumented migrants. Italy’s identity is slowly shifting as a result of the high prevalence of immigration. With so many immigrants, the health care system needs to change in order to promote the well being of the entire population. It is important for changes to occur so that situations such as the one the young Afghanistan boy was faced with will no longer need to occur. Though this investigation, only more questions are asked pertaining to Italy’s health care system and its involvement with migrants. The future of this health care system and how it decides to deal with this high flow of immigrants into the country is a pressing concern for Italy.

            When gathering information on this topic of access to health care for undocumented migrants, there were many barriers. Since this topic deals with issues involving breaking the law in order to help migrants get care, many were unwilling to talk about specifics on the issue or their involvements. Only after reassuring people that this information would solely be used for educational purposes would people be willing to share information and still I felt as if I were not getting the entire story. In addition to the barrier of having people not want to share information that could get them in trouble with the police, it was also difficult to uncover information about how undocumented migrants received care. Nothing had been published on the issue stating how illegal migrants broke the law to receive care. The only information gathered on the issue was from speaking with knowledgeable people on the issue. Overall, there were many hindrances to dealing with a topic so bound up in legal regulations.

Bibliography

France, George. "The Italian Health-Care System." Health Economics. John Wiley & Sons, Ltd., 14 Sept. 2005. Web. 2 Mar. 2011.

Galdo, Anna. Research and Projects Officer. CARITAS ROME. Personal interview. 28 Feb. 2011.

Grillo, Ralph, and Jeff Pratt. ""The Politics of Recognizing Difference"" Multiculturalism Italian Style Aldershott (2002). Print.

"Health System in Italy." Web. 2 Mar. 2011. <http://www.italytravelescape.com/Health system.htm>.

"Healthcare Economist · Health Care Around the World: Italy." Healthcare Economist. Web. 2 Mar. 2011. <http://healthcare-economist.com/2008/04/15/health-care-around-the-world-italy/>.

Maio, Vittorio. "The Italian Health Care System: W.H.O. Ranking Verses Public Perception." Web. 12 Mar. 2011. <http://www.pharmscope.com/ptjournal/fulltext/27/6/PTJ2706301.pdf>.

Poggioli, Sylvia. Immigrants Forced To Margins Of Italian Society : NPR. NPR : National Public Radio : News & Analysis, World, US, Music & Arts : NPR. 13 Jan. 2009. Web. 2 Mar. 2011. <http://www.npr.org/templates/story/story.php?storyId=99255579>.

Romero-Ortuno, Roman. "Access to Health Care for Illegal Immigrants in the EU: Should We Be Concerned?" European Journal of Health Law 11 (2004): 245-72. Martinus Nijhoff. Web. 2 Mar. 2011.

Sandra. Joel Nafuma Migrant Center. Personal Interview. 1 Mar. 2011.

Sina. Nusing Student. Volunteer at Joel Nafuma Migrant Center. Personal Interview. 6 Mar. 2011.

Wong, Aliza. "Race and the Nation in Liberal Italy." (2006). Print.

Rione Paper: Discovering Rione Trevi

When one thinks of the Rione Trevi, the Trevi fountain is probably the first thing that comes to mind. Although the fountain is a main attraction in this Rione, the area is dense in history, culture and character. Exploring the area and interacting with the residents of this Rione has opened my eyes to more about this area than just its’ spectacular fountain.

The Rione Trevi is very rich in history. Of the twenty-two riones, the Trevi is Rome’s second and was founded in 1763 by Pope Benedetto XIV. The name Trevi originates from the middle age word “Trivium” which means the crossing of three roads. This crossing of these roads occurs where the current Trevi fountain is today. The Rione Trevi’s coat of arms entails three swords, which is derived from these three roads. During the time of the Roman Empire, wealthier people lived up on the hills of the Rione. After the fall of the empire, people moved down to the river and construction on the higher parts of the city came to a standstill. It wasn’t until the Renaissance that the hills surrounding the Trevi became populated with new streets, churches and fountains.

Today, the Rione Trevi includes the busy Via del Corso, the Trevi Fountain, the Palazzo Barberini, the Palazzo del Quirinale and more than twenty churches. The Rione Trevi extends from the western side of the Quirinale hill and the plain between this hill and Via del Corso. It borders to the west on Pigna, to the south and the east on Monti and to the north on Colonna and the walls of Rome. It is one of the larger riones and includes a wide range of sites and regions of differing atmospheres.

The Trevi fountain is Rione Trevi’s most notable monument. It was completed in 1762 by Giuseppe Pannini and is the largest Baroque fountain. It was built to celebrate the end of Aqua Virgin aqueduct. This legend, which involves a young girl showing soldiers a spring that was the source of the aqueduct, is depicted on the upper panels of the fountain. Neptune, the god of water and the sea, can be seen in the center of the fountain taming sea horses symbolizing the mood of the sea. It is a tradition for tourists to come and throw a coin in the fountain wishing to come back to Rome one day. Thousands of tourists visit each day and according to a report by BCC, an astonishing 3000 euros are collected every day from the fountain and given to charity. This astonishing fountain is often the center of many top films including “Roman Holiday” and “La Dolce Vita.”

            Upon arriving into the Rione Trevi for the first time, it is easy to get caught up in the touristy atmosphere. Souvenir shops, street vendors and restaurants in every language line the small winding streets leading to the Trevi fountain. The piazza in front of the fountain is a central social gathering point for many and there is always a constant chattering and energetic ring in the area. The bustling buzz of the tourists definitely livens the area. This image of the Rione Trevi is what most visitors take away from their visit. After talking to a few of the tourists visiting the fountain on one of my visits, it became apparent that visitors coming to the area rarely explore the Rione Trevi other than the fountain.

We talked to a Swedish couple visiting Rome for the first time, which helped get the true tourist perspective of the area. Their perspective differs from mine since I do not consider myself a tourist visiting the city and instead a short term resident. This couple would view the area in a different light since they wouldn’t have an extensive amount of time to explore. They were only in Rome for four days and were hitting all the top sites on their visit, which included the Trevi fountain. Although they thought the Trevi was immense and remarkable, they had not planned to explore the area any further. Since many visitors don’t explore the Rione Trevi other than the fountain, I think it would be interesting for tourists to try and escape the tourist traps around the fountain and explore more of the surrounding area. Hopefully, tour books will include insights on exploring more of the area around the Trevi fountain since there are a lot of cute shops and beautiful buildings with a lot of character in the surrounding area.

            The atmosphere beyond the Trevi fountain is filled with small winding streets lined with apartment buildings and small cafes, shops and restaurants at their base. Walking around beyond the fountain I feel as if I have entered an entirely new area. Here is where the “insiders” of the rione Trevi live. They distance themselves from the touristy “outsiders” that tend to congregate around the Trevi fountain. About one block out, the constant hum of tourist’s excitement fades as people’s routine daily life and chores fill the streets. People carrying groceries, shopping in local stores and grabbing cappuccinos were common errands seen while wandering beyond the fountain. There is a distinct border that defines who belongs and who doesn’t depending on how far away from the Trevi fountain one is. As I meandered through the area surrounding the Trevi fountain, I didn’t necessarily fit the tourist description but was definitely characterized as an “outsider.” This was because I was not Italian and wasn’t completely familiar with the area, which made me stand out.

It is evident from just wandering through the Rione Trevi, that it’s wealthy. Vibrant and elegant buildings line the streets and the residents dress as if they are of a higher status. Security guards stand in front of luxury apartments impeccably decorated and full of character. Women dress in fine furs and walk with a purpose. These are all evident signs that the area is of higher economic status. The fountain is what brings the tourists to the rione and in turn a lot of money. During one of my visits to Trevi, we spoke with an ice cream vender who informed us that the Rione Trevi was an extremely expensive place to live. She could not afford to live in the area and instead commuted from outside the city walls like many other store owners in the Rione. Through both my observations and speaking with the women at the ice cream store, it became evident that this area was extremely wealthy. 

            Art is evident throughout the Rione Trevi. Between the vast amount of sculptures and fountains scattered throughout to the beautifully constructed buildings and churches, art is visible everywhere. In particular the Triton fountain is one of Rione Trevi’s most artistic fountains in my opinion. This fountain was the first of Bernini free standing urban fountains and was built in 1642. The fountain depicts Triton, a minor sea god, with four dolphins at its base. The Triton fountain strikes a dramatic artistic presence in the middle of Piazza Barberini. This piazza is immense and the fountain’s location in the middle draws lots of attention on the elegant fountain. Although there are many elegant statues and buildings throughout the Rione Trevi, I found it very difficult to see any evidence of graffiti or tags of any sort. This is most likely due to the higher economic class of the area.

            Overall, exploring the Rione Trevi in greater detail has opened my eyes to better understanding the area’s monuments, culture, history and residents. As a young college aged student living in Rome and exploring the area, I am sure that I got a different take on the area than others. For example, I was not impressed with the area directly surrounding the Trevi fountain due to the high amount of traffic as well as the numerous shops geared to lure in these tourists’ money. Someone visiting Rome for the first time might absolutely fall in love with this area and view this rione as being representative of all of Rome. In this way, people’s impressions on the Rione Trevi differ greatly. In the end, my impressions of the Trevi area changed drastically after my return for this assignment. In the beginning, I had always viewed the area as strictly for tourists, a place where one could not get the full “Italian experience.” Little did I know that only a few blocks away lay lavishly painted winding streets filled with quaint cafes, shops and smaller hidden restaurants. This assignment has taught me to look beyond what the tour books tell you in order to really get a feel for the area and its culture. I hope that in my last few weeks in Rome, I am able to return to the area and further explore to be able to deepen my understanding of the area.  

Blog 8: Reflections of my Service Learning at the Joel Nafuma Migrant Center

During the past nine weeks, our program has been focused around the topic of immigration and the changing Italian identity. As a part of this program I have been able to deepen my knowledge on this subject by spending time in the Joel Nafuma Migrant Center. This center is located in the crypt of St. Paul’s Church on Via Nazionale. The Joel Nafuma Migrant Center is dedicated to helping refugees become better accustomed to life here in Rome. According to their website, this center offers a place where these refugees can come “to get advice and aid, spend time with people who speak their own language, watch news bulletins from around the world, learn English, Italian, computer skills, and basic skills to help them adjust to life in Europe.” Overall, this experience let me see first hand how immigrants are becoming accustomed to life in Italy. In addition, I was able to walk away with a sense that I was able to make a difference in peoples lives.

In these past eight weeks, I have spent two days a week volunteering my time at the Joel Nafuma Migrant Center. On Tuesdays I usually spend the beginning of my time there in the kitchen. Here I help Salva, a refugee from Russia who once came to the center, prepare tea and cornettos. This job consists of making two large pots of tea and pouring them into cups. At 10:30am, we have the refugees form a line as we pass out these cups of tea along with a cornetto. After cleaning up the kitchen we move into the classroom where we teach English. When we come on Thursday afternoons we also help out in the classroom. Here, we have those at the center who want to learn English gather. Depending on who shows up, we devise a lesson plan around their knowledge level. This is often the most difficult part since usually the refugees that show up come from a variety of educational backgrounds. In addition to teaching English, we also help those who are interested in learning how to use the computer. In the classroom there are computers with special typing programs to aid the refugees in becoming more accustomed to the technologically advanced lifestyle in Italy. Many who come into the classroom wanting to use the computers have never used one before or are just starting to learn how to type. In addition to helping with tea and teaching, our group also helps out in the utility room passing out used clothes and hygiene products such as shampoo, razors and toothbrushes. Although this is not the job I usually assist in, I have spent a few of my days volunteering in this room. In the end, I feel as if our work volunteering in this wide range of activities has proven to make a difference at the center.

When I first arrived at the Joel Nafuma Migrant Center, I have to admit that I did not feel comfortable. Turning the corner into the main room at the center, I felt as if hundreds of eyes turned to look at the definite outsider barging into their personal space. Being an American female of middle-upper class it was obvious I did not belong. Before this time, I had not found myself in such a situation that involved myself feeling like such an outcast. I remember how I kept thinking how I was going to interact with these refugees if there was nothing we had in common since for most we did not even share a common language.

After a few weeks I began to get more comfortable interacting with the refugees. Everyone at the center began to recognize us as regulars and the glares once we entered began to fade. During our time making tea with Salva, he was able to inform us about the background stories of many of the refugees which made me feel more comfortable. He talked about how many were forced to leave their families and extremely unhappy being here in Italy. This helped explain the sorrow in people’s faces and the unapproachable attitude many possessed. He talked about how some wanted to talk, some wanted help fitting into Italian society and others just wanted to be left alone. It was up to them to approach you, and other than just wait there really was not much one could do to help these refugees. This talk with Salva helped me to both understand the stories of many of these refugees as well as not feel as if it was up to me to help everyone, since many wanted to be left alone. In addition, through learning more about immigration, migrants and the situation going on in Italy in class, I began to feel more comfortable spending time and interacting with people at the center. In particular, Grillo and Pratt’s piece titled “The Politics of Recognizing Difference” and Kitty Calavits’s “Law, immigration and exclusion in Italy and Spain” helped lay out the tension and marginalization of immigrants in Italy. My frame of reference had shifted as a result of my time in Italy in addition to my better understanding of the immigration process and situation going on in Italy from class. During our English lessons, we were able to speak with a few about the changing identity of Italy which enabled me to connect with these refugees on a deeper level since I was informed on the issue. By the time our time at the refugee center, I had become very familiar with the process at the center and had made many connections with the refugees.

Even though I was able to learn a lot about the Joel Nafuma Migrant Center, I still have many questions. It would be interesting to learn more about the history of the center as far as the story about how it began. It would also be interesting to get more information about those refugees I was never able to interact with due to the language barrier. I felt as if many had a very interesting story to tell as far as why they were in Italy and what life was like back at home to make them chose to move to Italy. In addition, it would be interesting to learn more about these refugees integration into Italian society once arriving. The language barrier hindered conversation that was this detailed. Some of these questions as far as ones about the center could be answered through contacting the coordinator Tuana while others about refugee’s personal stories will probably never be answered due to privacy issues and language barriers. In the end, I enjoyed my time at the migrant center. It was interesting to be able to work with and aid migrants first hand with the integration process in Italy, which is something we were studying in class.