Pruebas de hipótesis

The national and international policy implications of this study’s principal findings can be addressed at both patient-encounter and structural levels. The evidence presented here suggests that in Finland, as in other Northern states, physicians (as well as nurses to a lesser extent) lack key skills in treating patients with ethnocultural backgrounds that differ from their own. Medical education has been insufficient and deficient. A new curriculum that prepares all clinicians for diverse transnational encounters is needed in this age of population mobility. Based on findings reported here and elsewhere, a contemporary medical school curriculum would usefully embrace the following features:

● Prepare doctors and nurses for multicultural, subcultural, mixed-origin and transnational encounters rather than be limited to particular bicultural encounters.

● Rely on the individual patient as teacher, as the fluid starting point for discovery, rather than on memorization of formulaic lists of culture-specific characteristics (Betancourt, 2003: 562–3; Culhane-Pera et al., 1997: 723; Shapiro and Lenahan, 1996: 249–50; Smedley et al., 2003:

207).

● Focus on the global and local structural foundations, the proximate and distant sources, of health-shaping inequities (Wear, 2003: 551–2).

● Explore the impact of dislocation experiences, ‘unfinished endings’

(Lipson and Meleis, 1999: 89), current immigration/transmigration status and the presence/absence of social networks and patient power (see Cowen, 1991: 407; Valtonen, 1998: 57).

● Ensure that the comprehensive core of necessary transnational interaction skills is integrated across preclinical and clinical learning experiences and is reinforced longitudinally.

● Emphasize problem-solving approaches that identify assets and resources amid liabilities and vulnerabilities (Ager, 1999: 13; McPhatter, 1997: 269) and involve the patient and his or her family or community members in health maintenance and promotion (Valtonen, 1994: 75–7).

● Help students identify and negotiate complementary and creative combi-nations of biomedical and ethnocultural/personal health care beliefs and practices that are neither clinically nor culturally contraindicated.

● Encourage students to develop and demonstrate skills in formulating and securing institutional and community support for enabling approaches that take into consideration the effects of social context, including immigration status, on migrant health (Gerrish et al., 1996: 137–8).

● Prepare clinicians for advocacy on behalf of migrant patients with social service agencies and with local, national and international authorities that shape law and policy (see, for instance, Alegria et al., 2003).

In short, a far-sighted medical school curriculum would move beyond cultural competence into transnational competence. This insight applies not only to Finland, but across migrant-receiving countries. In 2005, for instance, three US medical schools initiated the process of introducing a TC curriculum by piloting changes in third-year clerkships that are aimed at enhancing students’

transnational analytic, emotional and functional competence (Swick and Koehn, 2005).

At the structural level, the expansion and variability of transnational clinical encounters presents daunting challenges for state policy and for health care providers. When public authorities, international organizations and NGOs respond to the forces of globalization that generate local health equity and social justice issues (see Janes, 2002), the context of their response makes a difference. The present study focused on one dimension of the socio-political context of migrant health care: the presence/absence of legal residency status.

Previous research has found that being granted legal residency status enhances personal/family security, economic opportunity/ contributions (Pitkanen and Kouki, 2002: 110) and the societal incorporation of migrants (Groenendijk, 2001: 226, 234). The patient perspectives analyzed here suggest that admission to residence also has positive consequences for migrants’ health outcomes and that prolonged insecure immigration status can be debilitating for both the resettlement seeker and the host society. This finding is consistent with research in other receiving societies concerning the adverse physical and mental health effects of such exile stressors as ‘fears of being sent home’ (Watters 2001: 1711; Sinnerbrink et al., 1997: 467) and the uncertainties and delays that surround the processing of asylum petitions (Carrington and Procter, 1995: 16; Silove, 2004: 92; Silove et al., 1997: 351, 353; 2000: 606).

Improved migrant health care advances population security (see Newman, 2003: 14–15). It reduces morbidity and mortality among those who traverse borders and their hosts, facilitates receiving-society acceptance, reinforces migrant resiliency (see Gozdziak and Tuskan, 2000: 197–8, 202, 214–16;

Watters, 1998: 285–6), and enhances opportunities for social adjustment, economic adaptation and political participation. The long-term consequences of failure to provide effective local health care for people in spatial transition include ‘increasing prevalence of pathogens within a [receiving] state’s population’, diminished state capacity and augmented prospects for

‘increasing proliferation of infectious disease within that society in a negative and self-reinforcing feedback loop’ (Price-Smith, 2002: 173, 1–4).

Thus, policy measures that bring about greater equity in the treatment site characteristics encountered by asylum seekers are in the national interest of receiving countries. In light of the current and projected scarcity of ethnoculturally concordant and transnationally competent primary care physicians, one way that the goal of clinical context equity can be advanced is by changing reception policies so that they provide asylum seekers with

relevant information about available clinicians (Schmittdiel et al., 1997: 1599) and with increased choice of principal attending GP. As House and Williams (2000: 108) observe, if disadvantaged groups ‘do not have access to the same type and quality of providers and the same kind of relationships and com-munication with them as more advantaged persons, the result is likely to be their receiving less regular, preventive, and appropriate care’. Two approaches that promise to advance this key dimension of context equity are immediately available. The first would expand the pool of GPs that reception center residents could access while government authorities process their petitions for political asylum. An expanded pool to choose from could be achieved either by importing a larger and more transnationally competent cadre of GPs to work with patients in resettlement centers or by arranging for asylum seekers to access physician resources (see Le Feuvre, 2001: 133) at local public health sites on the same availability and financially subsidized bases as neighborhood residents. In either case, it is important that the enhanced pool consists of clinicians who are ‘positioned and willing to play the advocate’s role vigorously’ and who can assist asylum seekers in accessing specialty care and other host society resources (Flaskerud, 1987: 156; Smedley et al., 2003:

185).

The second approach would focus on reducing the length of time involved in processing asylum applications in order to minimize the period during which asylum seekers are differentially cared for in a system that separates them from the rest of the population (Le Feuvre, 2001: 132). Two or more anxiety-filled years of role loss, dependency, uncertainty about one’s future and (often) the ‘medicalization’ of social and structural barriers to wellness are unnecessarily punitive and debilitating (Miller, 1999: 284, 294). If immi-gration authorities processed asylum applications in a matter of a few months rather than years, then petitioners granted asylum could begin to address post-migration stressors sooner (Miller, 1999: 294, 298, 302; Silove and Ekblad, 2002: 402) and, without health-adverse delay, would be able to exercise the same range of choice over one’s principal attending physician available to other legal residents. In promoting changes in asylum deter-mination policy and implementation, health care personnel and social workers can join forces with NGOs such as Helsinki’s Refugee Advice Center, which has characterized the normal one- to three-year waiting period as

‘highly unacceptable’ (cited in Kiuru, 2002: 17).

The situation of petitioners whose asylum applications are rejected also needs to be addressed. Presently, throughout Europe, many asylum seekers are denied legal residence, but few are deported. As Arthur Helton (2002:

169) points out, ‘the dirty little secret in western European asylum practice is that while relatively few are granted refugee status, very few rejected asylum seekers are removed. Instead, their stay is “tolerated” and they subsist under uncertain circumstances without the possibility to integrate into society.’ The context challenge presented here is that persons holding undocumented

status are not likely to be treated at all within the biomedical system until their condition reaches emergency proportions. Given the facility with which undocumented migrants cross national borders, this challenge requires an international burden-sharing policy approach. Although the study reported here did not encompass undocumented migrants, its findings suggest that uniform policy changes that would enable and encourage undocumented residents to secure medical care at community health centers as well as efforts such as the pan-European migrant-friendly hospital project (see www.mfh-eu.net) would result in improved individual and societal health outcomes.

In the effort to improve global health, it is important that policy makers take the structural context of medical care into account. The findings of this comparative study of transnational medical encounters suggest that inter-national and inter-national health policy-makers and non-state actors who are concerned with strengthening global health need to be centrally engaged in ongoing debates over determinants of equitable local health care – including policies that affect grants of political asylum and access to community health care resources.

a c k n ow l e d g e m e n t s

A grant from the Fulbright New Century Scholar program supported the research undertaken as part of this project. The author acknowledges the helpful comments of two anonymous reviewers on an earlier draft of this article.

n o t e s

1. Most of those admitted as Ingrian Finns are descendants of ‘Finns who in the 17th century settled in the lands around present day St Petersburg’ (Korkiasaari and Soderling, 1998: 15) or of ‘Finnish people who were incorporated into the Soviet Union at the end of the Second World War when part of the eastern district of Finland was annexed by the USSR’ (Pitkanen and Kouki, 2002: 105; see also Forsander, 1999: 56–65, 70n).

2. By 2002, according to Institute of Migration figures, the number of native Somali speakers exceeded 7000 (also see Tiilikainen, 2003: 60). Fully 37 percent of the Somali speakers living in Finland in 2002 were under 10 years of age, as were 18–28 percent of the Vietnamese, Kurdish and Albanian speakers (Finland, Institute of Migration, 2003b).

3. Many arriving asylum seekers were Roma from Slovakia, Poland and the Czech Republic. Finnish authorities held arriving Roma briefly in reception centers, where they subjected their applications to accelerated review and, then, returned them to their ‘safe countries’ of departure or origin (Nordberg, 2004: 717–18, 727).

4. Assigning patients to doctors on the basis of the geographic location of their residence parallels the Swedish model, although ‘recent [Swedish] reform initiatives have increased freedom of choice in some areas’ (Freeman, 2000: 35).

In many additional respects, moreover, the decentralized Finnish health care system resembles Swedish practice (see Freeman, 2000: 35, 37, 41–2, 105; Malin,

2000: 2; Lehto, 1999: 11–15). However, in contrast to the anecdotal evidence Freeman cites for Sweden (Freeman, 2000: 110), many of the foreign-born residents interviewed in this study changed doctors actively and rather frequently.

5. Juhani Lehto (1999: 10) points out that the detailed health instructions the center previously issued to local governments in Sweden and Finland have been relaxed in recent years and that central government subsidies are now issued as block grants.

6. Sources in Joensuu were: the Mannerheim League for Child Welfare (providing a randomly sampled blind list of returning Finns and Russian-speaking spouses);

Rantakyla District Health Center (randomly sampled lists of Russian-speaking and Vietnamese migrants); Rantakyla District social work office (a randomly sampled blind list of elderly returning Finns); and a Somali community leader’s list of available adults. Of those contacted, only three refused to participate (two from the social work list and one from the Russian-speaking-migrants list).

However, only one person out of the five selected from the Vietnamese migrant list showed up for an interview. One attending Joensuu physician (two cases) declined to be interviewed on grounds that he had moved to the health center of a different district. Two others (one case each) declined because they could not recall the patient.

Helsinki sources were: the Helsinki Foreigners’ Crisis Prevention Center (a randomly sampled blind list of current clients); Herttoniemen Subdistrict Health Center (adult patients seen mid-June through mid-July 2002); the Association of Nigerians in Finland (available adult members who had seen a doctor and/or nurse); the Ingrian Center (available adult members who had seen a doctor and/or nurse); three Somali community leaders (available adults); and a Vietnamese community leader (available adults). There were no refusals reported among the selected foreign residents in Helsinki. Among all the sources approached, only the Rehabilitation Center for Victims of Torture proved uncooperative. The psychiatrist contracted by the Foreigners’ Crisis Prevention Center (two cases) declined to be interviewed given the absence of monetary compensation. One other Helsinki physician (one case) said she was too busy to participate and one nurse (one case) refused.

Two migrants selected in Joensuu (one a 72-year-old returning male Finn and the other a male Somali) had to be dropped from the study because they had not seen a physician in Finland. In a handful of other cases, the doctor/dentist or nurse/dental assistant could not recall the patient or could not be sufficiently identified by the patient to be located.

7. For a full explanation and discussion of the items used to measure each dimension of TC in health care encounters, see Koehn (2004: 78–80).

8. In a few cases, we used statistical techniques designed to accommodate missing data when calculating mean TC scores.

9. The choice of cut-off points always is somewhat arbitrary (van Ryn and Burke, 2001: 816). The analysis reported here utilizes breaks where at least 20 percent of each group fit in the high-TC category and at least 15 percent fit in the least-TC category.

10. Three of the five reception centers included in this study are located a considerable distance from the city center in a relatively isolated setting. Only the reception centers in Helsinki and Kotka are centrally located. However, all reception centers are ‘open’, in that asylum seekers are allowed to move freely within the wider Finnish society.

11. It is important to recognize, however, that many South to North migrants possess their own transnational social networks. In the case of Kurdish refugees, for instance, Osten Wahlbeck (1999: 2, 84, 145–7) found that ‘almost immediately upon arrival in Finland the refugees were able to get in touch with compatriots, friends and relatives in Finland, Europe and Kurdistan’. With respect to Vietnamese resettlers, see Valtonen (1996: 476, 478, 486).

12. At least one clinician reported for 85 cases, yielding intersubjective data on 91 percent of the 93 medical encounters sampled.

13. For an illustration of provider functional competence in a clinical setting involving encounters with refugees from multiple national backgrounds, see Derges and Henderson (2003: 94).

14. An example of an especially helpful booklet that could be translated into languages other than Finnish and English is Hille Puusaari’s (n.d.) Settling Down in Finland: A Guide for the Immigrant.

15. This finding is based on cross-sectional data. Longitudinal studies that assess the long-term health effects of protracted asylum-seeking status are needed.

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