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Journal of Migration and Health
journalhomepage:www.elsevier.com/locate/jmh
The impact of COVID-19 on Venezuelan migrants’ access to health: A qualitative study in Colombian and Peruvian cities
Patricio Zambrano-Barragán
a,∗, Sebastián Ramírez Hernández
b, Luisa Feline Freier
c, Marta Luzes
d, Rita Sobczyk
e, Alexander Rodríguez
f, Charles Beach
ga Inter-American Development Bank, 1300 New York Avenue NW, Washington DC, 20577, United States
b Princeton University, 119 Julis Romo Rabinowitz Building, Princeton, NJ, 08540, United States
c Political and Social Sciences Department, Universidad del Pacífico, Jr. Gral. Luis Sanchez Cerro, 2141, Jesus Maria, Lima, Peru
d Centro de Investigación, Universidad del Pacífico, Jr. Gral. Luis Sanchez Cerro, 2141, Jesus Maria, Lima, Peru
e Faculty of Political Science and Sociology, Department of Sociology, University of Granada, C/ Rector López Argüeta s/n, 18071 Granada, Spain
f Oraloteca - Universidad del Magdalena, Carrera 32 No 22 – 08 Santa Marta D.T.C.H, Colombia
g University College London, 14 Taviton Street, London WC1H 0BW, United Kingdom
a r t i c le i n f o
Keywords:
Forced migration Healthcare Informality COVID-19 Colombia Peru
a b s t r a ct
ThisresearchseekstounderstandhowCOVID-19hasaffectedaccesstohealthcareamongmigrantsinLatinAmeri- cancities.Usingethnographicresearchmethods,weengagedwithVenezuelanslivinginconditionsofinformality infourColombiancities—Barranquilla,Cucuta,Riohacha,andSoacha—andthreePeruviancities—Lima,Tru- jillo,andTumbes.Weconducted130interviewsofbothVenezuelanmigrantsandstateandnon-governmental actorswithinthehealthcareecosystemsofthesecities.WefoundthatforcedmigrantsfromVenezuelainboth ColombiaandPerufacecommonobstaclesalongtheiraccesstrajectoriestohealthcare,whichwesummarize aslegal,financial,andrelatingtodiscriminationandinformationasymmetry.Bylimitingeffectiveaccessto careduringthepandemic,theseobstacleshavealsoaffectedmigrants’abilitytocoverthecostsofbasicneeds, particularlyfoodandhousing.Ourstudyalsofoundaprevalentrelianceonalternativeformsofcare,suchas telemedicine,easy-to-accesspharmacies,andextralegalcarenetworks.WeconcludethatCOVID-19hasexacer- batedpreexistingconditionsofinformalityandhealthinequitiesaffectingVenezuelanmigrantsinColombiaand Peru.
Introduction
Inrecentyears,LatinAmericaandtheCaribbean(LAC)hasexperi- encedanunprecedentedriseinintraregionalmigrationflows.Basedon datafromtheUnitedNationsGlobalMigrationDatabase,thenumberof migrantsinLACroseby77%between2000and2019,higherthanthe increaseof globalSouth-Southmigration(60%).1 Between2015and 2018,countriessuchasChile,Colombia,Ecuador,Guyana,Peru,and TrinidadandTobagohaveseentheproportionofimmigrantsrisebe- tween0.5%and2%—considerablyhigherthantheglobalaverageof 0.1%.
Venezuelanmigrantsarekeyprotagonistsoftheseunprecedented migrationtrends.Asa resultofworseningsocial andeconomiccon- ditions, close to five million people have left the country since 2015,ofwhomover fourmillionhavestayedwithin theLACregion
∗Correspondingauthor.
E-mail addresses: [email protected] (P. Zambrano-Barragán), [email protected] (S. Ramírez Hernández), [email protected] (L.F. Freier), [email protected](M.Luzes),[email protected](R.Sobczyk),[email protected](A.Rodríguez),[email protected](C.Beach).
(UNHCR,2020).2TheprimarydestinationsareColombiaandPeru,fol- lowedbyChileandEcuador;thisgeographicdistributiondescribesa southboundtrajectoryalongtheAndeansubregion,fromVenezuelato ChileandArgentina.Colombiaisnowhometoover1.7millionVenezue- lans,ofwhom55%donothavelegalstatus(MigraciónColombia,2020).
Between early2017andmid2020,1.3millionVenezuelansentered Peru;todate,over790,000havestayedandonly350,000havereceived formalpermitstostay(Migraciones,2020).
Themajorityofthese"recentmigrantshavesettledinurbanareas, typicallyinlargemetropolitanareasandbordercities.Upto500,000
1The Global Migration Database is available at https://population.un.
org/unmigration/index_sql.aspx.
2SomeresearchershavearguedthatVenezuelanmigrantscouldqualifyas refugeesundertheexpandedCartagenadefinition;seeFreieretal.,2020
https://doi.org/10.1016/j.jmh.2020.100029
Received30November2020;Receivedinrevisedform3December2020;Accepted4December2020 Availableonline9December2020
2666-6235/© 2020TheAuthors.PublishedbyElsevierLtd.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense
Venezuelanslivein justthree Colombian cities:Bogota,Cucuta,and Barranquilla.InPeru,closeto300,000livein theLimaMetropolitan area(MigraciónColombia,2020).AstheIOMpointsout,“migrationis essentiallyanurbanaffair” (IOM,2015,4,p.2).Thishasheldtruefor LACsincethefirstbigwaveofurbanizationinthe1950s,duringwhich largenumbersofpeoplemigratedfromruralareastocitiesinsearch ofbettersocio-economicopportunities.3Thoughtheexpectedcorrela- tionbetweenurbanizationandeconomicgrowthwasbroadlyrealized inLAC,arrivingmigrantsalltoooftenlackedaccesstoadequatehous- ingandbasicservicesandsettledinformallyinat-risk,peripheralar- eas(Ward,2015).Whilesomeofthesefirstinformalneighborhoodsare nowconsolidatedpartsofLACcities,newgrowthfollowssimilarset- tlementpatterns:low-incomeinternalandinternationalmigrantsmove intocommunitiescharacterizedbyinadequatehousingandpooraccess toservices,includinghealthandeducation.4
TheCOVID-19pandemichasexacerbatedpreexistingconditionsof informalityandinequalityinLACcities.Evenbeforethepandemic,itis estimatedthatupto30%ofhouseholdslivedprecariously(i.e.,inover- crowdedhomes,withoutbasicservicesorpropertitle)(Rojas,2019).
Inaddition,LACcitiesareamongthemostunequalintheGlobalSouth (OECD,2018).Theseconditions,coupledwithalackofmigrant-focused reliefstrategiesbythestate,havemadeitimpossibleforcommunities livinginformally toobservebasicpublichealthguidelinesandwith- standthepandemic(Fernández-Niñoetal.,2020).ByOctober2020, theregionhadcloseto10millionconfirmedcases,equivalentto27%of casesworldwide,andover350,000deaths,equivalentto34%ofdeaths worldwide—eventhoughLAConlyrepresents8%oftheworld’spopu- lation(Sullivanetal.,2020).
Thepandemicmayhavefurtherincreasedhealthinequitiesamong migrantcommunities.Researchfrommultiplecontextsinboththede- velopedanddevelopingworldhasshown thatmigrants,particularly forcedmigrants,tendtoexhibitdisparitiescomparedtohostpopula- tions,bothin termsoftheirstateofhealthandaccesstoqualityser- vices(Dookeranetal.,2010;NationalAcademiesofSciencesEngineer- ingandMedicine,2018;Huetal.,2016;Adigaetal.,2018;WHO,2010; Luckettetal.,2011;Salinero-Fortetal.,2015;RodríguezÁlvarezetal., 2014).WhiledataonhealthdisparitieswithinLACarelimited,recent datashowanassociationbetweenhighinflowsofforcedmigrationand arise in vaccine-preventablediseases (Ibañez andRozo,2020).Em- piricalresearch ontheimpactsofthepandemiconhealthdisparities isstillnascent,buttheseinequitieswillbemagnified byacombina- tionof urbaninformality,top-down policies restrictingmobilityand barrierstolegal status,andon-the-grounddiscriminationandmisin- formation(ILO,2020;LustigandTommasi,2020;VeraEspinozaetal., 2020).
OurresearchseekstounderstandhowCOVID-19affectsaccessto healthcareamongmigrantsinLatinAmericancities.Throughethno- graphicandqualitativeresearchmethods,weengagedwithVenezuelan migrantslivinginconditionsofinformalityinColombianandPeruvian cities.First,wesoughttounderstandhowVenezuelanmigrantsliving informallyaccesshealthservicesineachofthesecitiesandwhatkind ofbarrierstheyface,especiallyincomparisontohostpopulations.Sec- ond,weexploredhowCOVID-19hasaffectedaccesstocare.Third,we inquiredabouthowmigrantshavesoughtalternativestocarewhenfac- ingbarrierstoaccess.Ourresultshighlightfuturedirectionsforboth academicandpolicyworkbyidentifyingbarrierstoaccessandpoten- tialwaystoaddressthemthatcapitalizeonmigrants’ownresilience strategies.
3 Urbanizationratessoaredfrom41%in1950to64%in1980,duetocontin- uousmigrationfromruralareastocities(UN,2014).
4 Forexample,inArgentina,49%ofhouseholdswholiveinareasformally definedasinformalareforeign-born(VeraandAdler,2020,p.148).
Materialandmethods
Information aboutinformal settlementsandcommunitiesis often difficulttoaccessthroughtraditionalquantitativeandaggregatedata.
TheCOVID-19pandemicfurtherpreventedresearchersfromcarrying out work on the ground. Inaddition,migrants’ access tocommuni- cation technologies,such astelephones andthe internet,is uneven.
Finally, both the effects of xenophobia and thelack of legal status make migrantsmistrustthepresenceofstrangersinquiringaboutthe intimatedetailsoftheirlives.Combined,thesefactorspresentedcon- siderable challengeswhen engagingwithvulnerable Venezuelan mi- grants. We therefore designed a remote ethnographic methodology that capitalizedon existingresearch networksin bothColombiaand Peru.
Theauthorsusedqualitativemethods,particularlysemi-structured interviewsandlifehistories,tocaptureawidevarietyofvoicesand experiencesfromselectcitiesinColombiaandPeru.Tocomplement these ethnographic inquiries, the team also sought to map health- care optionsavailabletomigrants throughinterviewswithrepresen- tativesfromnational,regional,andmunicipalagencies,aswellaswell- establishedcivicorganizations.ToavoidtransmissionrisksofCOVID- 19,andin considerationof dataprivacyconcerns of potentiallyvul- nerable populations, interviews werecarried out remotelyby phone ordigitaltelecommunicationsplatformsthatofferend-to-endencryp- tion (e.g.,Signaland WhatsApp)andincluded eithersigned or oral consent.
Theresearchteamcompleted96interviewsinColombiaand34in PerubetweenJulyandSeptember2020.Interviewslastedbetweenone andtwohours.WefocusedonfourColombiancities—Barranquilla,Cu- cuta,Riohacha,andSoacha(metropolitanBogota)—andthreePeruvian cities—Lima,Trujillo,andTumbes.Thechoiceofcitiesrespondedto thefollowingcriteria.First,theinclusionofcitieswithlargeVenezue- lan migrant populations (Soachain metropolitan BogotaandLima).
Second, afocuson rapidlygrowingsecondarycitiesthat areamong thetop destinationsfor Venezuelanmigrants(Barranquilla,Trujillo).
Third, theinclusion of border citiesthat areamong thefirst points of entryformigrantsarrivingfrom Venezuela(CucutaandRiohacha alongtheColombia-VenezuelaborderandTumbesalongtheEcuador- Peruborder).Riohacharepresentsaspecialcase:thecityliesalongthe Colombia-Venezuelaborderbutisalsopartofabroaderterritoryhome totheWayúuindigenouspeoples,whosestruggleswithandinnovation in healthcareaccesshighlighttheneedforculturally-appropriate ap- proachestocare.
Thisworkbroughttogetherateamofresearcherswithspecificexpe- rienceineachofthestudy’scities,eachofwhomhavebuiltanetworkof relationshipswithmigrantcommunitiesandlocalresidentsthroughpre- viouswork.City-specificknowledgeallowedustoemulatearespondent- drivensampling,wherebyinitialinterviewsallowedparticipantstore- cruitpeersfromtheirsocialnetwork,thusexpandingthesampleand describingthecontoursoftheoverallsizeandcompositionofhard-to- reachpopulations(GileandHandcock,2010;Johnston,2014).Datacol- lectionwastime-boundtoensurefindingsremainrelevanttopandemic- focused workwhile stillallowingtheteam toidentifyvalid descrip- tivethemes.Aniterativeinterpretiveapproachwasusedtoanalyzethe data: first,city-specificresearcherscodedinterviewstoidentifycom- monandemergingthemes,andconducteddatareductionbyfocusing onstatementsmostrelevanttoourresearchquestions(Roulston,2014). The combined Colombia-Peruresearch team then further coded re- sultstoidentifycategoriesandthemesacrossbothcountries,withthe goalofachievingtransferability—todevelopcontext-relevantdescrip- tions—andtheoreticalvalidity—toestablishan effectiverelationship betweenourstudyandexistingtheoreticalframeworks(Roulston,2014; RavitchandCarl,2016).Despitetherobustnessofthedatacollected,ad- ditionalinterviewsandprolongedparticipantobservation,particularly insomeoftheselectcities,couldincreasetherichnessofourfindings (SeeTable1fordescriptivestatistics).
Table1
Summary statisticsfromqualitativedatacollec- tionamongstVenezuelanmigrantsin Colombia andPeru
Category Number Percentage Gender
F 88.00 77.19%
M 26.00 22.81%
LGBTIQ + 1.00 0.88%
Age
18-35 65 57.02%
36-59 47.00 41.23%
60 + 3.00 2.63%
No answer 2 1.75%
Status
Regular 55 48.25%
Irregular 58 50.88%
No answer 4 3.51%
Time in Host Country
Less than a year 9.00 7.89%
1-2 years 60.00 52.63%
2-3 years 32 28.07%
3 + 12.00 10.53%
No answer 4.00 3.51%
Household size
1-4 30.00 26.32%
5 + 80.00 70.18%
No answer 7.00 6.14%
Theory
Tanahashi (1978)describes accesstohealth asa seriesof stages that must be overcome in a succession. The modeltracks a trajec- torythatincludesserviceavailability,accessibility,acceptability,con- tact,andeffectiveness.Byunderstandingmigrants’trajectory,wecan investigatehowthe variousfactorsalter oraffect accessatdifferent instancesin theirhealthtrajectories.Althoughthisconceptualization is widely recognized asaneffective waytoevaluatehealthcare sys- tems,othermodelshavesoughtparticularlytounderstandtheinter- actionbetweenthesupplyofservicesandtheactivedemandforthem.
Frenk(1992)seekstodescribethecorrespondencebetweenthechar- acteristicsofthehealthcaresystemandthepopulationdemandsonit.
Morerecently,Levesqueetal.(2013)expandedthisviewtodescribe accessas"theopportunitytoobtainappropriatecareinsituationsin whichtheneedisperceived"(p.16).Byreframingtheissueofaccessin termsofopportunity,Levesqueetal.assumetrajectoriessimilartothose foundintheTanahashimodel,whileemphasizingthedynamicandcom- plexnatureoftheinteractionsbetweenhealthsystemsandpopulations acrosstime.
Venezuelansmigrantscanencounterobstaclesatvirtuallyeachstage of their access trajectory. In Frenk’s terms, the institutional supply ofhealthcare servicesisuncertainandlimitedinspacesoccupiedby forcedmigrants. However,migrantsalso facestructural barriersand challenges. Inarecent reviewof studiesthatfocuson migrants’ac- cesstohealthinLAC,PiérolaandRodríguezChatruc(2020)identify fourmainobstacles:1)lackofcoverage;2)discrimination,prejudice, andstereotypes;3)languageandculturalbarriers;and4)lackofinfor- mationandfearof deportation.Theauthorshighlighthowstructural obstacles,suchaslackofcoverage,areexacerbatedbysocialbarriers.
Althoughdiscriminationandlinguisticandculturaldifferencesareiden- tifiedassignificantbarriers,literatureontheseissuesinLACremains scarce.Similarly,thereportdescribesinformationasymmetryasasig- nificantproblembutfocusessomewhatnarrowlyonmigrants,whereas gaps in knowledge andinformation about health rights of migrants mayalsobepresentamongprovidersandotheractorson thesupply side.
Finally,COVID-19isanunprecedentedcrisisthatcallsfordeeper engagementwithliteratureontheimpactofhealth crisesonvulner-
ablepopulations. Inparticular, researchontheimpactsofHIV/AIDS highlightshowvulnerabilitytobiologicalhazardsis notequallydis- tributed toallmembersofsociety.Inasummaryoftheliteratureon thedistributionofrisk,Pellowskietal.(2013)describeHIV/AIDSasa
“pandemicofthepoor,” demonstratinghowdeterminingsocialfactors affectboththeoddsofcontractingthevirusandhealthoutcomesonce infected.CastroandFarmer(2003),reflectingontheprevalenceofin- fectiousdiseaseinHaiti,setforththeconceptofstructuralviolenceand arguethatthedistributionofdiseasearoundtheworldisnotrandom, butrathercentersonpopulationsthathistoricallybeartheimpactsof socialinequality.
Although academicliteratureon thedistributionof effectsof the COVID-19pandemicinLatinAmericaisscarce,analysescarriedoutin otherregionspointtotheneedtoobservehowsocialdifferencesframe theprogressofthevirus.InarecentstudyfocusedintheUnitedStates, vanDorn,Cooney,andSabin(2020)concludethatthepandemicex- acerbateschronicsocio-economicandmedicalvulnerabilitiesthatdis- proportionatelyaffectnon-whitecommunities,includingmigrants.For example,non-whitepeopletendtoperformjobsthatdonotallowthem topracticesocialdistancing(andthatwereconsideredessentialduring quarantining),exposingthemselvestogreaterrisksofcontagion.How- ever,thesesamepopulationshavemoredifficultiesaccessinghealthcare servicesandhavehigherratesofchronicmedicalconditions,whichfur- therexposesthemtothemostseriouseffectsofCOVID-19.Despitethe potentialfordisproportionateimpactonvulnerablepopulations,thedif- ferentialeffectsofeffortsmadetomitigatethespreadofCOVID-19have notreceivedsufficientattention.Intheirreviewofmorethan13,000 publicationsontheeffectsofCOVID-19,Andersonetal.(2020)identi- fiedonly50empiricalstudiesontheeffectsofsocialisolationmeasures, ofwhichnonementionrefugeesormigrants,andonlythreediscussef- fectsincountriesoutsideofEuropeorAsia,noneofwhichwereinLatin America.
Results
Below, we presentconsolidated results from both Colombia and Peru, highlightingspecific findings from individual citiesandciting emblematictestimonies. Basedon ourresults,wedivideobstaclesin fourcategories:legal,financial,discrimination,andinformationasym- metry.Inaddition,wesummarizefindingsaboutalternativeformsof carefoundbyparticipants.Wealsoincludeaspecificsectionaboutthe impactsofCOVID-19.
Legalobstacles
Overthelastfiveyears,duetotheunprecedentedlevelsofimmi- grationtoColombia,thegovernmenthasmadeimportantchangesand updatestothelegalframeworkgoverningmigrantstatus.Thesechanges haveadirectbearingonmigrants’accesstoservices,includinghealth- care.Broadly,therearetwostatuscategories.Legalstatuscanbeob- tainedthroughtheSpecialPermitofPermanence(PEP,inSpanish),a permanentresidencecard,orthroughcitizenship.Legalstatusgivesmi- grantsaccesstothesamehealthcoverageasnativeColombians.Mi- grantswhodonothaveanyoftheselegaldocuments—approximately 950,000byAugust2020(MigraciónColombia,2020)—areeligiblefor healthcareunderspecificextraordinarycircumstancesoriftheybelong tospecificgroups,suchas: 1)those facinglife-threateningemergen- ciesandarrivinginemergencyroomsatpublichospitals;2)thosefac- ingurgent maternityneedsandimmediatepregnancyneeds; 3)chil- dren,especiallyinfants,withneonatal,developmental,andimmuniza- tionneeds.Othersegmentsofmigrantpopulations—olderadults,men, non-pregnantwomen—andothercategoriesofhealthissues—chronic disease, non-life-threateningconditions, mentalhealth, etc.—arenot covered.Thoughthereareprovisionsforemergencycareandforspe- cificgroups,thisfreecoveragedoesnotincludefollow-upservicesand tests.Migrantsmustpayfortheseservicesontheirown.
Myhusbandfelloff hisbikeandfracturedhiselbow.Hewashospi- talizedfor15days.Initiallytheydidn’tgiveusanyproblems;the doctorsaw him.Butafterwards,they didn’twanttoperform the surgerybecausewecouldn’tpayforit,soIwenttolookforhelp atthesocialsecurity… Hehadanx-raydoneafter10days.Weare waitingfortheappointmenttoremovehisstitches,getanx-rayand atomography.Hewasdischarged[amonthago].Theyhaven’tre- movedhisstitches.Butwecan’tgotoadoctorbecauseIdon’thave anydocumentation.(Gleydimar,Soacha)
Similarly, in Peru, the biggest barrier to healthcare access for Venezuelanmigrantsislackoflegalmigratorystatus.Toaccessthepub- licIntegratedHealthSystem(SistemaIntegraldeSalud,orSIS,managed bytheMinistryofHealth),migrantsmusthavearegularresidenceper- mit,oratleastatemporaryresidencestatus(carryingaspecialpermit, thecarné deextranjería),andmustalsobeeligibleunderthenational socialregistry,theSISFOH(SistemadeFocalizaciónde Hogares).How- ever,thosewhohaverequestedasyluminPeru,orwhoholdatempo- rarypermitofresidencedespitetheirregularmigratorystatus,donot haveaccesstoSIS(exceptforpregnantwomenandchildrenfiveandun- der).Thisexcludescloseto500,000asylumseekersaswellasmigrants withoutlegalstatus(Migraciones,2020).Inoursample,only32%of migrantshadacarné andonly11%hadhealthinsurance.
Financialobstacles
Themajorityofparticipantsinterviewedacrossallcitiesworkinthe informaleconomy,andeventhosewhoenjoyformalemploymentface jobinsecurity,astheyreportbeingtargetedfordismissalandabuseand oftenlackresourcesforlegaldefense.Thiseconomicuncertaintyhassig- nificanteffectsonaccesstohealthcare.Duetotheirexclusionfromthe formaleconomy,mostofthemigrantsinterviewedcannotaffordhealth insurance.MigrantsinterviewedinColombiaoverwhelminglydepend ondailyworkforbasicsubsistenceneeds,meaningtheycannotafford tospendwagesonormissworkseekinghealthcare.Additionally,med- icalconditionsrepresentlossesineconomicproductivitythathavesig- nificantimpactsonthesubsistenceoflargefamilygroups.
Iworkalldayanddidn’thavetime.Iamtheonlyoneinmyhouse whoworks,andinordertogetallthepaperworkdone,theysayI needanentireday,andthatmeansnomoneytoeat.(María,Barran- quilla)
InPeru,anestimated87%ofmigrants hadnoformalcontract in June2020(EquilibriumCenDe,2020a).Thelackofsocialprotection formigrantsinPerualsomeansthattheyoftenhavetoincurexpenses withnohelpfromthestateandthereforehavelessdisposableincome forhealthcare(Luzesetal.,2020).TheinabilitytoaccessSIS(seeLegal Obstaclessection)meansthatmostmigrantswillincurexpenseswhen theyneedtousehealthservices,oftenvisitingprivateclinicswheretheir undocumentedstatusisnotabarrierbutthecostofservicesis.Thecost ofregularizingtheirmigratory statusalsoposesafinancialchallenge inadditiontoalackofinformationaboutthedifferentmigratorysta- tusesandincoherenceofrequirementsexperiencedbydifferentpublic institutionsandservices (EquilibriumCenDe,2020b).Thesefinancial andtransactionalbarriersreinforceeachotherandmakeithardformi- grantstobearthefinancialcostsofeither.
ToaccesstheSIS,migrantsmusthaveacarné deextranjería.MyPTP [PermisoTemporaldePermanencia]expiredafewmonthsago,andto accessthecarné deextranjería,Imusthave300-350solestogetmy criminalrecordandalltheotherrequirements.(Rosibel,Lima) Themostcommonwaytosupportthefinancialcostsofprivateor publichealthcarewhenmigrantsdonothaveinsuranceisthroughdona- tions,salaryadvancesfromtheirbosses,orloansfromrelatives,friends, andpeopletheyknow;42%ofparticipantshadtoaskforhelptosup-
porthealthcareexpenses.Anothercommonwaytofinancehealthcare costsisthroughpleasonVenezuelans’socialmedia.
Discrimination
Navigatingthebureaucraticrequirementstoaccesscarerepresents animportantobstacleformigrantsinColombia.Migrantswhodonot havethePEPandwhoseekcareinhospitalsinemergenciesfacease- riesofobstaclestobeingadmitted.Determinationofwhatconstitutesa vitalemergencyisoftenmadebynon-medicalpersonnel,suchassecu- rityguardsandreceptionstaff.Toaccessmedicalservicesinhospitals, migrantsmustbeadmitted(theycannotreceiveoutpatientcare),which impliesprocedureswithintheinstitution’ssocialworkofficesforcosts tobecoveredbyterritorialentities.Onceadmitted,severalmigrants havereportedbeingheldbytheinstitution’smedicalstaff untilhospital feeswerecollected.Forthosewholeavethehospitalwithdebt,theyare threatenedwithrefusaloffurthermedicalattentioniftheydonotpay theirfeesontime.
IgavebirthhereattheNiñoJesúsHospital,andthatwasalsoa wholeprocess...theyhadmewaitingforalmostanentireweek,until Igotallthedocumentstheydemanded...theresidencecard...some witnessesthatcansayIlivehereandsoon...Ihadanormalchild birth,withoutanycomplications,withoutanyneedforthemtokeep methere...Theysaid"no,youcan’tleavebecausetheyhaven’tdis- chargedyou"...butIknewitwasbecauseofthedocuments.(An- dreina,Barranquilla)
Womenbearthegreatestburdenintermsofaccesstohealthcarein themigrantpopulation.Mostoftheintervieweesreportthatitisthe womeninthehouseholdswhoareresponsibleforcaringforpeopledur- ingdisabilityorfor accompanyingpatients—evenastheysimultane- ouslyworktogainincomeorgoods.
InPeru,53%ofparticipantsmentionedsituationsofdiscrimination inthehealthsysteminPeru.Discriminatoryattitudestowardmigrants oftencomefrommedicalstaff.Wheninterviewed,onememberof an international aid organizationshared thatdoctorsandhealthprofes- sionalsarenotawareofthedocumentationandmigratorystatusesthat areavailabletomigrants,norwhocanandcannotaccessservices.In addition,experiencesofdiscriminationseemtobestrongerinbigger hospitalsandinhealthfacilitiesoutsideofPeru’scapital,Lima.
First,theytookalongtimewiththepaperworkanddidnotwant totreatmeuntilallthepaperswereinorder.Iaskediftheycould pleasetreatmewhilemyhusbandoversawthepaperwork,andthey repliedthattheycouldnot.Second,thedoctorthatperformedthe cesareandeliverydidnot likemebecauseIwasVenezuelan, and shemadethatverycleartoallofthedoctorsintheoperatingroom.
Iwasbetweenlifeanddeath,giventhatonceshetookthebabies out,thedoctorlefttheoperatingroomandtoldthedoctorstofind someoneelsetostitchmeupbecauseshehadalreadyfulfilledher duty.(Yherineth,Trujillo)
Informationasymmetry
VenezuelanmigrantsinbothColombiaandPerulacksufficientin- formationaboutthecountry’shealthcaresystem—itsrequirementsand procedures—aswellasabouttherightstheyhaveandtheresourcesthey couldtapintoforcare.Accesstohealthcare,particularlyforpeoplewith limitedresources,requiresthecompletionofvariousbureaucraticpro- ceduresthataredifficultformigrantstonavigate.Additionally,these procedures arenot consistentovertimeor acrossinstitutions,which meansthateventhosewithknowledgemayfindobstacles.Ineachof thecitiesanalyzed,theservicesofferedvaryenormously,andtherefore mobilityinnationalterritoryimpliestheneedtobecomefamiliarwith thecomplexorganizationalcontextofeachlocation.
Participantsreporthavingdevelopedinformationnetworksthrough bothestablishedandnewplatformstodisseminateinformationforre-
sourcesand opportunities.Virtualsocial networks—especially What- sApp,Facebook, andInstagram—offerspaceswheremigrantscanre- questandofferinformationregardinghealthcareservicesandaidavail- ablefromgovernmentalandnon-governmentalinstitutions.Thesenet- worksarecreatedandmoderatedbysocialleaders,peoplewithtech- nicalknowledgewhotypicallyareprofessionalsinVenezuelaandwho donotgenerallyreceiveincomefromtheseservices.Thesenetworks typicallyfunctionindependentlyfrominstitutionsthatofferservicesto themigrantpopulation,andeffortstocoordinatetheprovisionofser- vicesorassistancethroughthesenetworksareveryscarce.Naturally, wordofmouthremainsanimportantresourceforsharinginformation.
Despitetheseshortcomings,manymigrantslearnhowtonavigatethe healthcaresysteminthismanner.
IhaveaplatformthroughInstagram....Butapartfromthat,Itake individualappointmentsonmypersonalphone....Ihavemorethan 2,500migrantson myWhatsApp,sowhenIpostastatus,thatis alreadyaninformationchain...andpeoplealsospreadwhateverin- formationIpost.(Wilmer,Barranquilla)
Alternativeaccesstohealthcareservices
VenezuelanmigrantsinColombiaandPeruhavedevelopedstrate- giestoaccesshealthcare servicesthat responddirectly totheobsta- cleslistedabove,while alsoexpanding on practicesfrom Venezuela andthoseusedbylow-incomehostpopulationsandinformalcommu- nities.Thesealternativeformsofcareareextralegalorinformal,and, per our interviews, may include: pharmacies,healthcare profession- als whoformally practicein Colombiaand Peru butoffertheir ser- vicesandknowledge totheir neighborsoutside of theirprofessional practice,Venezuelanmigranthealthcareprofessionalswhoofferunoffi- cialservicestothemigrantpopulation,medicalprofessionalswhooffer theirservicesthroughinformaltelemedicinemodels,andprovidersof traditional/magical-religious/spiritualmedicine.
Pharmacies. Pharmacies are one of the most common informal healthcaresystemsusedbyVenezuelanmigrantsinColombiaandPeru.
Pharmacistsofferinformationon possibletreatments andindications regardingtheuseofmedicationinandoutsideoftheofficialmedical sphere.Theattitudetowardprescriptionmedicineinthesecountriesis lax.Forexample,inPeru,despitealawthatprohibitspurchaseofdrugs withoutprescription,theprevalenceofthesale ofantibioticsis very high,rangingbetween25%and58%(Rojas-Adrianzénetal.,2018).
Mostmigrantsweinterviewedhavetakenadvantageofsuchinformal practicesof pharmaciesin bothColombiaandPeru tobuymedicine withoutgoingtoaclinicorhospital.Someparticipantsreportedadverse effects,evensomethatrequiredhospitalization.Inallcases,migrants mustpayforalloftheseservices,whichcanrepresentadditionalfinan- cialburdens.Outofthe19migrantsinterviewedinPeru,morethanhalf haveresortedtoself-medicationinpharmacies.
Theinformalsectoristhemostusedbythemigrants—thepharmacy onthecorner.Evenwithoutaprescription,theywillsellyou[med- ication]becausetheyneedtosell.Ihaveseentwoorthreecasesof familieswhohavebroughtprescriptionsfromVenezuelaandthey weresoldthemedicationhere.Therearepeoplewithcasesofcan- cer,HIV,diabetes,hypertension… Duringthepandemictheseser- viceshavebeenusedmoreoften,peoplehaveself-medicatedmore.
(NGOrepresentative,Trujillo)
Network of Venezuelan Doctors. Participants reported having soughthelpfromVenezuelandoctorsorthosewhopracticedashealth- careprofessionalsbeforeemigrating.Theseproviders—fromnursesto generalpractitioners—tend tohavequalificationsbuthavenot com- pletedtheprocessneeded topractice formallyin ColombiaorPeru.
Notably,whenassessingwhethertopayforhealthcarewithinthefor- malsystemorwithin thisknownnetwork,many migrantsopttosee Venezuelandoctors,sincetheycan thus avoidsome oftheobstacles
presentinhospitalsandotherhealthcareinstitutions.Someoftheseex- tralegalpractitionersalsoofferservicesforfree.
Iwasstudying medicine....Ineededexactlyfourmore monthsto graduate...butIhadtocomehere,becausethesituationbecametoo complicated andthere werenomeansoftransportation,nofood, nothing,soIcouldn’tfinishmymajor....Myneighborscometosee mequiteoftenwhentheyfeelpain....Iguidepeoplequiteabit,at leastwhentheyhavechildren,Itellthemwhattodo,alsopregnant women....Idon’tchargeanything,andsometimestheytellmeto charge...butIwon’t.(Deyna,Barranquilla)
I have used these networks of Venezuelan doctors that I found throughVenezuelans’WhatsAppgroupsTheconsultationsarefree and,dependingonthecase,arecarriedoutinpersonorvirtually.
Ifit’sserious,theyreferyoutoadoctorinahealthfacility.Thead- vantages(…)arethatVenezuelansalreadyknowhowVenezuelan doctorswork,thereistrust,andweunderstandeachother’sdialect.
Especiallyinthese timesofCOVID-19,onecanuse theseservices thatdonotrequiregoingout,whichmeansthatthereislesschance thatonewillgetinfectedwiththevirus.(Yherineth,Trujillo)
Duetothedifficultandcostlyprocessofvalidatingforeignprofes- sionaltitlesinbothColombiaandPeru,especiallyinmedicine,many Venezuelanmigrantscannotexercisetheirprofessionsinthehostcoun- try.Additionally,medicalprofessionalsneedtobecomecollegiatepro- fessionalsinPeru,acostlyandprolongedprocessfewqualifiedVenezue- landoctorsresidinginPerucanpursue.Despitethisbureaucraticbar- rier,manystillpracticemedicinethroughvirtualappointments,inpar- alleltotheformalhealthcaresystem.
Telemedicine,Non-governmentalServices,andNon-Biomedical Providers.LocalVenezuelancivicorganizationsrepresentaninvalu- ableresourcefornewcomerstoColombia.Incitieswithalonghistoryof migration,suchasRiohachaandCucuta,Venezuelanorganizations,lo- calnon-governmentassociations,andreligiouscharitieshaveanequally longexperiencehelpingmigrantsandguidingthemthroughlocalser- viceoptions.Overthelastfewyears,theseorganizationshavebecome thefirstlineofassistancetomigrants.InBarranquilla,whereVenezue- lanmigrationismorerecent,therearenonethelessestablishedorgani- zationsthatarebuildingastrongnetworkofassistanceanddefenseof rights.Similarly,inSoacha,neworganizationsledbyorcollaborating withVenezuelanshaverecentlyemerged.
Someneighborstoldme..."Thereisgoingtobeahealthcampaign atthechurch...theywillhandoutmedicine;they’regoingtohelp uswiththeSISBENnonsense...."ThereImet[thenameofanorga- nizationleader]....Fromthenon,sheaddedmetothegroup,and eachtimetheyorganizehealthcampaignsandallthat,Ireceiveda messageandshealsoletsmeknow.(Veronica,Barranquilla)
Migrants have also turned to healthcare professionals outside of Colombiathroughinformaltelemedicinemodels.Someparticipantsre- portmaintainingcontactwiththeirhealthcareprovidersinVenezuela throughplatformslikeWhatsApp.Inothercases,migrantsestablishnew relationshipswithhealthcareprofessionalsin Venezuelaandinother neighboringcountries,suchasPanama.Thesehealthcareprovidersare paidthroughelectronictransfers.Telemedicineisoftencomparatively cheaper,butmigrantsacknowledgethatthisoptionprecludesaccessto ancillary servicessuchaslaboratorytests.Insome cases,paymentis notrequired.Primarily,virtualhealthcareisbasedonsocialtieswith specialistsinVenezuelaestablishedpriortoemigration.
Wealsonotethereportedpresenceof communitycenters(centros comunitarios)setupbythemunicipalitythatorganizedoctorvisits—a commonpracticeinresource-constrainedcities.InTumbes,Peru,the actorsweinterviewedsharedthattheystartedorganizingthesevisits duetotheincreasinginfluxofVenezuelanimmigrantsandtheneedto havefreeaccesstohealthcareintheircommunities.
Non-biomedical serviceproviders, such ashealers, massagether- apists, medicine men, and other specialists in traditional/magical- religious/spiritual medicine also represent a relied-uponoption. Mi- grants mustpay for these services directly, but as is the case with Venezuelanproviders,itisapreferableoptiontopotentiallybadordis- criminatorytreatmentintheformalsystem.Insomecases,thesehealth- careprovidersofferservicesthatrespondtoculturalconcernsanddif- ficultiespresentinsocialcontexts.AmongWayúupopulationsinRio- hacha,healersactasacomparativelymorewelcomingandaccepting formofcare.
Finally, participants also reported using medicine exchange net- works,which typicallyhelppeoplewithchronicconditionscommon amongolderadults,suchashypertensionanddiabetes.Migrantsdo- natedrugsforthosewhoneedthemandlacktheresourcestobuythem.
Medicinemaybeexchangedformedicineorforothergoods.Notably, medicineexchangenetworks alsorepresentanimportantplatformto buildtrustandcommunitybondsamongparticipants.
TheimpactsofCOVID-19
Participantsreportsevereeconomicduresscausedbythepandemic, whichhasincreasedtheirchanceof contractingthevirus,becauseit forcedthemtodisregardlock-downsinsearchforincome,whilelimiting theirabilitytocoverbasicfoodandhousingexpenses.Additionally,the pandemichastakenaheavytollonparticipants’mentalhealth.Eachof thesefactorsrepresentsignificantpublichealthchallengesintheirown right.InColombia,participantsreportedreductionsofbetween50%and 80%intheirdailyincome.InPeru,afterthefirsttwomonthsoflock- down,alargeproportionofVenezuelanswerereportedlyunemployed;
74%ofthesurveyedmigrantscouldnotaffordtobuyfoodandbasic necessities(Luzesetal.,2020).Combined,theypresentaconstellation ofchallengesthatdemandcoordinatedanddecisivecare.
It’shorrible,becausepicturethis,wecan’tworkasweusedto.Luck- ily,Ihaveajob,butonemustworkhiddenfromthepolice;they won’tletyouwork...Ihavetopayrentdaily,Imean,alsoSaturday andSundayanditisreallytough.IhavemybabyandIleavehim withasitter.(Merlys,Riohacha)
Participantsreportedadecreaseinthenumberofmealsconsumed daily,andsomereport eatingonlyoncea day.Accesstofoodisthe biggestconcernformigrantswhooftenhavetoborrowmoneytocover theirbasiclivingexpenses.
Theimpacthasbeenquitestrong.Mywifepreviouslyworkedata restaurant,butlostherjobduetothepandemic.Iwascalledbackto workandamgoing2-3timesaweek.Forthreemonths,wecouldn’t payrent,butluckilywewereabletoreachanagreementwiththe owner’sfamilytoschedulepaymentsonamonthlybasis.Beforethe pandemic,wehadagoodincome,weatewell,andweevensent moneytoVenezuelaonaweeklybasis.Now,weareeatingtwicea day—wegetuplatesowearenothungryinthemorningandeat lunchanddinner—andwesendmoneytoVenezuelaeverymonth ormonthandahalf.(Wuinson,Lima)
Withregardtohousing,thenumberofevictionsrosesharplyasmi- grantscouldnotaffordtopayrent;nationally,byJune2020,37%of migrantsinPeruwereatriskofeviction(EquilibriumCenDe,2020a).
DespitemoratoriumsonevictionsenactedinColombiaandexistingle- galprotectionsthatpreventimmediateremovaloftenants,Venezuelan migrantsreportedbeingejectedfromtheirhomes.Inaddition,thepan- demichasseenrentaloptionsreduced,sincemigrantsareperceivedto beeconomicallyunstable,pronetomovingwithoutnotice,andproneto livinginovercrowdedconditions.Difficultiesinaccessinghousingresult inotherhealthrisks,suchasdiseaseandmalnutrition.Critically,lack ofaccesstohousingdecreasesaccesstostateaid,astheidentification ofbeneficiariesoftentakesplacethroughhomevisits.
FollowinganemergencyhealthmeasureatthenationallevelinApril 2020, thePeruviangovernmentmadetheSIS availabletoeveryfor- eigner, irrespectiveof legal status, in case of showing symptoms of COVID-19(seeLegalObstaclessection).However,wefoundthatmi- grantsbelievedthatthemedicalstaff didnotknowtheVenezuelanpop- ulation couldaccesstheSIS,andthat ageneralignoranceabout the national lawwascommonplace amonghealthstaff. Regardless,even thespecial eligibilitygranted duringthepandemicstillexcludes the majorityofVenezuelans,sincemanyareasylumseekersandirregular migrants(seeFinancialObstaclessection).Participantsreportthatthe qualityandattentionofmunicipalhealthfacilitieshasworsenedduring thepandemic.Atsomepointinthebeginningofthequarantineperiod, smallhealthpostsstoppedacceptingpatientsastheywerealreadyop- eratingbeyondtheircapacity.
MyfriendinTrujillohasCOVID-19,andhehasbeenathomefora monthhavingtreatmentbecausehewenttothehospitalandthey told him thatthey were not going totreat himbecause hewas Venezuelan.(Delaskar,Trujillo)
In general, people haveposts close towherethey live,although sometimesthehospitalsarefurtheraway.However,duringthepan- demic,thehealthpostsdonotattendyouifyoudonothavetheSIS, nomatterhowmuchyoupayforyourconsultation.(CivilSociety representative,Lima)
Thestudycouldnotreliablydeterminethenumberofinfectionsor deathsfromCOVID-19.However,wenoteresultsfromPeruwhere,out ofthe19migrantsinterviewed,athirdhadcontractedthevirus.Interms ofaccesstohealthcare,participantssharedthatmanyVenezuelanswho areinfecteddidnotdisclosetheirhealthstatussothattheycouldkeep working,whileothersrefrainedfromgoingtothehospitalsbecausethey believedthatitwouldbesafertostayathometoavoidcatchingthe virus.Otherssharedthattheybelievedtheywouldnotbegivenmedical attentionatapublicorprivatehospital,orthattheywouldbediscrim- inatedagainstbecauseoftheirnationality.
Discussionandconclusions
Our qualitativestudyfindsthatCOVID-19has disproportionately affectedVenezuelanmigrantslivingininformalandprecariouscondi- tions.However,beyondthis broadobservation,we highlightspecific lessonsgathered fromacross thefourColombianandthreePeruvian cities.
First, wenote thecomplex interactions between nationalandlo- cal policyandactorsandhowtheseinteractions affectmigrants’ ac- cesstocare.Therecentintroductionoflawsandprovisionstoexpand care—suchas Peru’s inclusion of migrants in care in case of show- ing symptoms of COVID-19—do not necessarily translate intoeffec- tive access. Bureaucraticitineraries, per Abadia andOviedo (2009), stillpresentsignificantobstaclesintermsofcostandtime,andoften exposemigrantstodiscriminationandevenphysicaldanger.Migrants alsofaceunreasonablehurdlesathospitals’pointsofentry(e.g.,guards, clerks),eitherthroughignoranceordiscrimination,whicheffectively barmigrantsfromservices.Moreinclusivemigrationandhealthpoli- ciesofteninteractineffectivelywithothersectors,particularlyurban policy—alinkmostvisibleinrisingevictionsineachofthecitieswe surveyed—whichputmigrantsathigherriskofcontagion.
Second, we highlight how COVID-19impacts the interactionbe- tweenmigrants’ healthandaccesstootherbasicgoodsandservices, particularlyhousingandfood.Sincemostmigrantscannotaccessafree publichealthsystem—byvirtueoftheirstatusandimpossiblebureau- craticitineraries—theonlywaytogetmedicalattentionisbyhaving theeconomicmeanstocoverthetreatments.However,asparticipants in bothColombiaandPerureported,formaljobs arescarce,particu- larlygivenquarantinemeasures,andinformallaborputsthematrisk.
Whateverresourcesmigrantsmayhaveareconsumedbyhealthneeds,
which,inturn,makesitdifficulttocoverbasicneeds,furtherexacer- batingtheirvulnerability.Wealsonotethegraveeffectstheseburdens haveonmigrants’overallmentalhealth.
Third,inacontextofincreasedvulnerability,Venezuelanmigrants havecome torely onnon-state, oftenextralegalhealth services.Mi- grantsturntoloansorcharityorganizations,aswellastomedicineex- changenetworks,tohelpmanagecosts.Technologyhasalsoopenedup alternativeoptionsthroughtelemedicinewithdoctorsabroadandthe useofsocialmediatoexchangeinformationaboutcare.Thereisalsoa strongrelianceonVenezuelandoctorswho,evenwhenqualified,lack certificationtopracticeinColombiaorPeru.Manymigrantssimilarly prefernon-biomedicalhealthservices,whichhighlightstheimportance oftrustandculturalpreferencesregardinghealthcare.
Thesefindingsalsoprovideguidanceforspecificpolicyrecommen- dations.Givenlegalandfinancialobstacles,itisimportanttofacilitate accesstopublichealthservicesirrespectiveofmigratorystatus.Access shouldgivespecialattentiontoCOVID-19careintheshortandmedium termbutshouldfocusoncreatingandstrengtheningsystemsofaccess inthelongterm.Regardinginformationasymmetry,itiscriticaltofo- cuson boththe‘demand’and‘supply’sides; nationalandmunicipal authoritiesshoulddevelop,promote,andconsistentlydisseminateup- to-dateinformationonaccessoptionsall alongthevariouspointsof frictioninthebureaucraticitinerariesofcare(thisincludeshospitalse- curitystaff,supportpersonnel,secretarialstaff,etc.),andmustconsider preferreddigitalplatforms.Trainingsessionsforpublichealthstaff on nationalmigrationlawandinformationonaccesstoservicesisneces- sary,asthiswouldfacilitatetheoverallusageofpublichealthservices amongstmigrantsanddecreasediscriminationpracticesbystaff.Alter- nativepurveyorsofcareshouldbeapproachedasimportantresources inthesetasksofinformationdisseminationastheyalreadyeffectively workasintermediariesbetweenmigrantsandofficialhealthproviders.
Finally,andspecificallyforresource-constrainedpublicsectoragencies, policyshouldimproveproceduralandoperationaloptionstosupport andstrengthenthosealternativesourcesof carethatcan beeffective andsafe,suchastelemedicine,especiallyastheyarebecomingactive partsoftheoverallsysteminColombianandPeruviancities.
Wealsonotelimitationsinourstudy.Digital,qualitativeresearch, particularlygivenquarantine restrictions, isideallysuited toengage withvulnerablepopulations.However,giventhedigitalgapamongst migrantsandlow-incomehouseholds,participantscanbeparticularly hardtoreach.ThiswasespeciallytrueinTumbesandTrujillo(Peru).
Werecommendcomplementarywork,notonlyintermsofadditional digitalandtraditionalethnographies,butalsothroughbroaderquan- titativeandmixed-methodsresearchthatcanproduceafullandmore representativeunderstandingoftheimpactsofthepandemic,particu- larlyintermsofhealthandeconomicoutcomes.
Contributionsfromtheauthors
Patricio Zambrano-Barragán, in collaboration with Sebastián RamírezHernándezandLuisaFelineFreier, ledthedesign, methods, researchcoordination,andvalidationofanalysisandresults.Sebastián RamírezHernández oversawthe research in Colombia. Luisa Feline FreierandMartaLuzescarriedoutandsupervisedprimaryresearchin Peru.City-specificstudiesinColombiawereledbyCharlesBeachinCu- cuta,SebastiánRamírezHernándezinSoacha,AlexanderRodríguezin Riohacha,andRitaSobczykinBarranquilla.
Theauthorswouldalsoliketorecognizethecontributionsofthefol- lowingresearchers.SoledadCastilloJaraandAndreaKvietok,fromthe UniversidaddelPacífico,contributedwithprimaryandsecondaryre- searchforPeru.AndrésCubillos,CoordinatorfortheColombiaHealth andMigrationNetwork,contributedwithpolicyanalysisforColombia.
Antonio VásquezBrust,from theInter-AmericanDevelopment Bank, carriedoutspatialanalysis.DeenaMainali,fromPrincetonUniversity, contributedwithsecondaryresearch.
DeclarationofCompetingInterest
Theopinionsexpressedinthispublicationarethoseoftheauthors anddonotnecessarilyreflecttheviewsoftheInter-AmericanDevelop- mentBank,itsBoardofDirectors,orthecountriestheyrepresent.
Funding
ThisworkwassupportedbytheInter-AmericanDevelopmentBank [ESWRG-E1707].
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