This report summarises the Spring 2021 sessions of the PHED Commission on the Future of Healthcare Post Covid-19, which invited testimony from healthcare practitioners, civil servants, thinktanks, researchers, civil society, and other interested parties based on their experiences learnt during the pandemic. The evidence presented came from multiple geographies and levels, making it relevant both to Sweden and globally. It identifes several key recommendations for protecting and improving public health. These recommendations supplement and greatly expand upon those identifed in the report (‘Societal inequity makes us vulnerable to pandemics’) based on testimony from Fall/Autumn 2020, which can be accessed via: https://phed.uni.mau.se/. The wealth of experience summarized here goes well beyond the pandemic period, providing ideas and practical guidance for protecting and strengthening human health to be more resilient in the face of future crises.

Den här rapporten ger en sammanfattning av de seminarier som organiserades under våren 2021 av PHEDKommissionen för framtiden för hälso- och sjukvården efter covid-19, som bjöd in till vittnesmål från hälso- och sjukvårdspersonal, tjänstemän, tankesmedjor, forskare, civilsamhället och andra intresserade parter baserat på de erfarenheter de fått och lärt sig av under pandemin. De vittnesmål som framfördes kom från många olika geografska platser och många olika nivåer, vilket gjorde dem relevanta både för Sverige och globalt. De fastställer fera centrala rekommendationer för att skydda och förbättra folkhälsan. Dessa rekommendationer både kompletterar och i hög grad utökar de rekommendationer som togs fram i den första rapporten, som var mer fokuserad på Sverige (”Ojämlikhet i samhället gör oss sårbara för pandemier”) och baserad på vittnesmål från hösten 2020, och som kan nås via: https://phed.uni.mau.se/. Den stora mängd erfarenheter som sammanfattas här går långt utöver pandemiperioden och tillhandahåller idéer och praktisk vägledning för att skydda och stärka människors hälsa så att den blir mer motståndskraftig inför framtida kriser. 

International guidance set forth recommendations to protect marginalized migrant populations during Covid-19 given the significant inequalities in terms of social and economic well-being reported in the literature. However, a cross-country study of three European countries with high rates of Covid-19 infections and deaths has shown that migrant well-being has significantly decreased since the outbreak of Covid-19 in Europe from March 2020 and that policy measures to help those marginalized populations have been insufficient. The conclusions on migrant well-being during Covid-19 draw on interviews with prominent civil society organizations in all three countries that work specifically on migrant health and welfare. All interviews were semi-structured and conducted between October and November 2020. The analysis mainly focuses on objective/material measures of well-being related to access to health care, information on prevention of infection, housing and exclusion by host population.

Objective: There is an association between pre-migration exposure to threats and violence, and the risk for mental illness among newly arrived refugees (NAR). The aim of this study is therefore to investigate the effect of pre-migration violent and threatening experiences on the mental health of NAR in Sweden. The participants were recruited between February 2015 and February 2016, undergoing the naturalisation process in Sweden. In total, 681 questionnaires were returned (response rate of 39.5%).

Results: The results showed that almost 50% of the sample were at risk for mental illness. Analysis of pre-migration exposure to violence or threats, and risk for mental illness, showed a significant odds ratio for violence as well as for threats. Analysing men and women separately resulted in a significant odds ratio for women for pre-migration threats. For men, pre-migration violence and threats were significantly associated with the risk for mental illness. The host society receiving NAR must screen for mental illness and be prepared to provide support and care for refugees who were exposed to violence or threats, and who are subsequently at risk for mental illness. This must be considered in order to improve health and subsequently the social integration of refugees.

This chapter compares health communication towards migrants living at the margins of society – undocumented migrants, asylum seekers, and refugees – within the different Scandinavian countries (Denmark, Norway, and Sweden), to understand the present state of health communication and its role in both strengthening and, where being unequal, segregating societal inclusion within the Nordic region. We know that such migrants often experience health challenges related not only to their migratory journey, but often caused by the precarious situation in which they are placed upon arrival in host countries. Past studies show significant challenges in obtaining care, and difficulties with communication, including cultural awareness. Where health communication fails to meet the needs of a diverse population, we see growing societal segregation that often follows racialized structures with long-term consequences for society.

Introduction

In Sweden, often seen as one of the most egalitarian countries, the COVID-19 pandemic exposed high levels of health inequality, especially harming people with a refugee background. This is also despite Sweden’s image as a refugee-friendly country. In this context, the aim of this paper is to better understand how Swedish health- and social workers have reacted to the health- and social needs of refugees during the pandemic. The Swedish case is particularly interesting because, as seen in the paper, health- and social workers had the task of communicating health guidance to refugees who were sometimes more reliant on information from abroad where the consensus on COVID-19 restrictions ran contrary to the approach recommended by the Swedish public health authority.

Method

The study utilizes a qualitative content analysis of 13 in-depth interviews with health- and social workers in Sweden, active in the care of refugees within different kinds of health- and social care settings. 

Results

The analysis showed that healthcare services have remained open during the pandemic but with new precautions at reception areas impacting how refugees access healthcare. As discussed in the article, the shift to digital tools has particularly impacted refugees, worsening already existing barriers to healthcare services faced by those with refugee status. Public health recommendations were poorly designed to the needs of refugees whose living conditions often prevented them from self-isolation and social distancing. Furthermore, Sweden’s initially non-restrictive approach to the pandemic instructed health- and social-workers to encourage refugees to take far fewer precautions (e.g. self-isolation, home-schooling, pregnant women to avoid virus hotspots) compared both with European neighbours and the international media typically used by refugees. When Sweden shifted towards a more restrictive approach, health- and social-workers had to revise their guidance in relation to the new recommendations around precautions.

Conclusion

Refugees have faced increased barriers to maintaining their health and well-being during the pandemic that exceed those experienced by the rest of the Swedish population. Refugees have, in general, taken precautions in regard to social distancing and followed recommendations but faced challenges with social distancing due to isolation and crowded living. Public health authorities have often failed to acknowledge that individuals use increasingly diverse sources of knowledge when trying to protect their health, and that not everyone has access to the knowledge needed to access healthcare and social systems. At the same time, there is a need to acknowledge that refugees are sometimes a source of expertise that was ignored by the Swedish health and social system during the pandemic. There is a need for urgent efforts to halt the worsening health conditions for this specific group, but also to counter knock-on societal effects and rising health inequity.

Under hösten 2020 organiserade PHED-projektet i ett samarbete mellan Malmö och Lunds universitet en kommission och bjöd in till muntliga och skriftliga vittnesmål om framtiden för hälso- och sjukvården efter covid-19. Efter att initialt ha fokuserat på Region Skåne, utvidgades diskussionerna till att omfatta ett bredare nationellt fokus liksom internationella jämförelser med Frankrike och Storbritannien. Undersökningen omfattade vittnesmål från såväl yrkesverksamma inom hälso- och sjukvård som tjänstemän, civilsamhället och forskare. Överlag framställde vittnesmålen covid-19 som både en tragedi och ett lärotillfälle som skulle kunna stärka samhället. Flera centrala rekommendationer för att skydda och förbättra folkhälsan togs fram.

During Fall/Autumn 2020, the PHED project between Malmö and Lund Universities organised a Commission inviting oral and written testimony on the future of healthcare post Covid-19. Focused initially on the Scania region, the discussions expanded to include a wider Swedish national focus, and international comparison with France and the United Kingdom. The inquiry included testimony from healthcare practitioners, civil servants, civil society, as well as researchers. Overall, the testimony pointed to Covid-19 as both a tragedy and a learning moment by which to strengthen society. It identifies several key recommendations for protecting and improving public health.

Background: The project “Precision Health and Everyday Democracy” (PHED) is a transdisciplinary partnership that combines a diverse range of perspectives necessary for understanding the increasingly complex societal role played by modern health care and medical research. The term “precision health” is being increasingly used to express the need for greater awareness of environmental and genomic characteristics that may lead to divergent health outcomes between different groups within a population. Enhancing awareness of diversity has parallels with calls for “health democracy” and greater patient-public participation within health care and medical research. Approaching health care in this way goes beyond a narrow focus on the societal determinants of health, since it requires considering health as a deliberative space, which occurs often at the banal or everyday level. As an initial empirical focus, PHED is directed toward the health needs of marginalized migrants (including refugees and asylum seekers, as well as migrants with temporary residency, often involving a legally or economically precarious situation) as vulnerable groups that are often overlooked by health care. Developing new transdisciplinary knowledge on these groups provides the potential to enhance their wellbeing and benefit the wider society through challenging the exclusions of these groups that create pockets of extreme ill-health, which, as we see with COVID-19, should be better understood as “acts of self-harm” for the wider negative impact on humanity.

Objective: We aim to establish and identify precision health strategies, as well as promote equal access to quality health care, drawing upon knowledge gained from studying the health care of marginalized migrants.

Methods: The project is based in Sweden at Malmö and Lund Universities. At the outset, the network activities do not require ethical approval where they will not involve data collection, since the purpose of PHED is to strengthen international research contacts, establish new research within precision strategies, and construct educational research activities for junior colleagues within academia. However, whenever new research is funded and started, ethical approval for that specific data collection will be sought.

Results: The PHED project has been funded from January 1, 2019. Results of the transdisciplinary collaboration will be disseminated via a series of international conferences, workshops, and web-based materials. To ensure the network project advances toward applied research, a major goal of dissemination is to produce tools for applied research, including information to enhance health accessibility for vulnerable communities, such as marginalized migrant populations in Sweden.

Conclusions: There is a need to identify tools to enable the prevention and treatment of a wide spectrum of health-related outcomes and their link to social as well as environmental issues. There is also a need to identify and investigate barriers to precision health based on democratic principles.

Refugees are already a vulnerable group in society and are in a stressful situation due to their often uncertain legal status in seeking asylum and integration in the new society after migration. Refugees are, in general, at greater risk of poor health outcomes when contracting Covid-19, exacerbated by poor living conditions and difficulties in accessing healthcare. The longer-term social consequences of the pandemic also disproportionately impact refugees, including social isolation, unemployment and difficulties to obtain correct health information. The aim of this paper is to review the social and health consequences that Covid-19 has brought to the refugees residing in Sweden. This needs to be emphasized in order to mitigate against these likely consequences and improve the overall well-being among such a highly vulnerable group in society. As Covid-19 demonstrates, human health needs to be understood holistically, meaning that the vulnerability of any individuals, or even nations, is a vulnerability for the whole population requiring urgent action. 

Keywords: Covid-19, refugees, social situation, health information