Migrants and Health

Political and Institutional Responses to Cultural Diversity in Health Systems

Christiane Falge, Carlo Ruzza

• Publisher: Routledge
• Year: 2016
• Print ISBN:
  9780754679158
• eBook ISBN:
  9781317096573
• Topic: Social Sciences
• Subtopic: Politics
• Index: Social Sciences

Integrating newcomers and minorities into the social fabric of receiving countries has become one of the crucial challenges of contemporary Western societies. This volume seeks to understand patterns of changing institutional practices and public policies where the challenges of including cultural diversity into the social fabric are most pronounced: namely the health care system. In recent years, pro-migrant organizations and anti-racist activists have repeatedly voiced and politicized demands to improve migrants' access to the health-care system giving rise to a lively debate about migrants' access to health-care and responsiveness of institutions to their needs. In a nutshell the book achieves the following: - Provides a conceptual framework to link patterns of political advocacy/mobilization and processes of migrants' socio-political inclusion - Integrates the (multi-disciplinary) literature on political mobilization and accommodating cultural diversity in an innovative fashion - Presents a comparative study on accommodating diversity in the health care system from a comparative transatlantic perspective - Generates insight into best practices in the health care system that will be of interest to scholars as well as practitioners in the field. The analysis of health care provision offers an opportunity to test new public policy strategies and the policy consequences of the now widespread aspiration to include citizens more fully in designing and implementing them.

Chapter 1
Diversity in Health Care—A Discursive Field between Multiculturalism and Universalism

The Grand Debate on the Effects of Multiculturalism

In research on migration, the debate on how to include newcomers into society and accommodate cultural diversity1 takes place primarily as a normative debate and on a remarkable level of abstraction. The scholarly community is essentially split between two camps with opposing views about the scope and form in which the state should develop policies to address the challenges of increasingly pluri-ethnic societies. On the one hand, there are those who defend individual-based liberal universalism against any attempt to introduce group-specific entitlements and legal rights. For this group (most prominently Barry 1991, 1995, 2002; Esser 2004; Offe 1998), the multicultural agenda of specifying groups’ rights on the basis of cultural identities is fundamentally incompatible with the egalitarian principle of liberalism. Any attempt to challenge liberalism’s individually-based notion of universalistic rights and fairness on cultural grounds is perceived to undermine the very notion of a social and political community built on the egalitarian virtues of modern democracy.

In its social and political effects, the “politics of difference,” or multiculturalism, is said to open a Pandora’s Box of group-specific claims, setting the stage for a dangerous anti-universalism. At the core of this perception is the idea that the specific cultural or ethnic composition of a community2 is of no (positive) constitutive relevance for individuals. Instead, multiculturalism represents a normatively illegitimate threat to individual autonomy as well as an extremely hazardous risk to society as a whole. Accordingly, this conception sees the public recognition and legal empowerment of group rights as a genuine threat to the welfare state and “its social cohesion” (Cheong et al. 2007: 40; Pero and Solomos 2010; Vasta 2007: 21). Therefore, the socio-political implication of this view is to adhere to an implicit or explicit model of assimilation; an expectation that dominant socio-cultural practices and institutions need to be defended as guarantors of freedom, equality and social cohesion defined in terms of national unity.

The opposing position—most prominently represented by Will Kymlicka (1995, 1998) (see also Habermas 1996; Modood 2007)—argues that it is only by publicly recognizing and protecting minority rights that principles such as equality, freedom and justice can be achieved in a pluri-ethnic society. In a somewhat oversimplified way, one can summarize Kymlicka’s crucial theoretical idea as follows: the formal principles of individual freedom and autonomy are critically dependent on a societal culture to make them work and it is only by relating in a profound way to their community (defined by sharing a culture, language, a territorial homeland, and so on) that individuals can make meaningful choices and take advantage of opportunities. Essentially, Kymlicka seeks to remind liberals that questions of political and socio-economic equality cannot be decoupled from issues of cultural diversity. With this he suggests a sweeping reconceptualization of liberalism in terms of perceiving minority rights as something that concerns the viability of its fundamental values. In line with this critique of liberalism, Gerd Baumann also questions the universalist claims of a concept based on European philosophy. He casts doubt on the conceptualization most multiculturalist discourses apply to culture, which view society as a patchwork of fixed cultural identities. Instead, Baumann calls for an understanding of culture that more resembles an elastic web of crosscutting and always mutually situational identifications.3

The opposition between the positions of individual universalism and multiculturalism4 has been entrenched in scholarly debates as the choice between two fundamentally opposed and incompatible ways of perceiving and reacting to cultural diversity. Yet already at this level of the discussion, some of the difficulties of this debate become apparent: as much as many of the key concepts in the debate—such as culture, integration, accommodation or acculturation—are meant to describe a social reality, they are at the same time highly political, and thus contested notions. In this respect they become part of the reality that they claim to analyze. Specifically, in their popularized versions in public discourse, these notions frame the problem in a particular way, establishing norms and expectations about the way in which the inclusion of migrants and minorities into society ought to evolve.

Next to the underlying normative scripts that the two main approaches promote, there is a problem that is of greater significance for the research question under investigation here. Both positions that are not by accident prominently articulated by (political) philosophers are surprisingly void of suggestions on how these general ideas should inform day-to-day practice on the ground. On the one hand, the advocates of universalism rely on the naïve assumption that the allegedly superior norms and institutions of Western liberal societies could simply master enough authority and require minorities to adapt them. In this respect, the task of accommodating diversity becomes one of a gradual learning process in which minorities need to learn to live up to the expectations of mainstream society. By equating society with culture, this assumption conceptualizes the nation-state as a homogenous unit that is based on an equality which further assumes that its hegemonic core values are universally accepted (Glick Schiller and Wimmer 2002, 2003). This conception largely denies the internal differentiation of societies in nation-states. On the other hand, the advocates of multiculturalism similarly tend to perceive migrants’ or minorities’ cultures as fixed and inflexible, ignoring that these communities gradually change in contact with other communities (Vasta 2007: 23). Indeed, academic and public discourse tends to reify and legitimize identity constructions by promoting cultural traits as essential to given social groups. From this perception of multicultural society emerges a normatively and empirically critical question: “Who determines (and how) whether somebody is religious, ethnic, or national enough to deserve equal recognition?” (Baumann 1999: 105).

At times, multiculturalist approaches can be similarly vague in specifying how their normative expectations should materialize in practice. It is not by accident that one of the key proponents of multiculturalism, Will Kymlicka, is rather elusive about how the rights of migrant communities should be accommodated, even though he is articulate about the legitimate claims of so-called national minorities. One key reason behind this omission might indeed be that collective identities are not fixed entities that determine a group’s sense of community and its entitlements. Rather, group identities are in flux and continuously negotiated in terms of the meaning that cultural, ethnic or religious differences have. Group identities are constructed, reproduced and contested in social interaction; they are subject to strategic decisions and politically-driven boundary constructions (Eder et al. 2001). It is within this conceptual framework—acknowledging the importance of identities for patterns of inclusion and exclusion while being aware of their constructed nature—that we analyze how practices in the health care system are shaped by such competing understandings of the challenge of accommodating diversity.

We argue that although these membership criteria and the related identities on which they are based are constantly changing, they tend to remain relatively stable long enough that in our specific empirical cases they can be assumed as temporary criteria for multicultural entitlements. We posit that their relative stability is a historical variable that we will document in the different societies that we analyze. In normative terms we would then envisage enough group entitlements to shore up identities and provide needed resources but not at the cost of hindering their transformations by crystallizing the policy arrangements on which recognition and redistribution is based.

Accommodating Diversity in the Health Care Sector-Conceptual Challenges

If one starts relating these general debates to the issue of the accommodation of minorities’ and migrants’ cultural identities in the health care sector, the recognition of cultural diversity in this societal system seems to be a straightforward task at first sight: it is about the recognition of multicultural society as being composed of identities that are simultaneously collective in terms of language, religion and certain cultural practices, and inter-relational toward, as well as shaped by, other groups or individuals. Viewing society in this way would help us to develop institutional practices and, in the case of health care, improve access and service delivery. Yet social reality often proves to be more complex. Some of those whose interests these reforms regularly target, along with other critical voices, contest what is introduced as a multicultural opening of institutional practices.

First, there is the question of what acknowledging ethnic-cultural diversity in the health care system is meant to look like. On the one hand, old imperatives of assimilation (advancing the simple adoption of so-called “mainstream cultural norms” and the corresponding loss of cultural distinctiveness) have become questionable and no longer provide a valuable path to allow for successful integration of migrants (Alba and Nee 2003). By bringing the concept of methodological nationalism to migration theory, Wimmer and Glick Schiller question the very concept of integration and the way it is based on a container model of state and society (Wimmer and Glick Schiller 2003). The experience of socioeconomic, socio-spatial and symbolic exclusion, as well as perceived opportunity deprivation, has generated discontent and disenchantment, particularly among visible minorities. Yet on the other hand, the notion of differentiating access and entitlements for citizens on the grounds of ethnic or cultural identities appears to be in conflict with some basic principles of modern Western societies. The idea of universal, individually-based rights and the status of equal citizens are normative principles that form the basis of contemporary liberal democracies. Empowering cultural groups actually empowers the elites of each culture, privileging their personal visions of what multiculturalism is about. Thus, it might involve perpetuating hierarchies (Barry 2002; Okin 1999) as defined by a culturalist avant-garde, rather than by the common people whom these groups claim to speak for.

Second, the issue of access and proper services in the health care system is only partly shaped by belonging to a particular ethno-cultural or religious group (Laroche 2000). Individuals’ socio-economic status or family structures can also be critical factors in this respect. Migrants are often affected by a mix of racial discrimination, material deprivation and patriarchal power structures that have been recognized only to a very small degree by policy-making or even larger public discourse concerning how to tackle the thorny question of providing adequate medical services. As we will further elaborate later in the book, the regularly precarious legal or socio-economic status of migrants is a particularly important determinant of access to adequate services.

The third central problem in implementing such multicultural rights and institutional reforms is a state-centered (and at times paternalistic) approach. From their inception, multicultural policies suffered from a lack of agency for migrants and cultural minorities. Besides the lack of agency, migrants are also described as lacking social capital, explained as a result of a low level of cohesion with the receiving society. However, for lack of empirical data we have little evidence about receiving societies with its cross cutting class and gender boundaries to be more socially cohesive than migrant communities. Besides, assumptions about agency and social cohesion as harmonious community relations are naïve in a context where people are confronted with institutional racism (Cheong 2007: 40) and persistent forms of social exclusion.

By conducting a discourse analysis of the interviews with health experts in our national cases, this chapter analyses how the issue of cultural diversity is framed and conceptualized as an issue that does or does not deserve institutional and political reform. We also show how group identities and cultural differences are discursively imbued with a host of controversial and competing meanings. In particular, we focus on arguments justifying approaches that are based on individual universalism and multiculturalism, and the way these arguments are articulated in the health care systems of countries with respectively specific migration histories and traditions. Here we refer to the theoretical debate on the relationship between individual freedom and a societal culture (Kymlicka 1995), relating it to the challenges of accommodating diversity in the health care sector. Essentially, the arguments oscillate between a multiculturalist position which asserts that proper access can only be guaranteed by recognizing the group identity of individuals and the universalist claim that freedom and equality need to be exclusively based on individual rights.

In this chapter we will highlight how, from the perspective of those who work in the system, different understandings and expectations of what constitutes the successful inclusion of migrants into a system like health care informs practice and constitutes the demand for change. This perspective is informed by the idea that the conceptual understanding of the issue, as it is embedded in discursive practices, critically shapes the normative and practical expectations of those working in the field. We adopt a comparative approach as our analytical tool to shed light on the specificity of how such a general understanding of the issue structures options and approaches in the field of medical service provision. In the following analysis of dominant discursive strategies, we seek to detect the dominant understanding of the status of the multicultural challenge in health care by comparing our three national case studies. This study will be organized around an analysis of the competing meanings assigned to the two central concepts of the debate: universalism and multiculturalism.5

Constructing the Challenge of Diversity in National Contexts as a Discursive Field

As much as our understanding of—and the political meaning attributed to—cultural diversity is constructed in discursive practices, it is subject to specific national cultural traditions. The meaning of key terms in the debate varies considerably across national contexts. On the most basic level, the meaning of the term “multicultural” or “multiculturalism” is subject to nationally-specific understandings and expectations. For instance, we found that in the European context our interviewees often used this term in a strictly empirical-descriptive sense. It is meant to depict the social reality of cultural diversity in contemporary society without necessarily denoting any normative or political expectation. From this perspective, “multicultural” is simply meant to refer to the de facto degree of ethnic and cultural diversity.6 The discursive arena for discussing such issues is radically different in the Canadian context. Here, “multiculturalism” represents a concept that is inextricably linked to the political project of accommodating diversity as it was launched in the Trudeau era of the late 1960s and early 1970s. Using the term “multicultural” in a conversation thus explicitly or implicitly entails the idea of a state-sponsored program to publicly recognize and protect minorities. In the Canadian context, the term evokes notions of normative and judicial entitlement.7 The interviews that were conducted in Vancouver and Montreal highlight the degree to which the task of accommodating diversity has come to shape public discourse and establish an expectation in all policy fields (including health care) that cannot simply be negated by service providers or the policy community on the ground.

In order to understand the following analysis of discourses on multiculturalism and universalism, it is worth considering the seemingly obvious: Germany and Italy do not have a similar history of entrenching the rights of minorities in policy practices and, equally importantly, they do not share a distinct multicultural ethos portraying cultural diversity as a positive, enriching component of contemporary society. Against this backdrop it is not surprising to find that the very term “multicultural” is subject to far wider sets of meaning and, in terms of its practical meaning, political projections. The very principle of dealing with diversity in societies that, such as in Italy, have been countries of emigration until very recently is conceptually and politically highly contested.8 Similarly in Germany, with the exception of the experiment of the Office of Multiculturalism in Frankfurt, there is no established political, legal or social practice providing a commonly shared sense of what multiculturalism represents or what exactly it demands from those involved in the policy process of providing services in the health care sector.9

Against this backdrop it does not come as a surprise to note that in both Italy and Germany the debate on multiculturalism is strongly tied to other, more prevalent discourses about key issues that figure large in the Canadian context. For example, a representative of a Vancouver-based immigrant organization summarizes her approach as follows: “Because part of integration is being able to work and be part of a safe and inclusive community, this is where the multiculturalism, anti-racism, human rights aspect comes in” (Migrant Organization, Vancouver, 2006). The mandate of multiculturalism strongly resonates with “universalistic” values of anti-racism and humanism (the link between the two will be subject to a more detailed discussion towards the end of the chapter). In terms of the “metanarrative”10 in our European cases, this basic perception of “multiculturalism” is shaped far more strongly by fears of undermining universally applicable rights and entitlements through the introduction of “special privileges” for specific cultural groups. Throughout the interviews from Naples and Trento in particular, there is a recurrent reference to the alleged threat of “ghettoization” or illegitimate “ethnic privileges.” At the most abstract level of framing the issue, our interviews from Germany and Italy showed there is the strong assumption that introducing multicultural principles would inescapably compromise key values of their political culture, namely equality and fundamental rights. This normative orientation informs the description of the issue of diversity in the health sector in the Ita...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Contents
• List of Tables
• Preface
• List of Abbreviations
• Introduction: The Political Fight Over the Accommodation of Cultural Diversity
• 1 Diversity in Health Care—A Discursive Field between Multiculturalism and Universalism
• 2 Community Engagement and Political Advocacy in Canada, Germany, and Italy
• 3 Political Advocacy in the Health Care System
• 4 Barriers in Access to Care
• 5 Strategies for Change among Institutional and Civil Society Actors
• Conclusion: Political Advocacy and Institutional Change in the Health Care System
• Bibliography
• Index