Medical Xenophobia: Zimbabwean Access to Health Services in South Africa

Series Editor: Jonathan Crush
Authors: Jonathan Crush and Godfrey Tawodzera

Migration Policy Series No. 54

Executive Summary

Medical xenophobia refers to the negative attitudes and practices
of health sector professionals and employees towards
migrants and refugees on the job. There is considerable
evidence that many officials (especially the police, home
affairs officials, refugee determination officers and customs agents) bring
xenophobic attitudes with them when they come to work. Those in the
"helping professions" (such as teachers, social workers and health care
professionals) also come into contact with migrants and refugees in the
course of their jobs. They have the power to withhold services and they
can certainly influence the way in which those services are delivered.
This report asks whether and how xenophobia manifests itself within the
public institutions that offer health services to citizens and non-citizens.
It presents and discusses the question from the perspective and experiences
of the foreign patients who try to access the system.

The study extends the findings of earlier research and suggests that
the phenomenon of "medical xenophobia" is very real in the contemporary
South African public health system. The bad treatment of foreign
migrants and refugees in public health facilities cannot all be ascribed to
xenophobia, however. Migrants are also caught up in the "crisis of care"
that affects every patient in the public health system. The paper concentrates
on those forms of ill-treatment that can be attributed to xenophobia
and argues that the withholding of treatment from those who need
it, and any form of discrimination motivated by hostility to the patient
based on their national origins, is a form of xenophobic violence.

The fieldwork for this study was conducted in Cape Town and
Johannesburg in August and September 2010. Within each city, three different
types of neighbourhood were selected: a middle-income suburb, an
informal settlement and a township. The survey focused on Zimbabwean
migrants and used two major data collection methods: 100 in-depth
interviews and 10 focus group discussions, half in each city. The findings
of this survey are therefore indicative rather than representative. What
they do show is a troubling disregard on the part of some public health
professionals and workers towards the law and their ethical responsibilities
to patients. We do not wish to claim that all health workers display
the kinds of attitudes and behaviours described in the paper. Some
clearly do take their ethical and legal obligations seriously and act with
concern and care towards all patients, regardless of where they are from,
and despite often trying circumstances. The Southern African Clinicians
Society is a major case in point as they played a leading role in promoting
equal treatment for all People Living With HIV (PLHIV), both foreign
and local. However, by conducting research in six different communities in two major cities, this report suggests that there is a pattern of medical
xenophobia that is not just confined to one or two rogue individuals or

Medical xenophobia is a fundamental breach of South Africa's
Constitution and Bill of Rights, international human rights obligations
and various professional codes of ethics governing the treatment of
patients. Medical xenophobia manifests itself in several ways in the public
health system. Amongst the practices uncovered in this study were
the following: first, patients are required to show identity documentation,
proof of residence status and evidence of a home address before treatment
is provided. Patients who, for one reason or another, do not have
such documentation on their persons can be denied treatment. Second,
communication difficulties arise when health staff refuse to communicate
with patients in a common language or allow the use of translators.
Third, treatment is often accompanied by verbal abuse and xenophobic
statements and insults. Fourth, non-South African patients often have to
wait until all South African patients have been attended to even if they
have been waiting longer for treatment. Finally, migrants and refugees
have such difficulty accessing anti-retroviral therapy (ART) for HIV in
public institutions that many are forced to rely on the NGO sector. All of
these manifestations of medical xenophobia are examined at length, with
supporting testimony, in this report. The report concludes with a set of
recommendations for rooting out xenophobia in the public health system.

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