Situation assessment of statelessness, health, and - COVID-19
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Situation assessment of statelessness, health, and COVID-19 in Europe
Acknowledgements
The research was commissioned by the European Network on Statelessness (ENS) and sponsored
by the Rosa-Luxemburg-Stiftung with funds of the Federal Ministry for Economic Cooperation
and Development of the Federal Republic of Germany. This publication or parts of it can be used
by others for free as long as they provide a proper reference to the original publication.
The report was researched and written by Marie-Claire Van Hout (Public Health Institute,
Liverpool John Moores University), Charlotte Bigland (Public Health Institute, Liverpool John
Moores University), and Nina Murray (European Network on Statelessness).
The research team would like to thank and acknowledge all participants of the research,
research country partners, and the Expert Advisory Group (EAG). The content of this report is
the responsibility of ENS and its authors and should not be construed as reflecting the views of
funders or EAG members.
April 2021
Situation assessment of statelessness, health, and COVID-19 in Europe 2Foreword
The COVID-19 pandemic is more than a health crisis. As its repercussions continue to unfold, it has
developed into a rights crisis that affects all of us. Yet, it does not affect all of us equally.
Since the onset of COVID-19, I have urged and extreme vulnerability to human rights necessity for prioritisation on sound medical
authorities across Europe to ensure that abuses. I believe that States should step up evidence and the individual urgency of the
healthcare systems meet the needs of the efforts to put an end to the perpetuation of case. Health is a human right and must be
entire population, including the marginalised statelessness, in line with existing international treated as a public good, not a special benefit
and disadvantaged. I therefore welcome this standards. They should ensure, in particular, or a commodity.
research as the first of its kind to explore the that children born on their territory and who
extraordinary vulnerabilities and rights violations would otherwise be stateless are granted Authorities should therefore strive to identify and
experienced by stateless persons in relation to the nationality of the State concerned. This address the specific and interrelated barriers
health. It exposes a troubling lack of recognition is possibly one of the most effective tools to realising stateless people’s right to health
of the fact that statelessness continues to to curb the number of stateless persons in that the report identifies. Beyond their lack of
constitute a powerful barrier to accessing Europe. I will continue to highlight human legal status, these include multiple forms of
healthcare across Europe. Filling this gap is ever rights violations resulting from statelessness discrimination, fear and mistrust of authorities,
more urgent in the current pandemic context. in my future work, whether at national level digital exclusion, and the lack of access to
or in multilateral contexts, and to support the adequate health information. To guarantee
In most countries, legal status and formal authorities in identifying and implementing the right to health for all requires adequate
documentation are prerequisites for effective solutions. resourcing, and proactive research and outreach
accessing quality healthcare. They are also to ensure that diverse stateless populations
prerequisites for gaining access to important COVID-19 has demonstrated that the right to participate and are made visible in health
social determinants of health, including health cannot be protected at an individual policymaking. I therefore highly appreciate
employment, social protection, and adequate level. It requires effective systems that provide this valuable research on the nexus between
housing. Over 500,000 stateless persons in for inclusive prevention, treatment, and statelessness and health inequalities and
Europe, many belonging to minorities, do rehabilitation for all, leaving no one behind encourage States to take its recommendations
not enjoy the fundamental human right to and ensuring that structural inequalities are to heart in their efforts to build inclusive and
recognition everywhere as a person before not magnified over time but disrupted and resilient healthcare systems for all.
the law. Children continue to be born and to addressed. I have called on Council of Europe
grow up without a nationality, in yet another Member States to ensure non-discriminatory Dunja Mijatović
generation of persons who are compelled access to all pandemic response and Council of Europe Commissioner for
to live a life of destitution, marginalisation vaccination programmes, and to base any Human Rights
Situation assessment of statelessness, health, and COVID-19 in Europe 3“As Roma advocacy coordinator and “The research explores how the ongoing “Stateless communities have continually been
member of the research Expert Advisory COVID pandemic has affected stateless overlooked and hidden from the public eye.
Group, it was important for me that not individuals and outlines the shocking reality With the measures implemented in response
only fundamental rights, but also cultural of how one of the world’s most vulnerable to Covid-19, this marginalised community
rights be considered. I also advised populations can be left behind in such has become even more isolated, magnifying
specific reference to antigypsyism since situations. It defines vastly important areas the inequalities they face. The inclusion of
statelessness and antigypsyism are that are worth further exploring to make sure stateless communities in Covid-19 responses is
intertwined. Hopefully, the report will raise everyone is safe and has the right to health.” essential for a successful pandemic recovery,
awareness whilst creating more concrete and this research is critical in informing
actions. Bringing our voices together is needs and rights-based policies to ensure
crucial and knowing that the starting point that stateless people are not left behind.”
of stateless people is strength, we support Nowras Rahhal
this respectfully and wholeheartedly.” Individual ENS Member & Stateless Activist
Anila Noor
Managing Director, New Women Connectors
Michelle Mila Van Burik Bihari
Individual ENS Member & Roma Activist
Situation assessment of statelessness, health, and COVID-19 in Europe 4Contents
Acknowledgements 2 Stigma, scapegoating and hate crime 19
Vaccination roll out: universal? 19
Foreword 3
Conclusions 20
Background 6
Statelessness and the Right to Health 6 Recommendations 22
The COVID-19 health emergency 8 1. The Right to Health 23
Rationale for the research 10 2. Access to COVID-19 testing, treatment, and vaccines 23
Method 10 3. Immigration, nationality, international protection,
and civil registration procedures 23
Results 11 4. Addressing discrimination, racism and antigypsyism 24
The nexus between 5. Health information and digital inclusion 24
statelessness and health 12
6. State aid and humanitarian response packages 24
Impact of COVID-19 on the health and healthcare access
of stateless people 13 7. Addressing the invisibility of statelessness whilst
upholding the right to privacy 25
Environmental determinants of health and COVID-19 14
8. Support for civil society 25
Operationalisation of public health guidance 15
9. Further research 25
Health emergencies, morbidities, and mortalities of
stateless people during COVID-19 15 References 26
The role of civil society and best practices in supporting
the health response 16 Annex I: Methodology 30
Institutional mistrust and fear of data sharing between
Annex II: EAG Members & Country Partners 33
healthcare and immigration authorities 17
Legal and immigration processes 17 Annex III: Data Collection Instruments 34
Socio-economic exclusion, and lack of access to government
support packages 18 Endnotes 42
Situation assessment of statelessness, health, and COVID-19 in Europe 5Background
Statelessness and the Right to Health
Statelessness was described by António Guterres, the UN High
Commissioner for Refugees (UNCHR) in 2011, as the world’s “most
forgotten human-rights problem” (van Gilder Cooke, 2011). Article 1
of the 1954 Convention Relating to the Status of Stateless Persons
defines a stateless person as “a person who is not considered as
a national by any State under the operation of its law“. UNHCR
estimates there are millions of stateless people in the world, but the
true extent of statelessness globally is unknown, as fewer than half of
countries submit data on their stateless populations. 1 Some people
are born stateless, whilst others become stateless over the course of
their lives. The main causes of statelessness include discrimination
(including antigypsyism), gaps or conflicts in nationality laws, state
succession, and deprivation of nationality.
When a person lacks a nationality, they lack the rights and duties
attached to belonging to a State, which leads to violations of many
other human rights, including the right to health. 2 According to the
World Health Organization, “the enjoyment of the highest attainable
standard of health is one of the fundamental rights of every human
being”, with “health“ being defined as “a state of complete physical,
mental and social well-being and not merely the absence of disease
or infirmity”. 3 The 1948 Universal Declaration of Human Rights (UDHR)
refers to health as part of the right to an adequate standard of living
(Article 25), which is also recognised in the International Covenant
on Economic, Social and Cultural Rights (ICESCR). Article 12 ICESCR
Situation assessment of statelessness, health, and COVID-19 in Europe 6stipulates everyone’s right to healthcare and does not prescribe a particular mechanism Many stateless people have never crossed
States are under an obligation to respect this for determining statelessness. At the time of borders and find themselves stateless in their
right by “refraining from denying or limiting writing, 12 European States have established “own country“ (referred to as “in situ stateless
equal access for all persons, including dedicated statelessness determination persons“). In the Balkans and countries of the
prisoners or detainees, minorities, asylum procedures in law to provide protection to former Soviet Union, many Roma and other
seekers and irregular migrants”. The right to stateless people under the 1954 Convention.6 minority groups remain stateless or at risk
the highest attainable standard of health also In addition to the two statelessness-specific of statelessness because of discrimination
falls within other international human rights conventions, many other human rights treaties and the legacy of state succession.9 Others
treaties. 4 It spans environmental determinants set standards for the protection of stateless find themselves stateless in a migratory
of health, standards of healthcare, and people, avoidance of statelessness, and the context, for example, stateless refugees
rights to privacy and medical confidentiality. right to a nationality. At regional level, the are among those seeking asylum in many
The right to health is closely linked to the European Convention on Nationality and European countries.10 Statelessness in Europe
fulfilment of other rights, which stateless the Council of Europe Convention on the therefore disproportionately affects migrant,
persons are often denied such as the right Avoidance of Statelessness in Relation to refugee, and minority groups, including Roma
to education, social security, and food. State Succession are two key instruments and ethnic Russians living in the successor
According to the Committee on Economic for the prevention of statelessness. In the states of the Soviet Union and Yugoslavia.
and Social Rights, the right to healthcare is UN framework, the Universal Declaration UNHCR reported that there were 527,959
“indispensable for the exercise of other rights” on Human Rights, the Convention on the stateless persons in Europe in 2019, based
5
with universal application and with access to Rights of the Child, and the Convention on on information provided by governments
healthcare services ensured to every human the Elimination of all forms of Discrimination and other sources, although this is likely an
being without regards to race, religion, or against Women, amongst others, all contain underestimate.11
other criteria, including legal status (UNHCR, provisions to guarantee the right to a
2008; Rechel et al., 2013). nationality. Thus, all European States have Statelessness prevents many of those
obligations under international law towards affected from accessing fundamental
The two most important international stateless people and the eradication of rights (human, civil, social, cultural, and
instruments addressing statelessness are statelessness, regardless of whether they are political) creating or exacerbating significant
the 1954 Convention relating to the Status party to the core statelessness conventions.7 marginalisation and exclusion spanning
of Stateless Persons, which provides the access to healthcare, education, housing,
definition of a stateless person and the Statelessness in Europe8, as elsewhere, employment, and other civil rights such
international legal framework for the affects both migrants and refugees, and as birth and marriage registration. Due to
protection of stateless people, and the 1961 people who have lived in the same place for the lack of domestic legal frameworks to
Convention on the Reduction of Statelessness, generations, but it remains a largely hidden identify and solve statelessness, including
which sets rules around conferral and phenomenon, due to the incompleteness and mechanisms to determine who is stateless
withdrawal of nationality. Whilst the 1954 sparsity of data. Disaggregated data and and due protection under the 1954
Convention establishes the international data on stateless people held in immigration Convention, stateless people’s enjoyment
legal definition of a “stateless person” it detention are particularly lacking (ENS, 2019). of rights varies significantly from country
Situation assessment of statelessness, health, and COVID-19 in Europe 7to country.12 The right to access healthcare care for people without identity documents, marginalisation and discrimination stateless
and social security is usually contingent on including due to an inability to register with people face, potentially worsens the impacts
residence or legal status. In the migratory a general practitioner (UNHCR and R2P, of COVID-19 (ISI, 2020a; ISI 2020b; Murray,
context, people recognised as stateless 2020). Undocumented migrants in the UK also 2020).
(in countries with mechanisms to grant face many barriers to accessing healthcare,
protection under the 1954 Convention) are including fear and mistrust and lack of States’ obligations under international
usually permitted access to healthcare and understanding, according to a recent study.14 law continue to apply in crisis situations
social security in line with nationals (for such as COVID-19 except to the extent
example, in Spain, France, Italy and the UK).13 that relevant treaty obligations have been
Stateless people recognised as refugees The COVID-19 health emergency formally derogated from, through notification
or holding subsidiary protection status, are to the relevant international authorities
also usually granted access to healthcare in On 11 March 2020, the World Health (International Commission of Jurists, 2020).
line with nationals. However, where stateless Organization (WHO) reported that the In line with Article 11 of the European Social
migrants hold a temporary residence permit, global outbreak of the corona virus disease Charter, which enshrines the right to health,
or a form of “tolerated“ or irregular stay, (COVID-19) was a pandemic (WHO, 2019). the European Committee of Social Rights
they will often face significant challenges At the time of writing, there are a reported (ECSR, 2020) has stated:
in accessing healthcare. In situ populations 36,607,500 cases of COVID-19 in Europe
affected by statelessness who lack identity with 830,948 deaths (ECDC, 2021). Europe
documents and/or legal status will also face was the epicentre of the pandemic for a In times of pandemic, during which
significant barriers to accessing healthcare. large part of 2020. Success in countering the life and health of many people are
the COVID-19 pandemic centres on an
under serious threat, guaranteeing the
Healthcare for migrants in an irregular inclusive rights-based response, “leaving
right to protection of health is of crucial
situation is generally restricted to emergency no one behind“, with the inclusion of all
populations in domestic, European, and importance, and governments should
care through emergency care services
only (FRA, 2016). In the Netherlands, several international responses (Orcutt et al., 2020; take all necessary steps to ensure that it
studies report that whilst undocumented Orcutt et al., 2020a; Lancet Migration, 2020). is effectively guaranteed. In light of this,
persons have the legal right to access Particularly vulnerable populations during States Parties must ensure that the right
“medically necessary“ healthcare; individuals COVID-19 include ethnic minorities, homeless to protection of health is given the highest
may not be aware of this right. They may people, migrants, refugees, asylum seekers,
priority in policies, laws and other actions
be wrongly denied access or experience stateless persons, and Roma communities
(Lau et al, 2020; Varga, 2020; Kirby, 2020; taken in response to a pandemic.
discrimination; they may fear data-sharing
between authorities; and may be unable to UNHCR and R2P, 2020). Stateless people
pay medical charges (Hintjens, Sigemann and have been highlighted by UNHCR and others
Staring, 2020; International Institute of Social as a group at particular risk of being left
Studies, 2020). Studies in the Ukraine have behind in the COVID-19 response. The invisible
also reported a lack of access to medical nature of statelessness, coupled with the
Situation assessment of statelessness, health, and COVID-19 in Europe 8Despite these assurances, there are rising (including language, health literacy, and Stateless people’s navigation of this public
concerns around the structural underpinning logistical barriers), and discrimination by health crisis, and their experiences are also
of statelessness, human rights, health rights healthcare providers (Zolberg Institute, 2020; at grave risk of being omitted or indeed
and the right to nationality worsening as the Varga, 2020; Murray, 2020). During a public misinterpreted in the global response (ISI,
COVID-19 pandemic takes hold (ISI, 2020a; health crisis, stateless people in particular 2020a; ISI, 2020). There are identified gaps in
Murray, 2020; ISI, 2020b). may also refrain from accessing health government engagement with marginalised
services for fear that their lack of residence or communities and in the availability of
Statelessness is linked to political and legal status can put them at risk of detention, translated and targeted COVID-19 risk
economic marginalisation and discrimination deportation or further discrimination (UNHCR communications across Europe (Maldonado
(including antigypsyism and other forms of and R2P, 2020; Murray, 2020). et al., 2020). Despite government assurances
racism). Many stateless people in Europe to include marginalised populations,
face hate speech, exploitation and abuse, Significant health risk factors are also linked including Roma, migrants, and refugees in
detention, insecurity, and restricted movement, to the contexts in which many stateless comprehensive COVID-19 responses, State
with serious consequences for their health and people live and work. For example, densely public health guidance and measures do
well-being and livelihoods, particularly during populated areas, factories, camp settings, not necessarily reach them, particularly in
a public health crisis (ISI, 2020; Murray, 2020). collective shelters and informal settlements, the case of stateless people due to their
Wider social, structural and environmental and immigration detention settings. All these invisibility (Varga, 2020; ISI, 2020; Zolberg
determinants of health experienced by settings have been linked to an inability to Institute, 2020; Council of Europe, 2020). They
stateless people are worsened during COVID-19 adhere to public health guidance, including may not have full access to public health
and centre on the significant rise in evictions, to self-isolate during illness (Raju and Ayeh- information, or be included in health policies
scapegoating and hate crime during COVID-19, Karlsson, 2020; Armitage and Nellums, 2020; and responses during emergencies such as
poor and congested living conditions, lack Hargreaves et al, 2020; Varga, 2020; Heaslip COVID-19, and without legal rights and access
of sanitation and hygiene, chronic ill health and Parker, 2020; Milkova and Larkins, 2020). to essential services, including healthcare
and stress, overrepresentation in informal Stateless people, especially children and and public funds, many stateless people in
sectors where no work means no pay, and women, who lack residence status and/or Europe are at risk of exclusion from access
lack of access to social security, humanitarian identity documents and live in relative poverty to COVID-19 testing, contact tracing, and
and government aid packages, all of which are at significant risk of social consequences medical care (UNHCR and R2P, 2020; Junior et
compound their health disparity, and of COVID-19 (such as inter-generational al, 2020; Varga, 2020; Hargreaves et al., 2020;
potentially grave outcomes. statelessness, evictions, homelessness, Raju and Ayeh-Karlsson, 2020; Armitage and
poverty, gender based violence, interrupted Nellums, 2020; Heaslip and Parker, 2020; Wood
These risk factors are exacerbated for many schooling, lack of access to online schooling, and Devakumar, 2020; Paprah, 2020; Parry-
stateless people in Europe due to barriers health risks) (Raju and Ayeh-Karlsson, 2020; Davies and RAPAR, 2020; Aragona et al., 2020).
to accessing knowledge around rights and Armitage and Nellums, 2020; Hargreaves et al,
entitlements to support their right to health 2020; Varga, 2020; Heaslip and Parker, 2020;
and help seeking, as well as institutional Milkova and Larkins, 2020; OSCE, 2020; UNHRC,
mistrust, barriers to accessing health services 2020).
Situation assessment of statelessness, health, and COVID-19 in Europe 9In relation to Roma populations in particular, Member States will need to make Rationale for the research
there have been widespread reports of decisions on which groups should have
lockdowns in Roma settlements, rising hate priority access to the COVID-19 vaccines so Whilst the literature base is growing, the
speech against Roma, and reports of State as to save as many lives as possible. These impact of COVID-19 on stateless people in
enactment of disproportionate or militarised decisions should be driven by two criteria: Europe is currently under researched, and
measures targeting Romani neighbourhoods to protect the most vulnerable groups there is an imperative to understand their
or towns (for example in Bulgaria and and individuals, and to slow down and experiences and situations. The European
Slovakia) based on a racist and antigypsyist eventually stop the spread of the disease. Network on Statelessness (ENS) responded to
narrative exemplifying Roma as a health this need and sought and was granted funding
threat (Holt, 2020; Matache and Bhabha, 2020; (European Commission, 2020)
from the Rosa-Luxemburg-Stiftung Geneva for
OSCE, 2020; Milkova and Larkins, 2020; Council this project.
of Europe, 2020).
At the end of 2020, the International
Given the deadly nature of COVID-19 in all Organisation for Migration (IOM) stated that Method
people with underlying health conditions, COVID-19 vaccination plans must include
alongside the unique risk factors and migrants, regardless of their migration
The research team conducted a rapid
discrimination already affecting stateless status, in government vaccine deployment
situation assessment (mixed method
communities, anti-discrimination measures plans (IOM, 2020; PICUM, 2020). This was
consisting of a survey, interviews and focus
are vital to a comprehensive public health supported by two later press releases from
groups) to explore and assess the nexus
response (Murray, 2020). Notwithstanding the European Centre for Disease Prevention
between statelessness and health during
the health harms in disease spread, the and Control (ECDC) (ECDC, 2020; ECDC,
COVID-19 in the Council of Europe (CoE)
mental health impact of statelessness 2020a). On 28 January 2021, the International
region. The full methodology is detailed in
and its detrimental impact cannot be Romani Union released a press statement,
Annex I. The research aim was to better
underestimated and requires dedicated action which outlined concerns for equal access and
understand the intrinsic link between
planning (UNHCR, 2020a; United Nations, uptake of COVID-19 vaccinations for Romani
statelessness and health, and make evidence-
2020). In October 2020, a Communication populations, and the presence of deep
based policy recommendations for the short,
by the European Commission on vaccine institutional mistrust and vaccine hesitancy.15
medium and long-term, inform responses and
preparedness, referred to including actions to protect stateless people’s rights,
“communities unable to physically distance” guide inclusive policies and programmes, and
(such as in “refugee camps”) and “vulnerable tailor public health interventions and service
socioeconomic groups and other groups provision accordingly.
at higher risk” (such as “socially deprived
communities to be defined according to
national circumstances”) as “possible priority
groups” for vaccine deployment:
Situation assessment of statelessness, health, and COVID-19 in Europe 10Results
25 CoE 29 survey 19 in-depth 5 focus
countries respondents interviews groups
29 key stakeholders completed the survey administered by ENS
representing 20 CoE countries (UK; Romania; Czech Republic; Sweden;
Georgia; Croatia; France; Netherlands; Kosovo; Greece; Italy; Belgium;
Serbia; Ukraine; North Macedonia; Russia; Switzerland; Moldova;
Ireland; Portugal). 19 in-depth interviews were conducted with
key stakeholders identified by ENS and represent the regional and
specific country level perspectives (Germany, Ukraine, Netherlands,
Greece, Spain, UK, Italy). Five written reports were submitted by the
focus group facilitators in priority countries.
It is important to mention that whilst perspectives were provided
on the nexus between health and statelessness in general, and
some survey and interview responses give insight into the picture
of health and healthcare access of stateless people during
Situation assessment of statelessness, health, and COVID-19 in Europe 11COVID-19 times, overall there was a lot of identification, or health insurance to access substantiated in stakeholder interviews.
uncertainty from respondents in being able mainstream medical care. For example, in Some examples included:
to answer questions, with many feeling many countries, migrants are only able to
they were ill-equipped or did not have the access emergency medical care, with long- In Romania, stateless people living in
necessary information to comment on term care options available only to those with government-run facilities are provided with
the specific situation of stateless people. certain categories of residence permits and regular access to doctors and medical
Overall, whilst challenging from a research formal documentation. In many countries, personnel. During COVID-19, newcomers
perspective, this is indicative of the lack stateless migrants are among those least are placed in isolation.
of data and information available in the likely to hold identity documents or residence
region on statelessness. This lack of specific permits. Financial costs towards medical care
response regarding stateless people further are noted by many as being a huge barrier to In the Czech Republic, in general, if
emphasises that statelessness is an “invisible accessing medical care, particularly for those someone is detained in an immigration
issue“. The full impact of COVID-19 on who may not be able to self-fund care or do detention setting, emergency care is
stateless people and communities does not not hold medical insurance. As an example provided; but if they are asylum seekers
appear to be recognised or documented. On of this, it was reported by a stakeholder from and housed in a refugee centre, they have
a positive note, data across stakeholders and Ukraine that: access to public healthcare.
stateless people were indicative of general
consensus on the situation, with no outliers
Only those stateless persons who Referring to COVID-19 times, a
observed.
representative from Greece stated: “Yes,
have a permanent residence permit in
there is a difference. For people who
Ukraine are receivers of free medical care
The nexus between are living in the camp for settlement or
in Ukraine. Others should pay for medical reception centres, the health services
statelessness and health services. Those persons who apply provision was restricted, they didn’t allow
for recognition as a stateless person people to move out of the residence.”
Whilst the right to healthcare is a fundamental
human right, with universal application and will not receive free medical services,
with access to healthcare services ensured to because they are regarded as temporary In Ukraine residents of "official"
every human being without regards to race, residents in the territory of Ukraine. accommodation facilities (immigration
religion or other aspects of a person’s identity, detention centres, municipal homeless
including nationality status, this appears not shelters, etc.) are provided with better
to be the case for stateless people. When Survey responses on the differences in health access to healthcare, as those who run
asked about stateless people’s access to service provision for stateless people as the facilities are responsible for organising
health services in general, a high proportion a result of their accommodation settings healthcare. “Those who live in informal
of those who responded to the survey and both in general and during COVID-19 times, settlements has to apply for medical aid
those interviewed detailed the requirement for highlighted marked differences in provision on a general basis, which in most cases is
people to have legal documentation, formal in different countries. This was further impossible without personal documents.”
Situation assessment of statelessness, health, and COVID-19 in Europe 12Representatives from Serbia stated that: Impact of COVID-19 on the Similar observations were made regarding
“Roma who are at risk of statelessness the link to the informal economy and
living in informal settlements have
health and healthcare access of anecdotal reporting of COVID-19 cases in
difficulties in accessing healthcare stateless people accommodation centres for asylum seekers in
services. We have not heard of any Ireland (“direct provision“), Roma settlements,
mitigating measures that have been taken When trying to gain an understanding and accommodation where migrants live in
to ensure accessibility of healthcare in regarding the prevalence of COVID-19 other countries. Focus group participants
response to COVID-19 for the inhabitants amongst stateless people and communities, specifically touched on the prevalence of
of the informal settlements.” the majority of survey respondents and those essential frontline workers in these population
interviewed were unable to provide detailed groups (migrants, refugees, minority groups),
information on this. A small number were with a specific example being provided by a
One stakeholder who was interviewed able to outline areas where COVID-19 had focus group participant from the Netherlands:
described how in the UK (prior to COVID) impacted on groups in which stateless people
an individual (who, although not formally are likely to be represented, such as in the
recognised, was very likely stateless or at Czech Republic where immigration detention A large number of Filipino nurses
least at risk of statelessness) could not centres were closed due to an outbreak of were sent to work on the frontline
access surgery to remove a cancerous the virus; and in Ireland and Germany where in the hospitals fighting against the
tumour because it was not considered meat plants (in which migrant workers and
emergency care and could wait until the virus in Spain, which resulted in a
members of minority groups disproportionately
individual “returned to his country of origin“. high fatality record amongst them.
make up the workforce) experienced clusters
The likelihood of return for this person was of infection. Representatives from Switzerland
very low given his country of origin had at also responded that there were indications
that point twice refused to recognise and Both the survey responses and interviews
that migrant communities may have been
document him for return. with stakeholders, as well as the focus
disproportionately affected by the pandemic.
groups, discussed the impact of COVID-19
The reasons for this inequality were linked to
Many stakeholders observed during restriction measures on health service
a number of factors, including: the population
interviews that as mental healthcare is provision (coverage, access, and availability)
containing a higher proportion of individuals
part of secondary (i.e., non-emergency) referring to the general population, groups
working within essential sectors such as
healthcare, this adversely affects stateless in which stateless people are represented,
health services or retail (which remained open
people who are disproportionately affected and stateless people specifically. All
throughout); these communities typically
by poor mental health and lack of access to referred to an overall reduction in health
having a more densely populated housing
dedicated mental health support. service accessibility for everyone during
situation; and the likelihood of more frequent
COVID-19 restrictions on movement and
travel between their country of origin and
on health system operations, primarily due
Switzerland (although in the case of stateless
to the reduced availability of in-person
migrants, this may be more unlikely as they
appointments, and planned procedures being
often face barriers to free movement or lack
cancelled or rescheduled as health services
travel documentation).
Situation assessment of statelessness, health, and COVID-19 in Europe 13were overwhelmed. Whilst the general Environmental determinants of In refugee camps, medical care
population is affected by disrupted service
provision, groups such as migrants, refugees,
health and COVID-19 is at great shortage. Social distancing
and minorities (and stateless people within is almost impossible to be maintained,
them) are disproportionately disadvantaged Many of those interviewed described how and the number of PCR tests done is not
and vulnerable both to physical and mental ill conditions of housing impacted on the enough. NGOs are stopped from entering
health and contracting COVID-19. Cessation ability for specific groups disproportionately
the camps to provide help or take
of general health services during COVID-19 affected by statelessness (for example
minority groups including Roma, migrants, and
interviews. Even when an interview was
surges was described as impacting on health.
refugees) to adhere to public health guidance allowed, according to a participant based
For example, children’s vaccinations ceased
in many countries. The trauma that many relating to social distancing, hygiene, in the Netherlands, a woman was forced
stateless people have experienced was sanitation and mask-wearing. This was viewed to take it with her children together in the
described as warranting specialist mental as especially difficult during lockdowns room so that she does not talk honestly
health and medical care and was observed to for Roma living in congested settlements about her domestic violence case.
be worsening during COVID-19. (for example, in Albania), with poor water
and electricity supplies; and for migrants
who were referred to as often living in large
In terms of specific barriers to accessing Both focus group participants and
households in overcrowded apartments. In
healthcare, the reconfiguration of services interviewees felt that the environmental
this sense, those interviewed described a
during the COVID-19 pandemic was described conditions in which many Romani people live
reliance on other members of the community
by many as impacting on the ability of have often been a detriment to their ability
to ensure continued supplies of food and
stateless people (and the wider groups to adapt in COVID-19 times, with close living
medicines into the settlements or other
in which they are represented (migrants, conditions and lack of income increasing
places of accommodation. Some participants
refugees, minority groups) to engage with their risk of contracting the virus, creating
referred to stateless people facing lengthy
medical care professionals during COVID-19. a stressful living environment. Financial
periods of arbitrary detention in conditions
During COVID-19 lockdowns, many countries sustainability was also seen as a factor for
tantamount to degrading treatment, and
operated appointments digitally, which was protection from disease, with it being felt
conducive to the spread of disease and poor
observed to disadvantage those without that many stateless people may not have
mental health.
access to internet, laptops, and confined to the financial means to purchase items not
their homes. provided for free (such as masks or sanitizer).
Focus group facilitators from the Netherlands Focus group participants concurred with
highlighted participants’ experiences of the these findings, stating the importance of
reduction in medical care within refugee financial sustainability to being able to adhere
camp settings and immigration detention to public health guidelines. A participant from
centres, which were explained to be a direct the Bulgaria focus group simply stated:
result of restrictions on NGO service providers’
access to these settings:
Situation assessment of statelessness, health, and COVID-19 in Europe 14You pay to visit the doctor, you pay or refugee camp settings). However, when Health emergencies, morbidities,
asked if they felt the public health guidance
for the PCR test, you pay for medicine.
was delivered effectively to stateless people, a
and mortalities of stateless
We have to pay for masks, gloves etc. number of key themes emerged. people during COVID-19
Firstly, one significant barrier to campaign The impact of statelessness appeared to be
Operationalisation of public comprehension was language, with many ill-considered by some government public
publications not being produced in a range health responses. Of the 29 stakeholders who
health guidance of languages, and in-person medical advice participated in the survey, a large number
primarily being provided only in a country’s detailed the increase in emergency health
Many of those interviewed observed that main or official language. Secondly, those service usage during COVID-19 leading
COVID-19 public health measures were who are without internet access, or who do some respondents to report overcrowding
targeted at the general population and were not access services (such as support groups, in hospitals and limited access emergency
not reaching the groups to which stateless government offices etc.) may not have care due to restrictions being placed on
people belong; thereby heightening health received the full guidance being distributed. attendance (for example, a requirement to
risks, vulnerabilities, discrimination, and social The impact of this is further exacerbated for present a negative COVID test prior to being
exclusion. The invisible nature of statelessness those populations who are not able to access admitted for emergency care). It was also
was observed to make it difficult to target medical services due to lack of residence reported that in some countries (for example,
health messages specifically to stateless status and documentation. However, a Sweden), a digital ID was required to access
people. Equally relevant, is the lack of large proportion of survey respondents and a COVID-19 test. Most stateless people do
comprehensive data on statelessness in interview participants did feel that with not have a digital ID so are unable to access
Europe making it difficult to provide evidence the exception of those residing in remote testing. In contrast to this, many other
to inform policy and practice. locations, or who faced language barriers, countries stated that during the pandemic,
most people (regardless of statelessness) exceptions were made to such formal ID
At the time of interview, no respondents from would be aware of the regulations and requirements, enabling all those requiring
any of the data collection methods reported guidelines, if only through word of mouth and a COVID test or treatment to be seen,
being aware that stateless people were community dissemination. regardless of residence or documentation
specifically included in their country or region’s status.
COVID-19 information campaigns. That being Thirdly, no research participants were able
said, some respondents noted that stateless to confirm whether stateless people or There were some anecdotal reports by
populations were included on some level representatives of communities affected by those interviewed of hospitals turning
by individual NGOs, or with assistance from statelessness were consulted in developing away those with COVID-19 symptoms and
UNHCR.16 Many instances were described of their country or region’s COVID-19 information without documentation (such as a passport,
NGO-led communication of government health and wider response. ID card, stateless status, or residence
guidance using remote technologies (visual, permit). In COVID-19 times with hospitals
digital, and multilingual mediums) and mobile overwhelmed this was observed to heighten
health units (for example, in Roma settlements the vulnerability of stateless people to both
Situation assessment of statelessness, health, and COVID-19 in Europe 15COVID-19 severe disease, and also general ill- direct relief (including food packages and The Government of Portugal temporarily
health and morbidities. It was also felt by one other basic necessities). This was further granted all migrants and asylum seekers
participant that the additional strain COVID-19 validated by focus group participants. NGOs residing in the country with pending
has placed on health services has increased were reported by many as having been immigration applications full access to the
the likelihood of stateless people and other actively providing sanitation and hygiene country’s healthcare services. Other good
groups being dismissed when raising health supplies, masks and food aid to those in need practice government responses mentioned
concerns, resulting in incorrect diagnosis, or in many countries, however, this was limited included new ways of surveillance and
poor-quality care being received. Particularly due to overwhelming demand for such items. monitoring of disease spread via “track and
vulnerable stateless individuals were In Serbia, organisations such as the Red Cross trace“ Apps; the use of technology to support
described to be the elderly; those living with distributed food and basic hygiene items vulnerable groups; and the extension of
several family or work colleagues in confined to the residents of informal settlements. residence permits and visas so that individuals
spaces; those with existing poor mental health However, as a representative from Serbia could access healthcare during COVID-19
or other identified COVID-19 risk factors or co- explained, these packages came with a times. Support responses were described
morbidities; and women affected by domestic requirement that individuals have personal as difficult to mobilise, and very dependent
abuse. Several UK respondents described documentation, which excluded stateless on community organisations with existing
instances of severe COVID-19 disease leading people or those at risk of statelessness from trust and credibility with stateless people
to fatalities due to inability to access medical such relief measures. and groups disproportionately affected
care. by statelessness (migrants, refugees, and
One example of government intervention minority groups). The use of cultural mediators
in health service delivery was detailed in and interpreters was deemed as essential.
The role of civil society and Croatia, where essential hygiene products, Other best practices included free COVID-19
best practices in supporting the running water and electricity were distributed testing without any requirement for residence
health response to a segregated Roma community. Assistance or documentation checks, and the “Patients
from the government was also reported in not Passports“ toolkit in the UK, accessible
France, with free masks and sanitiser being regardless of immigration status. There were
Both the survey and interviews revealed
distributed in the streets, as well as increased some reports of exemptions from medical
that whilst some countries did provide some
support being offered in government-run charges when people present with COVID-19
additional measures for identified vulnerable
accommodation centres. However, this was symptoms, but these were not deemed to
populations such as migrants, minority groups,
not available for those outside of official have been communicated sufficiently by
and the homeless, none specifically targeted
procedures, including those with irregular governments.
stateless people, and the vast majority of
residence status or without accommodation.
actions to protect vulnerable groups were
Focus group participants from Estonia also
not government-led. Instead, this gap was
reported that pensioners in the country had
backfilled by NGOs who operationalised
received a one-time delivery of 50 disposable
public health information sharing, community
face masks, to help them protect themselves.
support via WhatsApp groups, engaged in the
provision of mobile health units, and provided
Situation assessment of statelessness, health, and COVID-19 in Europe 16Institutional mistrust and fear of Civil registration services, such as birth A small number of respondents detailed
registration, were reported to have continued varying practices with some governments
data sharing between healthcare using adapted formats in many countries automatically extending temporary residence
and immigration authorities (for example, in France procedures were permits (for example, Portugal, Croatia and
adapted at city levels with cities developing France) at the onset of national lockdowns
Some interview participants observed specific guidance to ensure continued birth and restrictions of movement. Others, such
that COVID-19 has amplified institutional registrations). However, there were certain as Switzerland, failed to provide any amnesty
mistrust, thereby exposing stateless people time periods during the pandemic when this to those with expiring temporary residence
and groups disproportionately affected was not always the case. For example, in permits. One participant from the Netherlands
by statelessness, to increased health risks. Moldova, between 15 March-15 May 2020, focus group who was residing in what they
Cultural and language barriers to accessing only registration of deaths took place, with described as a “refugee camp“ detailed their
medical care were described by many. Roma births being backdated after this point. It experience of delays as a result of COVID-19:
in particular were described as having lasting was highlighted by some participants (in
historical experiences of being turned away the Netherlands and Serbia), that whilst civil
from hospitals. Both survey and interview registration procedures such as birth and It took me 9 months to have my
respondents described a heightened fear death registrations continued to take place, case proceeded, during these months I
amongst stateless people and communities procedures for the acquisition of nationality was at risk because I was sharing rooms
of contracting COVID-19 when accessing a ceased, resulting in many people being left and bathrooms with other people and
medical service, as well as fears of refusal of “in limbo“ with regards to their nationality
it was very risky and hard to be safe.
services, and that information would be shared status and, in some cases, access to services.
between the medical practice or hospital and COVID-19 restriction measures also impacted There were loads of cases in the camp
immigration authorities. A resulting reluctance on access to lawyers and legal representation. without proper precautions, so I left.
to access healthcare on the part of stateless
people was observed by many to contribute to Additionally, it was reported by the majority
increased levels of ill health. that, where applicable, statelessness The majority of research participants
determination procedures were delayed by indicated that no attempts had been made
COVID-19, with some halting completely, and by governments to create a firewall between
Legal and immigration processes others moving to online platforms. There were health and immigration authorities during
some reports of ceased or interrupted asylum COVID-19. One participant referred to Ireland,
Delays in statelessness determination, and residence permit procedures during where the Irish Government has firewalled
residence permit, and asylum procedures COVID-19; and some reports of extended their national health service data from other
during COVID-19 were observed by many deadlines. Some governments shifted to online government departments.
stakeholders. It was highlighted that this in renewals of residence permits, potentially
turn had an impact on the universal right excluding those without access to the internet There were also some reports of people being
to health and access to healthcare due or a computer. Digital exclusion was described released from immigration detention during
to the link between proof of residence or by many as impacting severely on those the pandemic. However, concerns were raised
identity documentation and health rights. without access to laptops and the internet. with regard to the lack of housing and food
Situation assessment of statelessness, health, and COVID-19 in Europe 17aid support offered to those released. Others working whilst sick and without adequate Ukraine: “There was no financial support
described extensions so that people could stay protection from disease; and inability to available for anyone.”
on in asylum reception centres. However, it access government pandemic employment
was also reported that some asylum reception assistance and non-emergency or “medically
centres were shut down during this time due to necessary“ healthcare were mentioned. Many France: “Exceptional financial support
staff shortages. also described the difficulties in supporting was proposed to precarious households
children’s continued home schooling due to and young persons who already benefit
When asked what solutions could be lack of space, access to laptops, and internet. from other financial allowances (requiring
operationalised to support stateless people There was a huge variation in the financial legal stay). These are not applied to
during COVID-19, an overwhelming majority assistance made available to people in their asylum seekers or irregular migrants which
of interview participants recommended that country or region. There was consensus across can include stateless persons. However,
governments grant residence permits and the survey and interview respondents that persons benefiting from a stateless status
identity documents to all affected. As one UK stateless people are impacted by lack of by the OFPRA could benefit of this support
participant said: access to public services and social security if they meet the criteria.”
systems. This impacted on their ability to
meet their financial and basic needs during
Georgia: “Stateless persons were among
It makes absolute sense for all COVID-19 lockdown measures. Focus group
the beneficiaries of the government
those in the legal process or who are participants from Albania reported that whilst
anti-crisis/economic recovery plan but
undocumented to immediately be two government financial grants had been
unfortunately not all can benefit. There
made available during the pandemic, at the
given “Indefinite Leave to Remain“ is a distinction between stateless people
point of interview, only one had been paid
so that their personal safety with permanent and temporary residence
out. Additional examples of responses from
and the safety of the community permits. Those with permanent residence
the survey regarding government pandemic
permits qualify for assistance, others
generally is on a better footing. support packages, and their eligibility criteria
can’t.”
include:
The Netherlands: “No, only Dutch Serbia: “In April 2020, the Government
Socio-economic exclusion, and companies and employees are receiving brought a decision to pay 100 euros to all
lack of access to government financial support packages; people with citizens in order to reduce the negative
support packages a migrant background are often left out, effects of the epidemic. However, stateless
and for Roma it is even worse, they are persons, persons without permanent
Many participants observed how COVID-19 and not being supported financially from the residence and a valid identity card (the
its restriction measures have exacerbated the government in any way for extra help and vast majority being of Roma nationality
existing discrimination, social exclusion and such.” [sic]) were excluded from this measure.”
deprivation experienced by many stateless
people. For example, the impact on living
conditions; loss of informal employment;
Situation assessment of statelessness, health, and COVID-19 in Europe 18Stigma, scapegoating and hate “Hate speech against Roma and Travellers people in the community and ensure dose
rose in some countries during the COVID-19 continuity.
crime lockdown measures. Politicians would use
them as scapegoats for the spread of the Some detailed observations were made
Some observations were made by research virus based on stereotypes. (ex. Bulgaria by interviewees about vaccine hesitancy
participants about a prevalence of political and Ireland).” and the impact of historical mistrust of
rhetoric blaming Roma or migrants for the
State institutions, particularly among Roma
spread of disease. Some participants in
communities. One participant referred to a
the survey and during interview reported
anecdotal instances of scapegoating, hate Vaccination roll out: universal? PICUM (Platform for International Cooperation
on Undocumented Migrants) press release,
speech and discrimination against several
which highlights the complexities of excluding
groups which are disproportionately affected At the time of this assessment, no
those who fear to engage with public officials
by statelessness. This was especially the case stakeholders were able to provide information
for fear of deportation, even when gravely ill
for Roma and Irish Traveller communities, around the COVID-19 vaccination protocol,
and states:
ethnic Russians, refugees and migrants. Five and whether stateless populations would be
out of eight (Romani) participants from the included in vaccination programmes.17 One
Albania focus group reported that on social participant observed; “the virus is invisible
Any vaccination campaign, to be
media they had seen hate speech against and so are stateless people“. Their realities
are hidden and forgotten.
effective, has to cover virtually everyone.
their communities such as calling them dirty
and being responsible for spreading the Including undocumented people is not
virus. Survey respondents provided further The lack of institutional trust among many only humane, it’s also public health
examples: stateless populations was observed by common sense. We’re all in this together,
many to be a factor that is likely to hamper and only together can we win this battle.
“Not specifically against stateless government roll out of a comprehensive public
persons. More generally there were some health vaccination programme spanning
negative media reports about persons test, trace, contact, and vaccinate. The
with migrant background travelling to their challenges highlighted in this regard included
countries of origin (mainly on the Balkans) how to address discrimination in access to
and "bringing in/bringing back" the virus.” healthcare, how to reach those invisible to the
system, how to secure consent to vaccinate,
and how to ensure follow up for second
“Whilst not definitely a proven link, for the doses of vaccinations. A particular challenge
first time ever, the exterior walls of CPR’s highlighted was how to reach stateless
reception centre for asylum seeker have people who are homeless or living in informal
been vandalised three times with racist settlements. NGOs and mobile health units
and xenophobic messages targeting travelling to communities were seen as crucial
refugees.” to vaccination rollouts to reach stateless
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