1994 VOL 5 NO 4
Copyright© IJDP Ltd.
EUROPEAN FREE MOVEMENT, DRUG USERS AND ACCESS TO HEALTH SERVICES
The free movement area in Europe is expanding and raises issues in relation to drugs, HIV and access to health and other services. Nicholas Dorn and Simone White describe these trends, draw attention to negative public health implications and advocate a clearer approach to policy-making on public health at the European level.
It is often suggested that movement of persons:
... enhances the spread of communicable diseases, makes increased drug abuse easier and makes it harder to care for the specific needs of migrant communities.
CEC, background report, framework on action on public health (7.2.1994)
But is it the movement of persons per se that raises these dangers and 'makes it harder to care' - or some policies of Member States and local authorities in the European Union (EU ), the European Free Trade Area (EFTA) and widening free movement area?
Movement of persons within Europe has been an itnportant political issue for many years and these broader policy issues have a drug policy dimension, with which this paper is concerned. In most cases, however, public and scientific attention has been directed to the potential consequences for Europe of the lowering of internal borders in relation to drug trafficking. The sense of threat generated initially in policy circles in the Benelux countries and, later, throughout the EU in response to the Single Market programme and the perceived mobility of criminals, found expression in a variety of 'compensatory mea-sures' aiming to counter cross-border criminality such as trafficking. The Schengen Agreement, through which nine of the twelve EU Member States cooper-ate, and the Justice and Home Affairs 'pillar' of the Maastricht Treaty have focused attention on this major criminality/trafficking side of things. But there is another side of European Union and free movement which, although perhaps less newsworthy, may have just as much significance in the longer term, as far as public health and social justice are concerned. This concerns not the 'big traffickers', but drug users moving from one country to another.
For European nationals who are mobile within the European free movement area and who use illegal drugs, the issue is not just the right to travel without undue hindrance within Europe, but rather the ques-tion of whether they find themselves economically and socially on a par with the nationals in the country to which they travel in search of work and/or services. Free movement of persons, in this sense, refers to the freedom of the nationals of participating states to move within an area, to settle in any part of the area, to work without the need for a work permit, and to have access to social benefits on a par with nationals (see Nielsen and Szyszczak, 1993 ). This article examines what this means in practical terms for European citi-zens who use illegal drugs and may require access to services, such as generic health services and specialist drug services.
THE EUROPEAN FREE MOVEMENT AREA AND ITS ENLARGEMENT
A European free movement area has existed for over ~three decades and it is getting larger as each decade passes. The European Economic Area (EA), agreed in 1992, came into effect on 1 January 19ä4. The 'four freedoms' (free movement of goods, persor«, services and capital ), as laid down by the Treaty of Rome establishing the European Community ( 1957), now apply not only to the twelve EU Member States (not forgetting French Overseas Territories and Gibraltar), but also to four of the seven EFTA neighbours (the so called 'FANS', i.e. Finland, Austria, Norway and Sweden, which are expected to become part of the EU in 1995, plus Iceland). The EEA agreement grants freedom of movement to an EEA population of 372.2 million people and creates the largest and most important integrated economic entity in the world, stretching from the Arctic to the Mediterranean. Additionally, the two remaining EFTA members, Switzerland and Liechtenstein, have not yet ratified the 1992 Oporto agreement establishing the EEA but do have bilateral arrangements on free movement with neighbouring countries (see Commission background report, 1993a).
These developments are precursors to an even larger economic area, through bilateral and Association Agreements with states in central and eastern Europe. In anticipation, some travel restrictions with eastern European countries have already been lifted, leading to the voicing of public health concerns in western European countries:
For ideological and for other reasons it is clear that several major welfare issues have been concealed in former eastern bloc countries . . . But AIDS is undoubtedly more prevalent, as is intravenous drug use, than has previously been acknowledged in many other countries. Prostitution is a problem in large Soviet cities and alcoholism rife. Poor health is a major issue for several reasons, notably because of the lack of environmental pollution control, inferior diet and the scarcity of safer forms of contraception. All these factors are likely to be both demoralising and costly and thus undermine social stability and solidarity.
Heidensohn and Farrell ( 1991, p. 273 )
There will be continuing public discussion of the health and other social implications of movement of flpeople. One aspect of these discussions focuses on persons whose status or behaviour makes them of concern from the point of view of service provision, cost-containment, public health or public policy. Drug users fulfil these conditions, especially when they become more visible, for example, through travel and cultural diversity.
THE DEBATE ON MOVEMENT OF PEOPLE,
TABLE 1. HIV rates and trends in some European countries
Note: the first column shows the total number of reported AIDS cases in 1990; the second the rate of infection per million population in 1990; the third the proportion of infected persons who are injecting drug users; and the last the total number of reported cases in 1991. Data from Wellings (1992)
DRUG USE AND HIV
So far, European policy-making on movement of people and the associated public health issues has been pitched at a quite general level. For example, as the Commission of the EU has observed:
Migration into the European community, the coming into effect of the Single Market and the general increase of travel and tourism are producing an ever larger intermingling of populations. The health implications of this trend include the propensity for spreading communicable diseases more rapidly, the potential for increased drug abuse and the potential difficulties of providing for the specific needs of migrant communities.
Some commentators insist that increased mobility per se should not be seen as a threat to health. Rather, it is the mixing of unlike cultures and health profiles of populations that may cause problems:
Mobility in itself need not have medical consequences . . . However people in an alien environment . . . are influenced in their attitudes and behaviours by the fact that they lack certain aspects of their usual social and cultural settings. . . In terms of epidemiological developments, however, growing mobility can have consequences for the spread of HIV and AIDS. People from regions with low HIV-prevalence move to countries with high HIV-prevalence, and vice versa; tourists from epidemic centres travel to places where HIV is still very rare and the other way round.
Hommes and Van der Vleugel ( 1993, p. 7)
It has to be acknowledged that in terms of HIV infection, health profiles can be very different within western Europe, and so can the rate of spread of HIV infection, as is illustrated in Table 1. Sharing of unsterilised injection equipment is high-risk activity in relation to HIV infection. Estimates made in the mid-1980s, and taken up by the committee of MEPs chaired by Sir Jack Stewart Clark, suggested that there were 1.5 million heroir users in the then EEC and that five major countrie had about 200 000 each (European Parliament 1986). Aproportion of drug injectors makes up a high ly mobile group within Europe. Some migration i motivated by the wish of drug users to escape a rela tively harsh regulatory environment - and by a desire to live in an urban environment in which availabilit) of drugs and lifestyle is facilitated by the presence o large (sometimes 'open') drug markets. Also, drug injectors are, arguably, more likely to have unprotect ed sex with casual partners when away from their home city.
This propensity to engage in high-risk activities when away from home, Hommes and Van der Vleugel ( 1993 ) argue, is due to the disorientation involved in being in an unfamiliar environment. A complemen tary explanation has been that in some Member States, 'one reason why people might share injecting equiErment or have unsafe sex is that they do not know where to get clean needles, syringes and condoms' (European Project on Drug use, 1993). Other com mentators have suggested that low threshold services can be valuable in reaching those whose lifestyles dis tance them from mainstream services. For example, Kaplan et al. ( 1993a) have pointed out that mobile populations (travellers or migrants) often remain hid den from treatment-based services and that this has important implications for the spread of HIV. Becausc they have 'irregular' lifestyles, drug users often 'fall r out' of the welfare net, especially when staying in another Member State (for reasons we explore in T some detail later).
Furthermore, Grusser et al. (1995) found that, even when they had an alternative, drug users visiting Berlin from other Member States sometimes preferred Iow-threshold services, particularly when main stream services were strictly based on abstinence.
Clearly, because of their ability to 'reach' people who would not otherwise be in touch with mainstream health, advice and support services, low threshold services have fulfilled an important public health function in many settings with drug scenes. Their streetlevel qualities - easy access and lack of administrative intrusiveness - are much appreciated by users.
Such considerations might lead to the proposal of further campaigns to publicise such low threshold services, and improved referral networks, providing a 'seamless web' of referral from the street to mainstream, generic health and social services (see, for example, Grosse, 1990; Heckmann, 1990; Grusser et al., 1995 ). Such approaches no doubt are valuable - but they do not address the questions of whether peo-ple 'qualify' for, and can effectively gain access to, the mainstream services. If not, then all the networking and public information campaigns in the world would be of limited use to them. It is to this question that we now turn, looking first at some developments at the level of Member States and then at some city-level developments. We suggest that the developments that we describe make it more difficult for many drug-using European nationals to gain access to main-stream services.
EU LEVEL DEVELOPMENTS
In terms of provision of health care systems generally in the EU, there has been little direct harmonisation, although there has, as we shall describe, been some convergence and harmonisation of the criteria for other EU nationals' access to whatever heakh care facilities are provided in the individual dember States.
There is a wide disparity in national expenditure in health generally in the EU. In 1990 France spent the highest proportion of the GNP in the EU on health care with 8.9%, and Greece the lowest with 5.3%. It has been observed that:
With the exception of Denmark and the UK, who spend relatively small amounts on health care, Member States can be attributed either to a group of high-income, high-expenditure countries, or to a low-income, low-expenditure group.
Leidl (1993, p. 112)
Such disparities seem likely to remain for some time, because health care per se is not referred to in the treaties defining the EU - the Treaty of Rome ( 1957 ), the Single European Act and the Maastricht Treaty ( 1993 ) - and 'health service issues are not yet on the European Community political agenda' (Leidl, 1993, p. 11). Following the Single European Act, a number of Directives established the basis for a European market in health services, in so far as the 'General System Directive' of 1989 provides for the mutual recognition of higher education diplomas, guaranteeing the free movement of health care providers and other professional workers. However, the EU has made little impact from the perspective of the consumers of health services. What this means in practice is that a drug user moving from one European country to another may or may not find a pattern of services that resem-bles that 'back home'. The Maastricht Treaty does refer to public health and drug dependence, but in terms of cooperation rather than harmonisation. In practice, leaving aside a commitment to glossy public-ity for the annual Drug Prevention Week, policies on health promotion in general and drugs and HIV pre-vention in particular vary a great deal throughout Europe (seeWellings, 1992).
However, notwithstanding the variations between states in health service expenditures and drugs/HIV policies, and the lack of harmonisation of these services per se, there has been considerable har-monisation of eliggbllity for health services (including mainstream drug treatment services). Such harmoni-sation is being facilitated by the broader process of harmonisation of rules on health insurance in the EU. eThere also has been some convergence of eligibility S g ~pr social security (social support, housing benefit, etc.), through the development of national rules on residency status. We describe these pan-European developments, and then go on to note some locally generated developments.
INSURANCE STATUS AND ELIGIBILITY FOR HEALTH SERVICES
In theory, it is envisaged that, in the EU:
Access to systems for the protection of human health, regardless of an individual's resources, can be guaranteed either through a system of health insurance, which is open to persons of all income levels irrespective of their individual risk profile, or through the free provision of health care and prevention within a public health service.
What is happening in practice, however, is that access to health care is not at all 'regardless of an individual's resources'. Gaining access to health care systems requires considerable personal resources in terms of ability to understand bureaucracies and to plan one's life in advance, and also requires considerable economic resources in terms of one's work history and insurance contributions.
For example, EU citizens travelling as tourists who have had the foresight to obtain an E111 form before travelling, are entitled under Regulatior 1408/71 to emergency health care in the Membe States they are visiting. The modalities of access an partial reimbursement differ from State to State (see Commission, 1993b, p. 41). Inpractice,many visitors do not get an E111 (many people, including many European readers of this journal, probably do not even know about it), and there seems no reason to believe that drug users are more likely to go through this procedure than other citizens
For EU citizens residing for more than six months, the health insurance system of the host Member State should take over - subject to the payment of national insurance contributions (which usually means current or recent employment). In practice, therefore those who stay beyond six months have only a qualified eligibility to use mainstream health systems. Qualified, because there is a way in which aczss to main stream health care has become more explicitly linked to past contributions through national insurance (through work or family entitlement) or through private health insurance. Directive 90/364, for example extends the right of residence to nationals (and their immediate family) of those Member States who do no already enjoy this right under other provisions of Community Law, provided that:
. . . they themselves or their families are covered by sickness insurance in respect of all risks in the host Member State and have sufficient resources to avoid becoming a burden on the social assistance system of the host Member State during their period of residence.
Directive 90/634 (Article 1 )
In reality, not all individuals contribute towards a health insurance scheme covering 'all risks' in thei country of origin and other countries.
To summarise, the situation throughout most of the European free movement area is that, after the first sin months, health insurance is required to qualify fo1 health services - either employment related or pri-vately financed. Those without such insurance have three choices if they become ill: either paying fol health care privately; or relying on street-level, low-threshold, free services (which are usually limited in scope); orgoing without treatment. It seems likely that drug users would often fall into the last two categories.
RESIDENT STATUS AS A PATH TO SOCIAL SUPPORT AND HEALTH SERVICES
Following the initial six-month stay as a 'tourist', EU/EEA citizens can apply for a residence permit. If granted, a residence permit may runfor an initial max S imum period of five years, following which a permanent residence permit can be applied for.
For practical purposes, a residence permit is best thought of as a 'passport' to non-contributory benefits in host Member States. Because of their usually poor or non-existent employment record, the call for non-contributory benefits is likely to be quite high among drug users travelling around the free movement area in search of work and/or services, and the question of whether or not they can get a residence permit can be quite important to them.
Furthermore, in certain states- such as Germany (see Grusser et al., 1995 ) - visitors who do not have appropriate insurance, covering health care (as dis-cussed above ), may nevertheless qualify for free health care if they are in receipt of unemployment benefit or social support. But, for this, they need to have a residence permit. Thus the residence permit becomes a passport not only to help with everyday living expenses but also to health care. In these circumstances the residence permit achieves a double importance.
One of the common criteria for obtaining a resi-dence permit is current and regular employment.
However, mobile drug injectors and some other groups may not qualify, because they may have a patchy history of formal employment and/or may work outside the formal economy, for example, in prostitution ( in which case they may have neither res-idence status nor health insurance). Such groups are apt to fall out of the welfare net altogether, qualifying neither for social support, housing support nor for mainstream health service care. They tend to rely on low-threshold services - which are not available everywhere and which may have a limited range of capabilities (of the 'patch up' type). Such services are of course valuable but are not the same as access to mainstream, generic health services.Limitations on access to social support and health services, deriving from eligibility criteria for residence status, can have consequences for health. From a pan-European public health perspective, therefore, there are questions to be asked about residency as an exclu sionary concept and potentially dangerous practice.
CITY LEVEL DEVELOPMENTS
Just as health care policies and expenditure on health vary between Member States, so local authorities determine their own priorities for expenditure ondrug and HlV-related matters. These decisions may depend on drug policies, on broader social policies and on economic considerations.
An estimated 350 000 400 000 young tourists visit Amsterdam annually, a 'liberal' city in drug policy terms of only 800 000 people (Kaplanet al.,1993a, pp. 11/119). They are often referred to as 'drug tourists'.
Additionally, about 1000 German nationals and others with EU citizenship who are considered to be
'addicts' are living in Amsterdam on a permanent basis, of which about 50% are HIV positive (as com-pared with 10-20% of the Dutch addicts). It is the German addicts who mostly answer to the desG,ription of 'drug refugees', referring to their preferensce for a regulatory environment less harsh than that which was cultivated over the border (at least up until the time ofthe unification of Germany):
It is understandable under the circumstances that the city should attempt to contain the costs connect-ed with the deterioration of the neighbourhoods and low threshold services for drug users; such services have now been reserved for those who are lawful local residents.
In addition to the restriction to local residents, the Foreigners and Prostitutes Project in Amsterdam has provided a 'repatriation service' to drug users who are not registered as addicts, and do not have health insur-ance. In 1991, for example, it helped to 'repatriate' 339 patients, mostly Germans. The philosophy of the project is to try and repatriate sick drug users to their own country on a voluntary basis, where it is thought that more fundamental drug treatment and re-sociali-sation can be provided (see De Witt,1992) .
In Switzerland (not part of the EEA at the time of writing, but having Agreements on free movement with some of its EU and EEA neighbours on a bilateral basis), there are anestimated 20 000-30 000 seropositive people. According to Wellings (1992) 'Until 1989, Switzerland had the highest annual incidence rate in Europe, but was overtaken by France and Spain in 1990. . . Injecting drug users [in Switzerland] form 37% of total AIDS cases . . .'. In fact nearly half of drug addicts in Zurich in 1985 were HIV seropositive (Wellings,1992,p.169).
A city such as Zurich, with a well-known drug scene and good health services, has been very attrac-tive to dealers, users and potential users. In response, the Canton of Zurich first tried to expand health ser-vices for the drug users, then, feeling overwhelmed by the open drug scene, turned to more restrictive mea sures (see Fahrenkrug,1995) . One of these measures has been the Rueckfueruhrungszentrum - a centre arranging for the 're-location' of sick Zurich non-res-idents to their own Canton. The Centre has room for 90 druguserswaiting to be sent back to theirown can-tons. This raises issues of care and control:
According to Swiss law (Article 397a of the Code Civil) users can only be held for 24 hours against their will, although a legal extension to three days is sought, as it is often difficult to make arrangements within 24 hours.
Der Bund, Swiss German newspaper (28.8.93)
Neighbouring cantons have co-operated and indicated willingness to come and pick up their 'own' drug users.
Tribune de Geneve, Swiss French newspaper( 27.8.93)
This is summarised by Cattaneo et al. (1993, p.93):
In the Zurich canton, in 1991, 80% of communes agreed to a 'decentralising' of the aid given to drug users. This meant taking steps to send those not resident in Zurich back to their own communes, which are held to be responsible for taking care of them.
The relocation and repatriation ( although it is not known how many actually go 'home' ) of drug users has been seen as a worthwhile social work service, although some practitioners have expressed doubt about the way the procedure is carried out. On the whole though, not too many eyebrows have been raised, in spite of the constitutional and human rights implications.
The tendency to refuse services to non-locals and to relocate some of them may have serious implications in terms of public health. However, this rather nega-tive social engineering is not something peculiar to authorities' responses to drug users, or to non-nation-als - rather, it seems to be an instance of a more gener-al emerging tendency for localities to encourage the moq)ingon of social groups regarded as undesirable from perspectives of cost containment and/or political advantage.
In the UK, for example, the Westminster Council in London has been criticised by a state Auditor for allegedly having moved out poor (often Labour-vot-ing or non-voting) council tenants, then selling the housing stock to richer people (often Conservative-voting). It is suggested that this so-called 'gerryman-dering' had the effect of altering the social fabric, the economic character and the political complexion of certain neighbourhoods in Westminster.
This is a contentious matter and the ink of history is not yet dry but the Auditor's report does seem to raise some issues that may be relevant in the conttext of enquiry into European free movement and access to services. Insofar as drug users and others with a need for social support, welfare and health services may be over-represented among those who live in poor hous-ing in 'marginal' zones of the city, so any general 'moving on' of these poor persons will also have the effect of reducing demands for, and cost of, services. Any such general chasing away of poorer persons cannot be regarded as directly discriminatory under EU law - because it applies regardless of nationality. Neverthe-less, this 'Westminster model' ( to give a new meaning to an old phrase) does seem to provide another approach to the 'moving on' of non-local populations whose faces may not fit and whose pockets are not so deep.
European cities with (open) drug scenes have understandably sought to contain the costs connected with the deterioration of certain neighbourhoods as well as the costs of welfare, and in particular health care, which can be considerable. As a result non-locals have been encouraged to move away, and to go home for the provision of expensive health services.
Mobile drug users with poor contribution records may find it difficult to qualify for mainstream health services in any case. In the same way as nowadays an increasing minority of Americans do not have health insurance ( see Summer,1994, pp.409-414), groups of people also 'fall out' of the health insurance system in Europe, even when the same system claims to reach all sections of the population. It is indeed easy to under-stand how a group such as prostitutes would 'fall out', and would campaign to be integrated into the nation-alhealthsystem (seeJames,1994).Thisphenomenon is of course directly or indirectly related to the lack of employment, or at least the lack of contribution record. Drug users may also find that their access to low threshold drug specific services is curtailed by a 'locals-only' eligibility criterion.
Interestingly this criterion, because it does not discriminate on the grounds of race or nationality, appears to be legally unassailable; it also has the politically correct hall-mark of 'subsidiarity'. However, once refused services, drug users may be likely to get infected, and thus more likely to infect others, or, if already infected, more likely to become ill. Kaplan et al. (1993, p. 13) remarked that: 'The withholding of methadone services in Amsterdam to foreign addicts perhaps was successful in stemming treatment flow from Germany, but may have in turn been related to the finding that Germans in Amsterdam had the highest HIV risk.' Any idea that all those who need in- or outpatient treatment will obediently return (and stay) home, where they may or may not qualify for health care, is pure conjecture.
In our opinion, the issue of drug-using populations converging on particular cities in the free movement area in search of exciting drug scenes, and subsequent using health and welfare services at a financial cost to local (and national) tax payers, has not yet been tackled at the appropriate level. Localities are ill-equipped to resolve a problem of international dimensions. They all too easily fall back on solutions which encourage the exclusion of outsiders. These measures resemble those administered by the parishes in the fifteenth century in Britain, at the time of the Black Death, when proof of birth or apprenticeship in the parish was required before destitute people were admitted(see Somerville,1994).
More research is needed to ascertain the actual access to and use of services throughout the free movement area, to compare costs, and to consider the civil and human rights implications of present practices. Such research would be the first step towards developing a system aiming to spread responsibility and costs throughout the free movement area, while maintaining an effective health programme capable of reaching highly mobile individuals. Without this, the spread of HIV and other infections will prove difficult to stem.
It has been pointed out that, so far, 'a surprisingly small proportion of EU citizens have taken advantage of it [free movement of persons]. . . The number of Community nationals working on a more or less permanent basis in another Community country is relatively low, under two million' (Commission, 1989, p. 153 ). But, of course, such statistics exclude many people whose employment situation is variable and who do not have residence status. Following the ratification of the Maastricht Treaty and the continuing expansion of the EU, it seems reasonable to assume that there will be increases in both the numbers of 'workers/residents' and of 'others' moving about the free movement area.
It is sometimes difficult to separate legitimate concerns posed by drug injection, HIV andAIDS from the oft-expressed fears about foreign persons; foreign cul-tures and social disorganisation. Indeed, much of the existing literature on free movement and dtugs/HIV concerns itself with the health status and behaviour of the persons in movement. Of equal importance, we argue, must be the extent to which EU/EEA citizens visiting or residing in other Member States find their stay or their access to health services curtailed for reasons related to their economic history and situation, lack of local/family connection, lack of information about services and entitlement, personal beliefs or conduct, health status, or because of the potential resources and financial implications to the affected city.
Access to information and services may prevent health and social problems from arising; lack of access may contribute to these problems. As far as the late 1980s and first half of the 1990s are concemed, broad social policy tendencies such as cost-containment and localisation of responsibility for services seem likely to have a significant impact in restricting EU/EEA nationals' access to health and other services. In relation to drug use, HIV and public health concerns, the practical impact looks negative - in spite of good intentions at EU, national and local levels. It is to be hoped that in the future the EU/EEA will social insurance, residence, and 'local connection' criteria for access to health and social services.
Nicholas Dorn, Development Director and Simone White, Research Associate, Institute for Study of Drug Dependence, 32-36 Loman Street, London SE1 OOE, UK.
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