Sofia is out of breath, again.
Breathing freely is never easy for the 60-year-old grandmother – she relies on inhalers to manage her chronic lung disease – but lately even a gentle walk has been causing her to wheeze. Earlier this year, Sofia was found dazed in the bathroom having coughed up blood. She spent several days in hospital on a ventilator before the diagnosis arrived. Lung cancer.
For Sofia*, a Covid vaccine could be the difference between life and death. But she has been told by the authorities in Galicia, northern Spain, that she is not eligible.
“They’ve said I can’t get vaccinated because I don’t have a health card,” Sofia says, pressing a tissue to her cheek. “But I think that I’m at risk. One of the nurses told me it’s because of bureaucracy.”
Sixteen years ago Sofia fled persecution in Venezuela, a nation with 5.4 million refugees and displaced migrants around the world, and is now among Spain’s many personas sin papeles, or undocumented migrants: she lives in the country but lacks vital paperwork.
To be eligible for vaccination, people in Galicia must show a health card, which in turn requires proof of residence. Other autonomous regions in Spain have their own requirements, such as the presentation of a national identity number or a passport. While 74% of Spain’s official population of 47 million has received at least one dose of a Covid-19 vaccine, the country’s undocumented migrants – estimated to be as many as 470,000 people in 2019 – are being left behind.
Even a first dose would give Sofia enormous relief. But without the right paperwork, the jab remains out of reach.
Sofia’s story is not uncommon. The Bureau of Investigative Journalism can reveal that administrative barriers in at least 10 European countries are blocking access to Covid-19 vaccines for nearly 4 million undocumented migrants.
Countries including Germany, Spain, Norway and Bulgaria require some form of ID, health card or a residency permit. In Hungary, Belgium, Slovakia and Greece, vaccinations are officially available only to people with a social security number.
At the start of its vaccination campaign, the Netherlands only offered jabs to people with a registered address and a government-issued invitation letter. In Italy, a basic technical error has hindered vaccine access for 500,000-700,000 non-EU migrants without official paperwork. Despite each having been issued with a number to access essential healthcare, there is nowhere on the online registration form for them to enter it. The few regions that attempted to address the problem have had mixed results: in Lombardy, for instance, it can take several attempts before the system recognises the code, and even when it does, people often do not receive the expected text message with the time and place of their vaccination.
The UK is home to an estimated 1.2 million undocumented people. Anyone is allowed to get a Covid-19 vaccine as long as they have an NHS number or are registered with a GP, which does not require any specific paperwork. However, a recent investigation by Bureau Local found that less than a quarter of city GP surgeries surveyed across England, Scotland and Wales would register someone without proof of address, proof of ID or legal immigration status.
Vaccines are available in the above countries – almost all have fully vaccinated at least 40% of their populations. But while their national inoculation plans often say that migrants are entitled to the vaccine, the reality has been a story of frustration, fear and red tape.
In June, the EU agency that oversees Europe’s defences against infectious disease urged governments to recognise that undocumented migrants “face barriers to European health and vaccination systems on arrival or are excluded due to a lack of entitlement to free healthcare”.
Members of migrant communities tend to be especially likely to contract coronavirus, often because they live in crowded, poorly ventilated conditions and work in jobs that cannot be done remotely. Without general access to basic medical care, it is common for undocumented migrants to develop underlying conditions that go untreated and could leave them more vulnerable to infections. It is unsurprising, then, that migrants are disproportionately likely to die from Covid-19.
In Germany, jabs are technically available only to those with a residency permit. A joint committee of the six major welfare organisations in Germany has criticised the German government for offering undocumented migrants insufficient access to Covid-19 vaccines.
Without a health card – obtained via official papers – undocumented migrants will be turned away from most GP surgeries and hospitals. They may be told to try the benefits office, which supplies vouchers to reimburse medical costs in exchange for personal information. But their details will be logged and sent to immigration authorities and border control – who will likely deport them.
This absence of a “firewall” between the health service and immigration authorities compounds an already difficult situation for Germany’s undocumented migrants – of whom there are up to 1.2 million – who maintain a fraught relationship with wider society.
A firewall is essential in preserving the very different goals of the health service and immigration forces, said Jacqueline Weekers, the director of migration health at the International Organization for Migration. “Public health authorities must take into account years of widespread discrimination and criminalising policies that may have eroded the trust of migrants in irregular situations, leading them to avoid seeking healthcare for fear – and actual risk – of arrest or deportation.”
“What we have in Germany – the opposite of a firewall, basically – is implemented to find people who are hiding,” said Christoph Krieger, a sociologist and head of a refugee camp in the northern state of Schleswig-Holstein. “The distrust between the authorities and migrants is huge.”
Krieger also volunteers at Medibüro in Kiel, northern Germany, one of about 40 NGOs across the country working to ensure equitable healthcare access for undocumented communities and people without health insurance. Their network of health workers, regional authorities and migrant communities is largely held together by what he calls “a system of trust”.
“I doubt that every undocumented migrant [will find] a way to a coronavirus vaccination. That’s nearly impossible, because it’s so complicated and you need to find someone you can trust, someone who will help you,” Krieger said. “In many places, you’re lost if you don’t have anyone who pays for you or gives you the treatment of [an NGO].”
In Belgium, Lily Caldwell is working with four NGOs to vaccinate 5,000 homeless undocumented migrants in Brussels. So far, her team has given 1,400 one-dose vaccines. One of them was to a man living in a Metro station who was afraid to stray too far in case the police took away his mattress and bags. Caldwell vaccinated him next to a car while a colleague watched over his belongings.
Caldwell says the key to their strategy has been to speak to migrants directly. “[They say], ‘Oh, I’ve got a couple of friends. I know three or four guys, I don’t think they’re vaccinated and they live over there.’” Caldwell said. “They’re looking out for each other. They’re worried about their friends getting vaccinated or not getting the right information. And they’re really making sure that everyone’s getting the same access, especially [with] the vaccination.”
The job has been made more difficult by the fact that Belgium is one of many European countries with a devolved healthcare system, meaning that regions or states set local vaccine strategies in lieu of an overarching national approach. The upshot is that even within the same country, the experiences of undocumented migrants are varied and often hugely dependant on their proximity to centres that can help.
After she caught Covid-19 last winter, Sofia was hospitalised with pneumonia and blood clots. She barely made it home. When she did, the bill arrived. “The autonomous communities in Spain are all different,” she said. “In Seville, I had a hip operation after an accident, and they never sent me the bill. But here … they bill you for €16,000. I thought, ‘How can I pay this?’ In Seville, Doctors of the World helped me and I had a lot of healthcare … But here in Galicia it’s very different.”
Hope for some
Norway’s vaccination system – like the UK’s – relies heavily on GP surgeries to supply patient information. The thousands of migrants without the residency permit needed to register with a GP are at risk of being overlooked.
Lyn, a Filipino migrant living in Oslo, has spent more than a decade saving for life-altering surgery for her son, who was born with a hole in his heart and is being raised by his grandmother in the Philippines. She used to work in Singapore – as little more than a slave, she says – for employers who would allow her to eat only the leftovers of the meals she cooked for them. Her life changed when she was granted a two-year visa to live in Norway. Once it expired, and she couldn’t afford any means of getting it renewed, Lyn decided to stay and keep working.
Through word of mouth, she heard about a local health centre run by the Red Cross and Church City Mission that was offering free care to undocumented migrants, and began therapy sessions there in early 2021. A few months later, she received a text giving her directions to an address where she could receive her first dose of Covid vaccine.
“It was very easy, actually,” said Lyn. “When it comes to the vaccine, you know, it should be equal. If they want to protect everyone, they have to give the vaccine to everyone.”
The clinic is one of only two that provide free healthcare to undocumented migrants in Norway, and it draws people from all over the country – but there are many who live in rural areas who don’t know about it or cannot afford to get there. “The Red Cross is the one who's helping a lot of immigrants,” said Lyn. “Without [them], I don't know how we're going to survive.”
The Norwegian government told us that in the largest cities, undocumented migrants are being offered vaccinations but the process in health centres elsewhere is less systematic.
Public health officials say that vaccinating vulnerable communities should be a priority. Leaving pockets of populations unvaccinated – therefore allowing continued infections and the emergence of new variants – could be disastrous.
“If vaccine campaigns … end up not being as inclusive as they should be, that undermines the effectiveness of these public health goals,” said Belkis Wille, a senior researcher for Human Rights Watch. “There's particular concern with regards to undocumented migrants that they are already, in some countries at least, in a more vulnerable situation when it comes to access to healthcare. And so there is a particular reason to ensure that vulnerable people are protected by vaccine campaigns.”
Sofia does not talk about the violence she faced in Venezuela but, like many undocumented women, she is acutely aware of her own mortality. Another bout of Covid-19 could kill her. She is not used to giving up but her options are limited. She says sometimes she tries to remember that she’s not alone, and dread gives way to hope.
“I don’t know what I’ll do from here on. I hope they’ll give me treatment. I want to get past this,” she said. “If I stop … I’m done for.”
* Some names have been changed
Reporters: Sarah Haque and Laura Margottini
Desk editor: Chrissie Giles
Global editor: James Ball
Investigations editor: Meirion Jones
Production editor: Alex Hess
Fact checker: Lowri Daniels
Legal team: Stephen Shotnes (Simons Muirhead Burton)
Illustrations: Soofiya Andry
This article is part of our Global Health project, which has a number of funders including the Bill & Melinda Gates Foundation. None of our funders have any influence over the Bureau’s editorial decisions or output.