Report Campaigns of Hate

CAMPAIGNS OF HATE

A YEAR OF PROJECT CAPITANATA: social health outreach service in the ghettos of the province of Foggia, in response to the needs of agricultural workers in exploitative conditions

DATES OF THE ON-GOING PROJECT: 7 JUNE 2018 – 30 APRIL 2019 CO_intersos.pdf 1 10/09/19 12:05

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intersos_ok.indd 2 10/09/19 09:56 intersos_ok.indd 2 10/09/19 09:56 SUMMARY

1. Project Capitanata and the context of intervention: seasonal work in Puglia and the province of Foggia...... pag. 5

2. Social-health analysis...... pag. 13

2.1.a – Chronic pathologies...... pag. 17

2.1.b - Mental Health...... pag. 18

2.1.c –Social-health questionnaires for users and health operators...... pag. 19

3. Working conditions...... pag. 20

4. The stories of users regarding the difficulty of stay permit...... pag. 22

5. Edited by A.S.G.I.: The legal condition of foreign citizens in informal settlements...... pag. 24

6.Conclusions: The not-to-be-repeated failure of evictions with no valid alternative and the road needed towards a multidisciplinary approach...... pag. 29

7. Appendix: complete data of Project Capitanata...... pag. 30

7.1 – Medical visits...... pag. 31

7.1.1 - Breakdown of the patient population...... pag. 32

7.1.2 –Lengths of residence in Italy and Foggia...... pag. 33

7. 1.3 – Personal social-health data of patients...... pag. 34

7.1.4 – Breakdown of pathologies...... pag. 35

7.2 – Health orientation...... pag. 36

7.3. – Employment orientation...... pag. 36

7.3.1 – Social-health questionnaire surveys...... pag. 37

7.3.2 – Focus group...... pag. 40

7.4 Social-health questionnaires: an analysis of the information and of the perception of services...... pag. 41

7.4.1 - Personal data of interviewees...... pag. 41

7. 4.2 - Social health information of interviewees...... pag. 42

7. 4.3 - Health integration...... pag. 43

7.4.4 - Interviewees’ use of A&E emergency services...... pag. 44

7.4.5 - Screening activity for chronic ailments...... pag. 46

1. Project Capitanata and the context of ulation of the Italian countryside that began during intervention: seasonal work in Puglia and the economic boom of the 1960s, where agricultur- the province of Foggia al workers relocated to other jobs, the workforce has been steadily replaced by a migrant component The phenomenon of the exploitation of that lives in a state of cultural and linguistic isola- agricultural work tion. In the Capitanata area of Foggia 30% of Italy’s Employment exploitation is a phenomenon where industrial tomato crop is produced, half of which rights are denied in every phase of the work, from is then exported, as is the case with citrus fruits in the methods of recruitment to the regularity of con- the Gioia Tauro plain. The ghettos thus appear as tracts, from transport to work safety, up to and in- “extensions of companies”, perfectly functioning cluding housing and monetary retribution. Often to maintain migrants in sub-proletariat conditions. the recruitment of people is carried out by an inter- Interventions of assistance and information in the mediary, a foreman or ‘caporale’, who, in the early ghettos are perceived by those who exploit them as hours of a day, collects a group of workers to have endangering the intensive agricultural system as it them work in ‘black’ or in ‘grey’ in the fields, with- is now, based entirely on exploitation, as would be out providing them with adequate protection, either calls for responsible consumption on a large scale. in terms of safety, rest or compensation, far from The word “caporalato”2, however, risks distracting the contractual minimum wage of 41.85 euros en- from the real causes of the problem. The ‘caporale’ visaged by law in the provincial third sector collec- (foreman) is merely one link in the chain of ex- tive contract for agricultural workers on temporary ploitation and the most easily identifiable symptom contract; in other words, 6.4 euros net per hour for of a complex pathology. It is therefore important to 6.5 working hours per day1. Following the depop- underline the contribution to causing this chain of

1 - Data refers to last national collective contract of June 2018.

2 - Caporalato (the use of ‘foremen’) is a penal offence under art. 12 of Law Decree 138/2011, then modified by 148/2011 which introduced into the Penal Code article 603-bis containing the new offence of illicit intermediation and exploitation of work that comes under crimes again individual liberty. Exploitation is considered retribution not inserted in a regular employment contract or when this is disproportionate to the quantity and quality of the work performed; the violation of norms regarding hours of work, weekly time off and holidays; the violation of norms of safety and hygiene in the workplace, such as to compromise the health and safety of the worker; submitting the worker to degrading conditions of work, surveillance or housing.

5 exploitation that is played by the significant role of and 60,000 in ‘grey’ (with an apparently regular the market on the part of Major Organized Distri- contract but with many elements of irregularity, bution in its degenerate forms of putting pressure such as the declaration of a minimum percentage on production prices. As we analyse later, more of days worked and very few contributions paid), as than half of the sample of those who completed a highlighted by the regional office of the FLAI-CGIL social-health questionnaire carried out during the union in June 20173. winter declared that they did not work through a ‘caporale’, thus demonstrating how the phenome- Agricultural workers, in an absolute majority non of intermediation through ‘caporali’ is overes- migrants, suffer from a seriously precarious timated, consequently obscuring the complexity of legal status and conditions of housing. They lack employment exploitation. an awareness of their right, for example, that sustainable working hours should be respected Context of intervention: seasonal work in Puglia and defined by law, their right to receive food and and the province of Foggia lodgings according to regular agricultural contracts, but also to have easy access to the National Health From the beginning of migrations towards Europe, System, which the workers often need given the the Capitanata area in the province of Foggia has extreme conditions of their work. This mechanism of seen a large presence of seasonal workers who strong subordination is reinforced by mechanisms gather in informal groups, occupying abandoned of violence at work, such as threats of non-payment, buildings, in particular farmhouses, and shanty or arbitrary non-payment, verbal aggressions and, towns. at times, physical aggressions at work. Of the approximately 400,000 people involved The very absence of mechanisms of effective in the ‘caporalato’ system, Puglia has 40,000 formal recruitment of workers and the supply of workers in ‘black’ (with no employment contract) lodgings on the part of employers, determines the

3 - Third report “Agro-mafia and the caporalato”, edited by the Placido Rizzotto Monitoring Centre, 2017

6 genesis of the so-called “ghettos”, in the form of The life of exploited agricultural workers in the shanty towns or abandoned farmhouses, with little Capitanata area or no access to drinking water, sewage systems and forms of heating, in an area with very rigid I., senegalese winters. Here, however, we see the resilience of the “I work twelve hours a day harvesting asparagus. If I communities, who respond to the subtraction of all don’t work I can’t survive here. I don’t want to bother rights by organizing themselves and, in some cases, others by begging, or worse, by stealing. I prefer recreating a small ‘urban dimension’ that attempts to labour in the fields, work and live on what I earn. to respond to their denied rights and the absence Home bus, bus home. Ever since I was a child I’ve of services. been accustomed to manual labour. Here in Foggia, if The discrimination is not only in the workplace, but you don’t work you can’t survive. You work to survive. is also perceived by a part of Italian society, which But you can see with your own eyes how we survive expresses hostility towards the foreign workers, here.” poorly tolerating the urban presence of labourers that can flare into physical violence against them, D., Nigerian, aged 50 such as the sequence of aggressions that occurred “In my country I graduated in philosophy. I worked in Foggia in July 2019, when stones were thrown at for fifteen years in the fur sector in Piacenza. Then I migrants going to work on bicycles. lost my job and now I find myself here, in Cerignola, harvesting asparagus all day in the fields. My life is The harvest of tomatoes (due to be processed over.” in Puglia or, more frequently, transported and processed in provinces around Salerno, Naples A., Ghanaian, aged 60 and Caserta) sees a peak in the number of workers “I’ve been living in Cerignola since 2008. I work in between July and September. In these months of the fields. I harvest asparagus, olives, first of all intensive harvesting at least 6,000 workers seek tomatoes, eight, nine, ten hours a day. They never shelter in the shanty towns and the abandoned pay you in the same way. For asparagus they give farmhouses, in extremely precarious health- you five euros an hour, sometimes only four. And you hygiene conditions. Some people, estimated at need to be pretty strong to work on the olive trees. around 1,500-2,000 in the seven settlements The wage depends on how many trees you manage where INTERSOS supplies assistance, live in these to do in a day. For 200 trees they give you 100 euros. conditions throughout the year, including the You live segregated here. We foreigners have an winter, with all its critical issues, in an extremely entire economy in our hands but we have no future fertile region with a wide variety of crops, harvesting in this country. The laws don’t protect us. In fact, in particular cabbages, potatoes, asparagus, on the contrary, they are all against us, while we do tomatoes, zucchini, eggplant, peppers, olives, everything to help the country. Every time I appeal to artichoke and fennel. a public office for help I get turned away. They ask for Except in very cases of job placement through the my residence. I’ve been living here since 2008 and I regular employment registries, foreign workers still haven’t been able to get a single document. I don’t self-organise their transport after contacting an even have electricity connected to my house. And employer, or are otherwise enrolled by a ‘white’ I’m not the only one. There are dozens of people like boss, who at times owns the field, and a ‘black me here. Only in Italy do you earn 3-4 euros an hour boss’ (as they are commonly called by the workers), to work in the fields. Yet Puglia is one of the leading who forms the work team, recruiting migrants in regions in the Italian economy. The town council the ghettos and who often handles transport to should come to see how we live and help us. There work. The employment exploitation continues are people who have been living like this for twenty through under-paid work, irregular contracts and years, and I, too, have been in Italy for twenty years. contributions, grey work and black work. Years ago, there were only Ghanaians here. Now we

7 live in peace with many other Africans. But we have no the tomato harvesting season (even though the services here. We don’t even have bathrooms in our provincial collective contract envisages a day homes. When we need a bathroom, we have to go into of 6.5 hours) a worker therefore earns 42 euros. the fields, the same fields that we work in. We love the However, from this figure the cost of transport earth, but where else can we go? They know we exist. operated by the ‘caporale’ is subtracted (on average They know we live here. But we live in the dark. And yet 5 euros), as well as the rent of any huts or space in we don’t want to live outside the law. We live here. But a farmhouse and any protective items (in particular we want our rights to be recognised.” gloves, due under contract from the employer but almost never supplied). Besides work in the fields, The agricultural workers of foreign origin in Puglia many migrants are employed in informal economic are principally concentrated in the province of activities: the rent of bed space, canteen work (on Foggia, where migrant workers in the high season average 3 euros/meal), the sale of foodstuffs, can total 35-40,000 people, of whom no more than clothes and work equipment, the repair of bicycles, half are regularly employed. Those with irregular motorcycles, cars. The earnings of a male or female employment contracts or without contracts come worker is therefore cut to a minimum. principally from Nigeria, Ghana, Senegal and Gambia, while the majority of those registered are But if the conditions are so critical, why do Romanian citizens, more than 10,000, followed by people not report their employers? 4,000 Bulgarian citizens and only 3,000 Africans4. The alarm clock rings at 4.30-5am. The day’s N., aged 37, replies in this way: “I ended up here work can last up to twelve hours. In most cases because it was my last hope of finding work. I had the daily pay is 3-3.50 euros/hour during the no information about anything. I knew a friend who tomato harvesting season, which involves the lived here. I found work but got very little money and largest number of workers. In a 12-hour day during they treated me very badly. An Italian told me I could

4 - Third report “Agro-mafia and the caporalato system”, edited by the Placido Rizzotto Monitoring Centre, FLA/CGIL, 2017.

8 report the people who were exploiting me. But friends Ceesay (Gambia, 24), Alasanna Darboe (Gambia, told me I should be very careful, because if you report 28), Anane Kwase (Ghana, 34), Awuku Joseph someone they can find you and hurt you. The Italians (Ghana, 24), Bafoudi Camara (Guinea, 22), who come here tell me to file a report. But it’s not so Djoumana Djire (Mali, 36), Ebere Ujunwa (Nigeria, easy. 21), Eric Kwarteng (Ghana, 32), Lahcen Haddouch The problem is that if you report someone you still (Morocco, 41), Mouse Toure (Mali, 21) and have to sleep in the ghetto, which is not a safe place. Romanus Mbeke (Nigeria, 28). And what if they find you? The Italian told me that if I At dawn on 11 August 2018 Fouseni Sissoko lost file a report then they will protect you. But I don’t know his life while heading to work on his bicycle on the anyone to whom this has happened. It sounds like a provincial highway 75, run down by a car that did fairy tale. People are afraid of the consequences.” not stop to offer assistance.

This resignation to a lack of justice goes along with After suffering major burns in a fire in the former a low perception of protection for those who bring Borgo Mezzanone airport on 1 November 2018, employment exploitation to light. In the absence of Bakary Secka (Gambia, 30) died 6 November 2018. protection, fear prevails over a desire for revenge, On 28 March 2019 Daniel Nyarko (Ghana, 51) was while the workers only see the intermediaries (or killed by two gunshots fired by unknown persons. As merely the drivers) being pursued, thus fuelling a guard to a farmhouse, he had in the past defended it vicious circle of distrust, fear and insecurity. from burglary, getting the thieves arrested.

This picture of highly precarious employment, Samara Saho (Gambia, 26) died in his hut on the that extends to social conditions and housing, former Borgo Mezzanone airport during the night of unfortunately involves a lot of victims. 25 May 2019.

While the killing of Soumaila Sacko roused public Two persons of African origin, both agricultural opinion, the other victims of agricultural and workers, died in an accident following wounds employment exploitation in the Foggia countryside suffered in the same accident 6 June 2019 in the has not done the same. More than one year after the San Severo countryside. beginning of the mobile social-health assistance Radu Cheleneagra, a Romanian citizen aged 57, project in the Foggia province, we need to recall died following a sudden ailment during the tomato some of the names of workers who, since the first harvest in Serracapriola. of May 2018 until now, have lost their lives in the Foggia area, all attempting to survive in conditions In a traffic accident 19 August 2019, Al Housseini of serious marginalisation and exploitation. The Sow, a young Senegalese, died while returning majority of these people were the victims of traffic from work in Trinitapoli. accidents going to or from their workplace, and thus register as workplace deaths. To these twenty-three deaths in the last fifteen months in the province of Foggia others, too many, While returning from work on 4 August 2018 a major can be added throughout Italy, either caused by accident on the provincial highway 105 between accidents at work or while going to or from work. Ascoli Satriano and Castelluccio dei Sauri claimed In addition to deaths and accidents, even more the lives of Aladjie Ceesay, (Gambia, 23), Ali frequent are the intimidations levelled by Italians at Dembele (Mali, 30), Amadou Balde (Guinea Bissau, migrant workers. Users refer to threats of all kinds, 20) and Moussa Kande (Guinea Bissau, 27). often suffered while in transit in towns, in particular in Foggia, while on foot or bicycle, up to and While also returning from work, a major accident including homicide, as in the highly serious case of on the State highway 16 in Ripalta claimed the Daniel Nyarko, mentioned above, or the sequence of lives of Lhassan Goultaine (Morocco, 39), Alagie violence that occurred in the outskirts of Foggia East

9 in July 2019. At dawn on 13 July two persons from the safeguarding of social-health and employment sub-Saharan Africa were hit by stones thrown from rights. a car while they were going to work. Also at dawn, on The province of Foggia is a constellation of 15 July, with the same dynamic and in the same place, isolated farmhouses inhabited by many vulnerable three workers were hit by stones, two of them in the categories of people. It is a kind of major head. On 17 July, also at dawn and in the same area, employment “port” where workers from throughout a migrant going to work on his moped was run down Italy depart and return, making a constant mapping by a car. While he was still on the ground someone of the area impossible. got out of the car and battered his moped. On 23 July three persons on bicycles were hit in the head The largest settlements in the area are the former by stones thrown from a passing car. One of them Borgo Mezzanone airport, the Gran Ghetto of had to undergo a surgical operation for a compound Rignano Scalo and the Ghetto Ghana of Borgo fracture to his face. Tre Titoli, followed by a factory and a multitude of These are deaths, accidents and intimidations farmhouses occupied sporadically in a range of suffered by an exploited and unprotected population. 50km around Foggia. The huts and farmhouses are occupied throughout the year, under extremely A study of the territory – an assessment, Feb- difficult living conditions, with a lack of access to ruary 2019 water and sewage systems, of electricity, a system of waste disposal and forms of secure heating. During February 2018 INTERSOS carried out a 20-day operational assessment in the province of Of the two largest settlements, the only town Foggia. The assessment revealed a strong need reachable by public transport is Foggia, while no for intervention in the social-health and protection public transport links the Borgo Tre Titoli settlement sectors, linked to two macro-factors: the absence with the nearby town. of structured interventions, daily and over the length In this location in particular, it is clear that the of a year, with outreach services in the various marginalisation of a ghetto is locked in a vicious ghettos in the province of Foggia; and the lack of cycle. If a worker is sick, he or she doesn’t work. And

10 if they don’t work, they don’t have any money. In a the inhabitants of the settlements, with the aim condition where the private social sector doesn’t of demonstrating the complexity of the territorial intervene, if the worker does not have the ten euros problems, in order to raise the awareness of needed for private transport into town, he or she institutions and consumers and to highlight the has no way to initiate the bureaucratic pathway for imperative need for a multidisciplinary approach, insertion into the social-health system (acquiring one which places the affected communities a domicile/residence, revoking any previously at its centre, beginning with the processes for assigned general practitioner, and finally accessing conceiving alternatives. a new doctor). Considering that these steps cannot be completed in one day, the cost increases and, The Capitanata project in the absence of money, the worker remains even The INTERSOS Capitanata project began its activities more isolated. in 2018, pursuing as its primary goal the safeguarding of the individual, often a seasonal migrant worker, who Given the large size of the territory and the quantity of inhabited farmhouses far from any nearby urban finds himself or herself, temporarily or permanently, centre, the conditions described at Tre Titoli can be outside the system of welcome and the mechanisms multiplied by the many isolated farmhouses spread of social-health protection, and the promotion of throughout the area, and should lead to a reflection inclusive changes to the health system through the on the removal of obstacles to the access of following kinds of intervention, daily and continuative services. throughout the year:

The social-health and socio-employment analysis • To increase awareness of the importance of that follows profiles the actual conditions lived by self-protection and of the available social-health

Foto credit: Alessandro Tricarico

11 services (greater awareness of treatment in itself, of • Evaluation of the impact of seasonal work on health, the services and those which are most appropriate), through individual and collective information guided through primary medical assistance with two mobile by preceding focus groups, on the rights of seasonal units and an approach to overall health; medical workers and related questionnaires dedicated to check-ups and health orientation; beneficiaries;

• The promotion of on-line activities, with the • The accompanying of highly vulnerable patients. realisation of round tables of formal technical Project recipients: migrant agricultural workers social-health coordination, of regular informal (originating from Africa and Asia Minor) and workers multidisciplinary meetings of operational actors in in the informal economy induced by agricultural work the various areas (active in particular in the Borgo and by the informal groups. Workers from Eastern Mezzanone airport, Borgo Tre Titoli and the Gran Europe are additional recipients, although the areas Ghetto) and a monthly coordinating round table of of action do not include their principal settlements the social private sector; since they are assisted by a local association. • Sessions of health promotion, orientated towards identified risk factors or requests from the Staff 2019: community; - 1 doctor and project coordinator; - 1 doctor; • Sessions of individual and collective orientation - 1 Senegalese intercultural operator/mediator of territorial health services, guided by preceding expert in employment orientation; focus groups; - 1 Ghanaian intercultural operator/mediator and •Evaluation of public health services, through Arabic speaker; questionnaires aimed at beneficiaries, health and - 1 In the July-September period: 2 additional social operators employed by the Local Health INTERSOS operators in the area of health and Board and INTERSOS observers; protection

12 Mobile clinics intervene weekly in seven informal • Riuniti hospital of Foggia – department of settlements: infectious diseases; 3 times in the former Borgo Mezzanone airport; 3 • Fire Service Command for the province of times in the Gran Ghetto; Foggia (collaboration to prevent the risk of fires Once a week in Borgo Tre Titoli and surrounding in the informal settlements); areas – Cerignola; Borgo Cicerone; Palmori; the former factory located in Foggia East; in the area In March 2019 a provincial network of the private between Poggio Imperiale and Lesina. social sector in the province of Foggia was established, composed of 22 associations in the The service collaborates with the following territory, each operating with their own specific operational partners, with whom it realises joint activities with regard to the ghetto populations. activities.

The number of services provided up to April 2019, • ASGI (Associazione Studi Giuridici sull’Immi- with doctors’ visits, social-health orientation, grazione- Association for Juridical Studies on individual employment orientation and Focus Immigration); Groups with the same theme, totalled 587 sessions, • The Foggia Local Health Board; with a total of 4,895 accesses of which 2,978 were • The Arcobaleno Coop and Baobab office in first time users. All the data in this report refers only Foggia; to the first visits and first interviews. • Iris (anti-trafficking entity for the province of From the beginning of the project to April 2019, Foggia); 282 doctors’ visits were carried out, with 2,795 • Oasi 2 (anti-trafficking entity for the province of total accesses of which 1,860 were first time visits. Barletta Andria and Trani and for Cerignola; Regarding the activities of social-health orientation, • Caritas Foggia, Caritas Cerignola, Caritas San individual employment orientation or the activity Severo, Caritas Manfredonia, Caritas Borgo of Focus Groups, 301 sessions of social-health Mezzanone, project Presidio; information were carried out, with a total of 1,642 • OIM (Project Aditus); accesses, of which 834 were first time accesses; 164 employment and rights sessions, with a total of GRAPH 1 458 accesses, of which 284 were first time accesses

TOTAL PROJECT Sessions Persons New General medical visits 282 2795 1860 Social-health information 301 1642 834 Protection-labour information 164 458 284

Health System that has to treat them, thanks to its 2. Social-health analysis universalistic model, which must be safeguarded and promoted. Private health interventions of a As stated in the never too often reaffirmed article state welfare nature weaken the public service, 32 of the Italian Constitution: already tested by the advances of private health. It is therefore the task of associations to spread The Republic safeguards health as a fundamental awareness of the health system and try to right of the individual and in the collective interest, and guarantees free treatment to the needy. strengthen it. For this reason, the project focusses on actively Health is an inviolable right, for all persons regard- promoting its services and encouraging people less of their condition, and it is the Italian National living in marginalized conditions in the ghettoes,

13 workers and otherwise, to insist on their rights, relocation across the territory, as demonstrated beginning with health rights, on the basis of self- by the fact that of people awaiting validation of determination, and to avoid parallel welfare services their residency, less than 11% of applications are that would otherwise weaken their communities. in the Foggia province. In fact, one frequently meets people who, when asked where they live, Unfortunately, however, application of the answer that they have no fixed location but for universal principles of the Health System often years have moved from one settlement to another, encounter many obstacles, such as a lack of with pauses of various lengths in towns in order awareness of the right to health and of the modes of to renew documents. Faced with this, orientation access on the part of patients, the lack of transport towards registering with the National Health to reach services in rural areas, the difficulties Service becomes more complex, both considering of health registration, such as the frequently the time often required to find a domicile, as well low awareness of the modes of access to health as the difficulty of each time having to acquire the services by the very operators working in social- necessary information to register or deregister with health centres. each Regional Health System. Thus, the mode of intervention looks in two directions: to the communities in the settlements, This aspect demonstrates how the National Health increasing their awareness of their rights; and to System has greater difficulty with people who the social-health services, in order to increase do not reside permanently in one place, given its their accessibility and usability through constant fragmentation into Regional Systems, which places contact and collaboration with the Foggia Local many obstacles in the path of the large population Health Board. of workers attempting to claim their right to health services. If this is obvious with the male population, From the point of view of pathways to health insertion which moves autonomously and follows more reg- it is worth considering the regionalisation of the ular seasons, the picture is even more complex with Health System. As can be deduced from monthly reference to the female population, who are often demographic variations, the population of the the exploited victims of prostitution or traffick- informal settlements is characterised by constant ing and are therefore periodically moved from one

14 place to another, with a turnover of even less than of his/her treatment), the patient is informed of his/ two weeks. her possibilities in the National Health System and given directions on the basis of need and his/her In addition, the difficulty of integrating through condition at the time. An initial check-up lasts at the normal pathways of territorial medicine leads least 20 minutes. to an incorrect use of A&E emergency services. Recourse to a service for functions that it does not From the employment and social-health data carry out is at the basis of additional hardships and collected by the INTERSOS Capitanata project lack of a guarantee to the right to health. In fact, a picture emerges of the living conditions of the it often happens that once the immediate health inhabitants of the settlements, a young population problem is treated the patient is released from A&E where the age bracket most represented are and entrusted to a general practitioner, without 18-29-year-olds ((59%). confirming that the patient has been assigned one, No unaccompanied foreign minors were identified, or knows how to find one. Besides the patient’s own but in the bracket of young adults the share of frustration, a situation is created where it is impos- newly-adult persons (aged 18-21) was very sible to manage non-acute clinical conditions. relevant, representing a full 34% of the 18-29-year- old bracket. Of the newly adult, 70% reached Italy Every check-up carried out by INTERSOS doc- as minors, a fact that demonstrates a defeat for the tors has the support of an intercultural mediator. In pathways aimed at the insertion and safeguarding the first part of the check-up the patient’s gener- of minors. The nationality most represented among al social-health position is established and his/her the patients was Senegalese (26%), followed by awareness of his/her health rights and the norms Gambians (15%), Nigerians (13%) and Ghanaians regarding health services. Following the check-up (12%). and any eventual administration of medical drugs and a related behavioural form (which INTERSOS, The Nigerian component is significant as regards where possible, promotes in order to reduce the the presence of women, who almost all come from use of drugs and increase the patient’s awareness Nigeria.

15 In addition, the dating of the presence of migrant weeks), before then moving elsewhere and returning workers in the national territory and the province later. This tendency reflects the mechanisms of of Foggia was analysed. Regarding the percentage exploitation for prostitution or female trafficking. of beneficiaries present in Italy for less than three Women who have been in Italy for more than 3 years years one finds a peak between July and September have, on average, been in Italy for 9.5 years and more (rising from 56% to 64%), with a fall between October than 3 years and 4 months in Foggia. and February (down from 52% to 28%), an upturn beginning in March (43%) and a return to 50% in April. Although a quantitative survey has not been This trend highlights two aspects: on the one hand, the carried out, a number of patients say they are still well-known seasonal nature of the migrant worker housed in reception centres which they have only population and how this employment migration left temporarily. Another significant number say within the national territory begins on arrival in Italy; they have only recently left reception centres and and, on the other hand, how the Capitanata area is say they arrived in Foggia in order to find work in a place of stable residence (where the percentage agricultural harvesting, and that they are inclined to of workers never falls below 40%). Two periods of remain in the absence of anywhere else to go. The time were recorded for lengths of stay in Italy and the informal settlements are places of annual residence provincial territory: 0-3 years and more than 3 years. and many people who arrive remain in the absence Among those who have been in Italy for more than 3 of any alternative. This indicates the failure of social years the average length of time they have been in policies of integration and the safeguarding of the national territory is 6.5 years, and in the province employment. of Foggia 2 years and 4 months. The majority of people reached by INTERSOS As regards women beneficiaries, 64% say they have services are registered, or could be registered, been in Italy for less than 3 years, with an average with the National Health System, but a full of 8 months in the province of Foggia. However, 58.4% say they have not been assigned a general the length of time spent in a specific place is hard practitioner and, among those having that right, to evaluate, given that many female patients say only 10.6% say they have a general practitioner in they only spend short times in one place (up to two the province of Foggia. GRAPH 2 Number of Female population screening women %

Female population screening 149 61%

Last check-up from 1 year to 1 year 11 months 52 21%

Last check-up at least 2 years ago 42 18%

LeThe typical dynamics of trafficking mean that In support of the female population, INTERSOS women move in far faster cycles, in a less regular held two days of promotion of women’s health, way and not of their own free will. In this sense, dedicated to a restricted number of women coming integration into one of the Regional Health from the former Borgo Mezzanone airport. This was Systems becomes much more complex and held in the protected space of the Borgo Mezzanone with it also access to the right to health, both for clinic and realised thanks to fundamental extraordinary treatment as well as normal controls collaboration with the Foggia Local Health Board and screenings standard for female health. (clinic #2) and the Foggia anti-trafficking entity Iris.

16 During the clinic’s activity the areas of disturbances abandoned, while making it impossible for health and pathologies found (and identified according services to appropriately codify the inhabitants’ to the ICD10, International Classification of needs. The elements of health promotion Diseases)5, concerned the digestive system (17.7%, regarding common chronic pathologies – such as also including pathologies of the oral cavity), hypertension and diabetes – are lacking in cases of infections of the osteomuscular system (15.1%, isolation, diminishing the potential for treatment in with a maximum correlation with work activity) itself, of normal routine check-ups (one only need and the respiratory system (14.1%). 9% reported think of a simple blood pressure test, or a glycaemic non-specific conditions that were not identified by test), including attributing importance to alarm any clinical evidence, and a full 7.4% requested a symptoms, and thus impeding primary prevention medical check-up without reporting any particular (that is, avoiding the appearance of a pathology) disturbances. and secondary prevention (that is, intervening on a pathology in its initial stage). It is interesting to note the clinical record of the 9% of As patients have stated in social-health cases with symptoms of a non-specific nature. The interviews carried out by INTERSOS (see below), general symptoms ascribed to this category were a communication difficulties and sometimes hurried non-specific malaise, recurring headaches, a lack explanations given by health workers have, on a of appetite and asthenia. In an integrated context number of occasions, led patients suffering such these symptoms could lead to the prescription pathologies to interrupt therapy for years, with the of a routine haematological test, such as often condition worsening in some cases. Other reasons occurs in the general population, for check-up given were incorrect information (“my former doctor reasons. These tests can reveal deficiencies of told me I no longer had a right to the drug because I various kinds or even more serious pathologies in a was irregular”), an absence of information (“some precocious stage. The obstacles to health services volunteer doctors brought me my medicine, but then of the migrant population, even more so when it didn’t come, but they didn’t tell me I could get it from is in constant employment transit, often excludes a public doctor”) or out of fear (“I no longer have a such a component from the pathways of routine stay permit and I’m afraid doctors will report me to the examinations, thus exposing it to the risk of a worse police”). overall prognosis. The populations made to do highly exhausting 2.1.a – Chronic pathologies work, and with stressed daily living conditions and inadequate diet, risk precocious ageing. Of the All leading social medicine studies demonstrate total of pathologies (excluding therefore cases how a chronic pathology and its clinical evolution of check-ups with no diagnosis), the percentage corelate directly with low income, to the extent that of patients with chronic pathological conditions is one can state how mortalities for chronic diseases 3.8%, a significant figure given the average young such as diabetes and hypertension are higher in age of the sample. the poorest and most disadvantaged bracket of A screening was carried out of our catchment of the population. Given this premise, there is every users, with the following criteria for inclusion: a reason for clinical action in the informal settlements, maximum age of 35 (based on documented onset in beginning with chronic pathologies. the Central African and Middle Eastern population) In addition, the various settlements are isolated from and familiarity with a chronic pathology. The overall the community and from services, which leads their objective of this operation was to open a pathway inhabitants to perceive themselves as rejected and of responsibility for community medicine and to

5 - International Classification of Diseases: international classification of diseases and correlated problems, drafted by the World Health Organization (WHO).

17 prevent acute ill health. addition to these conditions, in many cases another two aspects emerge. On the one hand, the important The conditions investigated were principally role played in the majority of cases of traumas hypertension and hyperglycaemia (diabetes and experienced in countries of origin or on the migrant’s prediabetes), and those reported were: asthma, journey. Detention in Libya or violence suffered suspected polycystic ovary syndrome and hepatitis. along the way, as well as concern for the condition The results were particularly significant: in 72% of of relatives in countries of origin surface daily and cases patients with one of the conditions analysed are often seen as elements of mental disturbance, were not in therapy and were not aware of their health having a negative effect both on sleep and the ability problem and/or of the consequences that a lack to make plans for the future with serenity. of therapeutic intervention could lead to. Of these people, 2 out of 3 had not been assigned a general From an assessment interview regarding the actual practitioner, or had been assigned one but not in legal condition of beneficiaries another aspect the province of Foggia. It was equally interesting worth investigating further emerges indirectly. to note that that the remaining third, with a doctor In some cases, the sense of disorientation and assigned in the province (and often not frequented alienation that a migrant’s condition creates is due to linguistic problems, or problems linked to added to by an involuntary process attributed to transport or work timetables) nevertheless lacked the practice of infantilization that in many suffer the assigned therapy, besides being unaware of the within the reception system. We saw in a number of pathology. cases how the excessive welfarism experienced by inmates in reception centres, by depriving them of Chronic pathologies are an important critical issue an active role in a phase of their migratory journey, in the settlements, although they remain little not only increased their sense of impotency, but discussed in the assistance debate, suggesting the also amplified their perception of the difficulties need for a campaign of prevention adapted to these of integration within the European context, also specific contexts. understood as a point of arrival in their journey. In seeking to reconstruct the stages of registration in 2.1.b – Mental health the National Health System or the handling of civil In the informal settlements, the employment and registration, in many cases the reply was that they social context, the range of obstacles encountered had not been able to understand the mechanisms in Italy and Europe, daily discrimination and the involved because everything had been done by difficulty of concrete inclusion, all predispose operators without them either being included in migrants to a clear state of suffering and decision-making or the passages required. psychological stress. The situation is clearly An additional factor that emerged in interviews was complex and involves many factors. Even though a sense of failure and disappointed expectations. no specific assessment of mental health conditions In a significant number of cases, those who had left has been carried out, clinical experience and the their country were often overwhelmed in a family activity of cultural mediators in the settlements has context by their decisive role for the living conditions led to a number of considerations. of people who had remained in their country. The Among the most influential negative factors perception of their state of difficulty and often the affecting mental health are the loss of social impossibility of being able to guarantee support for references due to precarious living conditions and family members, or even, in some cases, the need distance from one’s own environment, the lack of to have to continue to ask for support themselves, prospects for the future, the weight of constant represented an important stress, even more so when uncertainty regarding the evolution of one’s legal social and state recognition of their work was denied. status, as well as the daily humiliation of one’s rights in agricultural work and social marginalisation. In The conditions most encountered were of three

18 kinds: low morale and states of compensatory naires to the population of the informal settle- anxiety; psycho-somatic reactions of hypochondriac ments. The questionnaires were handed out on tendencies; and states of acute mental imbalance. two occasions, with a total of 204 interviewees. 83 people were interviewed in August 2018 and 121 in The problems encountered in orientation are of December 2018. various kinds. While, on paper, the possibility of insertion in pathways of psychological support is A distinction is made between beneficiaries who possible in the majority of cases, the difficulties access an INTERSOS service, and interviewees, of the various bureaucratic passages described who answer the questionnaires without necessarily above even further encourage the loss of a highly making use of the humanitarian services and who vulnerable subject. In addition, added to this is the are not counted as beneficiaries. lack of, or the difficulty of finding cultural mediators More than half of the sample of interviewees were inside the territorial services. found to have been in Italy for 1-3 years, 18.8% for M., Liberia 4-6 years and 13.8% for more than 10 years. One “I don’t want to just sit here doing nothing. I get interviewee out of three said he/she had had no exhausted harvesting tomatoes, eight hours a day. source of information regarding social-health They told me I can’t stay in the reception centre any services, 17.4% that they had got information from longer. Now I survive here at the “Pista” (the former mobile clinics and a full 21.5% that they had got Borgo Mezzanone airport). I was born in Liberia. When information from acquaintances (and less frequently my mother died I no longer had anywhere to live. I was from pharmacies or employers), demonstrating the thrown onto the street. My father also died and I got importance of word of mouth communication. Only sick with the same disease. My neck got all swollen, 0.8% cited written information, and 0% the Internet. enormous (from medical examinations it emerged Awareness of the right to health services was that M. suffers from lymph node tuberculosis). I found to be low. Only 12% said they were aware didn’t have the money to go to a doctor, so I went to of the STP code- Straniero Temporaneament traditional healers who healed me with traditional Presente (Foreigner Temporarily Present), a Fiscal medicines. People began to say that I was cursed. Code substitute for persons with no valid stay One day, when I was washing myself in the sea, they permit in need of medical care - and approximately accused me of contaminating the water. They threw half said they were aware of the right to health for me out of the village. I had to flee. I crossed the desert. those awaiting a stay permit. Further investigation, Then I found myself in Libya where I was imprisoned. however, demonstrated that only a very few I came to Europe to find treatment for my health. I interviewees – less than one in ten – effectively don’t know what I have, but I always feel weak. I find it knew that they had a right to a general practitioner. impossible to put on weight. I keep having migraines. To get some relief I put my head under cold water. When asked what they saw as their principal From Libya I got to Sicily, then here in Puglia. I lived for source of health care, one in two people cited a year and a half in the C.A.R.A. reception centre, and emergency services and one in four private mobile when that finished I came here, to the Pista, where I’ve health clinics, relegating territorial medical care to been living for three months. I’m very scared. I want a very small percentage. Recourse to emergency to get treatment. I have no documents, but I would at services often appear inappropriate, due to a lack least like to be in good health.” of efficiency in the mechanisms of health inclusion in territorial medical care or a lack of awareness 2.1.c – Social-health questionnaires for users of it. Faced with this non-emergency use of A&E and health operators services, 64.3% of cases declared a low or zero satisfaction with the service, due to long waits INTERSOS handed out social-health question- (29.1%), a lack of cultural-linguistic mediation

19 (26.1%) and explanations that were either unclear or services. The operators maintained that the most lacking altogether. It is clear how non-emergency effective information was either written or found recourse to A&E services impacts negatively on on the Internet, stating at the same time that the the care supplied to patients, as well as on the level of patients’ awareness of services was either service itself, besides incurring a much higher zero or inadequate (90%). 76% said they spoke only cost to the Health System. This data, together with Italian and that no cultural-linguistic mediators the patients’ modes of information, underline how were available. In fact, when asked if there was any it is essential to focus on a promotion of territorial way to improve their service in terms of organisation services, through enhancing outreach social- or additional figures that could be added to staff health information and figures of cultural-linguistic in order to improve the service to the migrant mediation, in order to reduce the human cost, as population, many indicated the need to integrate well as the economic cost, of improper recourse to the figure of a cultural-linguistic mediator, a need the emergency sector. that intersected with that expressed by patients, as well as training in the norms of access to services In addition, 23 questionnaires were given to and a transcultural approach. operators with SerT (Drug Addicition Service), the Health Registry, Clinics, the Ineffectious Diseases 3. Employment conditions Department of the Foggia Riuniti hospital, the Public Relations Office and STP clinics, exploring From a brief questionnaire given to 931 patients operators’ perception of the appropriateness it emerged that 71.4% work in the agricultural of recourse to their service and indicators of harvesting or processing chain and the remainder in accessibility to them. The results were overlaid other jobs or are awaiting employment. with questionnaires completed by users of health The means of transport most used was a car (69.6%),

20 followed by bicycles and motorcycles (25.8%). euros, 5.3% earned three euros and 2.6% earned 5 83.2% said they acquired Personal Protective euros. The cost of transport played a part in these Equipment (PPE) at their own expense and this was earnings, which 75% of interviewees say they had to only supplied by employers in 13.3% of cases. pay for themselves (on average 5 euros), while only 26% said they did not have to pay rent for housing In addition, in January 2019, during the winter (where rates vary widely, from 150 euros a month, season, a more in-depth social-employment to lower rents or lump sums). questionnaire was handed out to a small sample of users, thus analysing the most stationary sample Apart from a few exceptions, almost all the of workers, and therefore those often with more interviewees did not know about employment contact with the territory, in a less intense period registries. Half of the interviewees did not know of agricultural work than that of the summer. It what a legal payslip was, and one out of four knew emerged that a third of cases worked seven days nothing about paying taxes, while 18.4% said they a week, 21.2% worked 5-6 days and 45.5% worked did know but never paid any. 4-5 days, with almost 60% working 7-8-hour days 51.3% of interviewees said they worked without and more than 20% doing more than 9 hours. Almost a contract, that is, in ‘black’, and 48.7% in ‘grey’, 1 in 4 did not get a rest break during the day, and of that is, with a contract containing seriously irregular the others 2 out of 3 only got a break of 30 minutes. elements (e.g. declaring far fewer days worked than were actually completed, not paying national During the winter season, 76.3% of the sample insurance contributions) and with no safeguarding were paid 4 euros an hour, 15.8% earned 3.5 on the part of the employer (e.g. secure housing or

21 transport denied to seasonal workers, protective of employment exploitation is more complex. equipment not supplied). Not one interviewee in the sample – as was the case with all outside interviews 4.Users’ stories regarding the difficulties conducted during the INTERSOS service – could regarding stay permits demonstrate being in possession of an entirely legal contract. “Documents are like the foundation of a house. You can’t build a house without a foundation. Finally, it is very interesting to note that 54.4% of It’s the same here. You can’t build without interviewees said they did not work through an documents. Now I’ve got toothache and I don’t intermediary, that is, through a foreman, ‘caporale’ know what to do,” M., Ghanese, Cerignola demonstrating that in a relevant number of cases exploitation is an act carried out directly by the M. aged 27, Ghanaian employer - thanks to contacts developed with “I don’t have any documents, and without documents the stable population of workers in the territory, I can’t work. Even to send money home or get a simple which in addition generates the exploiter additional profits. This reflects how the phenomenon of Postepay card, you need documents. Now they ask intermediaries is present, but often overestimated, for documents to work in the field. They didn’t do while a form of self-organisation by the community that before. It’s because the employers are scared of workers themselves is also relevant. Thus, of inspections and of giving field work to “illegals”. although the phenomenon of the ‘caporalto’ (that is, In 2017 I was in Turin but I was denied asylum. My intermediation) is strong and present, the full story lawyer didn’t contact me to tell me that the reply from

22 the Territorial Commission had been negative. Now were scared of the Carabinieri. Here they pay in cash, it’s too late to place an appeal. I slept for a number of which is why a lot of people have come here over weeks on the street. Then I came here (to Cerignola). time. Me, too, in the 20 years I’ve been living here But I’m here doing nothing, when what I want to do is I’ve never had any documents. I had a stay permit, work. I’m young. I love this country. The Italians saved but they wouldn’t renew it. The police headquarters me from the sea in 2016. It’s not easy to save other asked for my residence. But as you can see, I don’t people’s lives.” have one. I live here.” L., aged 30, from Guinea Conakry More than two thirds of people assisted by INTERSOS “It’s not easy to remain a good person, with a during the project are legally resident. However, clean heart, like me,” explains L., 28. He had been following the entry into force of the “Security recognised as deserving humanitarian protection by decree”, in October 2018, a steady increase has the Catanzaro Commission. But, in 2015, the hut he been seen in people without documents. was living in in Gran Ghetto caught fire and he lost In fact, the Law Decree 113/18, converted into Law all his possessions. He lodged a report in Foggia, 132/18, repealed stay permits given for humanitarian but in 2015 he was not able to supply a duplicate, reasons, which previously represented the most or get a renewal of his stay permit, due to constant frequent form of protection recognised for asylum deferments by the police headquarters. He relocated seekers. Those who obtained a stay permit for to the Borgo Mezzanone airport, where his hut was humanitarian reasons before the decree came first destroyed in the partial eviction of April 2019, into force can, when it runs out, convert it into and then a second time in the July eviction. an employment stay permit if they meet certain requirements, which include being in possession of M., newly adult, from Guinea Conakry an employment contract and a passport. While still a minor, M. fled from his country and was However, the majority of foreign citizens met by sold a number of times by traffickers along the route INTERSOS work in the fields without a regular through Mali and Burkina Faso. In Libya he was held employment contract. In addition, many are unable for 9 months in a detention centre run by criminal to obtain a passport from the Consulate of their gangs. He was tortured for reasons of extortion country of origin. Consequently, the majority before he managed to escape and board a boat. He of these workers, when their stay permit for is recognised as deserving international protection. humanitarian reasons runs out, are unable to either He suffers serious traumas due to the violence he renew it, or convert it into an employment stay experienced. “I believed I’d get to Italy and finally permit and thus remain without any documents, find protection, as my document states. But instead I condemned to social exclusion and exploitation. find myself here, in the Cerignola countryside. I hear In addition, La Decree 113/18 envisages that stay all my friends’ stories about how they can’t renew their permits requested for asylum purposes no longer stay permits for humanitarian reasons and I’m scared allow for civil registration, creating huge difficulties that can happen to me, too.” for the social pathway of those seeking international protection. S., aged 70, Ghanaian The new norms introduced by the “Security decree” “By now I’m old. I no longer have the strength to work impact negatively not only on those directly and I can’t find work anymore. They pay us 3.5 euros affected, who see themselves deprived of any an hour. I want to go home. In the past there were opportunity for a serene and dignified life in Italy, lots of tomato fields and a lot of people came from but also on Italian society, which risks suffering an all over Italy to work here during the summer. People increase in social marginalisation and insecurity, in came here because they didn’t have documents and contrast to the very objectives stated in the decree.

23 5.Edited by A.S.G.I.: the legal condition of formation on the normative changes and the possi- foreign citizens in the informal settlements bility of converting stay permits into ones given for reasons of employment (where legal requirements The legal condition of the male and female mi- are met) has impacted on those who could instead grants who live in the informal settlements spread have converted their permits before they ran out. across the province of Foggia varies widely and is complex, with many critical elements that relate to different profiles connected to conditions of social In reality, converting a stay permit for reasons of fragility, situations of exploitation, an absence of employment is impracticable for the majority of mi- legal information, a low awareness of people’s own grants who live in informal settlements in the coun- legal condition, obstacles in administrative-bure- tryside of the province of Foggia, above all because aucratic procedures, discretional practices that do they work in ‘black’ with no regular contract and are not conform to norms and are especially practiced therefore unable to meet one of the requirements by police headquarters and town councils, but also envisaged for conversion. In addition, the majority the effects of Law Decree 113/2018, converted with of foreign citizens are unable to meet the require- modifications into Law 132/2018. ment that they possess a passport from their country The majority of foreign citizens are legally resident, of origin. Obtaining a passport from a representati- principally holders of stay permits given for huma- ve of one’s country of origin in Italy is very difficult, nitarian reasons, but also for status and subsidiary both because many embassies and consulates do protection motives. A range of police headquarters not issue passports, but also because documenta- of origin are involved: foreign citizens encountered tion is required from the country of origin that tho- come principally from Puglia, Sicily, Calabria and se applying often don’t possess or find difficult or Sardinia, but also from Campania and regions in the impossible to obtain (birth certificates, personal ID north. Data confirms the high mobility of people who or those of one’s parents, etc.). Those who arrive in relocate in search of work or of somewhere where Europe, following a long and difficult migratory path, they can live, but also the inadequacy of the recep- rarely have passports or other documents with them. tion system, from which they are excluded or which For that matter, they often never possessed them, or they have left too early without having begun or con- left them behind on departure, or lost them or had solidated pathways of individual autonomy. them taken away by traffickers and find it hard to A general absence of information was found with recover them at a distance, also due to the lack of a regard to recent normative changes, especially in family network in their country of origin. The Foggia relation to the possibility of renewing/converting police headquarters, unlike other police headquar- stay permits and the new classifications introduced ters, does not recognise the principal certificates by Law Decree 113/18. The small amount of inexact issued by embassies and consulates (certificates and confused information acquired, mostly through of identity or nationality, which are easier to obtain word of mouth, had fuelled a widespread sense of from embassies and consulates) as appropriate do- dismay, confusion and frustration. cuments for the issuing or conversion of a stay permit Since October 2018, following the entry into force in the interim before a passport is obtained. For these of Law Decree 113/18, an increase has been seen reasons, even when a regular employment contract in the number of people without, or at risk of losing, is provided, conversion proves impossible and many their stay permit. foreign citizens, even those who have been in Italy Law Decree 113/18, by repealing stay permits for for a long time and live, work and have built relation- humanitarian reasons, has rendered irregular a ships in Italy, are losing their stay permits and be- broad swathe of the migrant population, which has coming irregular, unless the conditions exist for the seen requests for stay permit renewals rejected, issuing of a “special protection” stay permit in cases even where the request was made before the “Se- that meet the required provisions under article 19, curity decree” came into force. The absence of in- par. 1 and par. 1.1 of Law Decree 286/98. This stay

24 permit is valid for one year and renewable subject with associations and protection entities. In the case to the opinion of the Territorial Commission for the of claimants appealing a denial of a request for in- recognition of international protection. It allows a ternational protection, moving from territories where holder to work, but cannot be converted into an em- they were previously present has often led to a loss ployment stay permit and thus does not guarantee of contact with their lawyer and therefore a lack of any continuity of stay. information regarding the pathways for juridical protection of their case. For these reasons many foreign Even though the majority of migrants current- citizens, although having the right, find themsel- ly present have previously obtained recognition ves (often for a long time) deprived of a stay permit of humanitarian protection, a relevant number are – with all the consequent risks - while being listed holders of international protection or subsidiary on the civil register as persons with no fixed abode protection permits. From interviews carried out, continues to be a critical issue with a strong impact many have not been beneficiaries of second-line on the enforceability of their rights. The Foggia city reception projects, or have been dismissed from council has envisaged a “ceiling” to the civil regi- them before completing the social-employment stration of persons of no fixed abode, even though inclusion pathway, and have had no alternative but civil registration is a subjective right that can be done to relocate to the informal settlements. While pri- immediately and involves no discretional evaluation or to the entry into force of Law Decree 113/2018 on the part of a public administration, except for the the reception system as a whole was clearly ina- activation of powers of verification covered by exi- dequate. The dismantling of a system distingui- sting norms. In fact, article 2, par. 3 of the civil re- shed by phases and the introduction of a system gistration Law 1228/54, modified by Law 94/2009, based on legal status will increasingly broaden envisages that “a person of no fixed abode is consi- the percentage of foreign citizens who cannot ac- dered a resident in the city where he/she has establi- cess a certified reception system and second-line shed his/her domicile. The same person, on reque- reception projects, nor receive any support in so- sting registration, is required to supply the registration cial-employment inclusion pathways. Exclusion office with the necessary elements for the carrying out from adequate reception pathways will encourage of inspections aimed at establishing the effective exi- the spread of informal settlements and situations of stence of the domicile.” Therefore, a legally resident marginalisation, fuelling circuits of social exclusion foreign citizen who demonstrates the effective exi- and exploitation. A relevant problem involves stay stence of his/her domicile in the territory of the Fog- permits that have expired (humanitarian reasons, gia City Council – for example, through documents subsidiary protection, status, asylum requests) or supplied by associations, unions or other entities – been lost, principally in the fires that continue to has a subjective right to civil registration as a person affect all the informal settlements. Foreign citizens of “no fixed abode”, irrespective of the number of ci- living in this situation say they haven’t been able to vil registrations carried out monthly by the council’s renew their stay permit or obtain a duplicate be- registration offices. Refusing civil registration to a cause the Foggia police headquarters requires a foreign citizen with “no fixed abode”, due to the fact certificate of residence or a statement of hospitality that a monthly numerical “ceiling” has been excee- and won’t recognise their residence in the informal ded or for any other reason not envisaged by existing settlements. In many cases the Foggia police immi- norms, is a seriously illegitimate act, sanctionable gration office told foreign citizens to apply at their by administrative authorities or competent judicial border police office of arrival. But since they are no authorities. longer present in that territory and are unable to demonstrate any concrete territorial link, they find In addition, Law Decree 113/18 has created further it impossible to obtain a renewal or a duplicate of difficulties by intervening on the issue of the civil their stay permit. Moreover, relocating from other registration of asylum seekers. But with regard to cities leads to a loss of contact with the territory, this, the addition of par. 1-bis to article 4 of Law

25 Decree 142/2015, according to which “a stay permit forcibly transferred from terrestrial border posts under par. 1 does not constitute entitlement to civil in the north to the Taranto ‘Hotspot’ and who then registration pursuant to the decree of the President of subsequently reached Foggia. According to the pe- the Republic 30 May 1989, #223, and article 6, par. 7, ople we met, the Foggia police headquarters often of the legislative decree 25 July 1998, #286”, cannot denied, delayed or placed strong conditions or li- be interpreted as excluding asylum seekers from mits to the access procedure for requesting inter- civil registration. According to a constitutionally national protection. In the majority of cases, these orientated interpretation made by relevant judicial foreign citizens also said they found it impossible to authorities as well as many unions and other Italian even enter the police headquarters in order to state cities, the provisions of article 13 of Law Decree their desire to request international protection and 113/2018 do not place any explicit prohibition on were repeatedly told to return days or even weeks registration, but limit themselves to excluding that later. While it is true that no formal limits exist for a stay permit granted for asylum can be considered accessing the police headquarters in order to lod- a useful title for formalising a request for civil re- ge a request for international protection, nor fixed gistration. For requests for international protection days, nor a daily limit on numbers, the possibility the regularity of the stay is demonstrated by forma- of entering the Foggia police headquarter’s offices lising a request for international protection through (and therefore be able to access the procedure) is the compilation of “Form C3” and/or identification highly restricted and includes discretional closure, carried out by a police headquarters. One or both due to constant postponements by personnel on documents certify the regularity of the stay in Italy, duty and requests for non-envisaged documenta- perfectly meeting the conditions envisaged by law tion, without the applicant being given any written for civil registration and therefore constitute va- note certifying his/her desire to request asylum, nor lid documents that also allow civil registration for any appointment. asylum seekers. In this regard, 3 May 2019 the The frequent postponements and long delays in for- Network of associations in the province of Fog- malising a request have heavy repercussions on the gia sent a letter to the Foggia City Council, which life of individual applicants and the territory. They to date has not received a reply. In addition, the encourage the creation of a large swathe of “invisi- impossibility of obtaining residence and therefore bles”, people deprived of any legal status who drift an identity card seriously impedes access to ser- in a limbo awaiting the possibility of exercising their vices. In fact, although the norm introduced by the right to protection and access to the rights affor- decree specifies that holders of a permit requested ded stay permit holders (for example, the chance for asylum have the right to access services on the to work once the sixty days required to formalise a basis of their domicile, in practice a residence is al- request for protection have expired). The situation most always required for registration with the Natio- is even worse in the presence of conditions of parti- nal Health Service, to register with the Employment cular vulnerability and exposure to risk factors. This Centre, to open a bank or post office account, etc. demonstrated practice is not coherent with existing The impossibility of obtaining a residence therefore norms, aggravates administrative procedures and, creates enormous difficulties for asylum seekers in in many cases, impedes them. It should be consi- their pathway of social and employment insertion. dered illegal and harmful to the rights and the di- During the course of working in the settlements one gnity of the persons affected. In particular, it vio- found people who were requesting international lates the EU directives 2013/32/EU and 2013/33/ protection but were outside the reception system, EU and the Law Decrees 142/15 and 25/08. Among as well as others who typified the difficulties invol- the main problems is the request for a declaration ved in accessing the procedure for requesting in- of hospitality prior to access to the procedure. The ternational protection. Principally these are people European directives and internal norms do not envi- who reached Italy through the Balkan route (land sage any requirement for the purposes of lodging a and sea), or – in some cases – people who were request for asylum. Law Decree 142/15 defines the

26 modality for declaring a domicile and any additional tation of a request for international protection, ap- documentation should be considered illegitimate. plicants will be given a document bearing their name Article 5 of Law Decree 142/15 clarifies that the that certifies the status of the applicant […]; and ar- obligation to communicate a domicile is absolved ticle 6, par. 6 states: “The member states shall not by the applicant through a declaration to be atta- require unnecessary or disproportionate documents ched to his/her request. For the purposes of pre- nor impose on the applicant other administrative re- senting the request, no other documentation regar- quirements before recognising their rights conferred ding the domicile is required. Article 5, par. 1. must by the present directive, for the mere fact that they re- be interpreted in the sense that, the impossibility quest international protection.” for an applicant to indicate a precise place where EU directive 2013/32/EU establishes the timetable he/she has effective domicile, does not in any case for the registration of requests for protection, also preclude access to the presentation of a request for in cases of extraordinary influx: “When whomsoever asylum: “Save that envisaged by par.2., the obligation presents a request for international protection to a to communicate to a police headquarters ones domi- competent authority with the right under national nor- cile or residence is absolved the applicant through a ms to record such a request, its registration should be statement to be attached to the request for interna- carried out within three working days after presenta- tional protection. Following any eventual subsequent tion of the request.” And article 6, par. 5 states: “In change of domicile or residence the new domicile or the case where simultaneous requests for interna- residence shall be communicated by the applicant to tional protection from a large number of third country the same competent police headquarters for the pur- nationals or stateless persons make it very difficult in poses of a stay permit renewal under article 4, par. 1.” practice to respect the timing stated in paragraph 1., In addition, according to article 4, par. 4, “access to the member states can rule that said deadline is po- the measures of reception and the release of a stay stponed for ten working days.” permit according to par. 1, are not subordinate to the existence of additional requirements regarding tho- With regard to access to the procedure for a re- se expressly required by the present decree.” quest for international protection one can find in the The norms envisage that formalisation takes place informal settlements a not inconsiderable number within three, or a maximum of ten work days from of international protection permit applicants/ presentation of the request. Article 26, pars. 2 and holders readmitted into Italy under the terms of 2bis of Decree 25/2008 envisage that a police hea- the Dublin regulations, for whom no undertaking dquarters, once it has received a request for inter- was activated at the moment of their re-entry into national protection, should draw up a report of the Italy and who have reached the informal settlemen- applicant’s statement on the appropriate C3 form ts because they have not been inserted into any re- and then proceed to formalising the request for ception pathway and are without personal resour- protection; within three work days from the stated ces. All the “Dubliners” met have encountered great desire to request protection, or six days in cases difficulty in reactivating their request procedure for where the desire is stated to a border police sta- international protection in police headquarters in tion, and ten days in the presence of a large number Italy, or in asking for a renewal of their stay permit. of requests following a substantial and close-to- The problems met involve a lack of reception on gether arrival of applicants, a situation not compa- re-entry into Italy, access to immigration offices, rable to normal conditions. EU directive 2013/33/ long procedural delays and requests for a declara- EU indicates the timetable for the release of a cer- tion of domicile. tificate bearing the applicant’s name and forbids Many are foreign citizens who have expressed a de- states from demanding unnecessary or dispropor- sire to present a new request for international pro- tionate documents or imposing other requirements. tection in the light of new elements in their country Article 6, par. 1. states: “The member states should of origin or personal situation. Already before the do so in order that, within three days of the presen- entry into force of Law Decree 113/2018, while ha-

27 ving presented a written request through a lawyer, various settlements, also outside the region, is gre- they have not been able to formalise their request ater than that of the men. but have been simply invited to present it again at They request little legal support and almost exclu- a police headquarters, even after a full year, with sively when they have an undelayable need (such a simple hand-written note added to their request as a Commission audition or, much more often, and with no official stamp. In at least two cases, when they have been informed that their request for following a police inspection the foreign citizens international protection has been denied). In the received an expulsion order and were transferred majority of cases they initially arrived accompanied to a Repatriation Centre (CPR). We cannot exclude by a man. They often do not possess a stay permit, that the illegitimate practice adopted by the Fog- nor appear aware of their legal condition. In cases gia police headquarters has not had similar conse- where support was requested in order to have in- quences for a wider number of people than those formation on the state of their procedure, when an noted so far. inquiry was carried out it emerged that they had presented a request for international protection in Within the settlements there is a numerically signi- another territory, which they had then left or had ficant number of newly adults who arrived in Italy been made to leave, and were found to be untra- as minors and were dismissed from minor commu- ceable following a summons by the competent Ter- nities when they reached adulthood, even when ritorial Commission. The emergence of conditions they had not completed the bureaucratic process of trafficking and exploitation appear critical and for requesting international protection, which is weak, also for the purposes of having internatio- the principal procedure initiated for minors. Many nal protection recognised. In some cases, an initial possess a stay permit requested for asylum, both condition of trafficking for the purposes of sexual because they are awaiting an audition with the Ter- exploitation emerged, which then became employ- ritorial Commission, and also have lodged an ap- ment exploitation. peal against the decision to deny them internatio- Within the female category, there is one group of nal protection. None of the new adults met either stationary women who have been in Italy for some possessed or knew about the measure that would years and live full-time in the informal settlements. extend them administrative protection by the terri- This target group has in general received little atten- torially competent Tribunal for Minors, nor that they tion and little interest from specific projects. The wo- could proceed with a request for a foster care stay men are no longer young and almost all have a stay permit and the possibility that they could be inser- permit for humanitarian reasons. During the course ted into projects run by the Siproimi network (In- of activities individual interviews were carried out terior Ministry Circular of 3.1.2019: “The SIPROIMI giving legal orientation and information on normati- can develop a system of reception and inclusion for ve changes and the consequences for them as stay unaccompanied foreign minors which, as a result of permit holders. Their employment situation does not measures introduced by article 13 of Law #47 of 2018 allow them any chance of converting their permits (that is, hereinafter an administrative function) can since they principally do “cleaning work” within the continue, in the presence of requirements envisaged settlements. It appears important to highlight that by said law, their pathway of reception up to the age in all cases where the need to flee their country of of 21 years.” origin was determined by persecution due to their gender and/or domestic violence, these elements The condition of women living in the informal sett- were not taken into consideration for the purposes of lements deserves particular attention. Although affording them international protection, while a con- they are a significant presence, their presence is dition of vulnerability connected to their condition as silent. In general, they are very young, also newly single women was considered. From an examination adult and principally Nigerian. The majority live of their documentation, their personal situation and temporarily in a settlement awaiting transfer el- their country of origin, it emerged that all these wo- sewhere. The mobility of the young women in the

28 men would suffer serious harm were they to return of fragility of these male and female workers. to their country, also due to their migratory path. The The example of the Gran Ghetto eviction is repeal of their stay permit for humanitarian reasons, emblematic: some 20 years ago, in Rignano Scalo, as an effect of Law Decree 113/2018, has a signifi- halfway between San Severo and Foggia, the first cant impact on all these women, even though they Gran Ghetto, created by a community of workers have been in Italy for many years. in a former sugar factory, was forcibly cleared. Considering the difficulties of social-employment Following the eviction, the community of workers inclusion that the women encounter even more settled in an area some 15 minutes away by car, than men, especially among those who already live immersed in the countryside. Almost 20 years in conditions of social exclusion inside the informal after its birth, in March 2017, the Gran Ghetto was settlements, together with their personal condi- again cleared and a small share of its inhabitants tion (age, health condition) and bureaucratic diffi- (obviously only those with regular permits) were culties – such as, for example, the impossibility of offered alternative housing in tents and containers. obtaining a passport – it is clearly evident that the Immediately following the eviction, some of the majority will soon become irregular and thus even community relocated to other settlements in the more exposed to the risk of marginalisation, black- Capitanata area, most of all to the former Borgo mail, abuse, discrimination, trafficking, exploita- Mezzanone airport, while others rebuilt in the same tion and gender violence. While many critical issues place, thus immediately recreating the Gran Ghetto. emerge regarding the condition of migrant men According to local popular opinion, the eviction and women in the settlements, the latest norma- eliminated the ghetto, to the point that many are tive interventions and practices applied seriously surprised to find that it is still being supplied with aggravate the situation and, in the near future, we assistance. The removal of a marginalised place by can expect to see their overall gravity have con- the media leads those who remain in an even more sequences on the territory. And, while constituting silent state of marginalisation. an indisputable restriction on the rights and liberty of all the men and women, they have an even more For what reason do so many people prefer to find significant impact on the condition of migrant wo- alternatives in other ghettos, if the institutions men and those who find themselves in conditions of propose their own alternative? For what reason have they all not demanded out loud to access vulnerability, encouraging their disappearance into a shadowy world where blackmail, abuse, violence such programmes? and exploitation are common thread. Here we provide three significant statements given by workers in reply to these questions: 6.Conclusions: The not-to-be-repeated “We are here to work, and I must be able to get to failure of evictions with no valid alternatives work autonomously, which I have found by myself. I and the road of a multidisciplinary approach know that employment registries exist, but they don’t that needs to be taken work. I know that my rights at work should be respect- The social and health conditions in which people ed, but this doesn’t happen in reality. The day before in this profound state of marginalisation find a police inspection (Ed: Employment Inspectorate), themselves is the consequence of an extremely my boss tells me not to come to work, so who will ever complex thirty-year-old problem, but also of see that they exploit us? And how does he know that emergency approaches that have so far been an inspection is coming? I’ve often seen police take adopted as a response. The overall health of these the drivers (of the vehicles used to get to work) but people lies as much in medical prevention and they never take the bosses. The truth is that Italians therapeutic-diagnostic pathways, as in housing want me to do this job in these conditions, because conditions, safety at work and the holding of it’s in their interest, even though I feel their contempt stay permits. Interventions that do not take this at work and every time I walk through the city (of Fog- complexity into account merely worsen the condition gia),” L., 32 anni.

29 I know that employment registries exist, but they don’t Employment, on which the Italian Republic is work. I know that my rights at work should be respect- founded, should be at the heart of every action ed, but this doesn’t happen in reality. The day before dealing the with ghettos. It is pointless to conduct a police inspection (Ed: Employment Inspectorate), evictions in the ghettos without any effective plan my boss tells me not to come to work, so who will ever for employment insertion, for regular contracts, see that they exploit us? And how does he know that eliminating both ‘black’ work as well as ‘grey’ work. an inspection is coming? I’ve often seen police take Housing, which is neither emergency nor margin- the drivers (of the vehicles used to get to work) but alised housing and provides for the well-being of they never take the bosses. The truth is that Italians male and female workers, envisaging structural want me to do this job in these conditions, because solutions that focus on safeguarding employment it’s in their interest, even though I feel their contempt and individual self-determination. at work and every time I walk through the city (of Fog- And finally, documents, stay permits. There is a gia),” Y., 23 anni. minority component of non-regular people who “You know, doctor, I don’t have any documents. I can’t accept this life, refusing forms of illicit sustenance go home because, even if here they say it’s not true, if because they are determined to maintain their hon- I go home my life is at risk. So, I stay here. But if I’m esty, their dignity. A political act of responsibility is here it’s because I never want to turn to stealing. I pre- required on the part of the Italian State, recognising fer to live in this hut and have this back pain. I’m here male and female workers without stay permits as because I don’t want to go stealing. It’s the employers such, and regularising with employment stay per- who are stealing from me, every day. I work in order mits those who otherwise, in the face of the facts, not to steal. They steal from me. And it’s not only them. will forever continue to live in a limbo of total invisi- The person who buys the vegetables steals from me, bility and a hell of abusive employment, keeping the and doesn’t know where they come from. And the per- phenomenon of exploitative employment alive. son who didn’t give me any documents stole from me, A profound reflection is required on all of these my future. I’m working in Italy, for Italy, but I’m invisi- three core themes, not only on an institutional level, ble! Is this fair? Why can’t people who are already here but also in a way that involves the settlement com- in Italy and are never going away have documents, if munities themselves in the processes of construct- they are working?” M., 27 anni. ing alternatives, until such a time that they can be Solutions are only possible through a concerted and effective. multi-disciplinary action – not merely an emergen- 7. Appendix: complete data from the cy response – and one that places at its centre the Capitanata project needs of those who work, and not only the question of housing, especially if that simply means contain- Instruments used ers. Interventions of this kind need lengthy prepara- tion and require synchronised action. Whenever a patient accesses the mobile medical unit, It is therefore essential to forgo actions that merely or a session is held outside the vehicle for non-clin- respond to symptoms, which do nothing except fur- ical purposes, a paper data collection form is filled ther reduce the affected population’s trust in institu- out, the elaboration of which is the basis for the data tional responses and make it less responsive when shown in this report. A card dedicated to an analysis effective future alternatives are supplied. of the employment context allows it to be analysed, with some results, still partial, shown below. Employment, housing, documents: these are the three elements that reoccur in every conversation, In order to have a connecting element with the vol- elements whose absence determines exploitation, unteer doctors who visit the informal settlements elements which, where lacking, allow the mech- from time to time, INTERSOS leaves patients with a anism of agricultural exploitation to continue to simple support paper, the Medical Booklet, the so- thrive, despite all counter measures. cial-health booklet already used in other projects in

30 Italy. The aim is to not duplicate therapies and to act of colleagues, patients are always given an coherently with the pathway already begun by the accompanying letter. patient and to leave a trace of useful information Questionnaires given to users of the social-health obtained via intercultural mediation, as well creat- services are used to elaborate data in section 4, and ing a direct link with the health worker who handled have been created in tandem with a questionnaire the various steps. for public health operators in order to enhance the points of view of both actors in the social-health During the medical check-ups, in order to reduce relationship. recourse to pharmaceutical drugs, patients are given behavioural forms referring to the most Data on the services frequent pathologies, based on an analysis of the average conduct and risk factors in the communities As indicated earlier, the total number of services living in the informal settlements: muscular and provided by 30 April 2019, including medical check- articular pains, gastric heartburn, constipation, ups, social-health and individual employment vaginal itching and chronic pathologies (such as orientation and Focus Groups on the same themes, diabetes and hypertension). came to 587 sessions, with a total of 4,895 accesses, of which 2,978 beneficiaries were first time users. All A guarantee of clarity in indicating eventual treatment (also indicated in the Medical Booklet) is data in this report refers only to first accesses. provided by the use of a schematic summary form From June 2018 a total of 282 medical visits were of pharmaceutical and behavioural therapies . carried out, with a total of 2,795 people accessing Pre-printed information forms are used to direct the service, of which 1,860 were first-time visits. As patients to social-health services, from visits regards the activities of social-health orientation and to their domicile or residence up to recourse to individual employment orientation, or through the specialised services. The same is done when activity of Focus Groups, a total of 301 social-health directing them to legal and employment services, information sessions were held, with a total of 1,642 which call on the services that INTERSOS has people accessing the services, of which 834 were established in the territory, in order to affect a rapid first time attendances. 164 informative sessions on and efficient connection. work and protection were accessed by a total of 458 In order to connect them with the offices or operators people, of which 284 were first time accesses. of the Local Health Board and facilitate the work

GRAPH 3

7.1 - Medical visits DIVISION OF USERS BY SERVICE People A total of 282 medical sessions were held, with 2,795 check-ups General medical check-ups 2795 carried out, of which 1,860 were new Social-health information 1642 patients, with a female component of 251 visits and 136 first time accesses. Labour-protection information 458

GRAPH 4 - MEDICAL VISITS FOR SESSION JUNE JAN. JULY AUG. SEPT. OCT. NOV. DEC. FEB. MAR. APR. 2018 2019 TOTAL 12 11 10,9 10,7 10,6 8,4 7,5 5,9 6 9 10

FIRST VISITS 11 9,7 7,6 7,1 6,8 4,2 4,12 3,3 3,2 5,7 6,5

31 As imagined, there is a descending curve of new were held in the morning, when some of the users visits and total accesses which drops below 9 and were away at work, it is however possible to note 5 between October and February and then rises that the migrant population in the settlements is in March, faced with a duration of sessions that primarily linked to harvest time and therefore drops remained constant through the months. Although in the winter. the data is influenced by the fact that some sessions

7.1.1 – Breakdown of the patient population

GRAPH 5 - BREAKDOWN BY AGE

NR 0-05 06 - 14 15-17 18-29 30-39 40-64 >65 0% 0% 0% 0% 58.2% 29.8% 11.8% 0.2%

is highly relevant, accounting for 34%, of which 70% The most representative age bracket is that of arrived in Italy as minors, a figure that rings as a young adults. No Unaccompanied Foreign Minors defeat for the pathways aimed at the safeguarding were identified. However, in the bracket of young and insertion of minors. adults the share of newly adults (18-21 years old)

GRAPH 5a e 5b -Sample chart of new adults NEWLY ADULTS AND AGE ON ARRIVAL UNDER 30 30% 34% Arrivo da Newly adult maggiorenne

66% 70% 22-29 age Arrivo da minorenne

GRAPH 6 - BREAKDOWN OF NATIONALITIES (NUMBERS IN PERCENTAGES) ALTRO 11% Almost all of the first sample analysed sees persons SENEGAL permanently present, or in employment transit, GHANA 12% 26% outside of the nuclear family.

NIGERIA 13% MALI 10%

BURKINA FASO GAMBIA

2% 15%

COSTA D’AVORIO 2% GUINEA CONAKRY 5% GUINEA BISSAU 4%

32 The nationality most represented among patients As mentioned above, among the female beneficiar- is Senegalese (26%), followed by Gambian ies, the vast majority come from Nigeria (83% - 64 (15%), Nigerian (13%) and Ghanaian (12%). patients, Figure 4.b) and 17% from other countries. The Nigerian component is heavily weighted by a Nigerian women are the majority in every settle- female presence, almost all of whom come from ment, including Gran Ghetto, the settlement that Nigeria (see below). The Ghanaian component records the largest percentage of women from oth- is weighted by the number recorded at Borgo Tre er countries (38%). Titoli, which is principally Ghanaian. Some data on nationality is influenced by seasonal flow, which is GRAPH 8 - Activities realised by settlement the case with workers from Mali, who totalled 11.4% PALMORI in the June-October period and 4.6% between FABBRICA EX DAUNIALAT POGGIO 7% November and February, demonstrating a group IMPERIALE 1% movement that follows the seasons of the Italian 7% harvest.

GRAPH 7 BREAKDOWN BY NATIONALITY OF BORGO EX PISTA BENEFICIARIES TRE TITOLI 11% BORGO SENEGAL 2% COSTA MEZZANONE D’AVORIO 46% ROMANIA 2% ALTRO GAMBIA 2% 6% 2% GRAN GHETTO GHANA BURKINA FASO 1 28% 2%

The number of new patients by area (Figure 4), breakdowns of which are also available separately through a more detailed analysis of each individual settlement, were clearly in the Borgo Mezzanone NIGERIA 83% airport and Gran Ghetto, due to the larger number of sessions carried out. Figures for the Borgo Cicerone settlement were incorporated in those for Gran Ghetto.

7.1.2 – Length of time in Italy and Foggia Data on the length of time in the territory was divided between those who had been in Italy for less than 3 years and those for more than 3 years, where 59% had been in Italy for less than 3 years and 41% for more than 3 years. Percentages by month (number of months present)

GRAPH 9- PERCENTAGES BY MONTH (Number of months present)

JUNE JULY AUG SEP OPT NOV DEC JAN FEB MAR APR

<3AA 60 56 58 64 52 51 44 33 28 44 50

> 3AA 40 44 42 36 48 49 56 67 72 66 50

33 GRAPH 10 - Length of stay in Italy While not having carried out a standardised survey, 100 56 58 64 52 51 44 33 28 44 50 many patients say they are still living in reception centres but have left them temporarily, and a significant share have recently ended their stay

72 in a reception centre and say they have arrived 67 in Foggia in order to work in the agricultural harvest, and that they are inclined to remain, in 56 56 48 49 50 the absence of anywhere else to go. On the basis 44 42 of this, it is possible to make an observation on the 36 demographic reality of the informal settlements: the fact that they are an annual place of residence and that many people arrive and remain due to the absence of an alternative demonstrates how these settlements are the manifestation of the 0 social failure of integration policies, which induce a JULY SEP NOV JAN MAR AUG OPT DEC FEB APR consistent number of people to gather in locations far from the centres of society, constituting a kind of > 3 YEARS < 3 YEARS geography of marginalisation. As regards female beneficiaries, 64% say they have The average figure for length of stay, supplied been in Italy for less than 3 years, with an average by the totality of the sample, demonstrates how length of time in the Foggia area of 8 months. the transitory presence of workers is more typical However, the length of time they stay in a specific among those who have been in the Italian territory settlement is hard to evaluate since many female for less than 3 years, while those who have been patients say they spend short periods (up to two here for more than 3 years mostly tend to remain in weeks) in one place, before moving elsewhere the Capitanata area. and returning later. This tendency recalls the Observing the percentage related to beneficiaries mechanisms of exploitation for prostitution or present in Italy for less than 3 years, one finds a clear female trafficking. The women who have been in rise between July and September (from 56% to 64%), Italy for more than 3 years have, on average, been with a sharp drop between October and February in the country for 9.5 years and in Foggia for more (from 52% to 28%) and an upturn beginning in March than 3 years and 4 months. (43%) and April (50%). This trend highlights two aspects: on the one hand, the well-known seasonal 7.1.3 – Patients’ personal social-health data nature of the population and how this migration of GRAPH 11 - SOCIAL HEALTH CONDITION workers within the national territory begins fairly Not registered Not registered With tax With tax soon after arrival in Italy; and, on the other hand, how with SSN and with SSN, code, code without STP but with STP without and TS nevertheless the Capitanata area is an area of stable card card TS card card residence (where numbers never drop below 40%). 30.5% 1.7% 36.6% 31.2% Those present in Italy for more than 3 years record an average length of stay in the national territory of Key: six and a half years and in Foggia for 2 years and 4 SSN: National Health Service (Sistema Nazionale months (in the month of February 2019 alone, and Sanitario) thus in the low point of the agricultural season, the STP: Foreigner Temporarily Present card (Straniero figures were 10.5 years and 4.2 years respectively). Temporaneament Presente), instrument used for For the most part these periods were spent in application for health assistance by non-EU citizens the same locations where the medical visits and irregularly present in Italy information sessions were carried out. TS: Health Service card

34 is that once a patient’s acute condition is stemmed, As shown in the chart, the majority of people he or she is dismissed from the A&E and entrusted reached by the INTERSOS services are registered, to his/her GP, without confirming that the patient or could be registered, with the Italian National has one, knows how to get one or understands the Health Service, even though more than half of those significance. In addition to the burden of frustration registered do not have a valid Health Service card. for the patient, a situation is created where it is im- A minimum number (1.7%) have an STP (Foreigner possible to manage non-acute clinical conditions in Temporarily Present) card, which is renewable territorial health care. In many cases this leads to a every six months and valid throughout Italy and relapse of an acute condition and the beginning of allows those without a regular stay permit to access a vicious cycle. urgent, essential and continuous health care. In the context of health care insertion, it is worth GRAPH 12 considering the role of the regionalisation of the ASSIGNED TO A GP Health Service. As can be seen from its monthly de- With a GP With a GP Without a GP in Foggia outside the province mographic variations, the population of the informal 10.6% 31% 58.4% settlements is characterised by constant territorial relocations. One frequently meets people who, Key: GP: General Practitioner when asked where they live, reply that they have no

fixed place of return but for years have moved from Of those registered with the Italian National Health one settlement to another, with pauses of various Service, only 10.6% have a General Practitioner as- lengths of time in towns in order to renew their doc- signed to them in the province of Foggia. uments. Faced with this, orientation towards registering with the Italian NHS becomes more complex, The 41.6% with a right to a General Practitioner, say also considering the time that is often required each they have one. Of these, 10.6% in Foggia and 31% time to obtain the information required for register- outside of the province (which, for more than four ing, or cancelling a registration with each Regional fifths of the sample, means outside the region). Health Service. However, one should point out that a significant number of beneficiaries simply state that they have While this is clear with the male population, which or had a doctor, usually supplied them by a recep- moves autonomously and follows more regular sea- tion centre, but have no idea of the significance and sons, the picture becomes even more complex with the role of this figure in the context of the Italian regard to the female population. The typical dynam- health system. ics of trafficking mean that the women move in much faster cycles, in a less regular way and not of their The difficulty of integrating in the normal pathways own free will. In this sense, integration into one of of territorial health care leads to an incorrect use of the Regional Systems becomes more complex, and the A&E emergency service. Recourse to a service with that also access to the right to health, both for for functions that it does not perform is at the root extraordinary treatment as well as normal check-ups of additional hardships and a lack of a guarantee of and screenings appropriate for female health. the right to health care. In fact, what often happens

7.1.4 – Breakdown of pathologies GRAPH 13 Other Dermato- Endocrine, Pyschological Eyes and Ear and infectious phytosis and nutritional and behavioural Nervous ocular an- mastoid Circulatory Respiratory pathologies protozoal and metabolic disturbances system nexes apophysis system system 2% 5.4% 0.7% 1.9% 0.6% 3.4% 2.7% 3.5% 14.1%

Skin and Pregnancy, Digestive subcutaneous Musculoskeletal and Genitourinary birth and Unclassified system tissue connective tissue system puerperium symptoms Traumas Check up 17.7% 7.1% 15.1% 3.5% 0.9% 9% 5% 7.4%

35 During clinical activity the categories of distur- represented above all by diarrhoea of a similarly in- bances and pathologies encountered, identified fectious nature, and a small number by STIs. according to ICD10 (International Classification of With the exception of only one case of a psychotic Diseases, drawn up by the World Health Organ- crisis, the 34 cases of mental disturbance are rep- isation) concerned the digestive system (17.7%, resented by reactive mood disorders of varying de- including oral cavity pathologies), disease of the grees. musculoskeletal system (15%, with a maximum correlation with employment activity) and the res- It is interesting to note the clinical records of the 9% piratory system (14.1%). 9% were classified with of cases with symptoms of a non-specified nature. non-specific conditions where no clinical evidence The symptoms ascribed to this category generally was identified. A full 7.4% sought medical attention involve a non-specific malaise, recurring head- for a standard check-up without complaining of any aches, anorexia and asthenia. In an integrated con- particular disturbance. 70% of these patients said text these symptoms would lead to the prescription they had last had a check-up more than a year ago, of a routine haematological examination, such as and 28% of these more than 2 years ago. usually occurs with the general population, for test purposes. These examinations can reveal deficien- Approximately 50% of pathologies regarding the cies of various kinds, or even more serious patholo- cardiocirculatory system involve hypertension and gies in a precocious stage. The obstacles to access other cases are represented by haemorrhoidal to health care facing the migrant population – even pathologies. more so when constantly relocating for work – often Approximately 25% of pathologies regarding the exclude such a component from the normal path- genitourinary system are characterised by vagino- ways of routine check-ups, thus exposing them to sis of various kinds. This percentage led to the de- the risk of a progressively worse prognosis. velopment of behavioural forms for intimate female hygiene. 7.2 Health care orientation

Approximately 30% of pathologies regarding the di- From the beginning of the project, health care ori- gestive system are represented by dental patholo- entation has been given to 1,642 users, of which gies. A change in diet to another one is generally not 834 were first time users. The orientation is given accompanied by an adaption of hygiene habits and together with every first visit, either in the mobile leads to serious levels of tooth decay. This aspect medical unit’s waiting room or actively inside the should not be underestimated when one considers settlements, on the basis of individual cases. The that a lot of dental care is not covered by health in- activity aims to give the user an awareness of the surance. This raises additional health implications health protection services and the ways of access- since we have heard of individuals dealing with ing them and to assign a GP to all those who have unbearable pain who have used makeshift means a right to one and state that they will remain in the to extract their own teeth. In this context one can territory for a medium to long-term period. When a understand how the issue of dental care assumes a user is vulnerable or with low autonomy he/she can greater significance given the possible further risks later be accompanied for the purposes of health involved in such practices. care insertion.

Among infectious diseases – excluding dermato- 7.3 Employment orientation phytosis, reported in only 36 cases (approximately 2% of total patients) – approximately 70% are Employment information has been given to 458 represented by previously diagnosed pathologies, persons, 284 of them first users, beginning with in particular hepatitis, less frequently HIV or TB, requests from individual workers or in the presence linked with the infectious diseases department of of a critical issue and explaining (to those unaware the Foggia Riuniti hospital. The remaining 30% are of them) their employment rights, the mechanisms

36 of the employment registries, links with unions Focus Group dedicato al tema delle norme stradali. when possible and the possibility of reporting employment exploitation. GRAPH 16 PERSONAL PROTECTIVE EQUIPMENT For the purposes of giving a picture of the phenomenon, figures of employment risk factors SUPPLIED BY NOT USED 3,5% are given below, drawn from 931 evaluations carried EMPLOYER out during medical check-ups. 13,3%

GRAPH 14 - TYPE OF EMPLOYMENT

OTHER ACQUIRED 28,6% PERSONALLY 83,2%

AGRICULTURAL 71,4% It is significant that 83.2% acquire their PPE (Personal Protective Equipment) at their own expense, and in only 13.3% of cases is it supplied Si è rilevato che il 71.4% lavorano nelle catene di by an employer, as envisaged by law (a fact often raccolta o lavorazione agricole e la restante parte in spoken of in smaller settlements and therefore altri esercizi o è in attesa di occupazione. likely by people who are almost all in the same work party), while the remained use no protective GRAPH 15 equipment. MEANS USED FOR REACHING EMPLOYMENT

ON FOOT 2,1% 7.3.2 Social-health inquiry questionnaires

In addition to an interview during visits in January, social-health survey questionnaires were given out BICYCLES to inhabitants of the informal settlements. OR MOTORBIKES A total of 41 detailed questionnaires were 25,8% completed, where 43.5% said they had already been in contact with our service team for one of our CAR activities. 69,6% BUS 2,5% The countries of origin of those interviewed were Senegal (18), Ghana (9), Guinea Conakry (3), Gambia (2), Niger, Chad and Mali (1). Eighteen of the interviewees were aged 18-29, fifteen between Il mezzo di trasporto più utilizzato è l’auto (69.6%), 30 and 39 and eight were over 40. seguito da cicli e motocicli (25.8%) e residualmente 38% said they had attended elementary school, l’autobus o a piedi, elementi che, insieme alle 23% secondary school and only 5% high school, richieste della comunità ed ai ripetuti incidenti while 33% stated that they were illiterate. stradali, hanno determinato la realizzazione di un

37 Mediators found that 68.4% of the interviewees had GRAPH 19 a poor knowledge of Italian, 28.2% a good level and EMPLOYMENT INTERVIEWS: only 6% excellent, even though 53% said they had HOURS WORKED PER DA been in Italy for 3-6 years, 28% for at least 7 years <0 =a 6 7-8 >=a 9 (half of which for at least 10 years) and 20% for less than 3 years. 20,5% 59% 20,5%

Almost all of the interviewees had lived in other cities When describing their working days, 33.3% of in- for work (in particular Rosarno, Naples, Trapani and terviewees said they worked 7 days a week, 21.2% Campobello di Mazara, Milan, Vicenza, Rome and approximately 5-6 days and the remaining 45.5% Palermo). Only 14% said they came from towns in worked 4-5 days. For the majority (59%) a working the province of Foggia, while the remaining 86% day lasted 7-8 hours, while 20.5% said they worked said they had been based in various cities in Italy at least 9 ho (Brindisi, Palermo, Milan, Varese, Verona, Pisa, Rome, Vicenza, Bergamo, Naples, Lecce, Livorno, GRAPH 20 Viterbo, Crotone, Florence, Ancona, Catania, EMPLOYMENT INTERVIEWS: DAILY BREAKS Genoa and Cagliari).

GRAPH 17 EMPLOYMENT INTERVIEWS: 0 BREAKS LEGAL STATUS OF THE INTERVIEWEES 22,6%

WITHOUT REFUGEE 17% REGULAR 1 BREAK STAY 77,4% PERMIT24%

HUMANITARIAN IN APPEAL 21% PROTECTION HOLDER 38% GRAPH 21 EMPLOYMENT INTERVIEWS: DURATION OF BREAK FOR THE 77.4% WHO HAD ONE: It is interesting to note that of the interviews shown here only 24% of the interviewees declared themselves irregular, even though it was reported 1 HOUR that 17% were still appealing their status, while 34% 15 MINUTES 16,6% were holders of a humanitarian protection permit. 16,6% The remaining 17% declared they had refugee status.

GRAPH 18 EMPLOYMENT INTERVIEWS: 30 MINUTES DAYS WORKED PER WEEK 66,7%

7 Days 4-5 Days 5-6 Days 33,3% 45,5% 21,2%

38 GRAPH 22 GRAPH 25 EMPLOYMENT INTERVIEWS: EMPLOYMENT INTERVIEWS: PRESENCE OF AN EMPLOYMENT CONTRACT DO YOU KNOW WHAT HEALTH INSURANCE (data collected during the winter season): CONTRIBUTIONS ARE?

YES, AND THEY ARE PAID 5,3% WITH A CONTRACT YES, AND 48,7% WITHOUT A THEY CONTRACT AREN’T 51,3% PAID 18,4% NO 76,3% GRAPH 23 EMPLOYMENT INTERVIEWS: DURATION OF CONTRACT FOR THE 48.7% WHO HAD ONE: GRAPH 26 18 MONTHS 5,2% EMPLOYMENT INTERVIEWS: 1 MONTHS DO YOU KNOW WHAT EMPLOYMENT 15,8% REGISTRIES ARE? 12 MONTHS Yes, Yes, but I’m 21,1% No and I’m registered not registered

97,4% 2,8% 0% 6 MONTHS 57,9% While 50% said they knew what a pay slip was, only 10% received one. Only 23.7% knew what health insurance contributions were but 80% were not paid any. Only one interviewee knew what an employment More than half (51.3% of agricultural workers registry was. He was not registered, however. interviewed had no employment contract, and for the majority of those that did, the contract was for GRAPH 27 6 months (57.9%). EMPLOYMENT INTERVIEWS: THOSE WHO STATED THEY WERE/WEREN’T RECRUITED GRAPH 24 THROUGH AN INTERMEDIARY EMPLOYMENT INTERVIEWS:

DO YOU KNOW WHAT A PAY SLIP IS SOMETIMES 8,6% YES, AND I GET ONE: 10%

YES, BUT I YES 34,4% DON’T GET ONE 40% NO 50% NO 54,4%

39 Compared with 34.4% of the sample who said they GRAPH 29 got work through a ‘boss’ (slang for a ‘caporale’ EMPLOYMENT INTERVIEWS: SOURCES OF IN- intermediary), 8.6% said they did sometimes, while FORMATION FOR WORKERS 54.4% said they didn’t, thus demonstrating that the phenomenon of an intermediary is present, but EMPLOYER 1,3% often overestimated, given that some form of self- WORD OF organisation among the community of workers is MOUTH also relevant. 17,9% GRAPH 28 EMPLOYMENT INTERVIEWS: HOURLY PAY RE- CEIVED (data collected during the winter season):

5 EUROS 2,6% 3 EUROS NONE 5,3% 79,5%

3,5 EUROS EMPLOYMENT 15,8% INTERMEDIARY 1,3%

4 EUROS In this context, 77.5% of interviewees said they received no information of any kind regarding 76,3% employment services, while 12.5% said they got information by word of mouth. Two interviewees said they got information by themselves, while 1 Despite the existence of a provincial contract was given information by a ‘caporale’ and 1 by his establishing a minimum union wage, no one is paid employer. that amount: 76.3% of the sample are paid 4 euros/ An even higher percentage (95%) said they received hour, 15.8% get 3.5 euros, 5.3% get 3 euros and no information about health assistance. 2.6% get 5 euros. The cost of transport affects this pay since 75% of interviewees said they had to pay it themselves (on average 5 euros), while only 26% 7.3.2 Focus group said they had to pay rent for lodgings (with very variable rates, from €150/month to lower rates or The Focus Groups (FGs) are group discussions lump sums). with a number of members of a community on an 51.3% of interviewees said they worked without established subject that allow them to exchange a contract, that is, in ‘black’, and 48.7% in ‘grey’, information, notice whether beliefs are correct or that is, with a contract with serious elements of not, gather proposals and identify critical issues irregularity (i.e. a lower number of days declared and subsequently hold Awareness Sessions than were actually worked, insurance contributions realised on the basis of the profile of the community not paid), and without protection by the employer that emerges. (i.e. transport or secure lodging denied to seasonal INTERSOS, which normally carries out these activities workers, protection equipment not supplied). None in other projects, in particular with its migration unit of the interviewees in the sample, and none of those in Greek refugee camps and in reception centres for interviewed elsewhere during INTERSOS services, MSNA in Sicily, began to realise FGs and subsequent could show they possessed an entirely regular Awareness Sessions in informal gatherings in August contract. 2018 on the following topics:

40 • Social health insertion; GRAPH 30 • The effects of Law 132/18 (in collaboration with INTERVIEWS WITH USERS OF THE SOCIAL ASGI – Association for Juridical Studies on Im- HEALTH SERVICES: NATIONALITIES INTER- migration); VIEWED • Agricultural employment and unemployment • Female health (in collaboration with the Foggia Gambia Senegal Mali Nigeria anti-trafficking entity Iris, and the Foggia Local 15% 32,3% 3,3% 9,1% Health Board Clinic 2); Guinea • Reaching service locations and the use of GPS; Niger Ghana Altro Conakry • Essential road safety norms; • Fire risk prevention (in collaboration with the 1,7% 6,6% 21,5% 10,5% Fire Brigade Volunteer Association). GRAPH 31 These sessions are held once every four months and INTERVIEWS WITH USERS OF THE SOCIAL- cover the same topics while adding other proposed HEALTH SERVICES: EDUCATION LEVEL OF by the communities. INTERVIEWEES

Secon- Ele- dary High scho- 7.4 Social-health questionnaires: analysis of in- Illiterate mentary Degree school ol diploma school formation and perception of services diploma

34,4% 18,7% 34,4% 12,5% 0 INTERSOS distributed these social-health questionnaires to the populations of the informal 34.4% of interviewees had completed secondary settlements. The questionnaires were distributed school, 12.5% had completed high school and 18.7% on two occasions, with a total number of 204 had completed elementary school, while 34.4% had interviews carried out: 83 in August 2018 and 121 in not had any formal education. January 2019. Interviews with users of social-health services: The questionnaires involved variable percentages of number of years interviewees in Italy the population residing in the informal settlements, although these are unquantifiable without a large range of variability due to the individuals’ erratic GRAPH 32 presence, which therefore makes it impossible to INTERVIEWS WITH USERS OF SOCIAL-HE- know the figure exactly. ALTH SERVICES: NUMBER OF YEARS INTER- VIEWEES IN ITALY

7.4.1 Personal data of the interviewees HOW MANY YEARS IN ITALY

Note: The interviewees are not calculated in the sum <1y 1-3 y 4-6 y 7-9 y >10 y total of beneficiaries, but rather as participants in 5 64 23 13 17 the contextual analysis and the on-going evaluation 4.2% 52.5% 18.8% 10.6% 13.9% of the project. They are therefore understood as:

• Beneficiaries: those who access one of the project’s humanitarian services; The majority of the interviewees had been in Italy • Interviewees: those who participated in the survey. for a period of 1-3 years (52.5%), approximately one fifth (18.8%) for between 4-6 years, and 13.9% The majority of the interviewees were male (93%), had been in Italy for more than 10 years. with a low female participation. Interviews with users of the social health services: nationalities interviewed

41 7.4.2 Social-health information of the interviewees GRAPH 35 INTERVIEWS WITH USERS OF SOCIAL- GRAPH 33 HEALTH SERVICES: STATED AWARENESS BY INTERVIEWS WITH USERS OF THE SOCIAL- STAY PERMIT HOLDERS OF THEIR SOCIAL- HEALTH SERVICES: INTERVIEWEES’ SOCIAL- HEALTH RIGHTS HEALTH INFORMATION Aware Not aware Principal Public Written Social source of health information operators 49,4% 50,6% information outlet Awareness of health rights by stay permit holders 0% 0,8% 12,4% 14% is greater. Approximately half say they are aware Private social Internet Other None of them. health outlet

17,4% 0% 21,5% 33,9% GRAPH 36 INTERVIEWS WITH USERS OF SOCIAL-HEALTH The data demonstrates how more than one third SERVICES: AWARENESS OF THE STP (TEMPO- RARILY PRESENT FOREIGNER) CARD of the sample of interviewees (33.9%) stated that they had no source of information in the social- health sphere and demonstrates the importance of Only those with valid Those with valid documents documents being regularised information from outreach services. For 17.4% of interviewees the point of reference were the health 42% 6,7% orientation and primary care services provided by Those with valid mobile social units, that is, the project underway Don’t documents being regula- Everyone know and similar ones. Therefore, the entry “other” rised and with STP card (with 21.5%) referred to information provided 4,3% 27,7% 19,3% by acquaintances, but also employers. Public health outlets accounted for 17%, while social Nevertheless, the percentage effectively aware of service operators, represented by operators from the requirements for accessing services such as reception centres or dormitories, accounted for a GP (General Practitioner) scale back the data. 12%. It is interesting to note that no one said they Around 19% say they don’t know, while 42% mis- used Internet and only one of the 121 interviewees takenly believe that only someone in possession of mentioned written information. a definitive stay permit can access a GP.

GRAPH 34 GRAPH 37 INTERVIEWS WITH USERS OF SOCIAL-HEALTH INTERVIEWS WITH USERS OF SOCIAL-HEALTH SERVICES: AWARENESS OF THE STP (TEMPO- SERVICES: STATED AWARENESS OF EXCEP- RARILY PRESENT FOREIGNER) CARD TIONS BY THE INTERVIEWEES

Aware Not aware Aware Not aware 12,4% 87,6% 12,2% 87,8% An awareness of exemptions is even lower, with only 12.2% saying that they know about them and The data highlights the low awareness (12.4%) of know how to access them. the STP card.

In addition, we add some comments made by the interviewees:

42 “We need to increase awareness and understanding GRAPH 40 through dialogue, not through leaflets.” (S., INTERVIEWS WITH USERS OF SOCIAL-HEALTH Gambian, 28, in Italy for 4 years and Foggia for SERVICES: PRINCIPAL POINT OF HEALTH 1 year, and Nigerian, 26, in Italy for 3 years and REFERENCE Foggia for 6 months); STP 2,5% “It’s hard to see my doctor in Foggia because he OTHER GP insists on an appointment, and the waiting time 12% 7,9% can be long so it’s often easier to go to the A&E,” (B., Gambian, 23, in Italy for a year and a half and Foggia for 1 year); PRIVATE MOBILE “My doctor speaks English, which has been CLINICS A & E fundamental for me to not always go to the A&E,” (O., 26,4% 51,2% Gambian, 31, in Italy for 5 years and Foggia for 3).

7.4.3 Health insertion

GRAPH 38 In 51.2% of cases the principal point of health reference was the A&E, followed by mobile private INTERVIEWS WITH USERS OF SOCIAL-HEALTH clinics (26.4%). 10% cited their GP as their point of SERVICES: REGISTRATION OF INTERVIEWEES reference, while 2.5% cited an STP surgery. WITH THE ITALIAN NHS Of the 20 interviewees (12%) who listed “other” as Registered Not registered their point of reference, 11 cited a pharmacy and 9 their employer/caporale 65,3% 34,7% GRAPH 41

Health Central Mental Use in Choose Assistance Booking health last STP A&E or change GP Clinics Continuity Office services 2 years: GP office Centre CUP clinic

% 10,4% 56,1% 7,4% 10,1% 1,9% 4,3% 0 0,8%

The figures give the health services in the province of Foggia most used by interviewees in the last year GRAPH 39 and, as indicated earlier, the A&E was the one most referenced. INTERVIEWS WITH USERS OF SOCIAL-HEALTH For each service indicated, the interviewee was asked SERVICES: HOLDER OF HEALTH INSURANCE to reply to questions on a specific area. The following CARD area shows the results for the A&E service. The other services, with a numerically less significant Holder awai- Card Card ting valida- sample, show a relative satisfaction with the STP expired never held tion of card surgeries, the GPs, the CSM and the CUP - although all reported a relevant linguistic obstacle and, in 27,7% 43,8% 28,5% some cases, a cultural one (where need and reply demonstrate a lack of understanding between the Less than half of the sample of interviewees (34.7%) parties) – and a low satisfaction with the choose were registered with the Italian NHS, of which more or change offices, where users reported rudeness, than a quarter (27%) were holders of a valid health services not supplied and, again, a linguistic lack of insurance card.. understanding, a situation that improved following an intervention by Health Board supervisors based on these reports.

43 7.4.4 - The interviewees’ use of A&E services Approximately half of the sample used A&E services. Of these, 61.9% once, 30.1% between 2 and 5 times and 8% more than 5 times. In the majority of GRAPH 42 cases (55.9%) for some illness, although 17.1% also INTERVIEWS WITH USERS OF SOCIAL-HEALTH used the service for “other” reasons, which some SERVICES – ACCESS TO A&E: THOSE WHO IN- said was to get pharmaceutical prescriptions. DICATED ACCESSING A&E SERVICES IN THE LAST YEAR GRAPH 44 INTERVIEWS WITH USERS OF SOCIAL-HEALTH 1 from2 to 5 >5 SERVICES – ACCESS TO A&E SERVICES: 61,9% 30,1% 8% PATIENT’S LEVEL OF SATISFACTION

SATISFIED GRAPH 43 INTERVIEWS WITH USERS OF SOCIAL-HEALTH SERVICES – ACCESS TO A&E SERVICES: REA- FAIRLY SON FOR ACCESS 36,4%

Accident Illness Other LITTLE VERY 29,3 % 51,2% 16 33 10 27% 55,9% 17,1% NOT AT ALL 34,1%

GRAPH 45 INTERVIEWS WITH USERS OF SOCIAL-HEALTH SERVICES – ACCESS TO A&E SERVICES: PROBLEMS REPORTED

Lack of Lack of Unclear or not supplied linguistic Long wait with No Problems: understanding of diagnostic-therapeutic cultural service abandoned problem how service works explanations mediation

18,8% 29,1% 26,1% 23% 3%

Satisfaction with the service provided by the A&E GRAPH 46 was found to be low or zero in 63.4% of cases, and INTERVIEWS WITH USERS OF SOCIAL-HEALTH among the principal problems that stood out was SERVICES – ACCESS TO A&E: INTENTION OF- the lack of intercultural mediation, followed by long FUTURE USE waits (often correlated with an inappropriate recourse to A&E) and, finally, unclear explanations, I will use it again for I will no longer use it which again correlate with the absence of linguis- non-emergency for non-emergency tic-cultural mediation. conditions conditions

86,6% 13,4%

44 86.6% said they will use A&E services again for non- difficulties and needs of the latter. Despite the limited emergency conditions data collected due to a low participation by the territory’s services, it is interesting to note some data. QUESTIONNAIRES FOR HEALTH SERVICE OPERATORS GRAPH 49 In January an exploratory survey was carried out on INTERVIEWS WITH HEALTH SERVICE OPERA- how health service operators in the territory viewed TORS: OPINION ON THE PATIENTS’ PRINCIPAL the issue of health in the migrant population. SOURCE OF INFORMATION Information source GRAPH 47 Social Written Social service INTERVIEWS WITH HEALTH SERVICE OPERA- service information operators TORS: AGE OF INTERVIEWEES operators

Age bracket 20.9% 34.3% 25.7%

25-35 35-45 45-55 >55 Private social Internet Other None health outlet 4,3% 0 21,8% 73,9% 8.7% 8.7% 8.7% 0% Twenty-three questionnaires were given to operators with Sert, the Health Registry, Clinics, With regard to accessibility and information the Riuniti hospital infectious diseases department, concerning services, 13% of operators considered Public Relations Office and STP clinics. Internet a source of information used and, at Approximately three quarters of the interviewees the same time, 26% believed that in general were more than 55-years-old. written information played an important role. This contrasted with replies given by beneficiaries of the project for who neither Internet nor written material GRAPH 48 represented a source of information. At the same INTERVIEWS WITH HEALTH SERVICE OPERA- time, however, 90% of operators considered the TORS: YEARS OF SERVICE level of awareness zero or inadequate.

Number of years in the service GRAPH 50 <1y 1-5 y 6-10 y 11-20 y >20 y INTERVIEWS WITH HEALTH SERVICE OPERATORS: OPERATORS’ OPINION OF THE 6,8% 13,6% 20,5% 22,8% 36,3% ADEQUACY OF PUBLICITY OF THEIR SERVICE Of these, the majority (more than a third of the Adequacy YES NO sample) had been with the same service for more of than 20 years, and 43.3% for more than six years. publicity 63,6% 36,4% The questionnaire was divided into three parts. One explored how operators perceived the way that migrants gathered information regarding GRAPH 51 their service and another explored the idea of INTERVIEWS WITH HEALTH SERVICE OPER- accessibility. A third focussed on the quality of the ATORS: OPERATORS’ OPINION OF THE ADE- service provided, including reference to problems QUACY OF OPENING HOURS encountered in the work. Adequacy YES NO The questionnaires set two objectives: to reveal of 19 5 possible incongruencies regarding the opinion of opening migrants and that of operators and to identify the hours 63,6% 36,4%

45 Nevertheless, 63.6% believed that the service they Instead, leading social medicine studies demon- worked with was well publicised, and two thirds of strate that chronic pathologies and their clinical interviewees that opening hours were adequate. evolution correlate directly with low income, to Instead, on the basis of the experience of medical the extent that one can state that mortality due to visits and orientation activities in the informal chronic ailments such as diabetes and hypertension settlements, it is clear that a lack of awareness of are ubiquitously higher in the poorest or most dis- the existence of the services and the typical length advantaged population brackets. Given this prem- of a working day represent a consistent obstacle to ise, there is every reason to suggest a clinical action access to health services. in the informal settlements that focusses on chronic pathologies. With regard to the provision of service, 38% of operators said they spoke only Italian, while 23% The conditions investigated have principally been: declared a poor knowledge of English and only hypertension and hyperglycaemia (diabetes and 11% spoke French. No linguistic-cultural mediators pre-diabetes). were available and 33% said they were dissatisfied The additional conditions recorded have been: with the way their service was provided. When asthma, liver disease, polycystic ovary syndrome asked about possible improvements in terms of and alcoholism. the organisation of their service or additional staff When considered opportune, a health check-up that could be added in order to improve it for the was combined with an interview regarding alco- migrant population, many cited a generic increase hol-related health problems. in personnel or technical instruments. However, The co-morbidities recorded were: overweight, many indicated the need to integrate the figure alcoholism, cataracts, disturbances in the mental of a mediator and, in some cases, mentioned the sphere (anxiety), stable angina and glaucoma. need for a socio-legal operator or a social worker. The anamnestic data recorded were: suspected Mention was also made of the need to respond OSA, familiarity with chronic ailment and TB. directly to an STP’s request without having to pass In all, 40 patients were recorded out of a total of 64 through clinical staff and the need to improve check-ups. the link between territorial services and hospital services in order to broaden diagnostic services. GRAPH 52 PATIENTS WITH CHRONIC PATHOLOGIES: AGE 7.4.5 Screening activity for chronic ailments BRACKET

During daily clinical activity, the need to pay greater 60 YEARS attention to chronic pathologies was perceived. Of 5,1% total pathologies (excluding however the cases of 50- 59 YEARS a check-up without diagnosis) the share of chronic 7,7% pathological conditions corresponded to a full 3.8% of patients, a highly significant figure given the 35 YEARS 45-50 YEARS young age of the sample. 25,6% 10,2% In popular opinion, a reflection on chronicity in medicine concerns elderly people and developed countries and, in particular, social classes with a 40 - 44 YEARS medium-to-high income. 23,1% 35 - 39 YEARS This creates the stereotype of chronic pathologies 28,2% as a health problem secondary to the mere resolu- tion of an emergency, excluding them for the pano- rama of primary and essential treatments.

46 GRAPH 53 GRAPH 57 PATIENTS WITH CHRONIC PATHOLOGIES: PATIENTS WITH CHRONIC PATHOLOGIES: REA- GENDER SONS WHY PATIENT ATTENDED A MOBILE UNIT

F: 23.1% Symptomatic condition 37%

A-symptomatic condition M: 76.9% 39% with previous diagnosis

Outreach activity aimed GRAPH 54 24% PATIENTS WITH CHRONIC PATHOLOGIES: at screening NATIONALITY It is important to record the reason that led a pa- IVORY COAST tient to seek a diagnosis from us, where a symp- 5,1% OTHER tomatic condition was found in one out of three GUINEA 10,2% CONAKRY patients. In its specific form the activity sought to 5,1% GHANA evaluate the patient’s level of awareness regard- 38,5% ing his/her pathology: SENEGAL 16,2%

NIGERIA GRAPH 58 25,1% PATIENTS WITH CHRONIC PATHOLOGIES: LEVEL OF AWARENESS GRAPH 55 Total lack of awareness 51% PATIENTS WITH CHRONIC PATHOLOGIES: LOCATION OF VISIT aware of the importance POGGIO IMPERIALE of handling it, it’s modality 18% PALMORI 2,6% and possible evolution 10,6% only partially aware 21%

BORGO MEZZANONE GRAPH 59 TRE 35,9% TITOLI PATIENTS WITH CHRONIC PATHOLOGIES: RE- 30,8% GISTERED WITH A GP GRAN GHETTO WITH NO 20,5% ASSIGNED GP 50% GRAPH 56 PATIENTS WITH CHRONIC PATHOLOGIES: HY- WITH A GP IN FOGGIA PERTENSION AND ASSOCIATED PATHOLOGIES 35,7% WITH A GP Simple hypertension 72.7% ELSEWHERE Associated with hyperuricaemia, 14,3% 15.5% hyperglycaemia or asthma Associated with alcoholism 11.8%

47 We therefore note that only 39% of patients who are a key aspect of health in the settlements, while potentially present a chronic pathology were aware remaining almost totally neglected in the medical of it, while in general (72% of cases) they did not discourse of such conditions, suggesting the need know they had a problem or were unaware of its for a prevention campaign adapted to the context importance. However, this led to a percentage of in order to bring specific medical practice closer to 36% of clinical cases (acute and otherwise) in our the World Health Organisation’s health promotion sample, demonstrating how chronic pathologies programme