Profile of participants
The first focus group was attended by 10 persons (three medical students, one nurse and six doctors, of whom four junior doctors), the second one by eight persons (two students, one nurse and five doctors, of whom three junior doctors). For most of them it was their first monitoring; only one doctor had years of experience. More than half of the health professionals who participated in the focus group were young and compassionate, often working with deprived groups in multidisciplinary clinics in Brussels (table 1).
Table 1. Characteristics of the participants |
gender | | |
man | 8 | |
woman | 10 | |
age | | |
19–29 | 12 | |
30–49 | 4 | |
> 50 | 2 | |
Profession | | |
medical student | 5 | |
nurse | 2 | |
junior doctor | 7 | |
medical doctor | 4 | |
Gaining new insights
The health professionals asked a lot of questions about the reasons why undocumented migrant workers would start a hunger strike. They believed that they did it to obtain papers, to be heard and to fight against injustice suffered. They also realised that other undocumented people in the past had obtained papers by hunger striking and that the same strategy might work for them. Others talked about the loneliness and exclusion of undocumented people and the shame they would experience upon their return to their home countries, where acquaintances had contributed financially to their travel, and that they would have to confess that their attempt to get a better life in Europe had failed. Health professionals were convinced that if there had been other, legal ways of obtaining legal documents, no one would have started a hunger strike.
Then they tell themselves that they are all alone and that they have to join the movement, that they cannot allow themselves to stay outside, to stay upstairs (with the people who did not join the hunger strike). (Junior doctor)
What is stupid to start with is that people have to go on hunger strike to be heard. (Medical doctor)
The participants were curious to know how it all started: had one person suggested starting a hunger strike and did the rest follow? How could 150 people reach a joint decision? Why did all the participants have the same profile (male, between 20 and 30, with African roots)? They also wondered how they stopped the strike. Some were puzzled to know whether the hunger strikers were happy about the presence of health professionals.
Had the request for medical monitoring come from them? Or from outside? Because I sometimes had the impression that they weren’t interested in their medical developments. (Nurse)
Almost everyone agreed that even if the hunger strikers said they wanted to die, they only wanted to be martyrs but would prefer to live. They argued that if they wanted to die, they would not have accepted the presence of medical personnel. The strikers said they wanted to go all the way, but they hoped the strike would end earlier, on their terms. Others expressed doubt:
I do not know if some are not ready to die, when you see those who cross the Mediterranean Sea, on inflatable rafts, knowing that so many before them drowned on the way and they do it anyway. (Medical doctor)
Some were puzzled by the paradox expressed by the hunger strikers of wanting to live but also to die for a cause, between having to be strong but getting weaker every day, of wanting to be heard but having no voice.
They are engaged in a fight where they stop eating so that their demands are met but when you see them, they are exhausted; they are very, very weak and therefore less able to fight. The physical strength lessens, but the mental strength must stay to do something in the long run. (Medical student)
They continue the struggle even if they are weak: by dying they can prove the horror of the situation. As health professionals we cannot do much, it’s very difficult to let people deteriorate. (Junior doctor)The health professionals explained it was a very new experience for them: the atmosphere was totally different from what they were used to, even if they had been in contact with other undocumented patients during their medical practice. Simply visiting them in the squat, witnessing their dedication and stubbornness in putting their health at stake just to obtain legal papers, was overwhelming for some of them. It also increased their awareness of the socio-economic situation of undocumented migrant workers.
We are really getting out of the normal routine, and we are not even forced to do it. (Nurse)
It's an experience that you can give yourself to measure the level to which people can put themselves in danger… and you can go to feel it yourself, you can experience it yourself. (Nurse)
Expressing disagreements
Some disagreed with the decisions taken. One health professional criticised the participation of the breastfeeding mother of a two-month-old baby in the hunger strike. Some also set limits on their participation in monitoring: they would never attend a hunger strike if the claims could have been obtained by other means. They resented situations where an attendance list of participants had been used or if people from the outside, who didn’t participate to the hunger strike, got involved in the discussions. Others were less self-assured:
We don't approve of the strike, but we let them take responsibility for what they're doing to achieve their purpose. (Medical doctor)
Many health professionals were concerned about the group pressure they felt. They resented the pressure from people outside the group of hunger strikers, meaning the people who lived ‘upstairs’ in the building and didn’t agree with the strike. As the hunger strikers monopolised the best rooms on the ground floor, conflicts arouse due to lack of communication and mutual understanding. But there was also a lot of tension inside the group: if someone decided to stop drinking, everybody would follow because they didn’t want to lose face and so they tried to be more radical. A major point of dispute was taking vitamins: the spokesperson had prohibited vitamin intake because he said they were nutrients and therefore forbidden. A discussion was held to convince the spokesperson of the long-term health benefits of vitamins and other medication. One health professional testified to how he convinced other hunger strikers that the only way to stay part of the group was by taking medicines. Some saw this peer pressure as a sign of group culture, of the strong family ties in non-western cultures. The positive side was that they looked after each other and when somebody lost consciousness, they always called an ambulance.
The group feeling needs to be very strong because, I think, you never do a hunger strike all by yourself. (Junior doctor)
I think they are very convinced that they want papers for all of them, not only for themselves. (Junior doctor)
It was better not to mention that they were vitamins because vitamins are associated with food, but to say that we were preventing paraesthesia and ultimately relieving pain. Then they started to take them and there was a reverse group effect, that is to say the ones who took the vitamins explained to the others why they were doings so and everyone agreed. They felt relieved that everybody could take them. (Junior doctor)
By talking to the hunger strikers, the health professionals discovered the economic, political and ecological reasons why they had left their home countries. They felt revolted that our society did not show more solidarity or humanity and that the hunger strikers had to jeopardize their health to be able to be heard, that they were willing to die to obtain a more dignified life.
We live in a country with a lot of money and we do not know how to welcome people and put them to work. (Nurse)
Coping strategies
To protect themselves emotionally some performed their jobs like robots: when asked them to do something they did it mechanically. Returning home after the job, they were overwhelmed and had difficulties managing their feelings. Some cried or had nightmares about the strike. They wondered if they were the only ones who were overwhelmed by the situation. They were tempted not to return to the place of the hunger strike and wanted to stay home in their own comfort zone. Finally they went back anyway.
I was not really myself, but I was not really a caregiver either, I was a person who was putting up barriers to avoid being overly affected by what was going on, someone who does what has to be done but is detached from myself and my role as a caregiver. (Medical student)
The first time I arrived back home, I started crying and I did not know why, I was all alone at home, everyone was gone and then, yes,… I was wondering what had to happen before you started doing that and yes, it was very intense .. I do not know how to explain what I learned but I learned something, but I do not know what. (Junior doctor)
Many felt paralysed by witnessing so much misery. They thought their medical knowledge had fallen short: they saw no way to alleviate the suffering and perhaps hoped the strike would soon end. They also felt relief returning to their daily jobs where helping others was much easier.
A strange feeling is that every time I leave, I want them to stop … I really want to receive an e-mail the next day that says 'ah, by the way, they stopped’. (Junior doctor)
What can we bring them with our limited means that they will accept, what can we do to help them?( Medical student)
Commitments as a health professional
The health professionals were confronted with the question of how far their commitment to the struggle of the undocumented people was supposed to go: should they simply be present or do the medical monitoring, or actively support the movement? They wondered why they were helping the people who were on hunger strike and not the other families who lived upstairs. One remembered that she had been gently criticised because she did not participate in a rally organised by the undocumented people. Keeping track of their weight loss was acceptable but giving this report to the press or government officials was a step too far. Some feared losing their credibility as a health professional.
Our presence proves that we support them. (Junior doctor)
If we don’t do a good job we will lose our credibility as health professionals: so we make weight charts. As a researcher I describe nature and make a medical report, but that is as far as I go. (Junior doctor)
I limit my commitment to the medical side and I can indeed issue a medical report that the press can see, but it stops there. As a doctor, demonstrating with them and asking for papers for people whose background you do not know, that is a step too far. (Medical student)
Other health professionals got much more involved. They saw their commitment embedded in the analysis of the World Health Organisation that describes the right to health as one of the basic human rights.
Your medical role as a doctor depends on your definition of health. If you believe that as a doctor, you have to fight for the health of your patients, and you consider the (hunger) strikers as your patients, then their (right to) health will only be achieved when they have the right to exist in this country. (Medical doctor)
There are different sides to the term 'strike': there are strikes for work, strikes against the austerity measures, and then there is this strike because they have no guarantee of their basic rights and it's basically in this context that I wanted to support the people there. (Medical doctor)
Improvements for the future
A lot of suggestions were made to make the monitoring easier. Health professionals should get together before the start of the hunger strike and an experienced doctor should provide information about managing the monitoring and how the international guidelines could be applied, provide information to the hunger strikers and convince the spokesperson that the medical advice (to take vitamins or medication) is to prevent the short and long term consequences of a fast. The experienced doctor should explain what the conditions are for professional monitoring: weights will be measured by the health professionals to provide regular media updates. The hunger strikers should write down in their own words how they want to be treated when they go into a coma. Consultations should be held in a separate room, where privacy is guaranteed, and outsiders should not interfere with people inside. The team should be multidisciplinary and the presence of a psychologist should be obligatory. Regular mail updates should be given and weekly medical meetings held. At the end of the strike, a medical report should be made for each hunger striker and everybody should be assigned to a general practitioner. A final evaluation, attended by everyone, is highly recommended.
I hope there will be no more hunger strikes, explain to the emergency physicians that we're on the same side, we're here to save people when they are in danger, …. That we do not support the hunger strike and that we're already doing triage on the spot so that they have fewer cases to take care of. (Medical doctor)
Wouldn’t it be useful, if there is another strike, for a psychologist to come and talk to them about how far they want to go, until death… but they should discuss this with a doctor, and regularly, because I think the idea that ‘we want to continue until we die’ changes in the course of the strike. (Medical doctor)