Impact of Structural Barriers on Undocumented Migrants at Risk of Chagas Disease in Switzerland: A Double Burden of Neglect

Abstract

Chagas disease, a major public health concern in Latin America, has become a global public health challenge. Switzerland is considered an example in providing healthcare access to migrants, however, Chagas disease remains largely underdiagnosed in the estimated three to four thousand Latin American migrants infected. This paper discusses the sociopolitical and economic factors that contribute to the neglect of Chagas disease in Switzerland. People with irregular migration status face structural constraints that hinder their access to care. The Latin American population in Switzerland, regardless of legal status, faces health inequalities due to the lack of services providing care for Chagas disease. Through a discussion of global inequalities and neoliberal markets, this paper argues that to provide migrants (regardless of their migratory status) with the optimal level of health care, Chagas disease must be considered a local public health issue, rather than an imported Latin American disease.

Chagas disease (CD) is a parasitic infection endemic to Latin America, with an estimated 6 to 7 million individuals infected (PAHO, 2022). The parasite responsible for CD has been present in rural regions of Latin America for around 9,000 years (Bonney, 2014) and is mainly spread by vector insects known as triatomine bugs. These bugs are commonly found in poorly constructed homes in rural Latin American areas. Other routes of transmission in Latin America include transfusions with infected blood or infected organ transplants, congenital transmission, or food-borne transmission.

CD was initially associated with rural regions of Latin America and was considered a “health problem limited to Latin America” (Bartoloni, 2022: 1; Bravo-Gallego et al., 2022). However, the spatial and temporal endemicity of CD has evolved throughout the 20th century (Chao, Leone, and Vigliano, 2020). Significant migration flows have led to CD spreading from rural to urban regions and from endemic to non-endemic countries. As a result, CD is no longer restricted to Latin American countries (Bravo-Gallego et al., 2022). It is now well recognized that the health problem posed by this disease is a widespread public health issue (Schmunis and Yadon, 2010). Thus, the burden of CD “is no longer (if it ever was) the sole concern” of Latin American countries (Gold, 2021: 492).

According to various sources, it is estimated that there are between 68,000 and 122,000 people infected with the parasite in Europe (Basile et al., 2011); over 300,000 in the U.S. (Ayres, Marcus, and Standley, 2022: 186); and 3,000 in Japan (Iglesias Rodríguez et al., 2023: 2). The term “endemic” can refer to an area that harbors an established population of vectors, or to the relatively stable presence of an event in a geographic area or population group with high prevalence and incidence rates (Bonita, Beaglehole, Kjellström, and World Health Organization, 2010: 133; Moreno Peniche, 2021: 498). Latin American countries (where transmission through the vector can occur) are designated as “endemic” countries (Moreno Peniche, 2021: 498).

In contrast, the so-called “non-endemic” areas generally refer to Global North areas such as Europe, the United States, and non-Latin American countries more broadly. However, the use of the dichotomous terms “endemic/non-endemic” to narrow the geographic scope of CD can be highly problematic. It portrays CD as a foreign disease that occurs among distant populations and in Latin American countries, which is brought into the Global North, “exposing” countries to an extraneous parasite (Moreno Peniche, 2021: 498).

In non-endemic countries, the main modes of transmission are congenital transmission and contamination through transfusions with infected blood or infected organ transplants. However, the distinction between endemic and non-endemic areas is complex due to the evolving endemicity. For example, the vectors of Trypanosoma cruzi have been increasingly identified in countries such as the U.S., Australia, and some Asian countries (Alarcón de Noya, and Jackson, 2020). The southern U.S. has established populations of vectors and autochthonously acquired infections of CD (Moreno Peniche, 2021; Garcia et al., 2015). Nevertheless, despite increasing local vectorial transmission (76 cases described in the U.S.) and some cases of transmission through transfusions and transplants (Garcia et al., 2015; Alarcón de Noya, and Jackson, 2020), these cases remain minor compared to the presence of a significant number of chronically infected Latin American migrants.

In 2012, an article titled “Chagas disease: The New HIV/AIDS of the Americas” (Hotez et al., 2012) was published in the journal PLoS Neglected Tropical Diseases, which highlighted CD as a serious public health concern in the U.S. The article received widespread media coverage, presenting CD as a public health threat imported by migrants. It drew attention to CD as a menace to populations in developed nations rather than as a disease affecting a significant number of chronically infected individuals who require medical treatment for decades to come (Bartoloni, 2022: 1).

This example highlights that CD has become a global public health challenge and, in a number of countries around the world, it can also be perceived as a serious emerging “Latino threat” (Moreno Peniche, 2021: 498). This reinforces stigmatization and fosters processes of “othering” Latin American migrants as disease carriers (Moreno Peniche, 2021), a colonial legacy. Additionally, depicting CD as an “imported Latin American disease” conveys the notion that it is not a concern for the host country. This can lead to the failure to consider CD a local problem that must be addressed by stakeholders and the public health system more generally. However, Chagas disease should not only be viewed from a security perspective due to the risk of spreading to non-endemic countries, but also in terms of its impact on the health of Latin Americans, both within Latin America and in other non-endemic countries (De Maio, Llovet, and Dinardi, 2014).

CD is embedded in a complex process of globalization that, through worldwide political and economic inequalities, fosters irregular migratory movements at the expense of migrants’ security and well-being. Therefore, in so called “non-endemic countries,” it seems important to consider CD not as an imported threat but as a local public health issue, and to question the determinants that maintain CD as a neglected disease.

In a previous article, I explored the recognition of CD as a public health issue in Switzerland (Rapp, 2021). In this paper, I focus further on sociopolitical and economic factors that contribute to the neglect of CD in Switzerland.

I begin by providing an overview of the Swiss healthcare system. Then, I shift the focus to the specific case of undocumented migrants, as the majority of Chagas disease cases in Switzerland fall within this group. Examining the impact of undocumented status on the precariousness of those affected and their access to healthcare, I analyze how structural violence perpetuates the marginalization of this minority and hinders their access to care, leading to challenges in diagnosing and treating CD. Additionally, I discuss how structural factors also impact the Latin American population with legal status through the lack of CD services in Switzerland, emphasizing that the recognition of CD as a public health problem requiring screening programs is highly dependent on political trends and the commitment of local actors. Finally, I open the discussion on neoliberal policies, their influence on migration movements, and the inequalities that are reproduced, including how they favor punitive policies for regulating migrants while benefiting from their labor force.

The Neglected Status of CD Among Social Science Production

Academic literature on migration and health tends to focus on the difficulties of access to care from a behavioral or cultural perspective. These perspectives have many limits, including the risk of cultural essentialization and homogenization of migrants (Castañeda et al., 2015: 380). Further, by focusing on individual behavioral responsibilities, scientific literature can hide structural determinants and social inequalities disproportionately affecting migrant minorities. Such literature production generally remains focused on resolving access to care and fails to explore the lay experience of the disease and the various health determinants affecting migrant health beyond access to health care (Castañeda et al., 2015). Consequently, the knowledge produced underemphasizes key political and economic complexities that affect migrant communities.

Despite the major role that social science can play in understanding sociopolitical determinants, knowledge production on neglected diseases is often overlooked by these disciplines (Vanderslott, 2017; Charmillot, 2014). Knowledge production for CD is primarily dominated by biomedical disciplines, while social sciences remain largely underdeveloped in this area (Gold, 2021; Ventura-Garcia et al., 2013).

In a previous article (Rapp, 2021), I have shown that CD in Switzerland receives the attention of a limited number of healthcare providers working with migrants or specialized in the field of tropical diseases. Along with an emerging attention since the early 2000s, an increasing literature production focusing on how to address CD has been produced by those actors, who have been active in raising awareness of CD as a public health problem rather than as an exotic tropical disease. This literature, which stems from healthcare professionals’ research, is predominantly biomedical, epidemiological, and clinically oriented.

Notwithstanding, structural barriers to care and inherent inequities are appropriately identified in this literature. Studies underline that CD is more prevalent among undocumented migrants experiencing socioeconomic disadvantage and barriers in access to quality medical care (Jackson et al., 2009; Jackson and Chappuis, 2011). Further, by providing scientific credibility, those authors aim to create awareness among public health policymakers so that a response to the health problem posed by CD is not confined to the local context but is addressed on a national scale. In other words, their engagement extends beyond the clinical context and aims at acting in the social context.

Those actors are committed scientists who can be described as activists (Vanderslott, 2017). Their commitments are based on medical as well as political and moral grounds, and on an imperative to reduce social inequalities (Rapp, 2021). The focus of the literature produced by these activist scientists is improving clinical practices and represents a call for social justice.

Yet, besides the engagement of those actors, CD remains a neglected disease poorly diagnosed in Switzerland, where screenings for CD as part of the public health system only takes place in two cities. In 2011, the prevalence of people infected with CD was estimated to be up to 3,000 (Jackson and Chappuis, 2011), with 89 percent to 95 percent of them undiagnosed (Basile et al., 2011). Over the past ten years and with the support of a major screening effort in Geneva, 422 people were diagnosed (interview of a healthcare provider, Geneva, January 2021). However, the under-diagnosis of CD remains high in Switzerland and thousands of infected migrants are unidentified and untreated across the country.

Hence, awareness-raising activities have not been sufficient to eradicate CD neglect throughout Switzerland. This points to the fact that the challenge is not solely related to the lack of knowledge among health care providers, but that CD is more broadly embedded in complex sociopolitical determinants that need to be addressed. Even if a growing body of researchers (both in Latin America and Europe) explore the lay experience of CD and/or structural factors in relation to access to care (Forsyth et al., 2019), critical social science approaches on how structural issues and dynamics of exclusion foster social inequality remain scarce. Many aspects still need to be questioned and more social science knowledge about CD needs to be generated. To partially fill these gaps, the present article discusses the sociopolitical and economic determinants that influence the health of Latin American migrants at risk for Chagas disease in Switzerland.

According to a study conducted in Geneva, the vast majority of Latin American migrants affected by CD are undocumented (83%) and work as domestic employees (Jackson et al., 2012). Therefore, in this paper I focus more specifically on the impact of structural factors on this minority. However, it is important to note that CD can also be found among migrants with legal residency statuses. Since the costs of screening for CD are reimbursed by health insurance plans, this should ensure access to CD care at least for insured migrants (e.g., legally residing migrants). However, we will see later in this paper that, although they are less exposed to economic, legal, and administrative difficulties in accessing care than undocumented migrants, many remain exposed to barriers such as the lack of facilities offering care for CD.

Political Organization and the Swiss Health System for Migrants

Before examining the influence of policies on the health of migrants, it is necessary to briefly describe the Swiss federal system. Switzerland is composed of 26 cantons (administrative regions) with a large degree of autonomy in policy implementation (Rossini and Legrand-Germanier, 2010). Health policy regulation is a decentralized system conducted at both the national and regional levels. Some aspects are regulated at the federal level, while the government has a subsidiary role in implementing concrete public health strategies across the country. Cantons enjoy considerable autonomy around the organization of care and significant influence over the definition of care management priorities. In this setting, local political trends significantly influence the implementation of health care.

In Switzerland, everyone has the right and the duty to contract a health insurance regardless of legal residence status. However, the Swiss federal government’s welfare system developed from a “liberal” system in which health insurance companies are competing private actors playing the role of service provider (Bilger, Efionayi-Mäder, Hollomey, and Wyssmüller, 2011). In this context, healthcare insurance is very expensive, and despite being enrolled in insurance, a patient is still required to pay a sum of money for every medical appointment. As discussed in more details below, many undocumented migrants do not have health insurance as a result of this (Plate-forme nationale pour les soins de santé aux sans-papiers, 2014).

Persons without health insurance have the right to access “basic” health care, defined as: “assistance when in need including all essential resources to lead a dignified human existence” (Bilger, Efionayi-Mäder, Hollomey, and Wyssmüller, 2011: 9). Cantonal authorities have considerable flexibility in the interpretation of this legislation (for example, how to define need, essential resources, and dignity) and in regulations to address issues.

According to the MIPEX indicator (Migration Integration Policy Index), ¹ Switzerland has the second best ranking out of 52 countries regarding migrants’ healthcare coverage and ability to access health services (Solano and Huddleston, 2020). This success is notably attributed to the mandatory health insurance system.

Switzerland is described as a leader in providing an “open health system for all migrants” (Abubakar et al., 2018: 23) and health is a priority area of integration policies at the federal level. Furthermore, a number of supportive programs from the state and NGOs aim to facilitate equal access to care for migrants (Solano and Huddleston, 2020; Ruspini and Kaya, 2017; Bilger, Efionayi-Mäder, Hollomey, and Wyssmüller, 2011). ² In this context, in theory, undocumented migrants should not face legal (or practical) restrictions to accessing healthcare and they should reach the same health coverage as legal residents. However, while at the federal level concern for the health of migrants is stated as a priority, a significant gap exists between the declared commitment and the concrete implementation of this policy.

Access to Full Health Care for Undocumented Migrants is Restricted by Migration Regulations

Even though the MIPEX report classifies the Swiss National Program on Migration and Health as world-leading, the more global picture of this report shows that, in terms of integration, Switzerland has among the most restrictive legal and political regulations on migration. Migrants face long-term obstacles to settle permanently (Solano et Huddleston, 2020). Further, obtaining residency and work permits is only possible if the applicant has housing and an employment contract prior to entering Switzerland. As these admission criteria are difficult to meet before arrival in Switzerland, they adversely encourage undocumented migration and undeclared work, especially for low-skilled workers (Conseil Fédéral, 2020: 15). Some Swiss political actors argue that Switzerland should have more inclusive policies for low-skilled migrant workers in order to combat the growing problem of undocumented migrants (CFM, 2019: 36). Others denounce that under cover of preventing abuses, in practice, the integration of migrants, naturalization, and asylum policy are more and more restrictive and problematic from a human rights perspective.

Differences in political stances regarding health and integration policies for undocumented migrants are reflected in political debates at the national level. For example, in 2010, a major far-right political party in Switzerland proposed excluding undocumented migrants from basic health insurance and promoting the exchange of administrative information between health authorities and immigration services (a practice that is currently forbidden).

Their arguments were based on the idea of a conflict between the duty of the state to control migration and the provision of health insurance for the undocumented population (Bilger and Hollomey, 2011: 16). This political proposal was rejected by the Federal Government, claiming that it violated the right of access to high quality care for the entire population and the fundamental right of access to basic health care enshrined in the Swiss Federal Constitution (Conseil Fédéral, 2020: 54). According to the law, any person on Swiss territory regardless of their nationality has the right to be insured against the vicissitudes of life.

Conversely, other groups (NGO and governmental actors) have submitted political proposals designed to introduce more extensive regulations, such as regularization of undocumented migrants currently living in Switzerland, or of those who have been living in Switzerland for at least four years, regardless of their canton of residence (CFM, 2019; CFM, 2011; Morlok, Meier, Oswald, and Efionayi-Mäder, 2015). Their arguments were based on the idea that many of them have been working on Swiss territory for years, that their labor produced profits for the host society struggling to overcome the shortcomings in the labor market and that the illegal labor market violates human rights and human dignity (Morlok, Meier, Oswald, and Efionayi-Mäder, 2015). However, the federal government refused to consider the regularization of undocumented migrants, either en bloc or by quotas (Conseil Fédéral, 2020: 86).

The arguments in favor of restrictive migrant policies are based on the idea that labor migration is a choice due to individual interest in economic opportunities. It fails to consider that so-called “voluntary migration” is driven mainly by structural violence and global social, economic, and political inequalities (Castañeda et al., 2015: 382; Echeverría et al., 2020: 4). Moreover, labor migration benefits host countries’ economies by supplying labor where it is needed (Abubakar et al., 2018: 7). Indeed, It has been shown that irregular migration fills the need for an inexpensive work force in Switzerland (CFM, 2011: 14). As Swiss legal residents prefer highly skilled jobs, domestic labor is mostly occupied by low-skilled migrants, some of whom are undocumented (Longchamp, 2005; Conseil Fédéral, 2020). Therefore, an inherent contradiction between the economic interest of the country, which benefits from an illegal labor force, and the implementation of restrictive migration policies leaves undocumented workers in precarious situations.

In this context, even if the social justice and human rights paradigm should be a major argument against restrictive migration policies, actions taken by the health sector do not have sufficient weight to erase the power disparities between those who argue from a national security perspective and those who promote better health for all. This highlights an imbalance between the power of the public health approach and that of the economy.

The Impact of Irregular Migratory Status on Precarity

Undocumented migrants are affected by complex and extensive processes of exclusion rooted in restrictive policies of migration regulations. Such policies expose undocumented workers to precarious situations. For example, being constrained to working illegally exposes them to specific vulnerabilities (such as fear of being deported, abuse of labor rights, and financial insecurity) that hinders their access to both health insurance and health care. This example is particularly pertinent to people affected by Chagas disease. Indeed, as shown in a study conducted in Geneva in 2011, 89 percent of them were living below the Swiss poverty line and 81 percent worked under unsatisfactory conditions (Jackson et al., 2012).

Fear of being reported to authorities and deported has a significant negative impact on health and daily life conditions (Asad, 2020). For example, it can lead to precarious housing, as renting implies registration with local authority. Undocumented migrants often have to find informal accommodation, which exclude them from enjoying their right to housing (Bilger, Efionayi-Mäder, Hollomey, and Wyssmüller, 2011: 19). It also heavily impacts the respect of their legal rights regarding working conditions. Indeed, Swiss labor law stipulates that any person in an employment relationship (regardless of their legal status) has the right to minimum standards of working conditions. ³ In practice, undocumented migrants can hardly claim their rights because labor courts must report illegal residence to the Federal Office for Migration.

This situation illustrates the significant gap between a theoretical protection of undeclared workers and its lack of concrete implementation, which has severe consequences. Indeed, the condition of undeclared work fosters a risk of exploitation by employers who have the power to impose low salaries and constraining work schedules (Conseil Fédéral, 2020). These precarious conditions can influence care-seeking behavior and health priorities (Iglesias-Rodríguez et al., 2019). For example, people are not given time off work to attend medical consultations during working hours.

In the context of CD, care-seeking behavior can also be influenced by the side effects of medications, which can be severe and visible. As a consequence, undocumented migrants may face fear of losing their job if the employer is unaware of the mode of transmission or because the care regimen requires repeated absences (Forsyth, 2015; Castaldo and al,. 2020). Furthermore, sending economic support to their families is generally a priority for undocumented workers. In a context of economic precarity, they can have major concerns about missing work, especially if work is hourly paid or does not provide paid time off for medical visits (Castaldo et al., 2020; Da Costa-Demaurex et al., 2019; Minneman et al., 2012).

Economic precarity impacts their ability to access health insurance, which is expensive. Further, even with insurance, a patient is still required to pay a sum of money for every medical appointment. Thus, the financial cost of health is particularly difficult for people in precarious economic and legal situations. In practice, many undocumented migrants do not have health insurance (Plate-forme nationale pour les soins de santé aux sans-papiers, 2014).

This picture provides a first insight into the economic and legal constraints that undocumented Latin American migrants can face. However, the social assistance system is designed to counteract these kinds of problems faced by disadvantaged people. According to the law, people in a “modest economic situation” are entitled to a reduction in their monthly health insurance payment. This policy, applicable to everyone, including undocumented migrants, can improve the affordability of health insurance. But undocumented migrants are often unaware of this possibility and this framework is insufficient to overcome other legal and administrative aspects they face.

Indeed, cantons have great autonomy in the implementation of social welfare; the conditions for the allocation of these premiums vary greatly among them. Some cantons require an official document (tax declaration or salary report) to assess the indigence and eligibility of welfare applicants. This process excludes from financial support those who would meet the criteria for assistance but cannot declare their work (Bilger, Efionayi-Mäder, Hollomey, and Wyssmüller, 2011a: 18). In this federal system, the affordability of health insurance depends on the policies of local public authorities. Local decisions and cantonal political trends play an important role in access to insurance and health care for undocumented migrants (Rossini and Legrand-Germanier, 2010).

Moreover, insurance companies sometime refuse to insure undocumented migrants even though this is a legal obligation. This is sometimes due to ignorance among insurers regarding these obligations (Plate-forme nationale pour les soins de santé aux sans-papiers, 2014). Yet this denial might also be driven by the fact that undocumented migrants’ health care costs may be higher than average. Another factor is that their precarious economic situation may prevent them from covering their insurance costs (Plate-forme nationale pour les soins de santé aux sans-papiers, 2014). These barriers to health insurance reflect the dominance of economic considerations over the right to a good standard of health.

Finally, some insurers require a residential address to purchase insurance, a requisite that violates the rights of undocumented migrants. This can lead to reluctance to make this purchase due to fear of being reported, even if, in theory, insurers do not have the right to transmit information to immigration authorities. The medical costs and difficulties in access to health insurance can lead to a reluctance to seek care. As a result, many undocumented people wait until the later stages of a disease to subscribe to insurance and/or to seek care (Jackson, 2009).

Disparities in Care Organization can Foster Inequalities

Every canton is obligated to guarantee uninsured people access to, at least, emergency care. However, health access restricted to emergency care is far from satisfactory because, among other things, it implies fragmented medical follow-up. This is particularly problematic for migrants with chronic health conditions and cardiovascular risk factors such as hypertension, diabetes, and heart conditions derived from CD. Undocumented migrants have a cardiovascular mortality rate that is twice the general European population (Jackson, Paignon, Wolff, and Delicado 2018: 10).

In practice, health care varies greatly among cantons, and can be very unequal. Indeed, among 26 cantons, only Geneva and Vaud have inclusive health care policies for undocumented people (Piccoli and Wanner, 2022). In both cantons, a university hospital is located in the main city (Geneva and Lausanne). These cities are the only places in which public hospitals offer uninsured people healthcare services. In 17 cantons, there are neither services nor NGOs dedicated to undocumented migrants, while 7 cantons provide limited care dedicated to undocumented migrants.

Inclusive health services are critical for lowering barriers to health care and overcoming problems related to economic insecurity, fear of being reported to migration authorities, lack of familiarity with the health care system, linguistic barriers, and discrimination by health care practitioners (Piccoli and Wanner, 2022). Research has shown a higher mortality rate for treatable and preventable diseases among undocumented migrants living in cantons with limited or non-inclusive health policies compared to Swiss citizens and legal migrants (Piccoli and Wanner, 2022). This discrepancy is not observed in cantons with inclusive health policies. This emphasizes the significant benefits of an inclusive system that contemplates care for undocumented migrants and the influence of local policies on undocumented migrants’ health.

For most migrants who are infected with CD and have neither legal status nor insurance, this context impacts their access to care and consequently their possibility to be diagnosed and receive antiparasitic treatment. However, other layers of disadvantages and inequalities also contribute to the neglect of CD. This is evidenced by the fact that CD can also be underdiagnosed among populations with legal residency.

Lack of Facilities Offering Screening and Treatment for CD

Beyond economic and structural limitations, there are other barriers to care which pertain to the health care system’s lack of attention to the issue of Chagas disease and therefore the lack of facilities providing active screening and care for CD. Inequalities in the implementation of health care between cantons undermine equity of care, particularly for undocumented migrants, but also more broadly for legally residing migrants. This situation is particularly apparent in the case of CD. Indeed, the attention given to the medical management of CD in Switzerland has emerged from health professionals specialized in tropical diseases or migrant care and working in the university hospitals of Geneva and Lausanne.

Most of these providers would like to see CD leaving the specialist sphere and being treated more comprehensively in primary health care across Switzerland (Rapp, 2021), but the attention given to CD remains confined. The costs of CD screening are reimbursed by health insurance, which should ensure access to CD care at least for insured migrants regardless of their residency canton. However, the hospitals in Geneva and Lausanne are currently the only two in Switzerland that have implemented CD screening procedures for at-risk migrants, such as systematic screening of pregnant migrant women from Latin America in maternity units.

The lack of more integrated care means that not all needs can be covered. As a result, for example, congenital transmission might occur in the rest of Switzerland. In the context of regional autonomy, the implementation of screening and treatment for CD is a complicated issue, highly dependent on political trends and the commitment of local actors. This lack of attention to CD is made more complex by the absence of an official national recommendation for CD congenital screening. National recommendations provide guidance for the implementation of care and healthcare providers’ practices, but these are not legally binding.

Yet, the general population is protected from the risk of CD transmission. Indeed, blood donations and organ transplants are controlled for CD throughout the entire country. The only risk of CD transmission remaining in Switzerland is through congenital transmission. As this risk affects Latin American migrants and their children, the absence of a national recommendation for congenital screening reinforces the dependence on local actors to implement CD care practices specifically for this population.

This general tendency where only specialized networks devote attention to CD is often observed in non-endemic countries. Screening and care for CD is mainly carried out by specialized centers, NGOs, or by specific community screening activities (Pinazo Delgado and Gascón, 2020; Mendes et al., 2022). Working with undocumented migrants and creating a network can draw attention to issues that would otherwise go unnoticed (due notably to rare clinical symptoms). As the financing falls to hospitals, it is also necessary to have institutional arrangements and favorable regional policies to establish structures dedicated to the care of CD.

Neoliberal Policies Fostering Punitive Migrant Regulations While Benefiting from Labor Forces

Undocumented migrants support local economies, social services, and health care in both origin and host countries (Abubakar et al., 2018: 1; Jackson, 2009), but suffer from discrimination by political and economic power holders obscuring the important economic role they play. Such strategies of exclusion and domination lead to the weakening of the identity of undocumented migrants as they are “othered.” On the other hand, integration policies have a positive influence on the health of migrants and on their sense of belonging to the society. Countries like Switzerland that are classified by MIPEX as having “temporary integration” policies foster the public’s perception of migrants as foreigners rather than as equals to native Swiss citizens. In contrast, countries classified as having “integrative policies” consider migrants “as equals, neighbors, and potential citizens, and invest in integration as a two-way process for society” (Solano and Huddleston, 2020: 233).

Punitive migrant regulation policies that run counter to public health reflect the way neoliberal policies and ideologies undermine citizenship by othering workers participating in the economy. Undocumented migrants are stigmatized as outsiders rather than considered as individuals who are part of Swiss society. However, the demand for work in the domestic labor sector (or other similarly precarious sectors) continues to grow for socioeconomic or demographic reasons. Therefore, the demand for an undocumented labor force is driven by economic considerations and benefits host countries’ economies.

CD has become a global health problem because a large number of infected individuals have migrated to non-endemic areas from Latin American countries due to political and economic pressures caused by neoliberal policies. The presence of CD in so called “non-endemic” countries is not the burden of foreign people importing diseases, but the consequence of a globalized system whose social, political, and economic inequalities drive migration. In this context, it seems fairer to convey that the global political economy that encourages liberalized trade (Abubakar et al., 2018: 2) has made CD an important public health issue in so called “non-endemic” countries, rather than considering migrants as potential disease carriers.

Undocumented migrants actively participate in society and contribute to the economic prosperity of Switzerland by assuming precarious jobs. They contribute to the economic system, which in turn should provide them with adequate health care conditions. More importantly, equity in access to health care should not depend on economic contributions but should be guaranteed for social justice imperatives.

Yet the rights of undocumented migrants are violated by direct and indirect discrimination, including regional health practice disparities, insufficient, or the absence of, dedicated health programs, restrictive integration policies, financial and administrative challenges in accessing health insurance, lack of awareness of rights and entitlements, and obstacles in asserting their rights to housing and work. These structural factors increase the vulnerability of undocumented populations and put those infected with CD at greater risk of suffering from this chronic, manageable disease.

Conclusion

In Switzerland, most people infected with Chagas are undocumented. Very few of them are diagnosed and in most of the country there is no clinical implementation, such as access to screening and treatment for CD. Focusing on the impact of structural factors on undocumented migrants, I have discussed the influence of Swiss local and national policies on access to care and, more broadly, on resources and the health status of migrants at risk for CD.

We have seen that gaps and bottlenecks occur between the official health integrated approach and its concrete implementation at the local level, particularly for undocumented people. As described in this article, restrictive integration policies maintain those minorities exposed to economic, legal, and administrative structural constraints that hinder them from achieving optimal health and from accessing the health care system without restriction. In this Swiss decentralized context, only two cantons have a dedicated health service for undocumented migrants within hospitals. These same cantons are the only ones that have implemented clinical care for CD.

The difference in the provision of care between cantons illustrates how the health status of people at risk of Chagas strongly depends on the commitment of local actors and the sensitivity and willingness of regional politics. The socioeconomic conditions of these groups are a major cause of health disadvantage. But more broadly, these groups are affected by complex processes of social exclusion. Undocumented migrants face considerable difficulties in daily life, which have a negative impact on their health, identity, and perceived belonging and inclusion.

Disparities in health outcomes according to legal status show that the Swiss hospitality system is a source of problems for some minorities rather than the reverse. The impact of these structural factors extends beyond undocumented migrants to affect the Latin American population residing in Switzerland with legal status as well. Indeed, the recognition of CD as a public health problem requiring screening programs is largely determined by political trends and the commitment of local actors specialized in tropical diseases or serving precarious populations. As a result, even those with legal status have limited access to healthcare and screening for CD.

Briceño-León and Méndez Galván (2007) argue that while it “has been said that Chagas disease is a forgotten disease . . . what really exists . . . is a forgotten population.” This statement can be applied to the case of Switzerland, where the sociopolitical factors that contribute to the neglect of CD are exclusionary processes and neglect of undocumented migrants. These structural factors have an even wider impact as most Latin American migrants do not have access to dedicated care for CD in Switzerland. I opened my article by raising the issue of the term “non-endemic” and how it can hierarchize the responsibility to address CD. According to some authors (Pinazo Delgado and Gascón, 2020: 209) “low and high endemicity countries” would be a better denomination. Further, CD is often intrinsically linked to poverty and not limited in specific geographical location. Therefore, as Gold (2021) stated, the terminology of “disease of poverty” would be more accurate than the one of neglected tropical disease. This shift of focus is important in order to overcome the perception of CD as an emerging and imported threat and instead consider dynamics that deepen (or perpetuate) social inequalities among disadvantaged minorities in low endemic countries.