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01/28/2014

“Health Care as Hospitality”: Organizational Ethics in a Migrant Health Clinic

Geylang is the red-light district of Singapore, east of the city center. It would be easy, and wrong, to describe Geylang as a different world from the skyscrapers and malls of the contemporary, booming city. Its restaurants and its vernacular “shophouse” architecture link its street culture to other parts of town. The migrant workers on Singapore’s ubiquitous construction sites live in dormitories in this neighborhood, and others farther out from the center.

Singapore’s population of 5.3 million includes one million migrant workers from other Asian nations who are employed on guest-worker contracts; unlike undocumented immigrants, they are legally present in the society in which they are working, but their ability to participate in society is constrained.

Female migrants typically work as “maids,” a category that includes child care and elder care, and they receive basic health insurance paid by their employers as part of their employment contracts. The limits on this coverage are a source of stress and uncertainty for these domestic workers and for health care professionals.

Like undocumented immigrants in the United States, male migrants in Singapore frequently work in construction; some are employed as street sweepers or in other types of maintenance work. A construction worker from Mainland China, Bangladesh, India, or Thailand earns the equivalent of $470 per month, and sends the equivalent of $313 home. Construction workers are eligible for no-fault compensation if they are injured on the job. The process of documenting medical claims and securing compensation can take many months; while the process is underway the injured worker cannot leave Singapore. With little or no income, and the likelihood of continuing medical needs, his day-to-day situation is precarious.

Even when a construction worker is healthy, his life is hard, given his grim living conditions and social isolation. According to Dr. Goh Wei Leong, a family physician who runs HealthServe, an innovative community health project in Geylang, male migrant workers – unlike domestic workers who live in their employers’ homes – may never have spoken to a Singaporean, even if they have a language in common.

Dr. Goh and his colleagues describe their organization’s core value as “health care as hospitality.” Amid the relentless pressures of labor migration and urbanization, they aim to create a community for migrants, using health care as the point of entry. On a weeknight, the HealthServe clinic, a small building in a traditional kampong-style courtyard just off a main artery, is packed. Injured workers, some on crutches, meet with volunteer lawyers and case managers for help in filing claims. Others come for medical care (the National University of Singapore’s medical school offers a family medicine clinical placement at HealthServe), for a meal, or to hang out. Geylang’s dormitories are a short walk away, and there are satellite clinics in other areas where migrants live or congregate. Dr. Goh addresses everyone as “friend,” and in doing so – cheerfully, emphatically – makes two points: all people are equal and creating community takes work. His outreach extends to getting to know the local gang leaders and brothel owners, so that the clinic’s role in the neighborhood is understood.

In response to the real problem of hunger among injured and impoverished construction workers, the clinic’s food project distributes tokens that can be redeemed at stalls at a local hawker centre, the outdoor food court that is the usual way to eat a casual (and excellent) meal in Singapore. Giving migrants the opportunity to choose what they want to eat and have a meal at the same table as anyone else was, in the view of HealthServe, friendlier than setting up a soup kitchen at the clinic or handling out boxed meals to eat on the street. Because some injured migrants may never be able to return to construction or other hard physical work – including farming back home – HealthServe also offers classes in English and in computer skills, mindful that the best opportunity for work in rapidly urbanizing Asia may be in the service economy, such as in a hotel in a developing nation.

Other health care and social service organizations draw on hospitality as a value, as do some moral theories. Duties to strangers are often prominent in religious ethics, for example, and in cosmopolitan perspectives on social ethics. Where HealthServe goes further is in emphasizing not that guest workers are “guests” – strangers in society – but that all persons are sometimes hosts, sometimes guests. When Dr. Goh describes visits to the dormitories, or other occasions where migrant workers share something of their lives with non-migrants, he refers to the migrants as “our hosts.” He also mentions how difficult it is for him to accept help, in the form of money, from migrants who had been compensated for their injuries and want to make a contribution to the clinic and the community. These experiences remind him how unsettling it is to be a “guest,” whether as a worker or an object of charity.

Nancy Berlinger is a research scholar at The Hastings Center. With Michael K. Gusmano, she co-directs the Center’s Undocumented Patients project. She served as contributing editor to Making Difficult Decisions with Patients and Families: A Singapore Casebook, an open-access online casebook launched this month.

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