Illustration photo: Johnny Glos / Unsplash
By Macel Ingles
The first immigrants who came to Norway as migrant workers are now old and in need of elderly care as the rest of the population. The need to adapt elderly care to this group is the new reality that the Norwegian health service is facing.
“They came to Norway to work as cheap labor and contributed to building this country. When they worked here, the plan was to save money and travel back to their countries but this has since become a distant dream,” says Fakhra Salimi, director of MiRA Resource Center for Minority Women.
She added that minorities, due to their diverse cultures and backgrounds such as age, color, gender, language, nationalities, color and reason for being in Norway can find themselves at an increased risk of reduced access to health and elderly care. Furthermore, Salimi pointed out that when minorities grow old, and in dire socio-economic situations, these traits and cultural backgrounds intersect and overlap which can further affect the vulnerability of minorities.
She particularly points out that discrimination when it comes to elderly care in Norway is being experienced at an institutional context. Social institutions such as the health service responsible for elderly care and help apparatus should adjust to the new reality of diversity in society and ensure that minorities from different backgrounds will have equal access to resources to deal with their difficult situations both economically and socially.
At the same time, she said that elderly with minority backgrounds also need to adjust to the Norwegian way of being elderly. They need coping strategies on the individual level, as well as the institutional level. Elderly with minority backgrounds also need resources, stronger networks, and support. The laws and regulations should also be changed to secure equal elderly care for everyone in Norway.
Studies presented at the national conference on equal elderly care – also for women with immigrant backgrounds organized by MiRA Resource for Minority Women confirm that racism and discrimination are being experienced by the elderly minorities, especially women, in Norway.
Epistemic injustice experienced by women of minority background
In her study on immigrant women and the health service in Norway, Sanjana Arora, a researcher at VID (vitenskapelige høgskole) in Stavanger revealed the “injustice” that these women experience and its implications for their capacity to access healthcare in Norway.
Stories told by Immigrants to Arora about their experiences revealed epistemic injustice, a term coined by feminist and philosopher Miranda Fricker to refer to the situation where statements by members of particular groups are systematically neglected or discredited.
Arora cited comments she gathered in the study from healthcare providers made on immigrant women telling them that they are creating drama over their illnesses, and calling their expression of physical pain as “cultural pain or ethnic pain” thereby discrediting information from immigrant women going to the health services. Arora said that these subtle forms of injustices, micro injustices are hard to pinpoint because the comments are not being directed at their ethnicity nor at the fact that they belong to a minority.
She also found that there are some people more at risk of it, people who are more likely to experience epistemic injustice are those who belong to a certain age, ethnicity, identity and gender. These are also stigmatized identities, meaning prejudice and stereotypes exist about them.
In her research, she found that all minority women experience a kind of insecurity in meeting healthcare professionals. This is largely due to a discourse about minorities (as fragile, dramatic or even incompetent) that is held by some healthcare professionals that deny authority to minorities when they seek medical help.
But she explained that women are being discriminated against not just because of age but also for being a woman. Stereotypes about age can be positive, such as association with wisdom, but can also be negative, such as associating old age with being fragile or even incompetent. This intersection of being between a minority and being old, as well as being a woman influences on whether they will be believed and taken seriously in healthcare encounters. In encounters with minority women where these stereotypes and stigmatization are in place, healthcare institutions can even create and reproduce this form of epistemic injustice.
She cited the case of an immigrant mother who has been subjected to criticism from the hospital for not learning the Norwegian language despite the fact that language learning has not yet been offered to immigrants.
A lifelong experience of being criticized for not having learned Norwegian for most minority women trigger feelings of underservingness or non-belongingness that hinder them from asserting their rights and are thus, at the receiving end of unequal treatment at the health service.
When some elderly women did talk about their experiences, their barriers, and the ways they were treated differently, they are left to wonder if the discrimination is due to their skin color, being a minority, or being a woman. Whatever the reason, whether language barrier or negative discourses about minorities, the effect is that immigrant women are seen as less credible in healthcare encounters.
One is therefore bound to ask if healthcare institutions have the resources and skills to understand the needs of elderly minority women. And if they will ever understand what these women are being subjected to is a form of injustice.
When cultural barriers are held up as explanations about elderly minorities in healthcare encounters, it also ignores the issue of power imbalance. The healthcare provider is using its power to take away the credibility from all minority women and to draw a focus on the cultural otherness of older minority women, giving it the power to problematize some cultures, some identities, and all the combinations of being an older minority woman.
Racism in elderly care of immigrants a risk factor
All other studies presented in the conference including that of Zeljka Cvetkovic from the University of Southeastern Norway (USN) on the Migration and Psychological health challenges among immigrants in Norway, Micheline van Riemsdijk (Uppsala University) on Home-base elderly care for immigrants by family members in Sweden, and Afsaneh Koocheck (Uppsala University) on Fair and Healthy Ageing for Minorities: Challenges and Opportunities all point to the same fact that experiences of racism and discrimination put immigrants in a vulnerable position in society and in their ability to access public elderly care.
Cvetkovic found that these experiences of racism and discrimination lead to psychological problems for elderly immigrants and overall health deterioration. For refugees, their experiences at the refugee centers stayed with them as bad memories and carried with them at old age. The lack of integration among migrants through family reunification (as most chose to devote their time and effort to their families) made them dependent on their families at old age and experienced social isolation. Work migrants are also left vulnerable when they find themselves in a situation of heavy work, low pay and not given a chance to learn the language because of workload. All these migrants eventually have difficulties in their social and economic situation that they end up isolated, disadvantaged, and vulnerable to psychological problems and abuse in old age.
She concluded that there is still so little knowledge and understanding of how health services can take care of elderly immigrants.
Economic vulnerability is also a factor in how minorities can access equal elderly care. Most immigrants do not have the same pension rights as the rest of the Norwegian population and this financial vulnerability is also affecting the health of elderly minority women and their capability to access public services. A study by Asla Maria Bø Fuglestad found that the majority of minority women who have not worked and lived less than 40 years in Norway only receive the minimum pension compared to only 22% of the majority population. The minimum pension only provides the barest amount for living expenses for a single pensioner equivalent to about 32% of average earnings.
Fuglestad pointed out that as things stand, the system (to access public services) is unintelligible to these elderly women due to language barriers, lack of knowledge of the system, and low digital skills. Lacking these, these women are unable to access public services and support that they are entitled to, and subject their families to stress in order to help them with their challenges.
She added that to ensure that all men and women get equal elderly care, it is important that homecare personnel and those in the healthcare services have knowledge of the vulnerability factors and take these into consideration, such as the use of professional interpreters for those who speak poor Norwegian. It is also important that the system considers that not all are adept at using digital services and has the same understanding of the system. Employees in elderly care must also have knowledge of the economic realities that many immigrants live in so that they may be able to provide adequate care.
In another study of elderly care in Sweden, Van Riemsdjik also found that elderly immigrants (and the rest of the Swedish population) are not satisfied with the elderly care being provided by the state and that there is a need to provide elderly care for the immigrants in their mother tongue. She concluded that equal elderly care needs cultural competence and cultural understanding of elderly immigrants is important.
So what can be done to cater to the elderly care needs of immigrants? Some of the good practices in other countries include free translation services over the phone in Portugal; cultural support for Russian-speaking elderly with dementia and to their relatives; helpline that provides 170 different languages in Great Britain giving elderly with immigrant backgrounds access to trained specialists that are available 7 days a week for guidance; and elderly care in the mother tongue in Sweden.
In Norway, Farahnaz Bahrani, Senior Adviser of the Directorate of Integration and Diversity (IMDI) said that the state is underway with providing equal elderly care, but admitted that it still has a long way to go. The state, she explained, should be more coordinated when it comes to public services for people with minority backgrounds. She added that there is a need for tighter interdepartmental cooperation and work when it comes to providing equal elderly care to people of minority backgrounds. Aside from the state, she said that the voluntary organizations also have a role in providing equal care to the minorities.
In Norway, legislation is already being changed to address issues on elderly care. The Parliament asked the government in 2021 to establish national guidelines based on the Swedish model on the investigation and handling of elderly abuse cases.
As a response, the government called for the establishment of Trygg Est, a system that addresses and works on the prevention of abuse of elderly persons at risk. It can be organized at the county level (kommune) and is composed of a team that specifically addresses the issue. At present, there are 19 kommunes that have Trygg Est teams in the country. There are a total of 356 counties in Norway.
According to Botngård, it should be made obligatory for every county to establish a Trygg Est team.
Despite problems and challenges, many elderly women with minority backgrounds, Salimi happily reported, have a high level of coping strategies due to their ability to turn to their own social networks and this, she said, should be celebrated.
Salimi also pointed out equal elderly care for minorities is more than just respecting the elderly but is also about adjusting this care to fit their everyday needs including having enough money to cover living expenses, having a place to live, and having the capacity to pay for bills. It further includes not just to exist or survive but also being able to do things extra in between – travel to visit relatives and friends, and not the least spoil the grandchildren.
She also said that as the number of elderly with minority backgrounds is rising in society, it is important and necessary that institutional care also includes them and their needs. She also hoped through the conference, a spotlight would be directed at how gender and ethnicity or intersectionality play into how it is to be aged in Norway and the challenges it brings. Also, she called for the strengthening of the work on equal elderly care and raising awareness of the special situation of immigrant women in Norway.