#4 Rethinking Primary Care and Support
Charlotte De Kock (UGent), Laurent Demoulin (DIOGENES), Camille Fortunier (ULB), Eric Husson (projet LAMA), Kevin Moens (projet LAMA) and Judith Racapé (ULB)
Editorial coordination: Céline Gautier
Translation: Jane Corrigan
The BSI Position Papers reflect the opinions, thoughts and recommendations of the authors, and are not attributable in any way to Brussels Studies and the Brussels Studies Institute (BSI). The authors assume full responsibility for them.
Some of the most vulnerable people do not have access to existing social and health services. We believe it is essential to strengthen institutional cultures based on a “low-threshold” approach. This means lowering the levels of requirements for beneficiaries in order to truly meet their needs.
The Covid-19 pandemic has greatly complicated the lives of people living in extreme poverty. The closing of social restaurants and public toilets and fountains,1 as well as the requirement to have a national number in order to access preventive services (e.g. tests and vaccines) have had a direct impact on their health and well-being. But, for these people, the health crisis has also above all been a social crisis, synonymous with the loss of financial resources (in particular related to informal work, begging, sex work, etc) and the loss of ties (due to the closing of public services, community centres, etc), as well as with criminalisation, as the order to “stay at home” was impossible to obey for homeless people.2.
This health and social crisis has therefore intensified the logic of coping and survival of vulnerable people and has increased their dependence on primary social and health services. But it has also caused an interesting break in the approach of some support professionals, who say that the crisis has pushed them to shake up their work practices, innovate, break rules, review the conditions and thresholds for access to their services and go beyond institutional compartmentalisation. “In the name of public health, in a practical way, these field workers have ensured the primacy of need over status and the maintenance of social connections, which is seen as vital.”3.
Among the innovations observed in Brussels during this period, let us mention the extension of the capacities of certain temporary housing measures4 and the urgent opening of numerous accommodations5, thanks to the requisition of hotels and with great flexibility regarding the lack of a legal residence permit. Hôtel Sabina, for example, has housed 39 homeless people. The non-profit organisations DIOGENES, L’Îlot and DoucheFlux were responsible for recruiting the candidates, managing the supervision and providing psychological and social support.
Among the innovations from the Covid period, let us also mention the pragmatic decisions taken in the name of health security and risk reduction. Some accommodation facilities therefore tolerated breaches of their internal rules and allowed the consumption of alcohol. A bar was also created within the Tour et Taxis reception centre in order to prevent people from going out during lockdown. Finally, the procedures which determine the right to urgent medical assistance were simplified by some CPASs (public centres for social welfare).
Can we see in these initiatives – born of a health emergency – an opportunity to think differently about access to services and ensure the continued existence of practices which are truly adapted to the public?
On the margins of society and its norms
We are thinking here of all the vulnerable populations, often with no social ties: drug users, sex workers, homeless people, people with a precarious residency status (migrants in transit or “undocumented migrants”, sometimes living in the country for several years or decades), inmates (prisons and detention centres), minors who are vagrants or in exile, etc.
In recent years, we have witnessed a threefold change in these populations: an increase in the complexity of their situations and more “double diagnoses” (30% of the people supported by DIOGENES in 2021 were homeless and had at least two other problems, namely alcoholism, drug addiction or mental health issues,6) as well as an internationalisation and, to a lesser extent, a feminisation of these populations. Marlene’s story illustrates the crux which people can find themselves in. After living on the streets, Marlène was able to obtain housing via Housing First7 and support from a service specialised in addictions, which helped her reduce and stabilise her substance use. She then wanted to find treatment for her depression but psychiatric hospitals refused to take her in because of her addiction. “According to the caregivers, the problem is not the one she complains of (depression), but the one the expert, the all-powerful psychiatrist, decides on (substance use).”.8 The complexity of individual situations therefore requires a holistic approach to care and support, combining social and health aspects.
Moreover, people in a precarious administrative situation (e.g. without a national registration number and/or without a reference address) are not included in official statistics. Support professionals sometimes refer to a 20th municipality of Brussels, made up of all of the homeless and unregistered inhabitants. The number of “undocumented migrants”, on the other hand, is estimated at 100,000-150,000.9 The lack of public and quantitative data on extremely vulnerable populations contributes to the invisibility of the number, the profiles and the needs in question. These people live in Brussels and contribute to the city economically, socially and culturally, but their living and health conditions are scarcely taken into account in the development of public policies.
Prerequisites and thresholds
Age, gender, possession of a legal residence permit, an administrative identity, a reference address and medical coverage are some examples of conditions required in order to obtain certain rights and access to social and health services. These conditions, also referred to as “prerequisites”, are imposed by our political and administrative system, which is split up into levels of competence and whose operations are compartmentalised.
The “thresholds” are the minimum requirements or constraints imposed on people in order for them to benefit from a right or a service. They depend mainly on public policies and the functioning of intermediate administrative or community structures. The theory of thresholds10 constitutes a crucial basis for understanding the issues of non-take-up of rights and the need to lower the requirements for access. Four main thresholds can be identified:
- The threshold of trust. Some socially excluded people do not trust or no longer trust the institutions, which encourages non-take-up. Few services work towards (re)building this trust, by adopting certain attitudes (proximity rather than distance, work based on the identification of needs rather than an explicit request, valuing people’s skills, etc) in order to reinforce their accessibility. Yet “it seems essential to cross this threshold of trust in order to be able to cross the others.”.11
- The threshold of registration or accessibility. Support is usually given following a request. However, it is difficult for some people to take this step, either because they are unaware of the existence of a service, or because they are afraid that the expected benefits will not compensate for the potential loss in terms of self-esteem (admitting that one can no longer manage on one’s own) or control (loss of freedom, independence, habits).12 Timing and the quality of support are key elements in facilitating the access to services.
- The threshold of competence. Requests for assistance must be made in a “compliant” manner: in the right language, at the right time, in the right place, through a standard procedure and consistent with the services offered. Future recipients of care and social assistance are asked to express their needs in the form of a personal project and to show motivation throughout the process (a missed appointment may be penalised with a refusal or termination of support). The right request should also be addressed to the right person in order to receive support (e.g. not asking a social worker for help with a psychological problem, or not asking a psychiatrist for social assistance).13
- The threshold of efficiency or effectiveness. The saturation of many services and forms of assistance (e.g. psychiatric services, treatments/aftercare, temporary housing, shelters, etc) leads to long waiting lists, which makes access to assistance and care complicated, prevents comprehensive care and demotivates people.
A study14 conducted in Flanders shows, for example, that the under-representation of non-Belgians in addiction services is not only explained by individual factors (lack of knowledge of the language, vulnerabilities, lack of trust of the users, exclusion based on language, etc) but also by organisational and political choices (lack of translators, waiting times, etc) which aggravate the situations. The latter are therefore the result of a combination of factors at micro (individual), meso (organisational) and macro (political) levels, and are certainly not due to an individual problem.
During the Covid pandemic, however, there has been an increase in outreach practices, which involve reaching out to populations rather than waiting for them to seek services in accordance with schedules and procedures, thereby reversing the logic of thresholds of accessibility and competence. Multilingual and multidisciplinary mobile teams have been set up15 and cooperation has been strengthened between shelters and services for drug users.
Taking action under the lowest threshold
From a theoretical point of view focused on action, the existence of conditions and thresholds of access to social and health care structures and the evolution of the profiles of marginalised people in our society should be seen from an intersectional perspective16 as well as from an ecosocial perspective17 in the study of health and social issues. This means that we should look at the issue of access as a complex problem involving different vulnerabilities and as an organisational and political problem.
In practice, this observation urges us to reject repressive policies which contribute to increasing social exclusion, to go beyond humanitarian policies which are used in times of extreme emergency but which postpone the search for structural solutions, and to advocate empowerment policies.
The latter will be achieved by broadening or easing the conditions of access to rights, through a structural review of several policies and laws,18 as well as through the strengthening of primary services and their initiatives in the area of access to care. It is a fact: at present, these services do not fulfil part of their missions. It is therefore urgent to encourage them to develop more inclusive strategies such as working with intercultural mediators or peer helpers, opening up to truly vulnerable populations, taking into account mental health concerns at the moment they arise, making the participation and empowerment of these populations visible and alive, and being fully in keeping with an ethic of care.19
This would also involve organising care collectively within different territories (between the Region, the municipalities and the five Brussels “care basins” defined by the Plan Social Santé Intégré20), coordinating paths and taking steps to include users referred by “low-threshold” stakeholders, the very ones which now make up the “0.5 line”21 (situated under the “lowest threshold”). This requires time, resources, advice and the ability to manage cultural change in the teams. This assumption of responsibility and the challenges presented by the territorial issue require us to leave our comfort zone in order to improve the daily lives of vulnerable populations as well as to cushion the blow of the crises to come.
FIND OUT MORE IN OTHER WAYSBooks, articles
On social inequalities in health:
WILKINSON R. and PICKETT K., 2013. Pourquoi l’égalité est meilleure pour tous, Paris: Les petits matins.
On the issue of social and health data collection:
KHALATBARI-SOLTANI S., CUMMING R.C., DELPIERRE C., KELLY-IRVING M., 2020. Importance of collecting data on socioeconomic determinants from the early stage of the COVID-19 outbreak onwards. In: J Epidemiol Community Health, 08/2020, vol. 74, no 8, , pp. 620-623.
DE KOCK C., BLOMME E. and ANTOINE J., 2020. Non-national clients in Belgian substance use treatment. In: Drugs and Alcohol Today, 10/07/2020, vol. 20, no 2, pp. 157-171.
On homelessness issues during the COVID-19 crisis:
ROLAND M., BEN ABDELHAFIDH L., DÉOM V., VANBIERVLIET F., COPPIETERS Y. and RACAPÉ J., 2021. SARS-CoV-2 screening among people living in homeless shelters in Brussels, Belgium. In: PLoS One, 15/06/2021, vol. 16, no 6. Available at: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0252886
On the migrant population and COVID-19:
RACAPÉ J., NOEL A.C., LUREL J., DAUBY N., COPPIETERS Y., GOFFARD J.C. and REA A., 2022. Facteurs de risque sociaux et cliniques associés à la COVID-19 en Belgique. In: Revue d’Epidémiologie et de Santé Publique, 08/2022, vol. 70, Suppl. 240. Available at: https://www.sciencedirect.com/science/article/pii/S0398762022006368
SPIRITUS-BEERDEN E., VERELST A., DEVLIEGER I., et al., 2021. Mental health of refugees and migrants during the COVID-19 pandemic: the role of experienced discrimination and daily stressors. In: International journal of environmental research and public health, 11/06/2021, vol. 18, no 12. Available at: https://www.mdpi.com/1660-4601/18/12/6354
RICHELLE S. and BACQUAERT P., 2022. Corps sales, ville sèche. Brussels: Par Chemins et Ruines. Available to listen to for free at: https://www.radiola.be/serie/corps-sales-ville-seche/
Films and videos
GERME, 2023. Inégalités sociales et Covid-19, Bruxelles: Université libre de Bruxelles. Available at: https://www.youtube.com/watch?v=M9MqeIZ9x_g&t=737s
FRANCHOMME N., 2021. Prostitution: la faim justifie les moyens. In: Libres, ensemble, 30/03/2021. Available at: https://www.laicite.be/emission/prostitution-faim-justifie-moyens/
SCHONBRODT P., 2022. Housing first: un retour en logement porteur d’espoir. In: Libres, ensemble, 18/01/2022. Available at: https://www.laicite.be/emission/housing-first-un-retour-en-logement-porteur-despoir/
DORME Y., 2020. Là maintenant. Brussels: AgentDouble and Les Films de l’Heure Bleue. Available at: https://www.youtube.com/watch?v=Y6Wh8OoW8qc
Charlotte De Kock is a postdoctoral researcher at Universiteit Gent. She conducts basic research and provides policy support on the accessibility of addiction services for people with an immigrant background in Belgium and Europe. She has worked with the Bureau fédéral de la politique scientifique, the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) and Fedasil, among others.
Laurent Demoulin is a sociologist and has been the director of the non-profit organisation DIOGENES since 2001. He has contributed to the creation and development of many social innovation projects for homeless people in Brussels. He recently initiated the creation of a R&D unit within his organisation.
Camille Fortunier is a doctoral researcher (FRESH-FNRS) at GERME, Université libre de Bruxelles. She is also a member of the InES think tank. Her research focuses mainly on social and health inequalities, as well as on the processes of invisibilisation and social exclusion.
Eric Husson is project director at Lama. As a field worker for 20 years, he works with other Brussels stakeholders on the care provided to vulnerable populations, risk reduction strategies and the implementation of low-threshold measures. He also teaches social work at Haute Ecole Louvain in Hainaut.
Kevin Moens is a psychiatrist who has worked at the university hospitals in Geneva, notably in programmes based on diacetylmorphine, and in the Brussels hospital wards devoted to the treatment of addictions. He is currently the medical director of Projet Lama. He also works at MASS in Brussels. His work is focused on improving access to care for the most vulnerable and disadvantaged.
Judith Racapé is a social epidemiologist at École de santé publique at ULB. Since 2017, she has coordinated the inter-faculty chair in health and precariousness in collaboration with Médecins du Monde, Solidaris and Fédération des maisons médicales. Her research focuses on social inequalities in health and the health of precarious populations.
To cite this post: DE KOCK Charlotte, DEMOULIN Laurent, FORTUNIER Camille, HUSSON Eric, MOENS Kevin and RACAPÉ Judith, 2023. Rethinking Primary Care. In: BSI Position Papers, no 4, 03/04/2023. Available at: https://bsiposition.hypotheses.org/1875
- MAY X., BACQUAERT P., DECROLY J.-M., DE GUIRAN L., DELIGNE C., LANNOY P. and MARZIALI V., 2021. Formes, facteurs et importance de la vulnérabilité hydrique dans une métropole européenne, in: EchoGéo, 15/11/2021, no 57. Available at: http://journals.openedition.org/echogeo/22098
- FORTUNIER C. and REA A., 2022. Les personnes précarisées et invisibilisées face au COVID-19 en Région bruxelloise, Research report, Brussels: GERME, Université libre de Bruxelles
- Ibid., p. 389.
- Notably https://ilot.be/issue/; https://www.diogenes.brussels/fr/news-articles/70-covid-19-et-logement-temporaire
- KEYMEULEN F., REA A., ROSA E. and STRIANO M., 2021. A strategy to end homelessness in Brussels. In: BSI Position Papers, 14/06/2021, no 1. Available at: https://bsiposition.hypotheses.org/165
- the Housing First approach is aimed at the social integration of homeless people into society through housing: http://www.housingfirstbelgium.be/fr/
- CENTRE FÉDÉRAL D’EXPERTISE DES SOINS DE SANTÉ (KCE), 2015, Quels soins de santé pour les personnes en séjour irrégulier ?, Brussels: KCE, KCE Report 257 Bs.;
VANMECHELEN O. and VERMEULEN S., 2021. Panorama du social et de la santé à Bruxelles, Brussels: Ars Collaborandi, Cahier 15.
- JACOBSEN K.D., JENSEN T.Ø. and AARSETH T., 1982. Fordelingspolitikkens forvaltning. In: Sosiologi i dag, 1982, no 3, pp. 29–49;
EDLAND-GRYT M. and SKATVEDT A.H., 2013. Thresholds in a low-threshold setting: an empirical study of barriers in a centre for people with drug problems and mental health disorders. In: Int J Drug Policy, 05/2013, vol. 24, no. 3, pp. 257-264.
- Ibid., p. 260. Our translation.
- VAN DOORN L., 2004. Botsende werkelijkheidsopvattingen: Institutionele ratio’s versus de realiteit van de straat. In: NUY M. and BRINKMAN F. (eds), Wanorde in een mensenleven: Een bezinning op thuisloosheid. Amsterdam: Uitgeverij SWP, pp. 57-86.
- Jean Furtos calls this “the semiological inversion of the request”: FURTOS J., 2008. Les cliniques de la précarité – Contexte social, psychopathologie et dispositifs. Issy-les-Moulineaux: Masson.
- DE KOCK C., TOYINBO L., LAUDENS F., ALEXANDRE S., HENSGENS P., MASCIA C., LECLERQ S., JACOBS D. and DECORTE T., 2020. Migrants et minorités ethniques: recueil sur l’accessibilité et l’interculturalité des services pour usagers de drogues. Antwerp: Gompel & Svacina;
DE KOCK C., 2021. Equitable substance use treatment for migrants and ethnic minorities: the entwinement of micro and meso barriers and facilitators. In: Journal of Ethnicity in Substance Abuse, 01/09/2021.
- for example, the Combo and Artha teams (Lama asbl) or the Outbreak Support Team (Médecins Sans Frontières and Médecins du Monde) for squats
- This perspective consists in taking different forms of discrimination or domination suffered by people into account simultaneously.
See in particular CARDE E., 2021. Les inégalités sociales de santé au prisme de l’intersectionnalité. In: Sciences sociales et santé, 03/2021, vol. 39, no 1, pp. 5-30.
- KRIEGER N., 2011. Epidemiology and the people’s health: theory and context. Oxford: Oxford University Press.
- among others, migration policies, housing policies, and the so-called “Drugs Law” (Law of 24 February 1921, concerning the traffic of poisonous, soporific, narcotic, disinfectant or antiseptic substances).
- THUNUS S., DONNEN A., CRETEN A. and WALKER C., 2023. Melting point: situations de vulnérabilité, accès et recours aux soins de première ligne en Région bruxelloise. Brussels: Observatoire de la Santé et du Social de Bruxelles-Capitale. Available at: https://www.ccc-ggc.brussels/fr/observatbru/accueil
- VIGNES M. and ROLAND M., 2022. Ligne et fonction 0.5 dans l’organisation social/santé à Bruxelles, Points de repère, Brussels: BRUSANO.