Legal nationality fulfills the "right to have rights" [20
]. That is, one is legitimized by their membership in a state-centered political community and loses crucial political recognition when nationality is withdrawn or withheld. Without such membership, individuals will almost certainly face grave challenges in accessing their right to health, including the ability to secure basic healthcare and essential medicines. Because our modern political system organizes human beings into nation-states with demarcated boundaries, citizenship of a state is often a prerequisite for claiming ostensibly universal human rights. Following massive displacements and growing statelessness after the World Wars, Arendt noted that such "supposedly inalienable" rights proved unenforceable "whenever people appeared who were no longer citizens of any sovereign state" [20
]. For this reason, statelessness has devastating consequences for the health of persons included within this category.
Academic discussions of the human right to health often assume that every human being has legal nationality. Largely absent from such discussions is a consideration of individuals who have no nationality claims anywhere: stateless individuals who lack any legal relationship to a nation-state. These individuals are deprived of nationality as a result of a "bewildering series of sovereign, political, legal, technical or administrative directives or oversights," including: arbitrary deprivation of nationality by the state, conflicts of law, procedural problems such as excessive fees or unrealistic deadlines, and failure to register a child at birth [3
]. Whereas academic discussions of the human right to health assume that every human being has legal nationality, international human rights law explicitly rejects such assumptions. Article 2 of the UDHR states that
Everyone is entitled to all the rights and freedoms set forth in this Declaration, without distinction of any kind, such as.... national or social origin... birth or other status.
In Article 2.2 of the International Covenant on Economic, Social and Cultural Rights, states commit to guarantee the Covenant's rights "without discrimination of any kind," including discrimination based upon national or social origin, or birth status.
However, the UNHCR's own studies of the efficacy of its human rights doctrines, and in particular the UDHR, have repeatedly demonstrated the difficulties associated with the special case of the stateless. For example, UNHCR's "Report on the Implementation of the 1954 Convention within the European Union Member States" formulated recommendations for harmonization, indicating that:
...most States have not put in place specific mechanisms which will allow the identification and recognition of stateless persons...The possibility for a stateless person to secure residence will often be the necessary prerequisite for him or her to exercise the rights provided for by the Convention, which for the most part are only applicable to persons lawfully staying in the country. States are therefore invited to introduce mechanisms to promote the acquisition of lawful stay in appropriate cases for recognized stateless persons, in particular for those who have no other option.
Signatory states remain unable to identify stateless populations, as most states do not have mechanisms that effectively identify cases of statelessness within their own borders [40
]. This, combined with an apparent reluctance to offer stateless persons access to a full panoply of human rights, has led to the conclusion that human rights law has not yet successfully transcended the barrier of statelessness. While there are ample and prominent acknowledgements of the rights of stateless persons in key statements on international human rights, these assertions have yet to achieve a level of applied efficacy that meets the standards of the organizations that have issued them. A recent evaluation noted that despite the steady increase of accessions in the last ten years, the statelessness conventions have still not been ratified by a sufficient number of states for them to have a truly significant effect on reducing statelessness and protecting stateless persons [40
]. Furthermore, the main thrust of UN efforts with respect to statelessness, and evaluations of the efficacy of documents asserting the rights of the stateless, has been directed at reducing and eliminating statelessness rather than asserting the rights of the stateless [41
]. In important respects this is a tacit acknowledgement of the dire challenges that come along with trying to accord stateless persons equal rights with citizens and, more generally, with justly governing the stateless. More specifically, it calls attention to the as yet unrealized goals expressed in which non-discrimination and free movement, among other rights, are identified as necessary to the realization of health rights for stateless persons [12
]. Furthermore, this approach skirts thorny ethical questions associated with populations that explicitly seek to avoid the imposition of legal nationality. Because of the obstacles outlined in the preceding section, those without nationality are often unable to access specific services and medicines usually available to full citizens. The impacts of these obstacles are reflected in overall poorer health, including higher rates of infection and chronic illness, as well as increased mortality. As noted above, statelessness has been directly tied to obstacles related to documentation, the inability to access healthcare, challenges related to mobility, and shorter-than-average life-spans resulting from the inadequacies associated with lack of legal status. The condition of statelessness is often described as legal invisibility, due in part to the inherent lack of state protections and services that include access to healthcare.
In addition to the status of nationality, individuals also generally require documentation of nationality in order to claim an array of human rights, including the right to health. For stateless persons, acquiring such papers is often impossible. Politics is increasingly governed by "documentary nations," or document-requiring societies which require papers such as passports and identity cards to access social goods ranging from education and healthcare to entertainment and mobility [42
]. Sometimes such documentation is explicitly denied to excluded groups, as was the case in Thailand when the Ministry of Interior directed district officials not to register the births of hill tribe children in 2002 [43
]. In other cases, weak governments simply lack the resources to effectively document their populations. Without proof of nationality many individuals cannot access even the most basic of health services. Lack of documentation (often resulting from ineffective systems of birth registration) plays a significant role in childhood deaths from preventable diseases, which impact millions of children each year from birth to age five. Stateless children may be denied services, including subsidized vaccination programs, or may be required to pay more than patients with citizenship, a circumstance that often erects insurmountable financial barriers [44
]. Children without birth certificates cannot be legally vaccinated in at least 20 countries, and more than 30 states require documentation to treat a child at a health facility [35
]. The availability of documentation has also been cited as a factor reducing the risk of childhood exposure to HIV/AIDS, since identification papers firmly establish a child's age and make them less susceptible to early marriage agreements and sexual exploitation; in Uganda and Zambia, for example, birth certificates are considered key for establishing police protection of children at risk for human rights violations. According to Unity Dow, a High Court judge in Botswana, "[A] person who lacks proof of identity is, in the eyes of officials, a non-person" [45
]. In other words, statelessness is a condition that can arise not only in circumstances of conflict and displacement, but also where state bureaucracies are not able to maintain a monopoly on the administrative facets of citizenship. For the purposes of individuals who need to claim rights such as the right to health, weak states produce an effect similar to ascriptive exclusion or war-induced displacement. At the end of the day each leaves people without legal nationality.
Despite these connections between nationality and the right to health, the medical community has largely overlooked the problem of statelessness. There are numerous clusters of stateless populations around the globe, including clusters in Côte d'Ivoire; Sahrawis taking refuge in Algeria; the Banyaumulenge in the Democratic Republic of Congo; Eritreans in Ethiopia, Nubians in Kenya; the Rohingya in Burma; ethnic "hill tribes" in Thailand; Bhutanese refugees in Nepal; Palestinians, Kurds and the Bidun (also Bidoon or Bidoun) throughout the Middle East; the Roma in some parts of Europe; Meshketians in Russia; a variety of other groups throughout former Soviet republics; and numerous ethnic groups across Africa and, to a lesser extent, Latin America [36
]. In many cases, these groups are absent by name from the medical literature or are mis-described with the use of terms like refugee. Arguments for a connection between the nationality of such groups and their access to health services are absent. Most discussion centers around the provision of specific or general medical services in ad hoc
fashion to ameliorate the immediate or long-standing consequences of displacement. However, there is little or no discussion of remediation via the recognition of a standing right to health, and the consequent responsibility of the host nation to provide such services - in effect, to recognize the medical citizenship claims of such groups. In the next section we present three brief case studies that illustrate the potentially direct connection between legal nationality status and access to healthcare: the Roma of Europe, the hill tribes of Thailand, and Palestinians in Israel.
The Roma, a linguistically and religiously diverse population that migrated to Europe in several waves from northern India over the past millennium, represent a major stateless population throughout Europe, particularly in the former Soviet bloc states. Although information on Roma populations is often limited and varies by country, many (but not all) Roma lack legal nationality [36
]. In many cases, desperately poor and ethnically marginalized Roma populations have been excluded from full citizenship by a patchwork of laws, as well as by circumstances that prevent full documentation [46
]. For some Roma, it may also be that documented legal nationality imposes costs and requirements that they regard as burdensome and intrusive on their own political identity [47
]. These situations occur despite the adoption of the 1997 European Convention on Nationality and the 2006 Convention on the Avoidance of Statelessness in relation to State Succession, as well as the aforementioned international agreements. Based on United Nations estimates, the Council of Europe estimates that there are currently 679,000 stateless individuals in Europe; the Roma makes up a significant portion of this population [36
The consequences of Roma marginalization (including poor educational opportunities, poverty, and stigmatization) certainly contribute to severely compromised health outcomes in essentially all Roma populations [46
], but it is important to also note the core problems of documentation and citizenship status impacting this group's ability to access rights in general. The European Roma Rights Center has recently reported a number of barriers to accessing documentation, including population displacement after the Balkan wars in the 1990 s, relatively low birth registration rates, difficulty in replacing lost citizenship documentation due to cost or illiteracy, and simple obstruction and arbitrary decision-making on the part of granting officials. Beyond these highly specific causes, more general citizenship policies have tended to draw citizenship lines around the majority population in many recently unfederated nations, to the exclusion of minority groups such as the Roma [46
The combined effects of these issues, which essentially deny nationality to many Roma, have downstream effects upon the right to health. For example, Boika and colleagues conducted a qualitative study of Roma healthcare seekers and policymakers in Bulgaria, and found that changes in one's place of residency and/or a lack of identity documents resulted in the inability to register with a physician in order to obtain health services [51
]. The European Committee of Social Rights ruled in April 2009 that Bulgaria was in violation of the European Social Charter by failing to meet its obligations related to providing Roma populations with adequate access to healthcare. The Committee found that "significant cases of discriminatory practices against Roma in provision of medical services" was occurring throughout Bulgaria, including government restrictions on health insurance and social assistance as well as a lack of systematic measures to promote health awareness [52
Similar problems facing Roma populations are prevalent throughout Europe. In Macedonia, for example, many Roma are explicitly excluded from Macedonian citizenship, and hence from state health insurance [46
]. In Romania, inadequacies related to Roma health have been linked to a lack of health insurance, specialized medical personnel, adequate medical infrastructure, doctors' goodwill, and basic information on fundamental rights. The exclusion of Roma from the national healthcare system is reflected in statistics illustrating high rates of premature births and infant mortality, chronic measles and tuberculosis foci, lice infestations, and a life-expectancy well below the national average [53
The Hill Tribes of Thailand
The stateless population of Thailand is currently estimated to number 2 to 3.5 million, despite efforts on the part of the Thai government to grant nationality to some members of "hill tribe" ethnic minorities. Part of the cause of Thai statelessness lies in other policies that contradict the nationality-granting efforts. As noted previously, policy decisions to not register the births of hill tribe children thwarts recognition of the existence of these individuals, and hence makes granting of nationality all the more difficult [43
]. Additionally, many members of the Karen and other hill tribes have been displaced over several generations of war in neighboring Burma, and their nationality is not recognized by either state [43
Lack of nationality and the resulting absence of documentation prevent stateless persons from accessing affordable healthcare in Thailand. The government introduced a subsidized "30-baht plan" in 2001 with the intention of universalizing access to healthcare. In order to take part in the program, individuals must present identity documents to local administering officials in order to receive a "gold card" that ostensibly allows them to obtain basic health services for a fixed fee of 30 baht, or roughly US$0.88. The program has covered nearly 14 million people who were previously uninsured [55
], yet roughly 4.4% of the population still lacks health insurance. Since its inception in 2001, a primary reason that people are denied access to the 30-baht plan is a lack of identifying documents [55
], which is a particular problem for the stateless population of Thailand. Without documentary proof of Thai citizenship, an individual cannot access affordable healthcare under the 30-baht national program.
While there is no established causal relationship between statelessness and poor health in the Thai population, it is probable that lack of legal nationality stands in the way of access to health services and coverage [54
]. As nationality begets documentation, and documentation begets access to the 30-baht plan, the lack of nationality amounts to a denial of basic health services that are available to all formally recognized Thai nationals. The effects of this denial are magnified for otherwise vulnerable populations, such as children and women of childbearing age. For example, the rate of child malnutrition is much higher among hill tribe children than it is for their urban, more fully enfranchised peers. These children also tend to have comparatively high rates of conditions associated with nutritional deficiencies, such as scabies, diarrhea, and lung infections [57
]. Physicians for Human Rights additionally links lack of nationality to the denial of reproductive health services for women and girls [43
Conflict within neighboring Burma has also contributed to the troubled health situation of hill tribe members in northern Thailand. Members of the Shan minority, for example, have been driven across state lines as a result of widespread abuses by the Burmese military regime. Denied refugee status or nationality in Thailand and often recognized only as enemy "insurgents" in Burma, these stateless individuals are often forced into exploitative situations (such as the Thai sex industry) and are simultaneously denied basic healthcare services. Data on stateless Shan migrants in Thailand indicates that this group bears a disproportionately high burden of infectious diseases, especially HIV, tuberculosis, lymphatic filariasis, and some vaccine-preventable illnesses. Not only does this situation undermine the right to health, it also undermines Thailand's ability to control many infectious diseases that may spread throughout broader populations [58
The complicated case of Palestine is a further illustration of the relationship between legal nationality and the right to health. Palestinians, who represent the world's largest stateless population with more than four million stateless people located throughout several countries [59
], often suffer negative health consequences due to their inability to freely travel to hospitals and access medical supplies. Israeli immigration and citizenship policies have been cited as human rights violations due to inherent discrimination based on race, and stateless Palestinians residing within the Israeli state's borders face detention as illegal residents [60
]. It is important to note that not all Palestinians are stateless, however. The term "stateless" here implies that some Palestinians have not secured legal nationality of an established state (such as Israel, Lebanon, or Egypt), not that this group currently lacks Palestinian statehood.
Stateless individuals in Israel have severely compromised and irregular access to national health insurance and social services. Although Palestinians residing within the 1967 state borders usually retain Israeli nationality and are able to access rights, permanent residents residing in the outskirts of Jerusalem and Palestinians living in the occupied territory do not have such state protections [59
]. They are at risk for interruptions in access due to policy shifts, such as when the Israeli Ministry of the Interior revoked residency status of Palestinians residing outside of Jerusalem, confiscated ID cards, and deprived these individuals of health services, national insurance allowances, and rights of movement [61
]. Some may access humanitarian aid via the United Nations Relief and Works Agency for Palestinian Refugees in the Near East (UNRWA), which means that many stateless Palestinians are not covered by the 1954 Convention Relating to the Status of Refugees (since those receiving UN assistance are not covered by the statelessness convention); those who have not attained Israeli or other nationality, however, remain stateless and often suffer the consequences of their lack of effective legal status [36
Although standards of health are generally higher in the occupied Palestinian territory than in several other Arab countries, they are substantially lower than in Israel [62
]. Health services for Palestinians in the occupied territory were neglected and under-funded by the Israeli military administration between 1967 and 1993, resulting in shortages of staff, hospital beds, medicines, and a range of services. Independent Palestinian health services have since been developed in an attempt to fill the gaps, yet they often lack health personnel (especially in areas such as family medicine, surgery, psychiatry, and nursing) and fail to meet consistent standards for training, equipment, and overall quality [62
]. These shortcomings have direct consequences on health indicators; for instance, infant mortality rates stalled at around 27 per 1000 from 2000-06, the same as in the 1990 s, and indicate a slowdown of health improvements, a possible increase in health disparities, or an indication of deteriorating conditions. Stunting in children, an indicator of chronic malnutrition and increased disease burden, has risen from 7.2 percent in 1996 to 10.2 percent in 2006. Additionally, incidences of pulmonary tuberculosis, meningococcal meningitis, and mental health disorders have also risen in recent years [62
Many Palestinians rely on only six hospitals for routine, emergency, and specialized treatments. Yet, the difficulties in securing necessary travel permits to drive to those hospitals have led to reductions in patient admissions by 50 percent [61
]. Researchers contend that denied or delayed passage at government checkpoints have significantly affected access to civilian medical care, and that Israel's prior closure of access to the Gaza Strip seriously impeded operation of clinics and hospitals there. At least 68 pregnant Palestinian women have given birth at Israeli checkpoints since the beginning of the second Intifada in September 2000, resulting in at least 34 miscarriages and the deaths of four women [63
]. A wall built to divide the West Bank from the rest of Israel has also impeded access to medical care, particularly for Palestinians living in the closed zones between the Wall and the Green Line; in that most vulnerable region, 79 percent of families are separated from health centers and hospitals [63
]. Unable to attain effective nationality and separated from health services allocated to the Israeli polity, many Palestinians cannot access their right to health.