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We’re Treating Them As Homeless: Health Care Access for Undocumented Migrants in Poland

Imagine you are a migrant, seeking economic and political freedoms offered by the European Union. You are one of many who have entered Poland, which as of 2004 became part of the border of “Fortress Europe” by entering the EU. Poland’s accession, combined with its Schengen implementation in December 2007, has created a burgeoning immigration situation. What happens when you, an undocumented migrant, need health care in Poland?

The short answer is, nobody really knows. To be an illegal migrant in Poland is to be, for all intents and purposes, homeless. When the word “homeless” is used by health care workers and government officials in the context of the undocumented, it is not a literal designation. It refers not to the possession of shelter and a bed, but to an utter lack of options and social connections. And “homeless” is an adjective that conjures exactly the right picture of health care access for undocumented migrants: there isn’t much of it, nor is there much knowledge about it. 

The long answer is, well, longer. Due to the scarcity of information, we rely partly on theory, a smattering of reports from people working on the ground, and extrapolation from what information there is, to tease out an admittedly hazy picture of undocumented migrants’ access to health care in Poland. All in all, lack of information is a big part of the story. With publications and urgent discussions on this issue taking place in EU member states to Poland’s west, the comparative lack of knowledge is frankly shocking. 

Theoretical Access: “Rights”, Laws, and the Polish System

The right to health care is anchored in international human rights treaties. It is most explicit in the UN International Covenant on Economic, Social and Cultural Rights of 1966. According to article 12(1), "The right of everyone to the enjoyment of the highest attainable standard of physical and mental health" is recognized. The Committee on Economic, Social and Cultural Rights specified this further: "States are under the obligation to respect the right to health by, inter alia, refraining from denying or limiting equal access for all persons, including prisoners or detainees, minorities, asylum seekers and illegal migrants, to preventive, curative and palliative health services; abstaining from enforcing discriminatory practices as a State policy…” (PICUM, 2007b).

Although the phrasing of the right to health care suggests that "everyone" has the right to the enjoyment of the highest attainable standard of physical and mental health, in practice the situation remains difficult and access to health care is often tied to citizenship. For example, Article 1 of the European Convention on Social and Medical Assistance (Council of Europe 1953) and Article 13 of the European Social Charter (Council of Europe 1961) require that the person's country of origin is party to the treaty and the person must be lawfully present in the territory of another contracting party in order to be entitled to the equal access to medical assistance. Put differently, the scope of the “the right of everyone to access preventive health care and the right to benefit from medical treatment” of Article 35 of the Charter of Fundamental Rights of the European Union can be restricted on the grounds of citizenship and migration status (Romero-Ortuño, 2004).
 
The European Commission acknowledges that “illegal immigrants are protected by universal human rights standards and should enjoy some basic rights, e.g. emergency health care and primary school education for their children.” In spite of this, EU member states sometimes resist extending equal access to health care to undocumented migrants, assuming that a "too generous" provision of health care may be a pull factor for illegal migration. However, empirical evidence shows that migrants usually do not compare the benefits of different welfare systems when choosing a destination country (Romero-Ortuño, 2004).

In Poland, when it comes to refugees, persons applying for refugee status and those under subsidiary protection can more reliably obtain access to healthcare. According to the Act of Aliens of 2003 (with an amendment in 2008), those waiting for refugee status are provided with care at reception centers. 

Access to health care in Poland must, above all, be seen in the Polish context. In other words, the Polish system and the laws governing that system impact the situation greatly. In European countries with national health systems, there are two basic categories: National Health Service (NHS) countries like the UK and Spain, and Social Health Insurance (SHI) countries like Germany, the Netherlands, and Poland (Romero-Ortuño, 2004). NHS countries entitle citizen taxpayers to a minimum standard of coverage, and they tend to lean toward “single payer” models – that is, the government paying providers directly. SHI countries, on the other hand, support the existence of third party payers. In Poland’s case, workers pay a compulsory percentage of their salaries (8.5%) as a premium for their insurance coverage by the National Health Fund (NHF). People who qualify for unemployment or social assistance benefits are covered completely by the Polish state, and people with asylum status or “tolerated stay” may qualify in one of these categories.  

Poland, unlike some other SHI countries (e.g. The Netherlands), has a highly developed private clinic system. This system is used by Poles unwilling to wait through the queues in the public system, who then essentially pay for care twice. 

The difference between SHI and NHS countries can have severe ramifications for people who are undocumented. “In SHI [systems], providers are reluctant to treat uninsured people who appear unable to pay because, beyond the specific clauses in the law, any expense incurred will not be refunded. Humanitarian behavior is thus perceived as synonymous with a loss of income”.  Doctors working in NHS systems are often salaried, and so do not have disincentives to treat people without insurance or documentation. 

The legal framework for migrant health care access in Poland stems from the Act on Aliens of June 13, 2003. Note the date: we are speaking here of policies implemented immediately prior to Poland’s accession into the European Union. This law provides for (mandatory) medical screening in detention centers, and the essential right to health for foreigners, that they may “access medical aid or be put in a medical center if his/her health condition so demands.”  Basically, this law provides for medical care for some immigrants – those in detention centers facing expulsion and those “documented” migrants seeking asylum or having some legal status. In most cases, the Polish state is picking up the tab. We will examine below whether this care is adequate in practice for documented immigrants, but it suffices to note that there is no mention of undocumented migrants outside detention centers. 

Who Are These People?

A migrant is considered illegal if he is staying in the territory of Poland without a required visa, permission to live in the territory of Poland, or permission for long-term residency in the European Community. Working illegally, as in most Western countries, can easily get one deported.   

In detention centers, which may represent (by percentage) a reasonable swath of the total population of undocumented, Vietnamese make up the largest group, followed by Chechens. The Office for Foreigners estimates that the total population in all centers, both detention and reception, is about 7,000.  This number has doubled in the last three years. By contrast, the Helsinki Foundation estimates that there are anywhere from 80 to 100 thousand illegal migrants living in Poland at the moment.  

The reasons for illegal migration, or “pull factors,” are also fairly clear. People are seeking the economic opportunities, political stability, and personal freedoms afforded by the EU, and the freedom of travel within it. Once expatriate communities establish themselves, whether above or below the radar, those communities can act as “pull-factors” in their own right.

Working it out on Paper: Barriers in Theory

Empirical evidence shows that undocumented migrants in many countries are using health facilities to a much lesser degree than the overall population. For instance, in the Netherlands it was estimated that the contact rate of undocumented migrants towards general practitioners is 70% that of legal residents. Apparently, there are certain barriers to accessing health care on the side of the migrants as well as on the side of the health institutions. These may prevent undocumented migrants from approaching practitioners and obtaining basic access to health care to which they are entitled by international treaties on human rights and/or national law (Romero-Ortuño, 2004). This section will give an overview of the theoretical barriers both on the demand and supply side which undocumented migrants may be facing. Then, we will try to understand how these barriers play out on the ground in Poland. 

In principle, there are two different areas which can affect access: demand and supply. Demand refers to conditions influencing undocumented migrants themselves, and supply to the institutions providing health care. Some factors, at least theoretically, reach across both areas. These factors include lack of information, complex administrative procedures, cultural issues, and language problems. One can see how these could affect both sides: lack of information, for instance, could apply to migrants (“How do I fill out all this paperwork?”) or to doctors (“How do I make sure I’m paid for this visit?”).

There are three factors on the demand side alone: fear, lack of finances, and lack of time. Immigrants, rightly or wrongly (depending on the country’s laws) may fear being reported by health care workers to the authorities. They may lack the money to access health care, as well as the time away from work and family. 

On the supply side, four obstacles can theoretically present themselves when undocumented migrants need health care: ambiguous legal definitions of entitlements, lack of implementation previsions, “the duty to denounce,” and discrimination. The first two issues present themselves when health care workers are unsure or unable to do what the law (or their consciences) requires of them. “The duty to denounce,” refers to the idea, which may be real or perceived, that civil health care workers have a mandate to report undocumented migrants to the authorities. Finally, health care workers may outrightly discriminate against migrants, regardless of what is theoretically required of them.

What is the Health Situation?

The public health situation among undocumented migrants in Poland is difficult to ascertain. There is, frankly, a complete absence of data on the subject. However, after speaking with activists and health care workers, and by extrapolating from groups whose conditions are better understood and catalogued, a rough picture has emerged.

We begin with information on Chechens in refugee centers. Although these migrants are not “undocumented,” they would reasonably be expected to represent the general health picture of Chechens in Poland, who do make up a sizable part of the undocumented population. @lterCamp, a project to help refugees with social and professional integration, gave a conference on 27 June 2008. In an attempt to provide much needed psychological care, they conducted a program in the Czerwony Bór refugee center focused on providing mental health services for refugees awaiting their status. Two psychologists for adults and two for children were provided one day per week at the center. Because Chechens dominate the population of Czerwony Bór, the project provided a “mentor” of Chechen origin as an on-site interlocutor. 

Chechens awaiting their status face psychological obstacles from multiple angles. Often fleeing under extreme economic or violent duress, their recent past can manifest itself psychologically and psychosomatically. Moreover, months of uncertainty while they await their status are stressful in the extreme. Psychologists in the @lterCamp program have described the results of these past and present pressures: nightmares, problems with memory and concentration, emotional numbness, and returning psychological problems that may have previously been in remission. 

Children in the camps face additional challenges. @lterCamp psychologists worry they are skipping essential stages in emotional development. One workshop revealed kids associating a cat’s purr with military tanks. Their very ability to make positive metaphorical associations may be compromised by their situation. The @lterCamp program ends June 2008, having run since 2006.

In comparison, workers and activists attest to a similar prevalence of psychological disorders within the undocumented community. Sister Maria of the Migrants Center is concerned with the number of illegal migrants who seem to have advanced “mental disturbances.” They are frightened and suspicious of most Poles, even those who are on their side. She related a story of a man who came into the center with a clearly severe mental illness. She “made the mistake” of arranging a hospital visit for the man through back channels, only to have him flee without returning. An immigrant from a former Soviet satellite state, she guesses he harbored a post-communist mentality about centers for mental illness: you go in but don’t come out. The Migrants’ Center attempted to alleviate this problem by having a psychologist come to the Center itself, but this also proved ineffective: most people who visit the center distrust even its workers, let alone a shrink from the outside.  

Such evaluations, however, deserve a heavy dose of caution. As Dr. Adam Tołkacz, a physician coordinating the Polish state’s medical response in the refugee centers noted, it is difficult for people without medical training to assess the health situation of people they come across. Mental illness, because it is often more visibly manifested than internal medical issues, is likely noticed more often. He went further, claiming that at least for people in refugee centers, psychiatric and psychological problems are no more prevalent than in the Polish population at large. 

At the very least, though, the mental health situation of undocumented migrants is different than for average Poles. The prevalence of these migrants coming from Chechnya increases the odds of post-traumatic stress disorder and related conditions among their population. In addition, psychological problems may result from prolonged stays in detention centers.  In summary, we can assume that there is a somewhat different mental health profile among undocumented migrants in Poland, resulting from experiences before and after immigration. 

What, then, is the internal medical profile of undocumented migrants? To answer this, we may assume that the profile of people in refugee centers at least somewhat mirrors that of the undocumented. These reception centers screen people for epidemiological threats (HIV, tuberculosis, hepatitis), and treat them for these conditions when applicable. In general, they have a higher rate of communicable disease than the population at large.  People coming from conflict areas such as Chechnya have higher rates of conditions associated with head and neck trauma, and orthopedic problems.  But without any good data, it is nearly impossible to construct a health profile of undocumented migrants in Poland beyond this. 

Access on the Ground: Does it exist at All?

Those who are not insured through their employer or a family member, and who do not qualify for insurance free of charge, are not eligible to receive care through the NHF. This is perhaps the starkest barrier facing undocumented migrants seeking health care in Poland. Until recently, there was an exception to this: children under the age of 18, as well as pregnant women (through childbirth and puerperium), used to be entitled to free care by the Polish state regardless of their status. This changed in 2007; now, anyone without insurance will be treated, but billed if they have no insurance through NHF.  

If the financial barriers do not deter undocumented migrants from accessing public care, fear of discovery may. According to the Helsinki Foundation’s interpretation, living in Poland “illegally” – that is, without proper documentation or status – is not a crime. Public officers and civil servants have a duty to report crimes, but undocumented migrants are committing something more akin to a misdemeanor subject to a fine, and thus there is not technically a “duty to denounce.” This interpretation is not uniformly shard by offices in the Polish government. There have been cases where registration offices have informed government officials that undocumented migrants approached the registration office in order to get married. Also, in some cases the registration offices asked for valid visa, despite the fact that such documents are not required by law in order to get married. Knowledge of such cases, and a reluctance to take the risk, likely deter undocumented migrants from seeking health care from public sources. 

Finally, there are nagging bureaucratic problems which confront undocumented migrants. Because they lack certain identifiers, like a PESEL number (akin to a Social Security number), they have trouble getting into the system and being processed. This problem can arise even for documented migrants with asylum status accompanied by native advocates, so a fortiori such barriers would exist for the undocumented. 

Sometimes, options run out. One undocumented woman, we learned from Association for Legal Intervention, gave birth in a NHF hospital after the 2007 policy change. Thus, she could reasonably have expected to foot the bill. The larger problem, however, was that she delivered after only five months of pregnancy. Facing enormous medical costs associated with neonatal intensive care, she applied for refugee status, in order to receive health insurance until the decision was rendered. Chrzanowska, who was familiar with her case, admitted, “In this sense she gamed the system, but what other choice did she have?” Her asylum case is still pending. 

Private doctors are a way to avoid queues and questions about documentation, but they require both financial and language resources many undocumented migrants do not have. There are exceptions, though. We spoke with one migrant who had immigrated twenty years ago from Zambia, to study in Warsaw. Upon completing his studies, he ended up staying, and has been living in Poland since. His financial resources, comparatively high level of education, and fluency in Polish make the private system an option for him. He has used private doctors for the last twenty years, paying out of pocket to doctors who ask few questions. Recently, however, he has applied for refugee status, and is now eligible for free medical treatment through the NHF as he awaits his result. 

Another broad exception is the Vietnamese community. Father Osiecki of the Migrants Center estimated that there are 30,000 Vietnamese in Poland, and roughly half are undocumented. The size and the strength of the community, however, give its members a large measure of protection. Combined, they have the financial resources to cover fees charged by private doctors. Dang Thu Huong, a recent graduate of the Medical University of Warsaw, is an example (though exceptional) of the community’s resources. She gives medical advice to Vietnamese patients, redirects them to appropriate institutions and clinicians, and assists in translating. According to Dr. Huong, the Vietnamese – whose health profile is little different than average Poles – only approach doctors if they have severe problems. For common ailments, traditional treatments are widely used. Medicinal herbs are bought and sold at places like Warsaw’s Stadion Dziesięciolecia.  

According to Father Osiecki of the Migrants’ Center, many Vietnamese actually opt to allow their legal status to expire once they are settled in Poland. Doing so saves them 8.5% of their income toward NHF health insurance, for example, a service they under-use anyway. Combined with the other taxes they avoid paying and the ability of the community to support itself internally, many Vietnamese view this as a good option.  However, this only works if serious, expensive illness is avoided. 

If the barriers to health care in the public and private spheres are high enough, there is another option. We wander the labyrinth underneath the Warsaw train station, through the shops and platforms and along the commuter train depot, and came across a modest sign with a red cross. On the sign is written, “Punkt Pomocy Medycznej” (“Point of Medical Help”). A small square window with crisscrossed bars and a heavy door stand between the train station staircase and a clinic whose size would qualify as livable only in the middle of Manhattan. An exam room with barely space for two people to walk past each other is up against what look like storage rooms. 

Point of Medical Help is a charity organization geared mostly at providing medical care for Warsaw’s homeless population. We talked to the nurses who staff this clinic every day. This particular one is headed by a priest of the Camillian order, whose monthly budget of 4,000 PLN is provided by the City Council. These two gregarious nurses run the place, though some physicians do have clinic hours a few times a week (a surgeon, dermatologist and internist). Of the 800 patients they see per month, most are homeless Poles, though some are foreigners and of these not a few are undocumented. To receive care here you must submit to a photograph and registration, but your identity is not verified, and police who occasionally snoop around are shooed away. 

With such a small budget, the care these charities can provide is very basic. Point of Medical Help can provide their patients with basic medicine and some prescriptions, but their resources are limited. According to the nurses there, psychiatric problems are one of the biggest issues, and go untreated.  Other charitable health care organizations have a similar profile. Doctors of Hope, an only slightly larger clinic near the Warsaw uprising cemetery, is funded by the City Council and supplemented by private donors, and has the same shortages. Specialists hold clinic there as well (dermatology, ophthalmology, psychiatry), but there is no lab equipment to conduct even basic blood tests, and no contract with NHF for outside assistance. But they see undocumented migrants as well, almost 70 in the last year, mixed in among the homeless Poles of Warsaw. 

Although it hardly qualifies as an “option,” should an undocumented migrant be detained in Poland, they are taken to a detention center. In accordance with the June 2003 Act on Aliens, health care is provided, paid for by the Polish state. These centers exist for the purpose of holding people awaiting deportation. “As for nationalities of detainees, the Vietnamese definitely make up the largest group, followed by Chechens, Armenians, Byelorussians, Pakistani, Sri Lankan and also Chinese and Africans” (Caritas, 2007). In the centers, migrants wait between three months to a year for a decision to be made on expulsion.  At the end of this period, they are either released back into society for lack of proof of their state of origin, or they are deported. The majority of people detained “are not criminals…[yet] the centers are prison-like places, with little respect and understanding for people from different cultures. The authorities justify the isolation imposed on detainees by recalling that they have disobeyed Polish law by entering the country without the legally required permission to do so” (Caritas, 2007).

The quality of care in the centers varies depending on who is asked. A 2007 Caritas report on Polish detention centers states, “Detainees undergo a medical check-up when they are placed in a detention facility, and they also have the right to visit the doctor. Most of them reported that the medical aid provided was very basic and that internal and psychological illnesses were not properly treated. Stress-related illnesses are somewhat ignored. Psychological support is available in the center on request, but detainees do not avail themselves of this service as they feel it is neither objective nor effective” (Caritas, 2007).

We went and talked to government officials about these claims. The Office for Foreigners stresses that refugees in detention centers do have access to specialists, whom they can approach either at the centers themselves, or externally. Outside consultations and treatment are based on agreements between the Office for Foreigners and the Central Clinical Hospital (CCH) of the Ministry of Interior Affairs and Administration. The CCH is responsible for coordinating the health system in the centers.  Whether they have adequate access is the real question.

In adjudicating between different perceptions of adequacy, we asked Agata Foryś of the Helsinki Foundation to provide some perspective. According to her, migrants often have very clear ideas of what they want from physicians, and are sensitive to perceived slights. This may stem, she conjectures, from an inflated perception of Western medicine’s efficacy some immigrants harbor from their countries of origin.  

A point of comparison for the detention centers are reception centers, which cater to those who are applying for refugee status in Poland. In contrast to the detention centers, these are overwhelmingly populated by Chechens.  The Office for Foreigners coordinates and pays for these refugees, persons applying for the refugee status and those under subsidiary protection to be cared for. They are able to access health care at the detention centers and at the Central Clinical Hospital and the hospitals nearby, at a level of quality very comparable to that of Polish citizens.  Katarzyna Sekuła of Caritas Polska and Foryś have both emphasized that, in many cases, what appears to be discrimination in the case of legal migrants attempting to access care through the NHF is actually the result of a less than optimal Polish health care system. “Polish citizens themselves face long queues when accessing specialists. At least for people who are legally in the country [i.e. refugees, those awaiting status, tolerated stay], the laws are fairly good, but the system itself is inadequate.”  

In fact, the situation for this group – refugees who have either been given a status or who are waiting for it – has actually improved recently. Aleksandra Chrzanowska of the Association for Legal Intervention has seen progress both bureaucratic and among health care workers themselves. Three years ago, for example, it was sometimes inordinately difficult to get migrants with state insurance but without PESEL numbers into hospital systems. She also saw cases of clear discrimination where nurses or doctors would avoid treating foreigners. Things have improved dramatically in the last few years. Except for the odd triage nurse or doctor who is discriminatory or randomly unhelpful (“Why are migrants coming here, when we have enough problems treating Poles?”), things are markedly improved. No law has changed in this period, only attitudes and practices. But again, we are speaking here of insured migrants, entitled to care while they wait for a verdict on their status.  

Conclusion: Policies and Perspectives

The Platform for International Cooperation on Undocumented Migrants, a platform of civil society organizations with more than 180 members in 20 countries in Europe and beyond, stresses the lack of access to health care (alongside with death at the border, exclusion from the workplace, and children's rights) as one of the major challenges which are faced by undocumented migrants (PICUM 2006).

In 2007, PICUM released a report on undocumented migrants' access to health care.  PICUM gives ten policy recommendations which governments should take into account when designing their strategy to deal with access to health care for undocumented migrants. 

When confronting the Polish situation with PICUM's policy recommendations, the Polish reality only “complies” with two of the ten. More specifically, Poland is in line with the recommendations to “Detach health care from immigration control,” meaning that no duty to denounce exists for Polish health workers (according to the interpretation of the Helsinki Foundation). Also, “No criminalization of humanitarian assistance” exists in Poland as far as we can tell; apathy rules, and what is not cared about is rarely criminalized. The eight other recommendations are irrelevant because they presuppose a government strategy to address undocumented migrants' access to health care. The Polish government simply does not have an official strategy to address the issue. However, the lack of government strategy does not mean that these migrants are completely deprived of health care. As outlined above, undocumented migrants can access private doctors (if they can overcome financial and language barriers), approach charity institutions which provide basic health care, and can receive treatments at public health institutions in case of emergency (though paying afterward). But, as we have shown, these are tenuous options, and reliable access remains elusive. 

The question begs to be asked: why doesn’t Poland have any official strategy to address health care for undocumented migrants? Perhaps a better question is, what conditions must exist for a developed country to have a policy? The United States certainly doesn’t have one, which is unsurprising for a country that lets 50 million of its citizens go without health insurance. Poland seems stuck in the middle. True to European form, it provides a means for covering all its citizens. But in a country on the border of Europe, which has had only four years of EU cash influx, concerns about the welfare of the Polish nation are understandably front and center. Yet the problem of medical care for Poland’s undocumented migrants will not fade away. If Poles in Dublin are returning to Warsaw, Poland will be no less attractive to those outside Europe’s walls. 

What, then, is to be done? The most immediate need is knowledge. Research must be done on Poland’s undocumented migrants, especially their health profile, as the first step toward ensuring they have care. Second, the efforts of the government, and the enormity of this task, must be acknowledged. Having been confronted with a doubling of the population in refugee and detention centers, a population that often appears non-compliant with treatment regimes, the Office of Foreigners has a huge job already. In sum, it will not suffice to blame government alone for its inaction on making sure everyone within its borders are cared for. Economic and social human rights are fundamentally different types of rights than civil and political; they cannot be guaranteed by simple legal enforcement, but only by sustained effort and societal infrastructure. In Poland, providing them will take detailed knowledge of the health situation we have pointed to, a government committed to a human rights view of healthcare funding, and a Polish nation willing to see itself as part of a larger community, both inside and outside of Europe.

References

Works Cited:

Caritas (2007), “Civil Society Report on Administrative Detention of Asylum Seekers and Illegally 
Staying Third Country Nationals in the 10 New Member States of the European Union”: 99-113
PICUM (2007a), “Main Concerns About the Fundamental Rights of Undocumented Migrants in 
Europe in 2006,” Brussels
PICUM (2007b), “Access to Health Care for Undocumented Migrants in Europe,” Brussels
Román Romero-Ortuño (2004) “Access to health care for illegal immigrants in the EU: should we be concerned?” European Journal of Health Law 11: 245-272

Other Sources:

@lterCamp conference, Anna Kowalska and Piotr Bystrianin presenting at Sofitel Victoria, 27 June, 2008
International Organization for Migration 

Interviews: 

Julian Curyła, Director, Office for Foreigners; Adam Tołkacz, M.D., Coordinator, Team 
for Medical Care for Foreigners; Teresa Danek, Main Specialist, Team for Medical Care for Foreigners (30 June, 2008)
Aleksandra Chrzanowska, Social Advisor, Association for Legal Intervention (30 June, 2008)
Agata Foryś, lawyer, Helsinki Foundation for Human Rights (26 June, 2008)
Dang Thu Huong, M.D., Vietnamese Graduate of Medical University of Warsaw (30 June,2008)
Sister Maria, Migrants Center (25 June, 2008)
Migrant (anonymous) (26 June, 2008)
Nurse (anonymous), Doctors of Hope (26 June, 2008)
Nurse (anonymous), Point of Medical Help, Warszawa Centralna (27 June, 2008)
Father Edward Osiecki, Migrants Center (27 June, 2008)
Katarzyna Sekuła, Coordinator of Refugees Project, Caritas (1 July, 2008) 

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