On Campsfield

Hi, it’s been a while. Campsfield Detention Centre, an immigration detention centre in Oxford, is scheduled to reopen today. I wrote about it in my masters thesis in the context of the medical education of trainees at the University of Oxford medical school; I’ve edited excerpts of that project and attach it here. I’m back in Oxford, working towards a masters in migration studies — wherever in the world you are, I hope you’re doing well <3

The ORHI Gaze: The NHS and the Medical Student

Throughout November, I encountered pamphlets in colleges and around the city for a “Keep Campsfield Closed” rally at the Campsfield House Immigration Removal Centre, north of Oxford City Centre. The immigration detention centre shuttered in 2019, but in recent years, the Home Office has proposed once again reopening the site for detentions. The demonstration is being organized by a coalition of local and national immigration organizations. I visit the camp a few hours after the rally, exiting the bus at a stop along a highway. I walk to the camp under grey, overcast skies. Bright orange, handheld signs blaring “Yvette Cooper” – the Labour party Home Secretary – “Keep Campsfield Closed” have been left on the sidewalk from the protest. I cannot get near the detention centre but peer through the gates. Multiple signs affixed to the fence inform visitors that they are under surveillance. I can see some movement inside and glimpse construction cranes. Birds sweep through the skies overhead. An NHS ambulance bay neighbors the camp. I feel unsettled. Here is a space for the homo sacer. Here is a space of bare life.

I turn now to the Oxford Refugee Health Initiative (ORHI), which engages medical students at the University of Oxford with the clinical and social care of local asylum seekers and refugees, aiming to “support the health and psychological needs of newly arrived refugees and asylum seekers in Oxfordshire” (ORHI n.d.). It began in 2016 as a pilot project and has operated in force since an influx in the asylum seeker population in Oxford in December 2021; it is guided by a student leadership committee. The group grew “exponentially” in response to the new arrivals, per James from chapter one, who is part of a team of physicians at NHS hospitals that supervise the students and facilitate many of the opportunities for clinical and nonclinical work with asylum seekers. Ari, child psychiatrist and co-founder of the organization, reflects that the twofold imperatives of medical education and care for local asylum seeker populations inspired the creation of the initiative. “Medical students don’t really leave medical school with a good understanding of this issue, and asylum seekers in Oxford really don’t get a great deal compared to asylum seekers in other cities,” she reflects.

Here, I consider how medical students working with the ORHI are trained to perceive the health outcomes and needs of asylum seekers. First, I employ Michel Foucault’s framework of the “clinical gaze” (1963, 146) to consider how the ORHI educates medical students, paralleling Seth Holmes in applying this framework to clinical approaches to migrant health (Holmes 2013). I find that the ORHI trains an “ORHI gaze” that considers social determinants of health (Hahn 2021) as an explanation of health outcomes; accordingly, through social prescribing, ORHI students contribute to the transformation of the asylum seeker from the homo sacer to the homo limbus. However, this training ultimately functions as a form of “antipolitics” (Ticktin 2011) that serves to reinforce the clinician’s role in upholding the processes and institutions of the UK asylum system.

The ORHI Gaze

First, I explore how the ORHI instructs the gaze of participating medical students. I build my approach based on Seth Holmes’ ethnographic account (2023) of how United States clinicians perceive the health status and needs of migrant laborers. Holmes frames his ethnography (114-115) through Michel Foucault’s construct of “the medical gaze” (1963). The medical gaze, per Foucault, “describ[es] how doctors modify the patient’s story, fitting it into a biomedical paradigm, filtering out non-biomedical material” (Misselbrook 2013). Holmes notes that contemporary forms of medical education have shifted framings of disease to the biological rather than the political (see 2023, 144); “physicians began to focus on the isolated, diseased organs, treating the patient increasingly as a body, a series of anatomical objects, and ignoring the social and personal realities of the patient, the person” (115). Broadly, this gaze is medicalization, “the process by which nonmedical problems become defined and treated as medical problems often requiring medical treatment” (Conrad and Bergey 2015). Foucault likewise asserts that this mapping of disease on the “anatomical atlas” is but one way of “spatializ[ing] disease” (1963, 1) – there exist alternatives beyond the medical gaze.

Holmes’ ethnography brings this theorization into the migrant clinic. Holmes observes a refrain amongst his migrant interlocutors in California that “doctors don’t know anything” (2023, 113). That is, the gaze underlying their clinical assessment diverges from patients’ understandings of their illness. “As would be expected in the paradigm of the clinical gaze, the clinicians I spoke to see the individual… bodies in their offices, yet they are unable to engage the social context that produces suffering,” Holmes concludes. “Physicians in the United States and Mexico are not trained to see the social determinants of health problems, or to hear them when communicated by their patients.” Instead, they “decontextualize sickness, transporting it from the realm of politics, power and inequality to the realm of the individual body” (152). Like Foucault observed, here, disease is seen as medical, not social.

The medical education practiced by the ORHI rejects this approach. Discussing the ethics of the program with Ari, I ask her what she hopes medical students take away from their experiences of the ORHI. She explicitly mentions training students in understanding the “social determinants of health,” “the conditions in which people are born, grow, live, work and age that shape health” – such as socioeconomic status and employment (Artiga and Hinton 2018). “We’d hope this would be a way to start a discussion about improving empathy, better understanding of marginalized populations. Better understanding of the social determinants of health, which hasn’t happened for the whole medical school,” she reflects. The aim is to shape the physician these students are training to become, to help them “perceiv[e] their ability to impact the system differently when they become doctors as well” – to build a new type of clinician, with a new type of gaze.

Similarly, discussing advocacy efforts and letter-writing initiatives by medical students in support of Oxford asylum seekers, I ask James how he frames the relationship between advocacy and care for the patients when working with medical students. “As a GP, you’re an advocate for your patient, regardless of status,” he replies. Part of that work involves identifying “the relationship between the person’s physical health and the socioeconomic situation they’re in… I feel it’s very much part of my job to support somebody’s health,” which can entail advocacy to change their circumstances.

To that end, the ORHI engages student volunteers in multiple dimensions of migrant healthcare. Prior to the reboot of the program in response to the influx of asylum seekers in 2021, the initiative was primarily a mentoring program for asylum seeker teenagers, James says. One of their ongoing initiatives is a series of health promotion campaigns at the hotel shelters for asylum seekers, with topics selected by residents. They have presented on health topics including scabies, child health, and sexual health, in a variety of the languages spoken by residents, and developed health information pamphlets related to such topics. Students have assisted James with letter-writing initiatives on behalf of patients, including when patients were detained on the Bibby Stockholm as discussed in chapter one. Other programs include efforts to bring asylum seekers to the park, exercise programs such as a run club and a football club, educational initiatives for other medical students not involved in the program, and educational initiatives for the wider community.

During my research, I interviewed several current and former student volunteers who have been involved in the programming and/or leadership of the ORHI at various stages of their medical training. Bella graduated from Oxford in 2024 and is currently an F1 doctor, in her first postgraduate year of training. As a medical student, she participated in ORHI programs, including working on health promotion classes on a variety of health concerns – including how to access the NHS. During our conversation, I ask her to reflect on what she learned from volunteering with the ORHI. She mentions “practical lessons, like how to talk to a translator” as well as “less concrete skills” – “improved listening skills,” a deeper understanding of “barriers to access to healthcare,” and less “immediate apprehensions, good or bad, about different demographics of people… I really had this image of everyone seeking asylum is having the worst time and they’ve got significant healthcare issues. So it was nice to learn there’s so much more complexity in the world.” The work has pushed her to integrate advocacy, volunteering, and health equity research into her future career. Georgia, a fourth-year medical student who volunteers as the ORHI secretary, similarly credits the ORHI with shifting her perspective on her patients. “I think it’s just showing me another side of medicine, like at medical school you kind of get… the obvious, like this is what you do when you see a patient… there’s so many other factors to take into account, especially when thinking about refugees and asylum seekers. And it is a very large population in the UK of people. And I think it’s something that needs to be taught more.”

Finally, I ask Jane, a medical student who leads the development of health information pamphlets in multiple languages, about how she perceives the role of the physician in the context of politics and advocacy. “I think a lot of the time clinicians are really well placed to advocate for these people,” Jane reflects. “they’re often, just through having a conversation, they’re able to get to know them, build some rapport, build some trust, and be someone that an asylum seeker or refugee can ask questions to and rely on.”

Speaking to Jane, I scribble “Virchow” in the margins of my notebook. The 19^th century physician-anthropologist Rudolf Virchow advocated for physicians, and medicine more broadly, to engage with how social forces contribute to the spread of disease. The slogans of his newsletter – “medicine is a social science” and “the physician is the natural attorney of the poor” (Brown and Fee 2006) – encapsulate his perspective on the relationship between medicine, the social sciences, and social institutions. Social critique is necessary to practice medicine, and the role of the physician is to advocate for those marginalized and sickened by social forces. This attitude is captured in the responses of Bella, Georgia, and Jane to my questions on how they perceive the role of the doctor in the context of the social structures that impact their asylum seeker patients’ health. This is the ORHI gaze, perceiving health and healthcare as involving consideration of the social forces underlying health, and going beyond the remit of biomedicine.

Yet as Virchow’s word choice of “attorney” hints, the physician’s role was not necessarily to overhaul the world as it is in support of his or her patients, but to work within existing systems to improve their health and wellbeing. As this chapter will discuss, this is true, too, of the ORHI.

Social Prescribing

I turn now to how the clinical gaze built by the ORHI relates to the work of the NHS staff to build the asylum seeker into the homo limbus. Here, I argue that ORHI programs function to advance the same mission as that work, engaging the homo sacer with social and cultural life in Oxford and the UK – that is, making them into the homo limbus. Early in my fieldwork, I am struck that much of the ORHI programming is linked to social rather than biomedical support. Beyond the health assessments, health promotion sessions, and health information pamphlets, there exist several initiatives designed to provide asylum seekers with social supports. One of the ORHI leadership adds me to the organization’s WhatsApp community, from which I can access an array of group chats related to past and present organizational initiatives, from “ORHI advocacy and politics” to the chat for the asylum seeker football team. Other initiatives include a mentorship program, pairing medical students with younger asylum seekers, which has been foundational to the group since its earliest days. As James tells me, many of these ORHI initiatives constitute “social prescribing,” a “way of linking patients in primary care with sources of support within the community to help improve their health and well-being” (Bickerdike et al. 2017), which began in the UK (Islam 2020) and has been encouraged as a strategy to reduce pressures on GP practices (Bickerdike et al. 2017). Such social prescribing, per James, is related to “very much supporting people’s mental well-being by supporting their integration into society, into local communities.”

Here, the ORHI continues the work of the NHS staff chronicled in the first chapter, equipping the homo sacer with increased social mobility and rights even amidst his suspended status in the asylum process. That is, they help build the homo limbus. They join British students on Oxford’s football fields, are rendered more mobile in the city in the running club, forge relationships with medical students through the mentoring program. The gaze built through social prescribing joins the broader effort to enfold the asylum seeker into the day to day activities and social relationships that constitute life in the United Kingdom; the work of the doctor, here, goes beyond the clinical assessment.

In several of our interviews, interlocutors mentioned asylum seekers being frequently and erratically moved by the Home Office between detention centres in Oxford and other cities. I ask Ari, the child psychiatrist and ORHI co-founder, for her impression of why these changes take place. “I don’t know why it happens,” she reflects. “It definitely goes counter to any of that understanding of well-being. So that’s kind of the most important thing to keep in mind, isn’t it? And these are also, these are kind of aspects of experience that can be changed… there’s a lot of that migration that I can’t change, can’t change anything that happens in countries of origin. I can’t change much that happens on the route. But when you come to the post migration environment, that’s all up for us to determine.” Her response, while not explicitly centring on the aims of the ORHI, encapsulates the governing ideology behind the ORHI’s work. The aim of the ORHI is to change what happens for the homo limbus, training a gaze attentive to the social determinants of health and shaping their experiences in the post migration environment.

Antipolitics

In the preceding sections of this chapter, I describe how the ORHI builds a physician that exists “in but not of” the world of politics. To conclude the discussion, I consider how the ORHI gaze relates to the long-term perpetuation of immigration governance in the UK. Here, I argue that the ORHI gaze perpetuates an “antipolitics” (Ticktin 2011) of care for asylum seekers, legitimizing state framings of migration, and the resultant management of the asylum seeker population, as an apolitical and decontextualized question. In an ethnography of humanitarian medical care for undocumented immigrants in France, Miriam Ticktin introduces the “imagined universal suffering body… the central figure of a politics grounded in the moral imperative… a victim without a perpetrator – a sufferer, pure and simple, caught in a moment of urgent need” (2011, 11). The “moral legitimacy” of this suffering body justifies a “moral imperative” of humanitarian intervention (12). Humanitarian care provided in response to this moral imperative becomes a twofold “antipolitics… of care;” its practitioners “generally claim to be apolitical – beyond or outside politics” and, “rather than remaining outside the system in their desire to not engage with politics… work to reinforce the status quo, the established order” (19). In the French immigration system, this “suffering body manifests itself as the ultimate… resource, supplanting all other social justifications for immigrants to be granted legal status and residing in a basic right to keep oneself alive as long as possible” (Fassin 2001, 7). The immigration system demands proof of the right to asylum; accordingly “the refugee’s body… becomes the place of an inscription… an inscription of power, through the persecution they suffered in their home country, and an inscription of truth, insofar as it bears witness to it for the institutions of their host country” (Fassin and D’Halluin 2005, 598). This is the antipolitics of the body in the immigration system; corporeal suffering is used to justify who has the right to be granted shelter in a country.

The ORHI health assessment exemplifies this relationship of antipolitics. James explains that GP practices in the UK receive 150 pounds per patient when they register asylum seeker patients, on the condition that the asylum seekers have received a “comprehensive health assessment.” Yet the time and labour required to conduct the health assessment mean that actually conducting the health assessment would result in a financial loss for the GP practice. Some practices navigate the shortfall through an online health assessment or by engaging health assistants or nurses to conduct the exam, methods that James characterizes as logistically complicated or “brief.” “I get medical students as volunteers to do a comprehensive health assessment, and I see that as kind of a win/win/win,” he says. “It’s a win for the practice,” who can claim the 150 pound bonus for registering the asylum seeker. “It’s a win for the asylum seeker because they get to spend a long time with the medical students... [and] it’s a win for the medical student that they get that exposure and experience to spend a long time with the asylum seeker to get all of the history.” Part of that involves an extensive encounter with the asylum seeker patient. “I encourage them to take a long time,” he says, collecting the “medical history... very much related to previous traumas and psychological history.” They then provide feedback to James on the well-being of the patient.

I message many of the members of the group chat for letter writing related to the Bibby Stockholm advocacy initiative, and connect with Nick, a final-year medical student who has volunteered extensively with James and the ORHI. We meet in Magdalen College in their MCR, and sit in an adjacent room, side-by-side on an oversized couch. Nick pulls his laptop out and places it on the coffee table – he has brought the forms with the questionnaire students use in health assessments to show me. He wears a pumpkin quarter-zip jumper and an NHS lanyard, a scrub top under his quarter zip. Nick walks me through the material included on the health assessment. It includes questions about health status, previous medical interventions including vaccinations and prescribed medications, symptoms and experiences that would lead to PTSD, as well as details such as religion and sexual orientation. There is an outlined diagram of the front and back of the body for physicians to mark physical injuries, including “from war, conflict or torture.” Nick acknowledges an awareness, when conducting the health assessment, that this information could later be used in the legal proceedings for asylum seekers. “We’re not volunteering to be a legal counsel… but I think you have to ask these questions to be entered in the system and it will be used for their asylum application.” Here, the ORHI health assessment literally creates the “universal suffering body” (Ticktin 2011, 11), marking the material evidence for the political and social circumstances that have displaced the asylum seeker. This becomes, as Didier Fassin describes, the “ultimate… resource” (Fassin 2001, 7) for the legal asylum claim. Yet in the outlined drawing on the page, the causes of these injuries and traumas – war, genocide, famine – are rendered apolitical. The aspiring physician produces the material that the legal process desires, legitimizing the legal system’s demand for a universal suffering body. That is, the ORHI medical student practices antipolitics.

This material from the health assessment can also be used in other forms of advocacy work on behalf of asylum seekers by members of the ORHI. Following the Bibby Stockholm saga, James recounts, many of his patients at the hotel suddenly had their asylum claims approved. This was “great in many ways,” he reflects, until they suddenly needed to secure housing and employment. Many turned to the “completely overstretched” housing department of the City Council, which requested that they provide a “priority needs letter” written by a GP stating that they deserve priority consideration for housing. The only justified grounds to qualify for housing support were medical vulnerabilities – attributes such as lack of English fluency or a lack of social contacts who can provide housing do not qualify as medical needs under the criteria provided to the city council by the government. Yet many asylum seeker patients “don’t have a lifelong medical record,” James says, creating a “bias” against their application.

In response, James’ letters to the council heavily emphasized the mental health status of impacted patients, integrating details of “previous traumas” from patient health assessments in the clinics. “That’s almost been normalised by members of the council,” he says. “They go, “oh, here we go... here’s another PTSD letter.” But attesting to the mental health consequences of asylum seeker’s trauma, he reflects, functions as an effective argument within the council system. “We can say that this person has had all of these traumas. And if they were going to be made homeless, this would really exacerbate their mental health.” The social attributes that may compound the vulnerability of asylum seeker’s positionality in the UK – their lack of English fluency, their lack of supportive community—are ignored in favor of a medicalized conception (see Conrad and Bergey 2015) of vulnerability. They are labeled as suffering bodies to meet the organizational demands of the political system. Here, again, the material of the ORHI health assessment becomes a tool of antipolitics.

Conclusion

In this discussion, I explore how the medical education of students involved in the ORHI forges their perception of the health needs and outcomes of asylum seekers, and how their volunteering relates to the politics of the immigration system. Ultimately, I argue that the ORHI trains a clinical gaze that links the social determinants of health to the health outcomes of asylum seekers, in turn facilitating the development of the homo limbus, yet enables antipolitics, justifying the terms of the legal and social systems surrounding the asylum process.

During our conversations, ORHI physician staff discussed whether they should bring students to participate in clinical assessments at the Campsfield House Immigration Removal Centre if it reopens. Ari opposed their participation, asserting medical participation in the operations of the detention centre tacitly abets its operations – that is, functioning as a form of antipolitics. “We shouldn’t have anything to do with these institutions, because if you step back, if medics refuse to go into Campsfield as a whole, if no medical doctor goes, they have to close Campsfield,” Ari argues. “But then the argument is that there are sick people who need to be cared for. And so I’m very sympathetic to arguments to go in and support these institutions because care needs to be given, but I absolutely don’t want these institutions to think it’s ok because I’m going in and providing care… enabling those institutions to justify keeping people in there.” She distinguishes between her personal beliefs and the aims of the organization, which she hopes to encourage as being primarily student run. “I don’t mind if they choose to go in and work in Campsfield… I’ll support whatever the organization does. I won’t go in.”

James, in contrast, raised an avenue for the ORHI to participate in the centre’s operations but minimized the likelihood that they would offer clinical support. He and other ORHI staff have participated in the campaign to close the centre in the past, he says, and “if there were more rallies and stuff, I think we’d advertise that on the ORHI group.” Yet he envisions a way that the ORHI could aid patients involved in the centre. “I would say maybe the most helpful thing to do would be to potentially offer a kind of… entry point to support asylum seekers who are there… basically giving supporting letters or something like that, if we are able to get in. Or maybe… just speak[ing] to them remotely.”

The proposal to reopen the detention centre has encountered significant public resistance; the physicians and medical students with the ORHI may never be forced to choose whether to participate in the care of patients at Campsfield. But it is a consideration that reveals the discomforting paradox of the role of the healthcare provider in the management and care of asylum seekers in the UK. Being a doctor risks perpetuating the systems that harm one’s patients.