>> In 2015, 2,136,945 immigrants were counted in Germany, in 2017, 2018 and 2019 there were around 1,600,000, and in the first Corona year 2020 there were only 1,136,702 (Federal Statistical Office 2022). Most people who immigrated to Germany in 2020 came from Romania (185,296). In second place were migrants from Poland (100,220) and the third largest group were people from Bulgaria (approx. 72,400) (Federal Statistical Office 2022). Germany has actually been a country of immigration for a long time. The current immigration situation is characterized by new immigration and the settlement of migrants from different countries of origin and increasing ethnic, cultural and social diversity. Questions of social diversity and social cohesion are increasingly viewed as relevant political issues and the demographic and economic importance of immigration for Germany is increasingly recognized and appreciated. Current and likely continuing migration trends are the immigration of qualified and unqualified workers, including the recruitment of health workers, family reunification, refugees from war and crisis areas, east/west migration within the European Union and so-called irregular migration, ie uncontrolled and Ultimately, the magnitude of the immigration of people without papers is also unknown.
This compilation underlines that people with a migration background are a very heterogeneous group. This heterogeneity arises, for example, B. also because you either have your own migration experience, i.e. H. the person himself immigrated to Germany, or was born in Germany as a direct descendant of this so-called first generation of migrants. Differences arise due to the country of origin, socio-economic status, level of education, gender, length of stay and residence status, ethnicity, religious and cultural orientations and, last but not least, the existing language skills of the country of immigration. Available statistical data show that the education and income levels of the population with a migrant background are on average lower than the non-migrant population and that job insecurity and unemployment are more common.
Various sources assume that depending on these factors, the risks of discrimination or Social discrimination against people with a migration background varies. Figure 1 summarizes the possible consequences and repercussions of the corona pandemic, the associated (health) political measures and the resulting consequences for the German healthcare system and the patients with a migrant background treated and cared for there. Below, on the basis of a selective literature search carried out in March 2022 on possible discrimination against migrants in the health system in the wake of the Covid-19 pandemic, we will address visible disadvantages for people with a migrant background. We present the resulting conclusions for future pandemic situations, but also for “post-pandemic everyday care.”

“Social discrimination” includes the disadvantage of people based on group-specific characteristics, such as ethnic and national origin, skin color, language, political or religious persecution, sexual orientation, gender, age or disability. The starting point of all discrimination is the construction of difference and the associated hierarchies and power relationships (Beutke and Kotzur 2015). What data and facts are available on possible disadvantages for people with a migrant background in the German health system?
Part of the “Annual Report of German Foundations for Integration and Migration” is always the so-called integration barometer. For the 2014 Integration Barometer, 5,659 people, 74.7% with and 25.3% without a migration background, were interviewed by telephone based on a stratified random sample. As part of this survey in 2014, subjective experiences of discrimination in various areas of daily life were also determined. Questions were asked about experiences of discrimination in educational institutions, on the labor market, in offices and authorities as well as in local public transport. Disadvantages in the healthcare system, in outpatient or inpatient care, were not discussed. The answers (see Fig. 2) were grouped according to the migrant background or country of origin of the respondents. The results “… show that people with a migrant background perceive discrimination in different forms in everyday life […] Overall, the level of discrimination in Germany does not appear to be very high: the vast majority of those surveyed stated that they had not experienced any disadvantages. However, people with a migrant background report experiences of discrimination more often in all areas than people without a migrant background...", whereby "people from different groups of origin see themselves affected by discrimination to varying degrees..." (SVR 2014).
The Federal Anti-Discrimination Agency published the survey “Discrimination in Germany” in 2015 (Beigang et al. 2017). A total of 1,007 German-speaking people aged 14 and over were interviewed in a representative telephone survey from November 1st to 30th, 2015; the selection was carried out using a random procedure. The authors state that the “results can be generalized to the entire population in Germany, taking into account the limitations usually associated with sample surveys” (Beigang et al. 2017). Respondents were asked to provide information about whether they had experienced discrimination in the past two years due to a characteristic listed in the General Equal Treatment Act (AGG) or for other reasons. Almost a third of those surveyed (31.4%) confirmed this. 8.4% of those surveyed in the representative survey stated that they had experienced discrimination for racist reasons or because of their (ethnic) origin; this particularly affected people with a migrant background: “Almost a quarter (23.2%) of them reported corresponding experiences of discrimination the past 24 months. The proportion of people without a migration background who report experiences of discrimination for racist reasons or because of their (ethnic) origin is 3.8%..." (Beigang et al. 2017). For the 343 people in the survey who had reported experiences of discrimination, the representative survey also differentiated according to the areas of life in which the disadvantage was experienced: 5.5% stated that they had often experienced discrimination in the health and care sector, a further 8.8% at least occasionally, 12.1% rarely and the remaining 73.6% never (Beigang et al. 2017).
The two surveys just cited were carried out well before the start of the corona pandemic, so they cannot contain any information about the effects of this special situation on experiences of discrimination. But in the report “Discrimination risks and protection against discrimination in the healthcare system …” (Bartig et al. 2022), which was commissioned by the Federal Anti-Discrimination Agency and published in July 2021, there is a passage on (assumed) discrimination risks in connection with the Covid-19 pandemic. 19 pandemic: “To what extent the effects of the Covid-19 pandemic differ between people with a migrant background (especially refugees) and the population without a migrant background with regard to participation in various areas of life, among other things. that of health is currently being analyzed in the project “Comparative analyzes of the effects of the Covid-19 pandemic on migrants and refugees at the Institute for Labor Market and Occupational Research…” (Bartig et al. 2022).
Results of this study by the Institute for Labor Market and Occupational Research of the Federal Employment Agency were published in September 2021. Brücker et al. (2021) summarize their research report as follows:
• “The German economy has adapted to the Covid-19 shock primarily through short-time work and the relocation of economic activities to the home office, as well as through other forms of reducing working hours. The effects of the shock vary between different groups in the labor market.
• Refugees and – to a lesser extent – other migrants were disproportionately affected by job cuts and short-time work during the first lockdown.
• Refugees were only able to carry out their activities from home to a very limited extent.
• Important causes of negative labor market effects are temporary employment relationships, short lengths of service and differences in job structures.
• Among refugees and other migrants, unemployment has risen much faster than their employment has fallen. This can be attributed, among other things, to the pandemic-related cancellation and interruption of integration and qualification measures.
• Immediately after the containment measures of the first lockdown expired, the employment of refugees increased again, but their employment growth in 2020 was much lower than in previous years." (Brücker et al. 2021)

Disadvantages can occur at different levels and in different forms. Six manifestations of social discrimination can be distinguished, namely individual, linguistic, structural, direct, indirect, covert and institutional. In the latter case, organizational structures have a discriminatory effect due to habits and values (Beutke and Kotzur 2015). There are practically no current results or published research results in the Federal Republic of Germany. Only in recent years have few research projects devoted themselves to questions about institutional discrimination and racism (e.g. Graevskaia et al. 2022).

Internationally, however, there are a number of reviews on the topic of “Covid-19 pandemic and migration” from 2021/2022 that were identified in the course of a selective literature search. The main results of this work are presented and interpreted below.
Politi et al. (2021) addressed the impact of Covid-19 on the majority population, ethnic minorities and migrants in the form of a systematic review of threat assessment. Table 1 summarizes the perceived threats of the respective majority population and ethnic minorities and migrants in keywords (Table 1).
Hayward et al. (2021) summarized their findings on clinical outcomes and risk factors for Covid-19 infection among migrants in so-called high-income countries based on a systematic review as follows: Covid-19 infections were high among migrants despite low testing rates disproportionately high. Hospitalization for Covid-19 is more common among migrants and they are also more likely to have been treated in an intensive care unit. Migrants had a higher risk of dying from or with Covid-19. The impact of the Covid-19 pandemic on mental health and associated restrictions is now well documented. According to Hayward et al., migrants are (2021) are particularly affected by this due to existing risk factors, (potential) exclusion and social isolation. Possible consequences include the worsening of existing mental illnesses. The Covid-19 pandemic represented an obstacle to social participation and integration for immigrants and people with refugee status. The negative social impact of the “lockdowns” in this group was a particularly high risk of poverty and economic hardship due to the pandemic measures and frequent unemployment.
Hayward et al. (2021) found risk factors that could explain an increased susceptibility to Covid-19 infection among migrants:
1. Chronic pre-existing conditions such as diabetes mellitus, high blood pressure and obesity, which appear to be associated with poorer Covid-19 treatment outcomes, were more common in the migrant population (Doan et al. 2021).
2. A lack of information, general, pre-existing language and cultural barriers as well as feared costs are considered obstacles to use or care.
3. Another risk factor for increased susceptibility to a Covid-19 infection are problematic accommodation conditions, such as shared accommodation, refugee camps, etc. offer (modified according to Hayward et al. 2021).
Figure 3 summarizes migrant-specific vulnerability factors, distinguishing between special exposure factors, risks and effects for groups of people with a migrant background.
There are a number of lessons for the future, which, however, should not only apply to the next pandemic situation. The following measures are suggested in the reviewed articles: initiation of large retrospective and prospective studies that adequately represent migrants, systematically take migration status into account and examine possible differences in tests and diagnoses, hospitalizations and Covid-19-related deaths; collecting and analyzing data on the vaccination situation, taking migration status into account; Ensuring continued and more complete integration of migration status into health surveillance and information systems, taking into account the gender, ethnic, linguistic, educational and occupational heterogeneity in migrant populations; Developing transnational pandemic plans that explicitly take migrant populations into account; Developing, producing and actively offering specific information materials on the prevention of the respective cause of infection, on testing procedures, treatment, contact tracing, self-isolation, etc. with particular consideration of cultural and social aspects as well as specific risk factors; Ensuring rapid and high-quality translation and more effective dissemination of public health information and guidelines in the main languages of respective migrant groups; intersectoral cooperation between responsible bodies; Consideration of special migrant groups living in refugee camps, reception centers, detention centers, etc. as well as “people without papers” (modified according to Hayward et al. 2021, Politi et al. 2021, Van Hout et al. 2021, Jaljaa et al. 2022, Doan et al. 2021, Obinna 2021).

1. Migrants represent a very heterogeneous group in the respective immigration countries for socio-demographic reasons. While the connection between social and health inequality has been widely proven, people with a migration background - for different reasons - also appear to be affected to varying degrees in the health systems of immigration countries around the world Being exposed to disadvantages in health care. People with refugee status represent a particularly vulnerable subgroup within the migrant population.
2. Most authors of the cited reviews assume that the corona pandemic will increase the unequal health care of people with a migrant background, especially those with precarious working conditions or with uncertain residence or refugee status.
3. The pandemic situation, like a magnifying glass, has reinforced or made visible the already existing deficits in the developed industrial countries.
4. This gives rise to the opportunity to carry out (self-)critical analyzes of the previously neglected problems and to develop solutions using the extensive data that is now available to be evaluated, which corresponds to an epidemiological study for the years 2021/22.
5. Future pandemic plans should sufficiently and appropriately take into account population groups with particular burdens, including migrants. <<

Around 82.4 million people worldwide are currently fleeing war, violence, hunger or poverty. Around 48 million of them are so-called internally displaced people who feel forced to flee within their home country (CARE 2022). According to the Federal Statistical Office, the following definition has applied in Germany since 2005: A person has a migration background if they or at least one parent were not born with German citizenship (Federal Statistical Office 2022). According to Article 1 of the Geneva Refugee Convention, refugees are defined as “persons who are outside the country of which they are a national or in which they have their permanent residence and who, because of their race, religion, nationality, membership of a particular social group or have a well-founded fear of persecution because of their political beliefs and cannot claim the protection of this country or cannot return there because of this fear of persecution…” (Federal Statistical Office 2022).
Men and women with refugee status therefore represent a special subgroup of people with a migration background. We are currently experiencing a new wave of refugees from Ukraine as a result of the Russian war of aggression.
“In 2020, according to microcensus figures, there were 21.9 million people living in German private households who, or at least one of whose parents, have not had German citizenship since birth. This corresponds to a population share of people with a migration background of 26.7%. More than half of them are German citizens, almost two thirds are immigrants themselves..." (BAMF 2020)