Refugees as a key representation of vulnerability: politics and biopolitics

Purpose – This article aims at the sociological inquiry seeking to identify meanings ascribed to the term of vulnerability by official spokespersons, to explore a novel public health policy with reference to vulnerable populations and to trace its enactment with particular attention to vulnerable populations in Greece; finally a case of contest among the state and the civil society over refugees ’ rights will be located against public health politics and biopolitics in the context of the pandemic Covid-19. Design/methodology/approach – The interpretivist perspective towards analysis of textual data is adopted. Discourse analysis and content analysis are applied to analyze four sets of data. Findings – The main findings show: (1) ambiguity over the terminology, (2) insufficient policy design and policy enactment towards the protection of vulnerable populations ’ health, (3) an illuminative case of contest among civil society and the state against infringement of refugees ’ human rights which may interpreted in terms of a tradition of solidarity. Originality/value – The Foucauldian notion of biopolitics provides the grounds to understanding how market prevails over life at the expense of those in greater need, and how the state, serving homo economicus, intensifies instead of alleviating health vulnerabilities.


Introduction
There is ample evidence that the health crisis of Covid-19 exposed but also exacerbated social vulnerabilities, health inequalities (Cheater, 2020;Marmot and Allen, 2020;Rimmer, 2020), discrimination (Sylvia, 2020) and racial racism (Bowman, 2020). As Covid-19 mortality statistics reveal, many deaths among vulnerable persons could have been prevented if governments had seen their lives as worth saving; instead, they have appeared more willing to save the lives of those who will benefit the state economically (Daher-Nashif, 2021). The dimension of politics remains to a large extent absent from public health discourses, although health policies are highly political endeavors, since they offer some individuals access to life, but create possibilities of death for others. Especially in times of a profound health crisis, the inherent politics in public health policies challenge the alleged political neutrality of public health (Daher-Nashif, 2021).
2. Literature review 2.1 Exploring conceptually "vulnerability" World Health Organization (2002) defines vulnerability as the degree to which a population, individual or organization is unable to cope with, resist and recover from the impacts of disasters. A more robust conceptual framework was proposed by World Health Organization (WHO) at the onset of the pandemic by releasing in a timely manner a guide on "Actions for consideration in the care and protection of vulnerable population groups from Covid-19" (WHO, 2020a) in which the spectrum of vulnerable populations is specified as follows: homeless people; people living in overcrowded housing; collective sites and slums; migrant workers; refugees; people with disabilities; people living in closed facilities; people living in remote locations (including highlands and island provinces); and people living in poverty and extreme poverty. In the particular document, WHO emphasizes that adherence to recommendations and measures for the general population may not be applicable for people who live in a condition of limited resources, deprivation or extreme poverty. It follows that targeted policy planning that policy makers need to design policy measures that are clearly targeted.
Nevertheless, literature appears profoundly ambiguous. For instance, vulnerability may be related to patients' experiences at a risk of a major health condition (Gillespie, 2012), or it is understood in terms of health risk and the stress it may consequently affect physiological, psychological and social functioning (Rotliman and Schwarz, 1998). Elsewhere the concept is reduced to "the way individuals think about themselves and their situation" and as such may be measured by using two scales of self-esteem and sense of coherence (Winding et al., 2013, p. 94). In contrast, Flaskerud and Winslow (1998, p. 69), ahead of their time, contend vulnerable individuals derive from "social groups who experience limited resources and consequent high relative risk for morbidity and premature mortality". Presumably, a greater agreementyet not a consensusis being generated, as vulnerability is more imbued by social justice values (Powers, 2016;Kahambing, 2020). It is more widely acknowledged that vulnerable social groups are at a higher risk of poor health outcomes and healthcare discrepancies and are also more likely to be affected by poverty, social stigma, gender discrimination and lack of access to medical services.

Reflecting on biopolitics
Having, to some extent, clarified the concept of vulnerability, as a departure point, the theoretical pillars of subsequent analyses are discussed. Several components of the Foucauldian theoretical construction acquire new relevance these days, such as the expansion of panoptic surveillance, the consolidation of social control mechanisms and the imposition of coercion and discipline on social actors. In particular, the notion of biopolitics derives from the notion of biopower and refers to the ways state power is exercised over both the physical and political bodies of a population, acting as a control apparatus over a population. The invention of new rationalities and techniques in the 18th century (e.g. ratio of births to deaths, the rate of reproduction, the fertility of a population, deviance, death rates etc) increased quantification, classification and evaluation of social groups which were then subject to discipline and sovereignty mechanisms operating by the state. However Foucault's critique of the state is differentiated from other theorists since he locates freedom as a component of State reason within liberal governmentality (Foucault, 2009;Means, 2021).
A cardinal component of the Foucauldian approach to biopolitics is the concept of "Homo oeconomicus", in that it correlates to governmentality, acts on the environment and systematically modifies its variables inasmuch as it considers "any rational conduct or behavior whatsoever as the possible object of economic analysis" (Foucault, 2009, p. 269). In this light, neoliberalism qualifies the principles of market economy as the driving force of the exercise of sovereign power and manipulates human behavior to the interest of the economic realm (Newheiser, 2016).
At the other end of the spectrum, civil society is viewed as the subject of rights and simultaneously the subject of interests. In Foucault's (2009, p. 296) words, "Homo oeconomicus and civil society are two inseparable elements. Homo oeconomicus is, if you like, the abstract, ideal, purely economic point that inhabits the dense, full, and complex reality of civil society. Or alternatively, civil society is the concrete ensemble within which these ideal points, economic men, must be placed so that they can be appropriately managed." However, the omnipresent government, from which nothing escapes, will have to conform concurrently to the rules of right, as represented by the civil society and the interests of the capitalist economy. The balance of serving both, often at odds, will be used as an analytical angle thereafter.

The context of social solidarity to refugees
Given the economic impact of the pandemic (Kaplan et al., 2020), the association of biopolitics and neoliberalism is used as a tool to capture cases of resistance and solidarity. Currently, a consensus is been established that the Covid-19 pandemic has triggered the deepest economic recession in nearly a century worldwide, jeopardizing a supply ranging from social goods to basic necessities of life. Greece had just left behind a ten years economic crisis with strong impact on the financial, political and social aspects, before the onset of the pandemic Covid-19, as explained in a multitude of relevant analyses, which is beyond the scope of this work to reiterate. The debt crisis led even to a reconfiguration of the national political space (Katsanidou and Otjes, 2016), to the deregulation and deterioration of working and living conditions and to the compromise of the welfare system, while also failed to deliver growth (Koukiadaki and Kretsos, 2012).
However, against the harsh austerity imposed by Greek governments in return loans to International Monetary Fund (IMF) and European institutions (known altogether as "Troika") and the severe impact on the social welfare and health system, especially to the most vulnerable segments of the society, a wave of social solidarity arose (Rakopoulos, 2014;Oikonomakis, 2018;Parsanoglou, 2020) to counter-balance the disastrous effects contributing to the widening of health inequalities (Karanikolos and Kentikelenis, 2016). These actions of solidarity have been undertaken by several social actors, ranging from the Church and NGOs to spontaneous neighborhood unions and, substituting the welfare system, they offered basic goods and services to those, mostly in need.
With regard to health, social solidarity medical centers and pharmacies emerged across the country as nearly 2.5 million individuals (out of 10 million of the total population) were left uninsured because of the cuts in National Health System, and access to public healthcare demanded paying in cash. This was resolved when the left wing government of SYRIZA (Coalition of the Radical Left -Progressive Alliance) came into power in 2015. The massive inflow of asylum seekers mainly from Syria, reaching over half a million sea arrivals over the first six months of 2015, rejuvenated the solidarity movement in Greece. In 2016 the EU-Turkey agreement resulted, among others, to shutting down the borders of Greece with the Former Yugoslav Republic of Macedonia, dismantling a popular route for refugees through Europe, and leaving around 60,000 people stranded in Greece living in camps and deprived conditions, which affected eventually their health, caused psychosocial distress and social suffering as a consequence of their uncertain and disrupted lives and the loss of social networks (Bjertrup et al., 2018). Despite solidarity towards asylum seekers, there is also evidence to suggest a negative attitude on the part the local stakeholders as to the effects of the refugees' inflows on the economic and social life of islands and on tourism (Tsartas et al., 2020). Given the above, this article focuses on refugees as a key representation of vulnerability.

Research methodology
In what follows, the four components of this methodological approach are explained: (a) the research paradigm, (b) the sources of data, (c) the time period, (d) the interpretative approach.
First, the qualitative research paradigm is chosen based on two grounds: (a) it is an appropriate method towards an under-researched phenomenon; (b) it has been a convenient method since this study was carried out in a time frame of general lockdown.
Second, three sources of textual data have been employed to explore meanings, power relations and contest among policymakers, parliamentary control and humanitarian organizations at the epicenter of public health in times of the coronavirus pandemic. More specifically the texts are derived from the following sources: (a) the transcripts of all the press conferences being held at the premises of the Ministry of Health (MoH) in collaboration with the General Secretary of Civil Protection, (b) the new public health policy, (c) political measures towards the protection of vulnerable populations, (d) in-depth analysis of an illuminative case of refugees' rights infringement.
Third, the data are gathered from the onset of the pandemic Covid-19 until early February 2021, completing almost a year of data collection.
Fourth, the methodology of content analysis and critical discourse analysis are utilized to analytically approach the corpus of data. On the one hand, content analysis is used to locate relevant terminology and to record political measures and interventions for the population under investigation (Kassarjian, 1977). On the other, critical discourse analysis was used to explore language texts and discursive instances and practices of socio-cultural practice, employing all levels of interpretation (i.e. micro, meso and macro). Fairclough's (1995) CDA (Critical Discourse Analysis) was selected since it has developed a dialectical theory of discourse to social change.
A series of research questions, leading this work's analytical framework, is cited below. These are thereafter linked with the methods and sources chosen to respond to each one.
(1) How often is the term "vulnerable populations" and "vulnerability" used by the spokesmen of the MoH?
(2) What meaning is ascribed to the term "vulnerable populations" and "vulnerability" by the spokesmen of the MoH?
(3) How often and in what ways are the terms "vulnerable populations" and "vulnerability" used in the newly Public Health Policy (Law 4675/2020 for Public Health)?
(4) What actions have been applied for the enactment of the L. 4675/2020 in respect to vulnerable populations and vulnerability? Excerpt A1: "And that is why we continue to raise the alarm to protect our grandparents, because these are the most vulnerable populations at the moment." (GM, 17-10-2020) Excerpt A2: "[to examine] how can we improve testing in Athens, we open Covid-19 quarantine hotels for asymptomatic people belonging to vulnerable health groups such as immigrants (VKi, Excerpt A3: "to accommodate drug addicts, as well as citizens from vulnerable and vulnerable groups who have been found to be positive for the virus." (NH, 29-9-20) Excerpt A4: "The tests will be targeted in accordance with the applicable protocols, in compliance with all safety and hygiene measures, aimed at protecting public health, and especially the vulnerable and vulnerable groups of the population". (VKi, 28-9-20) Excerpt A5: "for vulnerable groups, i.e. those in need of social care and welfare" (NH, 22-9-20) Excerpt A6: "the way we treat our parents, our grandparents, those who are vulnerable, those who are vulnerable groups, who are over 65 years old, those who have underlying diseases." (VKi, 21-9-20) Excerpt A7: "[refugees] is of the utmost importance and we must maintain the channels of communication-trust, so that there is effective information about their hygiene, as well as for the protection of vulnerable subpopulations." (GM, Excerpt A8: "Natural and isolated areas or areas with less access to the health system, which we treated as particularly vulnerable." (ST, Excerpt A9: "This year, this call must be heard even louder, as Roma across Europe are among the most vulnerable groups in the current pandemic, as some of them live in dilapidated housing and isolated settlements. Of course, the Roma can not be scapegoats and a target of hatred in the context of this epidemic. In some countries, unfortunately, the media refer to them as a threat. It is not a threat, it is a vulnerable group. Our fellow citizens will not be left alone to deal with this situation. They will continue to have equal access to health care, as do the rest of the vulnerable population currently suffering from the virus in many parts of the world, most notably the United States. There is no space for discrimination, for hate, for fear, for division, for division in our society or in other societies of the world." (ST, 10-4-20) Excerpt A10: "The health system today operates at all levels fully, adequately, in order to meet the needs of all fellow citizens and the vulnerable and susceptible groups and not only the patients with coronavirus." (VKo, 6-4-20) Excerpt A11: "And it does not necessarily change the way we treat vulnerable populations, such as refugees or people on a ship." (ST, 2-4-20)

Vulnerable and the new law
In the beginning of 2020, coincidentally a month before the outbreak of the pandemic, a novel legal framework for Public Health was voted by the Hellenic Parliament, since the previous one, was considered dated after fifteen years (Law 3370/2005). The bill under the title "Prevention, protection and promotion of health development of public health services and other provisions " was published on the formal website opengov.gr, which hosts for a certain period every piece of draft legislation, prior to their submission to the parliament, for the civil society to comment deliberately on each article of the bill. The bill was hosted in opengov.gr from the 4th to the 18th of February 2020. It was then passed as the Law 4675/2020 on the 1st of March 2020. In the following two sections the 3rd and 4th research questions are answered. The word vulnerable and its derivatives were discovered twice in the text of the new public health policy. More specifically in the 12th paragraph of the 2nd Article under the title "Principles of the National Public Health Strategy": Excerpt B1: "cooperation at central, regional and local levels and the strengthening of national, regional and local public health services to provide programs based on the needs of the local reference population with an emphasis on vulnerable groups" (MoH, 2020).
Seeking to understand further how vulnerability is meant in the 4th Article under the title "Primary, Secondary and Tertiary Prevention" the following excerpt is traced: Excerpt B2: "The National Vaccination Program (NHRP), which targets specific and vulnerable groups of the population, children, minors and adults, mobile populations and populations at risk, and includes vaccination programs for all of the above" (MoH, 2020).
It follows that vulnerable groups are identified in a very limited manner within the new legal framework. The vulnerable are loosely related to social determinants by referring to "mobile populations". Also, the conceptualization is overtly ambiguous and inadequate to precisely identify and name the spectrum of vulnerable social groups, as defined by WHO and other international organizations, not to mention the academic literature.

Vulnerable in practice
The next research question is answered by tracing whether the new Public Health policy (Law 4675/20) was enacted with particular reference to vulnerable groups over the span of the first year of the pandemic. Administrative data have been collected from "Diavgeia.gov.gr". "Diavgeia", which is run by the Ministry of Administrative Reform and e-Governance and constitutes a transparency (5Diavgeia in Greek) program initiative demanding all government institutions to upload their acts and decisions on the portal in order to be validated. Using the keyword "L.4675/2020" on "Diavgeia" I searched for circulars, ministerial decisions and joint ministerial decisions, that is administrative data.
The results showed that two acts have put the law into effect. The first one is excluded as totally irrelevant to this study (i.e. "Rejection of a request for disqualification of a drug from the List of Compensated Drugs"). The second document (i.e. "Formation and appointment of members in the Working Group for the creation of a special Register of Voluntary Organizations of Public Health Actions") was included for further consideration. It refers to a three members working group, all employees of the central service of the MoH, which aimed to produce the procedural details of the establishment and maintenance of the Register of Volunteers and Public Health Action Organizations, the terms and conditions of registration of the beneficiaries in the register and so on. Hence it was excluded also as irrelevant to the topic under investigation.
A significant finding emerges from the above: the novel legal framework on Public Health was scarcely if not at all used, showing its inadequacy to respond to public health needs at a time of a profound public health crisis. Also, it is evident from the above that the already poorly informed as for the vulnerable social groups (see Excerpts B1 and B2) novel Public Health law has never been applied in terms of the topic under investigation.

Manifestation of contest over discrimination
At this juncture, an illuminative case was revealed by media coverage but also due to a mass protest of humanitarian organizations, showing discriminative policies applied against a large in size vulnerable population, i.e. the stranded refugees living in camps, mostly situated in the touristic region of the eastern Aegean islands of Greece.
On the 3rd of July 2020, the neoliberal Government of New Democracy, in office since July 2019, decided to issue a Joint Ministerial Decision extending the authority of the previous one issued on 21st of March 2020 [1], according to which traffic restriction measures have been imposed exclusively on the refugee populations for the prevention of the spread of Covid-19, whereas the particular lockdown and traffic restriction measures had been already uplifted for the general population.
This political decision provoked a mass protest by twenty six humanitarian organizations active on the field of refugees' healthcare and human rights protection on the following grounds: This decision was taken (a) not based on any relevant evidence according to which refugees who live in camps throughout the territory present increased incidence of Covid-19 compared to the rest of the population, (b) not based on guidelines or instructions by international organizations such as the WHO and the European Center for Disease Prevention and Control (ECDC) that the isolation of entire hospitality structures effectively limits the transmission of coronavirus to reception and detention facilities or provides additional protective effects for the general population, and (c) while traffic control measures for the general population had long been lifted, which constitutes social discrimination against refugees in violation of an EU directive on the requirements for the reception of asylum seekers (2013/33, Article 8 on detention). The argumentation against this discriminative policy imposed to asylum seekers living in camps was adopted by Andreas Xanthos, the former Minister of Health and currently Shadow Health Minister, who submitted a relevant question to the Hellenic Parliament on the 17th of July 2020. The question was never answered by MoH.

Discussion, conclusions and limitations
The spectrum from conceptualizations to political measures in favor or against vulnerable populations at a time of a profound public health crisis was explored. This article confirms that the Covid-19 pandemic encourages neoliberal governments to exert increased measures of surveillance and discipline for population management, whereas the preexisting racial disparities woven into biopower are exacerbated (Sylvia, 2020). It is also confirmed that public health policies are structured through the biopolitical and necropolitical governmentality that sets priorities on what kind of lives are worth saving, based on cynical economic criteria: who benefits the state and who costs the state (Daher-Nashif, 2021).

Conceptual approaches to vulnerability
The meanings that official stakeholders assign to social groups affect policymaking. Reaching a consensus as to what is meant by "vulnerable populations" is essential in controversial times that comprehension of what is at stake is in a continuous flux. The richness of Greek language could have been utilized to differentiate synonyms of "vulnerable" [i.e. ευάλωτoς, ευπαθής, τρωτός] by origin of vulnerability (biological, environmental, social/economic) and achieve clarity in public discourse, which eventually may have been supportive to policymaking (Soultatou, 2020). The conceptual misuse of vulnerability is also observed by Chae et al. (2021) with reference to the cases of susceptibility and vulnerability, which are often used interchangeably. However it is interesting that Flaskerud and Winslow (1998, p. 69), for instance, view it as "social groups who experience limited resources and consequent high relative risk for morbidity and premature mortality" even before the WHO's explicit definitions in 2002 and 2020. Presumably a greater agreement yet not a consensusis being generated, as the concept of vulnerability is more clearly embedded with social justice values (Powers, 2016;Kahambing, 2020). In this light, vulnerable social groups are at a higher risk of poor health outcomes and healthcare discrepancies and are more affected by poverty, social stigma, gender discrimination and lack of access to medical services than the general population. As mentioned above, World Health Organization (2002), two decades ago, defined vulnerability as the degree to which a population, individual or organization is unable to cope with, resist and recover from the impacts of disasters, which echoes a more informed by the social justice and human rights' agenda.
Arguably the conceptual ambiguity discovered in this work, is interpreted against the inherent feature of neoliberal rhetoric to omit or downgrade the main roots of vulnerability, that is poverty, deprivation and economic disadvantage (Powers, 2016;Kahambing, 2020;Cardona, 2020;Smith and Judd, 2020).

Political actions towards the protection of vulnerable
The novel Public Health policy was explored seeking to discover to what extent it was informed by the concept of vulnerability in terms of policy design and subsequently whether and in what parts was enacted in terms of policy enactment. First, it was found that the concept of vulnerability was used loosely in the particular policy document, inclining to adopt a liberal account of vulnerability aligned with individual autonomy and the capability approach to health (Straehle, 2016). However, as explained above, vulnerability arises from a combination of socially situational disadvantage and contributes to an elevated baseline vulnerability to various types of losses occasioned by disasters (Powers, 2016). This finding is interpreted against the politics inherent in health terrain and the adherence of the government to neoliberalism (Daher-Nashif, 2021). However, as Cardona (2020) suggests, the neoliberal rhetoric of individual responsibility adopted at a time of global health is a disastrous criterion to the health and wellbeing for marginalized communities and may stigmatize the poor. Second, it was also discovered that the new Public Health policy was overall inapplicable to the reality of this major public health crisis since it was scarcely applied into practice. The two cases of law enactment traced in a year's span were irrelevant to vulnerability as shown.

Discriminative politics against refugees
In the name of public health, human rights may be sacrificed as a modern Iphigenia for the troops to conquer and dismantle Troy that is the pandemic Covid-19. Refugees living as stranded populations in camps situated in the highly touristic islands of eastern Aegean Sea (i.e. Lesvos, Chios, Samos etc.) have been purposely isolated from the general population and especially from the tourists on a purely discriminative logic (Devi, 2020). This political decision was taken despite guidance by international key organizations. The WHO (2020b) and ECDC (2020) emphasized that there is no evidence to suggest that SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) transmission is higher among migrants and refugees and, by contrast, WHO provided definitions of what constitutes vulnerability and offered concrete recommendations urging policymakers to take measures towards the protection of vulnerable populations. Also, at the time of the pandemic, the health promotion community has been urged to ensure health equity and social justice will remain at the forefront of pandemic responses, despite neoliberal forces which toss population health against national economic stability (Smith and Judd, 2020).
Despite the above, the particularly vulnerable population of asylum seekers have been prohibited from circulating outside the camps where they are in any case inappropriately accommodated, which provoked a mass reaction by the civil society. The civil society, from grassroots cooperatives (Rakopoulos, 2014) to international humanitarian organizations and non-governmental organizations (Orcutt et al., 2020) with particular emphasis on refugees (Oikonomakis, 2018), active at the time of capitalist recession and austerity lasting over a decade, provoked "contagious solidarity" (Cabot, 2016). The economic crisis in Greece, neoliberal agendas and severe austerity policies widened social inequalities and particularly affected vulnerable groups, such as undocumented migrants (Karanikolos and Kentikelenis, 2016).
The solidarity discourse found political expression when the left wing political party of SYRIZA came into power (from Feb. 2015 to Jul. 2019). The MoH then launched a new legislation providing universal health access to healthcare and medications for 2.5 million (out of 10 million in total) uninsured citizens as well as refugees and undocumented migrants (Economou et al., 2017). Concurrently, the MoH attracted fund from the European Commission (Internal Security Fund; Asylum Migration and Integration Fund) which then resulted to the comprehensive program "PHILOS -Emergency health response to refugee crisis", which sought to respond to the sanitary and socio-psychosocial needs of people living in camps, reinforcing also the Greek health system to manage the increased demands particularly in secondary care by recruiting numerous health professionals and support staff . As a result, the major pressures to the health system by those mostly in need had been alleviated over a certain period of time.
A shift in the political agenda was observed when the neoliberal government was elected in July 2019, as it abolished immediately the healthcare and social insurance number (AMKA) allocated to asylum seekers to guarantee access to free of charge health care. In spite of the official announcement that a new policy plan which would grant a Temporary Healthcare and Social Insurance Number for Foreign Citizens for asylum seekers, this has not been put into action yet (Joseph et al., 2020).
Concurrently, the negative attitude of local stakeholders regarding the impact of the refugees' inflows on the economic and social life of Eastern Aegean islands and therefore, on tourism prevailed (Tsartas et al., 2020). The pressures of the local stakeholders' economic interests to gain the most out of tourism during the summer of 2020, after a prolonged period of general lockdown, may be used to interpret the neoliberal government's decision to deprive the vulnerable asylum seekers population from freedom of traffic. Under the circumstance, numerous humanitarian organizations opposed to discriminative state, rejuvenating concurrently the solidarity movement, which had flourished in times of capitalist recession. In line with previous research, the Foucauldian analytical notion of governmentality is particularly useful to explore the technologies of governance inherent in the relations between the humanitarian sector and the state (Ofstad and Marin, 2019).

Limitations
As to the limitations of this study, it could be argued that social distancing of the first year of the pandemic Covid-19 affected sociological inquiry and particularly the scholars adhering to the qualitative research paradigm, since personal contact with participants is demanded. The lion's share in research was devoted, instead, to online surveys, a more convenient technique to generate data. The followers of the qualitative route to social realities utilized data from the public sphere. However the problem with this source of data is that, for the time being, we are missing the voices of people themselves. In conclusion, the main limitation of this work is the exclusion of vulnerable laypersons' own views, experiences and realities due to public health social distancing measures.