YOU NEED PAPERS TO SURVIVE.

Thomas Buhk is a punctilious person. His hair is cropped short, his white shirt ironed flat. He uses his hands a lot when he speaks - one finger per argument. Firstly, secondly, thirdly… Then he grabs each argument with his other hand and holds it tight as he speaks.

It's unmistakable - the 53-year-old is serious. He is unhappy because Hamburg city authorities are hindering his work, and he sometimes has to violate regulations to treat his patients.

As happened recently with a man from Ghana. The blood test was clear: the patient had an advanced HIV infection, with only 140 T helper cells per microlitre of blood. Anything below 200, and there is a serious threat of Aids-related illnesses like pneumonia. "It was obvious he needed treatment immediately," Dr. Buhk recalls. "At the very least he needed prophylaxes against the most dangerous infections."

DEATH - AFTER VISITING THE EMERGENCY ROOM

The patient had no residency permit for Germany, and therefore no health insurance. To prevent anything worse happening in situations like this, Dr. Buhk gets the necessary tablets from among his stock of remainders - even though doctors are not allowed to store medication and pass it on to patients.

"I have to improvise in these cases to make up for certain political shortcomings," the HIV specialist explains. His work often falls into a legal grey-zone.

For that reason he advised his Ghanaian patient to seek a lawyer and apply for asylum - the only way he'd be able to make use of social welfare laws for asylum seekers and gain access to medical care. "There are no guarantees, but the prospects for HIV-positive applicants are relatively good," he says - though HIV is not officially grounds for receiving asylum, and whether the infection can prevent deportation is another matter.

Those who don't want to risk being deported have to make do with an emergency programme. "A full HIV treatment is impossible," says the specialist. "The costs are too high." The recommended quarterly blood tests alone cost 260 euros.

In the worst cases, people pay with their lives - as happened to one Ecuadorean woman in Hamburg. She went to the emergency room of several hospitals with diarrhoea, headaches, and stomach cramps and - after a number of examinations - was sent home.

Three days later her friend found her dead in her apartment. The autopsy revealed that she suffocated during a seizure caused by a fungal infection in her brain - an Aids-related illness. "Under normal circumstances they would have carried out a CT scan, made a diagnosis and treated her successfully in time," explains Dr. Buhk. But because of her unclear insurance situation that didn't happen.

WE NEED A POLITICAL SOLUTION

"We have to make it easier for these people to get access to basic medical care," says Buhk. "And without having to declare their residency status." That's why he has been campaigning for a political solution to the problem, if only in Hamburg. But the authorities are blocking his efforts. They are concerned about high costs and the abuse of the health care system, but as far as Dr. Buhk is concerned, these are no arguments: "One possibility would be a health card, which patients could use to get certain limited services in emergency situations."

As long as politicians fail to find a solution, the doctor has to do what he can for each individual patient. He doesn't think he'll encounter any difficulties over his actions, and if he did, he would fight for his duty to save lives. But the reality is different: the Hamburg authorities know of his work and even send people without papers to his consulting hours.

Often Dr. Buhk can help. The HIV patient from Ghana has recovered well, and not only has his deportation been stopped, he has even found a job - working for the city of Hamburg authorities, of all places. Thomas Buhk seems satisfied when he tells the story. The "illegal" immigrant has become an ordinary patient. "That's how it should be!"

Philip Eicker

Dr. Thomas Buhk is doctor of infectious diseases at the Centrum Hamburg.