The first two doctors to die of Covid-19 on the NHS frontline were born in Sudan. In the Sudanese capital, Khartoum, there is a loan shark. Until last week, junior doctors with job offers in the UK represented a reliable income stream for him. The work visas they needed came with a host of conditions, but meeting those criteria counted for nothing unless they paid, upfront, an immigration health surcharge of £400 a year for every year of their work permit, duplicated for every member of their family if they had one.

Being recent graduates, most applicants had only pennies to their name. So the loan shark thrived, demanding an interest payment in advance, before personally entering his credit card details into the online application form.

His business may now be in trouble. On Thursday, the British government gave in to mounting pressure and exempted migrant NHS staff from the surcharge. This wasn’t an easily won concession. Cancelling the surcharge before the anger had reached its own backbenches could have been an early and obvious win. But that’s not how this government, or its Home Office, works.

The surcharge is (not was, as it is still paid by non-NHS migrants, many on low incomes and with few public advocates) not only outrageously costly, it is also immoral. Migrants pay taxes and national insurance contributions. Subjecting them to an additional charge to use an NHS they have already contributed to amounts to exploitation.

The fact that the government will not offer an exemption for people on low incomes, or deviate from its demand to pay in one lump sum, is a familiar feature of Home Office fee design. The policy is to put immigrants on the spot and extract as much as possible from them. On the other side of these fees there are jobs, training opportunities, university offers, spouses, partners and other loved ones to join. If you’re in the country already, the downside of failing to pay such fees renders them close to extortion. Refusing to stump up means having to take your life apart and leaving the country. What’ll it be: your money or your life?

I and many friends and family members have often had to make these kinds of decisions over the years. In the middle of a long, chaotic and insulting immigration experience you put your dignity, mental health and financial stability on the one hand; and the intricate, rich life you have built in this country on the other. The scales just about balance. This is what the government bets on.

As a result, it has built an immigration system that is geared not towards what is fair, but what it can get away with. And that is a lot. If one looks back over the last decade, two policies, austerity and the hostile environment, have defined the Conservative political agenda. The party not only managed to drive them through undiluted, it also spun these policies’ failures, to achieve prosperity or a reduction in immigration numbers, as success.

It is no surprise then that it took such a fight to convince the government to exempt NHS staff from the surcharge even as they were fighting a pandemic. Its commitment to the policy was never about money: numbers suggests that NHS staff contributions only bring in a measly £35m a year (not Boris Johnson’s deliberately inflated number of almost a billion).

The Tory party’s own MPs and peers condemned it. Politically, the surcharge put the government to the right of Ukip and at odds with the Daily Mail. But a habit forged over a decade is hard to quit overnight. The political software of nimble review and reform does not exist in the Home Office. In fact, it is inimical to the smooth running of the hostile environment, which is a complex policy infrastructure that is built for inflexibility. Combine that with this new government’s rapid centralisation, fondness for unsubtle apparatchiks like Priti Patel, disdain for the civil service, plus a dash of incompetence, and you end up with an administration that responds to nothing but public shaming.

Increasingly, the only way to get the Conservatives to ditch unethical policies is to provoke national outrage. The victims of the policies have to suffer, and then drag their pain and anger into the public realm and petition for mercy. Whether it is the suspension of Windrush deportations, free parking for NHS doctors, extending indefinite leave to remain to the families of all NHS staff, or this latest concession, the government only changed course when it became too embarrassing not to. There is no moral compass, no sense of responsibility over lives in its care, just a cynical cost-benefit analysis of which policies are worth the harassment in the media and at the dispatch box and which are not.

But we get them to move. One win at a time. It does mean, though, that we can only focus on one injustice at a time. The NHS surcharge may have saved junior doctors from a loan shark in Khartoum. But with every victory a question hangs: what about the others trapped in the latticework of the government’s meanness and incompetence, suffering in ways that will probably never come to light?

Nesrine Malik is a Guardian columnist

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