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Outline• Migrant health
– Historic and modern perspectives
– Definition
• Health and the Phases of Migration
• Determinants of migrant’s health at the destination country
Migration and Disease Historical Background
• The relationship between the international movement of people and diseases has been recognized since ancient times
• Historically, the focus has been mostly on:– Risk of introduction of infectious
diseases by migrants– Cost associated with providing
access to care to this population
Source “Quarantine” by Howard Markal
Migration and Health
A seriously neglected area of
research and international and national policies (Ingleby, 2005)
Expanded international attention
on migration and health1990: IOM/WHO First International Conference on the Health Needs of Refugees, Migrant Workers, other Uprooted People and Long Term Travelers
2004: IOM/WHO/CDC Seminar on Health and Migration (2004), Geneva, Switzerland
2007: Portuguese European Union Presidency: “Migrant health, better health for all”
2008: 61st World Health Assembly: “Health of Migrants” Resolution
2010: WHO/IOM/Spanish Government: Global Consultation on Migration and Health
Expanded international attention
on migration and health• Driven by:
– Growth in the volume and frequency of international travel
– Increasing immigrant population in more-developed countries
– Migrant health disparities and unique needs
– Role of migration on emerging diseases of international health significance
Migration: a bridge to global health
• Migration connects the health of communities in the countries of origin, transit and destination
• “Globalizes health risks and outcomes” (Gushulack, 2009)
Migration: a bridge to global health
Disease burden
Health risks:- Vectors
- Food safety
- Sanitation
- Others
Health beliefs/behaviors
Health infrastructure
Others
Disease burden
Health risks:- Vectors
- Food safety
- Sanitation
- Others
Health beliefs/behaviors
Health infrastructure
Others
ORIGIN COUNTRYORIGIN
COUNTRYDESTINATIONCOUNTRYDESTINATIONCOUNTRY
Disease burden
Health risks:- Vectors
- Food safety
- Sanitation
- Others
Health beliefs/behaviors
Health infrastructure
Others
Disease burden
Health risks:- Vectors
- Food safety
- Sanitation
- Others
Health beliefs/behaviors
Health infrastructure
Others
Migration
Migration: a bridge between countries
High prevalenc
e
High prevalenc
e
Low prevalenc
e
Low prevalenc
e
High prevalenc
e
High prevalenc
e
Low prevalenc
e
Low prevalenc
e
X prevalenc
e
X prevalenc
e
X prevalenc
e
X prevalenc
e
ORIGIN COUNTR
Y
ORIGIN COUNTR
Y
DESTINATION COUNTRYDESTINATION COUNTRY
25 - 49
50 - 99
100 - 299
< 10
10 - 24
No estimate
per 100 000 pop
300 or more
© WHO 2003
Estimated TB Incidence Rates, 2001
Estimated TB Incidence Rates, 2001
Migration health
• A specialized field of the health sciences that focuses on:– the health of migrants, and – the health effects of migration on
communities in countries of origin, transit and destination• Including second and later generations
(Adapted from IOM)(Adapted from IOM)
Migrant health
• “Health is a state of complete physical, mental and social wellbeing of migrants and not merely the absence of disease or infirmity” (Source: IOM, adapted from WHO, 1948)
• Unfortunately, many countries continue to have a limited view of “migrant health” as– (Infectious) disease screening and exclusion policies
– Policies regulating migrants’ access to health and social benefits
Migration health: an integral component of global health
• Global (and Migrant) Health:– International transfer or sharing of
health risks
– Health issues that transcend national boundaries and may best be addressed by cooperative actions
(Institute of Medicine, 1997)
Phases of Migration
Adapted from Gushulak, 2010Adapted from Gushulak, 2010
Origin country
1. Pre-departure
4. Return
Transit country (?)
2. Journey
Destination country
3. Post-arrival??
The Pre-departure Phase• The sum of the health determinants of the
migrant itself and the region of origin:
COUNTRY OF ORIGIN
Disease prevalence
Health risks:- Vectors- Food safety- Sanitation- Others
Health infrastructure
COUNTRY OF ORIGIN
Disease prevalence
Health risks:- Vectors- Food safety- Sanitation- Others
Health infrastructure
Individual factors
-Biology and genetics (eg., sex, immunity)-SES-Physical environment (e.g., housing, work)-Health beliefs/behaviors-Pre-existing health -Access to health care
Individual factors
-Biology and genetics (eg., sex, immunity)-SES-Physical environment (e.g., housing, work)-Health beliefs/behaviors-Pre-existing health -Access to health care
++
The Journey Phase
Individual factorsBiology and genetics (eg., sex, immunity)-SES (migration status)-Physical environment (e.g., housing, work)-Health beliefs/behaviors-Pre-existing health conditionsAccess to health care
Individual factorsBiology and genetics (eg., sex, immunity)-SES (migration status)-Physical environment (e.g., housing, work)-Health beliefs/behaviors-Pre-existing health conditionsAccess to health care
Factors associated with health effects of journey
1. Migratory status
2. Economic resources
3. Mode and quality of transportation
4. Duration of the journey
5. Regions of travel– Environment– Health risks– Safety
IOM
Mode and length of travel
• If legal migration => safe and short travel => limited health risks
• If enough economic resources:– Obtain falsified documents => use of
commercial transportation => limited health risks
• If unauthorized migration => smuggling => longer and high risk means of travel => serious health risks
Smuggling of migrants
• Assisting, for a financial or other benefit, the illegal entry of a person into a country without proper authorization*
• Increasingly dangerous– Especially for women, children, the elderly and
sick
• Repeated smuggling attempts
• Modes of transportation: all– e.g., cars, trucks, vessels, airplanes, by foot
*Adapted from Protocol to the UN Convention Against Transnational Organized Crime*Adapted from Protocol to the UN Convention Against Transnational Organized Crime
On March 18, 2002, Italian police stand by as more than 1,000 Kurdish refugees land at Catania, on Sicily's southeastern shore. Photo: Tony Gentile/Reuters
Many illegal migrants enter Great Britain at the Dover docks
Smuggling By Sea
In 2002, Chinese immigrants tried to smuggle themselves out of the country in this cargo vessel. The container was headed for an unidentified Western country. Photo: Reuters
Smuggling by Motor Vehicles
Migrant hiding inside a car compartmentMigrant hiding inside a car compartment18 of 100
immigrants crammed into a truck abandoned in Texas, were found dead of heat exhaustion (2003)
Photo: Joe Mitchell/Reuters
18 of 100 immigrants crammed into a truck abandoned in Texas, were found dead of heat exhaustion (2003)
Photo: Joe Mitchell/Reuters
One of 19 unauthorized immigrants injured in high-speed crash of smuggler’s van, pursued by Border Patrol on Interstate 8 east of San Diego (2003)
One of 19 unauthorized immigrants injured in high-speed crash of smuggler’s van, pursued by Border Patrol on Interstate 8 east of San Diego (2003)
Smuggling by foot
• Extreme weather• Ill prepared• Dangerous routes(deserts,
mountains)
Migrants begin hike into central Arizona desertMigrants begin hike into central Arizona desert
Smugglers’ violence
• Extortion• Assaults• Rape• Kidnapping• Assassination
Headed for the U.S, 72 illegal migrants from non-Mexican states were murdered at the U.S- Mexico border (August, 2010)
Headed for the U.S, 72 illegal migrants from non-Mexican states were murdered at the U.S- Mexico border (August, 2010)
The post-arrival Phase
Individual factors- Biology and genetics (eg., sex, immunity)-SES (migration status)- (New?) Health beliefs/behaviors- (New?) Pre-existing health
conditions
Individual factors- Biology and genetics (eg., sex, immunity)-SES (migration status)- (New?) Health beliefs/behaviors- (New?) Pre-existing health
conditions
DESTINATION COUNTRY Disease prevalence
Health risks:- Vectors- Food safety- Sanitation- Others
Health beliefs/practices
Access to health care
Work opportunities
Housing
Many others (eg., language)
DESTINATION COUNTRY Disease prevalence
Health risks:- Vectors- Food safety- Sanitation- Others
Health beliefs/practices
Access to health care
Work opportunities
Housing
Many others (eg., language)
++
Determinants of Health
• Biology and genetics
• Health beliefs/behaviors
• Social environment
• Physical environment
• Access to health care
Biology and genetics• Genetic predispositions (e.g.
Thalassemia, hemoglobinopathies)
• Natural or acquired immunity (e.g., malaria, immunizations)
• Migrant populations frequently have a different age/gender structure than the native population
Health beliefs/behaviors
• Diet• Obesity • Causes of illness and treatment• Expectations about health providers• Self-assessment of health• Disease prevention strategies• Mental health• Domestic violence• Use of alcohol, tobacco and drugs• Physical activity
• May be different than those of the host society
Social environment
• New social setting
• Legal migratory status
• Marginalization – Discrimination, stigmatization and xenophobia
• Loss of familiar and social support
• Socio-economic status – Education level– Occupation– Income (Poverty)
Social environment
• Language proficiency – Critical issue for:
• Social integration• Work opportunities• Health
– Understanding and using the health system– Exposure to health education– Communicating with providers
» Explaining their health problem» Understanding treatment
• Title VI of the Civil Rights Act requires healthcare facilities to offer interpreting services free of charge
Physical environment
• Weather• Environment (eg., air quality)
• Disease vectors distribution
• Housing and workplace conditions
Physical environment Housing and workplace
conditions
• Healthier environment in host country:– Housing with safe water and sanitation– Regulated work sites
• Poor environmental conditions– eg., exposure to disease, toxic
substances and physical hazards
Physical environmentHousing conditions
• Poor housing– Overcrowding– Noise disturbance– Unsafe neighborhood– Low indoor air quality– Limited recreation and transportation
opportunities
• Concentrated in ethnic/minority enclaves
Physical environmentOccupational factors
• Overrepresented in high risk jobs (e.g., agriculture, construction, transportation)
• Limited health and social protection
• Higher unemployment rates
Access to health care
• Vulnerabilities:– Differences in health systems and practices
between countries of origin and destination– Legal limitations on access to care based on
migration status– Many barriers to access to care
• Culture, language, cost• Limited awareness about available services • Lack of health insurance
– Disparities in quality of care
Return Phase• Migrants may be at increased risk for some
diseases or risks
• Higher risk populations: “Visiting friends and relatives” travelers, especially children of migrants– Because of lack of immunity or not taking preventive
measures)
• Migrants with old age, disabilities, severe chronic or terminal diseases may return to country of origin
• Potential for disease transmission and/or transfer of health behaviors to family and community