Lesson 3.1
Migration Health:
Conceptual Framework
Alfonso Rodriguez-Lainz, PhD, DVM, MPVM
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 health
1990: 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 moredeveloped 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
ORIGIN
COUNTRY
DESTINATION
COUNTRY
Disease burden
Disease burden
Health risks:
Health risks:
-
Vectors
-
Food safety
-
Sanitation
-
Others
Health beliefs/behaviors
Migration
-
Vectors
-
Food safety
-
Sanitation
-
Others
Health beliefs/behaviors
Health infrastructure
Health infrastructure
Others
Others
Migration: a bridge between countries
ORIGIN
COUNTRY
DESTINATION
COUNTRY
High
prevalence
Low
prevalence
Low
prevalence
High
prevalence
X
prevalence
X
prevalence
Estimated TB Incidence Rates, 2001
per 100 000 pop
< 10
10 - 24
25 - 49
50 - 99
100 - 299
300 or more
No estimate
© WHO 2003
Prevalence of obesity, 2005
Source: WHO
How could we define
Migration Health?
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)
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)
Health and the
Phases of Migration
Phases of Migration
Origin country
Transit country (?)
1. Pre-departure
2. Journey
4. Return
Destination country
?
3. Post-arrival
Adapted from Gushulak, 2010
1. Pre-departure Phase
The Pre-departure Phase
• The sum of the health determinants of the
migrant itself and the region of origin:
COUNTRY OF ORIGIN
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
+
Disease prevalence
Health risks:
- Vectors
- Food safety
- Sanitation
- Others
Health infrastructure
2. Journey Phase
The Journey Phase
Individual factors
Biology and genetics
(eg., sex, immunity)
-SES (migration status)
-Physical environment
(e.g., housing, work)
-Health beliefs/behaviors
-Pre-existing health conditions
Access 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
Smuggling By Sea
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
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
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 highspeed crash of smuggler’s
van, pursued by Border
Patrol on Interstate 8 east
of San Diego (2003)
Migrant hiding inside a
car compartment
Smuggling by foot
• Extreme weather
• Ill prepared
• Dangerous routes
(deserts, mountains)
Migrants 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)
3. Post-arrival Phase
The post-arrival Phase
DESTINATION COUNTRY
Disease prevalence
Individual factors
- Biology and genetics
(eg., sex, immunity)
-SES (migration status)
- (New?) Health beliefs/behaviors
-(New?) Pre-existing health conditions
+
Health risks:
-
Vectors
Food safety
Sanitation
Others
Health beliefs/practices
Access to health care
Work opportunities
Housing
Many others (eg., language)
Determinants of
migrants’ health
in the
destination country
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 environment
Housing conditions
• Poor housing
–
–
–
–
–
Overcrowding
Noise disturbance
Unsafe neighborhood
Low indoor air quality
Limited recreation and transportation opportunities
• Concentrated in ethnic/minority enclaves
Physical environment
Occupational 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
4. Return Phase
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
Summary
• Historic negative perceptions about migration
and health
• Migration as a component of global health
• Social determinants of migrants’ health
• Health consequences of the migration itself
and the different stages of migration