Lesson 3.1Migration 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 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

Prevalence of obesity, 2005

Source: WHOSource: 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)(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

Adapted from Gushulak, 2010Adapted from Gushulak, 2010

Origin country

1. Pre-departure

4. Return

Transit country (?)

2. Journey

Destination country

3. Post-arrival??

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

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

++

2. Journey Phase

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)

3. Post-arrival Phase

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 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 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

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