Diseases such as HIV/AIDS and the current swine flu pandemic have highlighted the connection between the large scale movement of people and health. With more than 200 million migrants in the world, migration - internal and across borders - is here to stay. It thus makes sense for all countries to put a migrant-friendly health system in place, argues Manjima Bhattacharjya
Over the last few weeks, the panic of swine flu has led to a new addition in the regular ‘check in-security check-boarding’ and ‘disembark-baggage claim-customs’ routine of international air travel. In between, you now have to line up before masked medical health professionals to ensure that you haven’t brought the H1N1 virus with you. It is usually at such times that migration or movements of people, and health, intersect visibly in the media and in the minds of people and governments.
But migration and health have been, for long, areas of concern for public health professionals, particularly in the last two decades when migration has increased manifold. Migration has occurred throughout human history, but globalisation has led to a new phase in its history with unprecedented movement of people. While HIV/AIDS (especially for migrant men) and trafficking (especially for migrant women) dominate the discourse around migrant health, it is increasingly imperative today to see the broader connections between migration and health or the implications of migration on health patterns of migrants themselves. More importantly, it is crucial to integrate migrants’ rights and their needs in health policies of a nation to arrive at more holistic results and, in public health terms, a healthy population.
Migration is here to stay
Migrants are mostly perceived in a negative light – as carriers of disease, as a burden on host countries or as a statistic that pulls down national health figures. Their health concerns still fall outside any positive efforts by a nation to create conditions for a healthy population. This is part of the general schizophrenia that seizes governments when it comes to migrants. On the one hand, many countries run on migrant labour -including undocumented migrants - and are heavily reliant on them across sectors. On the other hand, governments are erecting fencing along borders or putting into place stringent migration policies to make it more difficult for migrants to enter.
Such an attitude avoids addressing what could be a critical public health problem in the future. Migration, it has been established, is more or less an irreversible process, as irreversible as globalisation. For many groups of people both internal (rural to urban mostly) and international (developing countries to developed countries) migration has become a strategy for people’s livelihoods. In Rajasthan a study by the Aajeevika Bureau, an NGO that works with migrants (1), found that migration was no longer a response to drought or related to distress factors; instead, it had become a regular (and the most common) livelihood strategy for most men in the area studied, replacing agricultural labour. People spend about eight months of the year migrating to urban centres like Ahmedabad in Gujarat to work in certain sectors of labour (construction work, loading, hotel and restaurant labour, diamond cutting, and so on).
Millions of people move around the world or within their countries for many reasons – for livelihood, to survive, to create better lives for themselves, to escape conditions of poverty, drought, conflict or war-like situations.
The International Organisation for Migration (IOM) reports that there are over 200 million migrants in the world (not counting the estimated 20-30 million who are unauthorised migrants), whose labour in 2007 accounted for US$ 337 billion in remittances worldwide. Of this amount, US$ 251 billion went to developing countries. The IOM states: “Migration is one of the defining issues of the twenty-first century. It is now an essential, inevitable and potentially beneficial component of the economic and social life of every country and region. The question is no longer whether to have migration, but rather how to manage migration effectively so as to enhance its positive and reduce its negative impacts. Well-informed choices by migrants, governments, home and host communities, civil society, and the private sector can help realise the positive potential of migration in social, economic and political terms.” (2)
It is thus naïve to think that some day migrants will go back or reduce or such movement will stop and all will return to “normal”. Realistically speaking, then, it makes good sense for a government to accept this reality, recognise the different populations in an area and their different health profiles and needs, and design policies and schemes accordingly with the target of achieving a healthy, productive and happy population. To do this, it is vital for governments to understand, in depth, the implications of migration on health.
How migration affects health
Migration patterns show that people usually move away from conditions of relative poverty to more affluent societies, or at least to seek better lives for themselves. It is debatable whether they come from more “unhealthy” conditions in terms of poverty or disease stricken environments, but often the better life that they are in search of eludes them. Demographics show that migrant communities survive in difficult conditions in host countries as well, living in often crowded, unsanitary and inferior quality housing, often unable to afford healthy or sufficient food, and working in low-paid, insecure and sometimes dangerous areas of work.
In many cases they are affected by a new set of health concerns. Manuel Carballo and Aditi Nerukar of the International Centre for Migration and Health, in the journal Emerging Infectious Diseases (3) note that there are added risks and vulnerabilities of psychosocial disorders, drug abuse, alcoholism and violence. This gives us the impression that the experience of migration is a negative experience. However, there is also enough evidence to show that migration, especially for women, offers them an opportunity to escape many strictures and allows them to find many freedoms and realise many of their human rights that were not possible in their places of origin because of rigid social structures and watertight gender roles (4).
Migrants carry their “health prints” with them, which is essentially their own immune system often borne of their socio-economic conditions at the place of origin that will determine how susceptible or how resilient they are to some conditions, such as differences in weather, for example. If they come from places where there has been less focus on immunisation, this “non immunity” moves with them; migrants are therefore likely to carry with them vulnerabilities present in their original communities.
The question of immunity is particularly important in the case of diseases like tuberculosis (TB) or HIV/AIDS which are directly related to immunity. In the case of diseases like TB, for instance, migrants’ proclivity to contract the disease has been reflected in some national statistics where the data have been disaggregated. For example, Carvallo and Nerukar note that in nine countries of Europe, the incidence of TB was low till the 1990s, when increased migratory flows saw TB levels increasing too. In the Netherlands, TB rose by 45% between 1987 and 1995; over 50% of the known cases occurred amongst migrants. In England and Wales approximately 40% of all TB infections are estimated to occur in people from the Indian subcontinent. In Germany, migrants are three times more likely – and in France six times more likely – to be diagnosed with TB. There is a higher prevalence of TB in migrants, and given the connection between TB and HIV/AIDS, this is a concern for HIV policy also. Patterns of HIV prevalence, though, are not so stark or consistent: for example, HIV incidence is higher among migrants in Sweden, especially those from Africa, but in Italy, HIV among migrants is less than among nationals.
Migrants also bring with them their own cultural beliefs about what is hygienic, healthy or unhealthy, and approaches in general to death and disease. Sometimes, acknowledging mental health problems is taboo, making it difficult for people of that community to acknowledge that they need medical intervention for psycho social problems. In other communities sex-related health issues are taboo, making it difficult for women or young people to obtain information about contraception or sexually transmitted diseases. Practices like eating with chopsticks from the same plate or sharing a meal are seen as communal behaviour by Vietnamese but in Australia are considered unhygienic and conducive to spreading of disease (5).
Migrant women’s vulnerabilities
A defining feature of migration this decade has been the “feminisation of migration”, a term that refers to the phenomenal number of female migrants moving in search of livelihoods. Although discussed within the framework of marriage in the past, and later in the context of trafficking, more and more women are migrating independently. Statistics from the IOM show that women constitute 49.6% of global migrants. A large proportion of women are concentrated in the informal sector, including domestic work.
For women, unsafe migration and the vulnerabilities associated with it, including the dependency on possibly unreliable male escorts, can put them at additional risk of sexual abuse and exploitation. This makes them vulnerable to STDs and HIV in a specific way. Other vulnerabilities arise when they have low levels of information and poor knowledge about contraception, abortion and other reproductive health issues, and when they have low negotiation power to ensure the use of condoms. Young single women who migrate for work and may be sexually active are seen as especially vulnerable because of these factors; in some countries, the rate of unwanted pregnancies among them is high.
Statistics show that problems such as neonatal mortality, underweight births, premature or complicated deliveries are more common to immigrants. Part of this is due to the women’s health profile (such as a higher incidence of anaemia or malnutrition) in their countries of origin. And partly it is that immigrant women often approach the health system at later stages in their pregnancy or may not have undergone relevant monitoring or care under the larger health care system.
The challenge for governments
While migrant groups are likely to have different sets of issues, on the whole they share some characteristics, the most common being difficulty in gaining access to health systems in their new locations. Questions of legality, cumbersome and unfamiliar documentation, and the bureaucracy of health systems in many countries leave them outside the loop.
Sometimes, even simple problems remain untreated because of unfamiliarity with existing health mechanisms. For example, getting off-the-shelf medication is almost impossible in many western countries with a prescription being necessary even for common problems. In many developing countries, it is easier to buy medication off the shelf, and people go so far as to informally consult the chemist or pharmacist rather than a doctor for an ailment. Some see local quacks, or use alternative methods of healing or resort to traditional health recipes to treat the ailment. In a completely new and radically different health framework where each medication needs to be prescribed, many migrants are in a quandary, even across classes.
For any government all this poses a challenge to ensure that whoever lives in their country remains healthy. One of the biggest problems is that there are limited data to begin with on patterns and trends in migrants’ health and the problems they have in using the health system. There is no systematic gathering of the health profile of different communities nor is existing data disaggregated accordingly to devise suitable policies. There are enough studies, however, to indicate that migrants are, more often than not, more “unhealthy” than host populations.
Also a challenging issue, and one that immediately conflicts with human rights, is the system of health assessment that a government has for prospective legal migrants. Migrant rights activists allege that such assessments are used by governments to restrict the entry of legal migrants. For example, HIV testing for migrants is a sensitive issue. Often the screening process for employment of workers or professionals from other countries involves an HIV test, sometimes conducted without consent, confidentiality, counselling or general information support. Apart from the issue of the test, what are the implications of being found to be HIV-positive? Do people living with HIV have a right to migrate for livelihood or treatment? Also of concern is the treatment of migrants who are found to be HIV-positive. This is particularly relevant to victims of trafficking or migrant women in prostitution, who face additional discrimination, mistreatment and stigma and are deported back in inhuman conditions with no thought to what will happen once they are back in their country. The challenge is to define or find policies and public health responses – both preventive and treatment measures – that adhere to basic human rights.
There are, in addition, specific problems related to specific national health systems. This is less of a problem in internal migration (although there are problems here too, for example, the absence of the village health centre, having to go through bureaucratic procedures in large government hospitals, the financial constraints of private hospitals, and so on). In international migration there are likely to be gaps in understanding, information and access. What kinds of insurance exists, what is the health system, how formalised is it, what are migrants entitled to, what is the documentation required, what are the covers or schemes for specific occupation-related migrants and so on – this information has to be clearly available in languages that migrants understand.
Another gap is that even when specific schemes for migrant workers exist, they do not extend to cover families. This has been an important concern in international human rights and migrants’ rights circles. Families of migrant workers are often left out of the loop even if the male primary worker himself has some access to health benefits. This adds a special burden on women and children, whose health remains nobody’s concern.
Putting a migrant-friendly health system in place
The four principles of a good public health approach that takes care of migrant health concerns, or that could be the pillars on which a migrant health policy is based, have been expounded by the World Health Organisation (6) as the following:
- Avoid disparities in health status and access between migrants and the host country
- Limit discrimination, stigmatisation and impediments in access to the health system
- Put into place life-saving interventions so as to reduce excess mortality and morbidity
- Minimise the negative impact of the migration process on migrants’ health outcomes.
These are only broad goals which can help governments frame policies with the human rights of migrants in mind. Various countries though have different approaches and perspectives on the issue.
Some perspectives see the question of migrants’ health rights as an aspect of multiculturalism, as part of the “integration process” that countries with diverse populations talk about, like in Canada, the USA, France and Germany. Health care is often given as a good example of how “integration” can be mapped out in real terms, and tests whether public institutions are capable of dealing with cultural diversity. Pro-migrants and anti-racism organisations have politicised this issue consistently in some countries, forcing governments to ensure that cultural sensitivities are incorporated into their health care system. For example, pregnancy check-ups are sometimes an important first contact with national health systems and a time where cultural differences in approach exist. In mental health care, also, adjustments are needed to provide mental health care for groups whose social situation and cultural background is different from the mainstream population.
Governments need to invest money, time and thought into these matters proactively rather than as a response to isolated events. Sometimes it is only after an emergency or an incident reported in the media that they are pushed to respond or act. For example, the death of an Oriya migrant worker in Surat set off alarm bells and alerted the state to the fact that there are more than 600,000 Oriya migrant labourers working in Surat, many of them from Ganjam district. (7) Although no study was done, based on the assumption that there was an “alarming rise in AIDS among migrant labourers” the health department of the government of Gujarat and the district administration of Ganjam reportedly signed an agreement to issue health cards to migrant labourers. While a response that included both source and destination administrations was commendable, the strategy itself lacked an understanding of the problems and possible solutions.
Migrants’ health issues are not fully understood even by NGOs. The Kerala State Aids Control Society has a specific migrants’ sexual health intervention project. (8) Although Kerala has a low prevalence of HIV, there is a high rate of ‘in-migration’ into the state, and an initiative like this aims to maintain the low prevalence in the state. The project is based on the assumption that migrants are more likely to engage in risky behaviour as they have the “freedom to experiment with new norms”. The programme is focused on “construction workers, hotel workers, truckers, street vendors, cable workers” and comprises the regular elements of any HIV prevention programme – behavioural change communication, STI management, condom distribution and usage etc – without having any deeper understanding of the health concerns of migrant workers. Isolated HIV initiatives may be rendered ineffective if other crucial aspects of migrants’ health are not addressed.
The Aajeevika Bureau’s project which aims to build a robust support system for migrants has a deep understanding of the issues that affect migrants’ health, especially seasonal migrants who move from Rajasthan to Gujarat. These migrants are vulnerable to disease, accidents, unhealthy living conditions and inadequate nutrition because of high prices of food, and also difficulties in finding means and space to cook, as a result of which they eat poorly and irregularly. This results in much wider prevalence of tuberculosis and malnutrition. Aajeevika’s programmes run in both ‘destination’ and ‘source’ places thus providing a connection between the two. While some element of health is covered in their work, this is not a separate programme, and neither is the inclusion of issues like HIV/AIDS where testing, information, counselling or treatment can be sought, sustained or at least carried out properly over the period of migration.
This lacuna – the absence of deeper knowledge of migrant health issues within the HIV/AIDS programmes, and the absence of an HIV/AIDS component in migrants’ rights programmes – needs to be filled. Often, both HIV and migrants lobby groups work separately without realising the importance of bridging this distance and seeing the broader question of migrants’ health and its impact on migrants themselves and on the communities they have migrated to.
Moving beyond HIV/AIDS
Much has been said about migrants and their proclivity to spread HIV/AIDS, but their overall health condition and reduced access to health care has been ignored. Only recently has it been noted that the wider health implications of migration must be placed at the centre of the debate to really be able to address a range of public health concerns, including HIV/AIDS.
The IOM’s programme itself has changed to reflect this trend. In 2004 its key contribution in migration health was the document ‘UNAIDS/IOM statement on HIV/AIDS related travel restrictions’ (9) which described HIV related travel restrictions and their impact, reviewed relevant human rights laws and principles and discussed humanitarian and ethical issues, stating strongly that such restrictions have no public health justification and only result in the exclusion of people living with HIV/AIDS. This was an important validation of the human rights of people living with HIV/AIDS to travel and to migrate and a critical document. However, since then the scope has widened beyond HIV, and the mandate has been expanded to cover general health issues of migrants. It has started migration health activities (comprising assessments of migrant health situations, assistance to migrants as well as support in strengthening of national health systems) in over 40 countries worldwide, as compared with only a dozen five years ago.
The connection between migration and HIV/AIDS was made long ago, but it was within a paradigm of paranoia and fear and resulted in creating a stigmatic association, and, compounded by general antagonism to migrants, only added to their vulnerabilities. It is time to move beyond this; unless we recognise the overall health issues of migrants and how it plays out, we cannot really get to the heart of the problem and design effective responses.
- Aajeevika Bureau: solutions, security and support to rural migrants. www.aajeevika.org
- International Organisation for Migration. www.iom.int
- M Carballo, A Nerukar. ‘Migration, refugees, and health risks’ in Emerging Infectious Diseases. June 2001; 7 (3): 556-60. Available on: http://www.cdc.gov/ncidod/eid/vol7no3_supp/carballo.htm
- Jagori. ‘Rights and vulnerabilities: A research study of migrant women workers in the informal sector in Delhi’. New Delhi: Jagori; 2004. Available from: www.jagori.org/wp-content/uploads/2007/07/migration-final-report.pdf
- Quynh Lê, Thao Lê. ‘Cultural attitudes of Vietnamese migrants on health issues’. Paper published by the Australian Association for Research in Education. Available from: http://www.aare.edu.au/05pap/le05645.pdf
- World Health Organisation. Health of migrants: Report by the secretariat. EB122/11. 20 December 2007. Available from: http://www.who.int/hac/techguidance/health_of_migrants/B122_11-en.pdf
- Vikraman Pillai. Citizen Log. Surat Diary. March 30, 2008. Available from: http://www.merinews.com/clogarticle.jsp?articleID=131494&category=India&catID=2
- Kerala State AIDS Control Society. Migrants’ Sexual Health Intervention Project – Kerala. Available from: http://www.ksacs.in/migrants.php
- UNAIDS/IOM statement on HIV/AIDS related travel restrictions. June 2004. Available from: http://www.iom.int/jahia/webdav/site/myjahiasite/shared/shared/mainsite/activities/health/UNAIDS_IOM_statement_travel_restrictions.pdf
InfoChange News & Features, June 2009