6^th International Metropolis Conference

November 26-30, 2001

Rotterdam, The Netherlands

 

 

Workshop Title:  Shifting Paradigms from Quarantine to Migration Health.

Population Mobility, Health, and Globalization.

 

Co-Chairs:  Douglas W. MacPherson MD, MSc (CTM), FRCPC, Director, Office for Public Health Security, Centre for Emergency Preparedness and Response, Population and Public Health Branch, Health Canada, Ottawa, Canada.

 

Brian D. Gushulak MD, Director General, Medical Services Branch, Citizenship and Immigration Canada, Ottawa, Canada.

 

Presenters:  Neil Heywood MB, ChB, Director, Health Policy, Medical Services Branch, Citizenship and Immigration Canada, Ottawa, Canada.

 

Mark Wheeler, Assistant Director, Health Policy and Communications Branch, Health Canada, Ottawa, Canada

 

 

 

Introduction:

 

Some of the oldest documented interventions intended to protect the health of local populations were exclusion and containment of people, goods and their conveyances.  Depending on the circumstances of the health threat, and the understanding of disease etiologies, modes of transmission, patterns of spread, and the impact of the disease on the local population, various methods of control have been used over the centuries; including building stone walls around cities, holding ships in the harbour, detaining immigrants on islands, wearing special clothing or facial coverings.  In 1851, twelve European states met in Paris for 6 months to propose recommendations to respond to the European outbreaks of Asiatic cholera.  This conference resulted in 137 recommendations intended to prevent the international spread of disease and to protect the health of the public.  These recommendations were the forerunners of the International Health Regulations, which were still in place late in the 21^st Century, even though the original diseases of significant public health impact in Europe and the western developed nations; such as cholera, typhus, tuberculosis, Yellow Fever, and plague, have been largely marginalized in public health significance[i] by other transmissible diseases or by non-contagious causes of morbidity and mortality.  Given that rapid international movement is readily accessible and the relatively long incubation period for most serious, transmissible diseases, the benefit of an international border to prevent disease entry has been largely lost.  Exclusion of conditions of public health significance, by and large, is no longer possible.  Containment is constrained by several factors, including a lack physical facilities for containment, lack of health care system awareness in most migrant-receiving nations of the differential prevalence of disease in donor and recipient nations (prevalence gaps), the lack of technology for diagnosis, and an inaccessibility to the most appropriate management tools.  Hence, the basic tools of quarantine are largely ineffective in today. s context.

Currently, there is much discussion of  . agents of change. and . globalization. as important new concepts in international trade[ii] and international public health.  In the last 2 millennia of public health and quarantine, what has not changed is that mobile populations have health impacts on recipient populations.  These impacts are related to two characteristics of population mobility:  magnitude and demographics.  What has changed most significantly over the last 50 years, and continues to escalate in its rate of change, are the volume and rate of populations on the move, and the widening disparities in health and health determinants on a global basis between the recipient nations and the donor nations for permanent settlement and international travel.

 

MAGNITUDE

The World Tourism Organization (WTO) stated in a press release on March 9, 1997, that 600 million international journeys took place in 1996.  The WTO also estimates that early in the next century international arrivals will exceed one billion persons per year[iii].   Other specific mobile populations, such as migrant labour, foreign students, military personnel, and trafficked or smuggled persons also represent special demographic profiles on the move.  While not as large a movement as commercial travel or tourism in numeric terms, these other populations are still large and their health impacts are potentially considerable.  In discussing worldwide migrant labour in early 2000, the International Labour Organization (ILO) estimated that  "130 million people are working as migrants world-wide, up from 75 million in 1965. Moreover, the number of undocumented migrants is estimated at 10 million to 15 million"[iv].  The United Nations has estimated that 4 million individuals are the victims of international trafficking each year[v].  Of these, 700,000 are women or children, of which 175,000 are estimated to come from the former Soviet bloc, and approximately 45,000 to 50,000 arrive in the United States[vi].    The health implications of trafficking and smuggling of people are potentially very significant even though the total population involved in irregular movements may be small in comparison to regular movements.[vii]  Lastly, on January 1, 2000, the United Nations High Commissioner for Refugees (UNHCR) estimated that the total number of people . of concern. at 22.3 million:  refugees 11.7 million, asylum seekers 1.2 million, returned refugees 2.5 million, displaced and other persons of concern 6.9 million.[viii]  UNHCR also estimated that an additional 22-25 million people being displaced internally by civil conflict or environmental disasters.

It is within the total context of mobile populations that temporary and permanent migration and that of global public health needs to be considered.  The technological advances which allowed for inexpensive, rapid, mass transportation of people and goods; expansion of trade across great distances including information, education, commercial chattel, people and employment are part of the evolution of globalization.

 

DEMOGRAPHICS

            In the global public health perspective, the demographic of the population includes many classical health determinants; such as age, gender, and behaviour.  To this list of determinants must be added mobility.  Differentials in health outcomes are strongly linked to ethnicity and genetics, endemic prevalence of disease, and cultural-behavioural characteristics.  These prevalence gap characteristics move with an individual, or group of individuals, or populations across geo-physical distances in three phases:  pre-departure, transit and post-arrival.[ix] , [x].  Each of these phases represents a set of health risks and benefits and as such a specific transferable health determination.  The net health impact on the receiving population may be beneficial, neutral or detrimental depending on the nature of the outcome measured.

            The following tables taken from reference 8, taken sequentially, reveal a differential pattern of forced migration and its demographic and magnitude impact on recipient nations between regions of the world. These differentials in displaced persons, which leads to permanent-settlement, followed by immigration, and eventually leads to return migration either as tourists, business excursions or other regular but non-permanent travel, have long-term implications on a regional and inter-national basis for global settlement and immigration strategies, and public health planning.

i.  Comparative Regional Differences Related to Migration

            Regions of the world with physical, economic or procedural barriers to migration differ significantly in the current social and public health impact of migrant populations.  Some immigrant receiving nations have all three barriers e.g., Canada, Australia, and hence have very different immigration health impacts than nations or regions that have little migrant flow influence from these barriers e.g., Germany, UK, and many other European countries.  Short term effects; such as the rate of tuberculosis or syphilis, and middle to long-term effects; such as smoking associated disease, heart disease and stroke and the social health impacts of labour force growth, foreign born birth rates create challenges within these jurisdictions.

            ii.  Challenges Related to Differentials in Migration Magnitudes and Demographics

The major challenges to be addressed by nations, regions, and international agencies concerned with global public health are to integrate population mobility and health concepts into immigration policy, health policy and the view to the future, including essential research needs. The nature of these challenges will be the subject of the next three discussion papers. 

 

D. W. MacPherson MD, MSc (CTM), FRCPC

 

 Draft   September 24, 2001

Table 1.

ESTIMATED NUMBER OF PERSONS OF CONCERN WHO FALL UNDER THE MANDATE OF UNHCR [BY REGION]
REGION	TOTAL OF CONCERN
	January 1 1999	January 1 2000
AFRICA	6,284,950	6,250,540
ASIA	7,474,740	7,308,860
LATIN AMERICA and CARIBBEAN	102,400	90,170
NORTH AMERICA	1,305,400	1,241,930
OCEANIA	79,510	80.040
TOTAL	21,459,550	22,257,340

 

Table 2.

PERSONS OF CONCERN TO UNHCR [JANUARY 1, 2000, BY REGION]
REGION	REFUGEES	ASYLUM SEEKERS	RETURNED REFUGEES	DP, AND OTHERS OF CONCERN	TOTAL
AFRICA	3,523,250	61,110	933,890	1,732,290	6,250,540
ASIA	4,781,750	24,750	617,620	1,884,740	7,308,860
EUROPE	2,608,38	473,060	952,060	3,252,300	7,285,300
LATIN AMERICA & CARIBBEAN	61,200	1,510	6,260	21,200	90,170
NORTH AMERICA	636,300	605,630	---	---	1,241,930
OCEANIA	64,500	15,540	---	---	80,040
TOTAL	11,675,380	1,181,600	2,509,830	6,890,530	22,257,340

 

Table 3.

ORIGIN OF MAJOR REFUGEE POPULATIONS IN 1999 [TEN LARGEST GROUPS]
COUNTRY OF ORIGIN	MAIN COUNTRIES OF ASYLUM	REFUGEES
AFGHANISTAN	IRAN, PAKISTAN, INDIA	2, 562, 000
IRAQ	IRAN, SAUDI ARABIA, SYRIA	572, 500
BURUNDI	TANZANIA, D.R. CONGO	525,700
SIERRA LEONE	GUINEA, LIBERIA, GAMBIA	487,200
SUDAN	UGANDA, ETHIOPIA, D.R. CONGO, KENYA, C.A.R. CHAD	467,700
SOMALIA	ETHIOPIA, KENYA, YEMEN, DJIBOUTI	451,600
BOSNIA-HERZEGOVINA	YUGOSLAVIA, CROATIA, SLOVENIA	448,700
ANGOLA	ZAMBIA, D.R. CONGO, CONGO	350,600
ERITREA	SUDAN	345,600
CROATIA	YUGOSLAVIA, BOSNIA-HERZEGOVINA	340,400

 

Table 4.

ASYLUM APPLICATIONS SUBMITTED IN SELECTED COUNTRIES [IN 1999]
COUNTRY OF ASYLUM	ASYLUM APPLICATIONS	MAIN COUNTRY OF ORIGIN
GERMANY	95,110	YUGOSLAVIA, TURKEY, IRAQ, AFGHANISTAN, IRAN, AZERBAJAN, VIET NAM, ARMENIA, SYRIA, RUSSIAN FEDERATION, BOSNIA-HERZEGOVIA, PAKISTAN, INDIA
UNITED KINGDOM	71,150	YUGOSLAVIA, SOMALIA, SRI LANKE, RUSSIAN FEDERATION, AFGHANISTAN, TURKEY, CHINA, PAKISTAN, ROMANIA, POLAND
SWITZERLAND	46,060	YUGOSLAVIA, IRAQ, BOSNIA-HEREGOVINA
NETHERLANDS	39,300	AFGHANISTAN, IRAQ, YUGOSLAVIA, SOMALIA, AZERBAJAN, SUDAN, ANGOLA, IRAN
BELGIUM	35,780	YUGOSLAVIA, ROMANIA
ITALY	33,360	YUGOSLAVIA, IRAQ
UNITED STATES	31,740	CHINA, GUATEMALA, EL SALVADOR, MEXICO, HAITI, SOMALIA, INDIA, INDONESIA
FRANCE	30,910	CHINA, YUGOSLAVIA, DRC, TURKEY, SRI LANKA, MALI
CANADA	29,390	SRI LANKA, CHINA, PAKISTAN, HUNGARY
AUSTRIA	20,300	YUGOSLAVIA, IRAN, AFGHANISTAN, IRAQ

 

Table 5.

MAIN COUNTRIES OF SETTLEMENT OF REFUGEES [IN 1999]
UNITED STATES	85,010
CANADA	13,077
AUSTRALIA	8,330
NORWAY	3,940
NEW ZEALAND	1,340
SWEDEN	550
FINLAND	540
DENMARK	520
NETHERLANDS	20

 

References