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.

 

 

Workshop Paper

 

 

New Ways of Looking at Migration Health:

Population Mobility as an Important Health Determinant.

 

 

 

 

Brian Gushulak

Director General

Medical Services Branch

Citizenship and Immigration Canada

Ottawa, CANADA

           

New Ways of Looking at Migration Health:

Population Mobility as an Important Health Determinant.

 

 

Relationships between health and the movements of people have a long and complex history, which has been traditionally focused on controlling the admission of disease or illness. The consideration of the history of population mobility in relation to the biology of infectious diseases reveals episodes of relative stability separating times of sustained disease impact.  Many of these periods of increased infectious disease activity have been related or associated with changes in the nature or volume of human travel.  Examples include the epidemic outbreaks that followed European colonial endeavors in the Americas and the Pacific and the post First World War influenza pandemic.  In context, many of these historical episodes share similar associations with current global situations, in terms of expanded access to international journeys, faster modes of travel and new contacts between previously separated areas. 

 

From a sociological perspective, most of the concern and worry about real and perceived health risks posed by new arrivals have always been based on the desire to protect oneself and one. s own from external threats.  When these threats are illness or disease, the common response has been to transfer and refocus the fear to those who are believed to carry or transmit the illness.  The resulting dichotomy between the valid desire to protect the health of the public while preserving the rights and freedoms of travellers and migrants has been a continual point of consideration and discussion related to border and frontier health practices.  

 

In fact, it is possible to trace the first public health control practices, and possibly the origin of public health itself, to those attempts to deal with what, in common terminology would now be referred to as emerging infectious diseases.             Based on the principles of reducing the risks of importing epidemic diseases, attention was directed at trying to control those conditions where society is not able to provide either preventive or curative treatment.  In the absence of accepted processes of adequately managing the health concerns of society, attention turned to the isolation and limitation of movement of those infected, along with measures to reduce the likelihood of their contact with others.  Those practices initially resulted in the quarantine of arrivals and later became the foundation for national immigration medical screening and international attempts to control the spread of infectious diseases and global attempts at disease eradication.

 

While the fear and concern regarding imported illness and disease still provides a common focus for many international health issues current patters of population movement negate the effectiveness of those practices.  The processes of globalization and facilitated travel have combined to create increasingly mobile population groups.  Despite the ease of movement, however, significant health issues associated with large population movements continue. Interconnection and interdependence, major components of the process of globalization occurring against a background of persistent disparities[i].  Many of these disparities exist in or influence health sectors creating large gaps in health determinants between regions of the world. This combination of factors creates an environment where the health and well being of migrant communities is influenced by both new challenges and new opportunities.

 
 

Population Mobility in Context: Moving from administrative to functional considerations as a basis of migrant health.

 

            It has been common to consider migrants and other mobile populations in terms of specific defined groups traditionally delineated by their legal immigration status.  Generic application of classifications of mobile populations such as immigrants, refugees, and migrant worker, irregular and illegal migrants etc. is common.  However, as the origins and backgrounds of many migrants differ considerably there is marked disparity between migrant and mobile cohorts with the same formal immigration status.   The situation can become more complicated when specific administrative classification terminology such as convention refugee, refugee claimant and asylum seeker are used.

 

            The variations in characteristics, background histories and health determinants between populations of migrants and refugees can be extensive.  Health-related investigation and subsequent recommendations based on studies of some cohorts may have limited application or relevance to others, in spite of similar immigration status or administrative classification.   For example, health parameters and determinants in communities of immigrants originating in rural areas of the developing world migrating to join families may be much different from populations of business immigrants or skilled workers originating in the same nation. 

 

            Conclusions and recommendations regarding health prevention and promotion designed for one group may have limited relevance for the other.  Health service providers with limited experience in the process and dynamics of population movements and migration may have difficulty in transferring the results of studies in cohorts of . immigrants. or . refugees. to the migrant communities they serve.  The practice of reporting immigration status as a determinant of health may be less important than type of migratory journey itself.

 

            Modern migration patterns have changed significantly over the past 3 decades and some of the traditional aspects of international population exchange reflect these changes.  Refugee movements that have traditionally been based on patterns of permanent resettlement, such as observed during the Cold War, now encompass temporary relocation and return following the geopolitical stabilization, such as recently observed in the South East Balkans.  Ease of travel has allowed resettled immigrants repeated access to their place of origin, a pattern of movement markedly different from earlier migratory movements where return visits were uncommon.  International labour migration has become much more dynamic with large numbers of workers following global market shifts during their working lifetime.

 

            Recognizing that health is more directly related to the origin, behaviour, environment, educational and social make up of the population in question rather than their technical immigration status, this paper reflects a functional approach to population mobility.  Migrants and other mobile populations in this context, are considered in relation to the migratory journey itself, not simply in relation to specific legal immigration definitions.  This approach compensates for many of the important differences between communities that may have the same formal immigration designation. 

 

Through this functional approach, the multiple relationships between population mobility, migration health can be described in terms of three discrete, but connected components.  Those components are the pre-departure phase, the migratory journey itself, and the arrival phase at the journey. s completion.  Each of these components influences specific health determinants influences which are subsequently reflected in the health of migrants on the individual and population level[ii].  These influences may result in appreciable health concerns and issues during each of the phases of mobility.  Additionally, some of the health-related consequences may not be realized or appreciated until the individual is much further along the . migration. process and may have in fact settled and integrated into the new host environment[iii].  It has also been observed that some of the migration-associated health effects and outcomes will continue manifest themselves in the locally born offspring of migrants. 

 

Health Related Aspects of Population Mobility: Bridging Prevalence Gaps

  

The process of population mobility and migration can be considered in three related but distinct functional components.  Each of these components has specific influences and impacts on the health of both the individual and the community.  Overlaying the process of mobility and migration are the disparities between health sectors that are known as . prevalence gaps. .  Individuals and populations who move between disparate health systems in effect cross these gaps in socio-economic development and public health practices. The net result can be considered as a bridging of differential in health risks between two locations or situations by the migratory process.

 

Common examples are seen in the differential epidemiology of infectious diseases such as observed in the prevalence rates of tuberculosis between Eastern Europe[iv] and the West[v].   Prevalence gaps however, are not limited to geographic differences in disease distribution.

 

The Process of Mobility

 

a).        The Predeparture Phase

 

In considering the health of migrants and many other mobile populations it has been traditional to examine and deal with health issues in these communities after they have arrived at their destination.  The understanding of the health issues present after arrival however, may be improved though greater consideration of the migrant. s pre-existing background health profile.  The health of the migrant at the beginning of the process of relocation reflects community and public health environments present at the migrants. home[vi].  Aspects of the health environment include disease epidemiology at the place of origin, factors related to social equity such as poverty, housing, nutrition education, access to and availability of health care services[vii].

 

B).       The Migratory Journey

 

The type and nature of the migratory journey itself may affect the health and well being of some migrant and mobile populations.  The health effects of the journey are often more pronounced in refugee and other forced displacements, trafficked and illegal migrants and other irregular population flows.  The health status of the migrant during the journey can be affected and influenced by the duration of the journey itself, the nature of the transportation used and whether or not the terminal stage of the passage involves a licit or illicit entry to the destination.  Two specific migratory journeys may be associated with significant risk of mortality and morbidity.  Refugee and forced migratory movements are often accompanied by violence, hardship and lack of basic necessities while trafficked migrants often risk death, violence and environmental exposure during this phase of their mobility.

 

 

C).       The Reception and Integration Phase

 

There are several factors that combine to influence and modify the health of mobile populations after arrival at the destination[viii].  Depending on their origin, education and experience, many of these individuals may not be aware of, familiar with or have access to health programs and services[ix].   This can be a significant problem in irregular, trafficked or illegal migrants who may have reached the destination outside of the regular migration procedures[x]. 

 

The health characteristics of new arrivals will compare to those of the population in which they will settle in one of three ways.  Some determinants will be less favorable than those in the receiving population.  A common example is observed in the incidence of certain infectious diseases, such as tuberculosis, where migrants often represent a higher risk for the disease than the local population.  Some migrant communities will have health determinants that are more favorable[xi] than those observed in at the destination[xii].  Nutritional status and dietary habits are commonly noted to be less problematic in migrant communities on arrival in North America, for example.  Finally the health characteristics of the mobile population may be the similar to or identical to those of the communities in which they settle making the movement neutral in health terms[xiii].

 

 

Population Mobility and the Future of Migration Health

 

How should this new manner of considering migration and population mobility influence approaches to health in migrants?  Two basic factors provide much of the rationale that supports new approaches in this regard[xiv].

 

Clearly, there is ample evidence and information indicating that many of the fundamental concepts upon which traditional practices of immigration health are no longer valid or relevant.  The entire concept of using the border or frontier as a reference point for infectious disease control or management has been invalidated by the speed of current travel.  When the duration of long distance travel became less than the incubation period of infections of interest to migration health practitioners, many frontier or border health interventions became redundant.  This single issue provides the context for one of the major changes in the consideration of health in mobile populations.

 

Many regulatory or legislative approaches to managing disease and health matters in migrants use the border or frontier as a reference standard.  The border has long been the point where procedures to assess or manage health risk in arriving individuals were begun, verified or continued.   Examination, inspection and public health follow up activities for international arrivals have historically been frontier activities, based on the principles that existing concerns would be identified on or prior to arrival.  While there was some historical justification for these beliefs, it is now clear that the vast majority of arrivals who may have underlying illness now clear arrival formalities and proceed into the community.  However, community based protocols, procedures, guidelines and reference materials supporting the recognition and management of disease or illness in migrants and mobile populations are often lacking.

 

The second factor relates to dynamics of travel and mobility itself.  As the forces of globalization have further reduced the importance of the border and frontier in terms of health, changes to travel patterns have correspondingly shifted many of the characteristics of mobile populations.  In an ever more mobile society previously established prevalence gaps are crossed by many travellers.  Health risks and concerns that historically were associated with specific populations are now spread across ever-wider segments of society.  As noted above travel patterns for migrants in the current world are much more extensive than they were for previous generations.  The process of mobility, by bringing humanity functionally closer together, in effect reduces isolation from distant health environments[xv].  In a global world, health disparities while geographically removed are functionally proximal.

 

Taken together these two components, the demise of the border as a reference point and the expansion of mobility related health risk exposure to the wider community, define the new paradigm for what was commonly referred to as migration health.    To meet the challenges posed by these factors it will be necessary to consider mobility itself as a health determinant.  This rather simple concept has profound implications.

 

Demography and global health disparities ensure that the health of migrants and mobile populations will continue to be an issue of current and growing importance.  Ill health and disease in mobile populations which while having direct effects on the migrant also has broader implications for the health of individuals and populations at the migrants. origin, those who interact with the migrant during the migration process, and ultimately, for the community into which the migrant integrates.  To better recognize and manage this issue several significant undertakings will be necessary:

 

·        The importance of population mobility as a determinant of health will need to be more widely described and accepted throughout all components of the health sector.

·        Appropriate surveillance programs will be needed to monitor and quantify the impacts.

·        Improved assessment and analysis of the health of mobile populations will be necessary to more expediently recognize population health trends in these communities[xvi].

·       There will be a need for appropriate interventions both in terms of health promotion and preventive health strategies to reduce the effects of disease and ill health in mobile communities.

·        There will be ongoing needs for educational and other health services to better equip the health sector to identify, respond to and manage the mobility associated consequences of global health disparities[xvii].