# Session Overview In this session you will learn about the different stages of migration, international agreements that have sought to address migration, the politicization of migration, and recent issues in the study of migration. ## Learning outcomes By the end of this session, you should be able to: · Identify migration trends, forms, and migrant groups; · Demonstrate an understanding of the different stages of migration, and health risks and opportunities at each stage; · Identify key policy instruments addressing health and migration and assess their effectiveness in particular country contexts; and · Critically evaluate current policy gaps and options for migration health at global and national levels. # 1. Background According to the 2022 IOM report, in 2020 there were around 281 million international migrants in the world, which is about 3.6% of the world population (IOM 2022). Most migrants leave their countries of origin voluntarily, in search for better economic, social, and educational opportunities. But the world is also witnessing high levels of forced displacement due to insecurity and conflicts. ## 1.1 International migration Defining international migrants vary based on administrative measures, such as the duration of stay. Someone might be categorised as long-term migrant if they stay in a country for more than 12 months, whereas short-term migrants remain for a period of more than 3 months but less than 1 year. Often this short-term migration is circular with migrants going back and forth, for example around seasonal work. In general, the category of international migrants does not include individuals travelling for tourism, business or to visit friends or relatives for short periods. International migrants might include international migrant workers, refugees, international students, and irregular migrants, such as undocumented workers or trafficked persons. There are profound differences between migrant populations, this can be problematic for understanding the health needs of different group ## 1.2 Internal migration Internal migration occurs within national borders, commonly from rural to urban settings. This mvoement is particularly responsive to economic expansion and contraction. Internal migrations may include: migrant workers, such as seasonal labourers, and people who are internally displaced, such as those who are fleeing conflict, natural disasters, or leaving their homes because of land confiscation. ## Activity 1 # 2. Health and the migration process ## 2.1 Migratory Process Framework Traditionally seen and viewed as permanent, one-directional movement from Location A to B. Contemporary migration is more accurately viewed as multi-stage process that may include some or all of the stages of: pre-departure, travel, interception, destination, and return. Many migrants can move easily, such as international students or highly skilled workers. Others, such as irregular or undocumented workers or persons feeling persecution across borders, may be intercepted before arrival or while entering a destination. Each phase pose health risks and opportunities. ### Pre-departure stage Individuals living in poverty where there is endemic disease, inadequate water and sanitation and food insecurity are likely to leave home in worse health than wealthy individuals from areas of low endemicity (Gushalak et al. 2011). Sometimes, it is precisely the dangerous conditions at home, such as family violence or conflict, that pose serious health risks and cause individuals or entire populations to leave. Labour migrants, however, are commonly younger, healthier members of the community, leading to the so-called “healthy migrant effect” (Castañeda et al 2015). This refers to a situation where migrants have a better health status than the population in the destination country. This has been described, for example, in the Southern African region, where many migrants in search of work are seen to be healthier than the general population of the country they are joining (Veary 2014). Access to, and individual experience of, health services in the home country are key determinants of health and how individuals will use—or not use—health services after migration. Preventive programs such as vaccination or diagnostics may be unavailable or disrupted in the country of origin, making migrants more susceptible to disease or being diagnosed with advanced illness. ### Travel and interception stages The period between departure and arrival. Could be destination; or when they are intercepted-for helpful (refugee or asylum-seeker support) or harmful reasons (prison, immigration detention)-en route to a destination (interception) (Zimmerman et al 2011). Among the most important distinctions for individual health during the travel phase are whether individuals are: a) Voluntary versus forced migrants b) Documented versus undocumented or ‘irregular’ migrants. Forced or irregular migrants are more likely to use dangerous modes and/or routes of transportation, as they often must leave their home without the required legal documentation. Transportation can include, for example, unseaworthy vessels or long, hazardous treks to arrive at their intended destination. In recent years the many tragic experiences and deaths of people seeking to travel by boat to Europe have put this stage into firm focus and at the forefront of much political debate. Transmission of pathogens can occur during travel, including air travel (Brownstein et al 2006) or once a person has reached their destination, including where people move from low to high-risk areas, for example from non-Malaria endemic countries to those where it is endemic (Lynch et al 2011). The link between people's mobility and disease came into sharp focus during the COVID19 pandemic, both with transmission during flights and with travel bans and entry measures by countries to slow the spread of new variants of the virus. The interception stage usually affects only a minority of migrants, depending on the route, but often involves the most vulnerable migrants and poses the most extreme health risks. Refugee camps are a common interception strategy in response to humanitarian emergencies. Mortality rates can be high in these settings, as lack of adequate water and sanitation leads to diarrheal disease; and crowded conditions and being under-vaccinated can also make infectious disease outbreaks common. ### Destination stage When individuals settle either temporarily or longer-term in their intended or accepted location. Cumulative effects of health influences during prior stages, incl past vaccinations, health knowledge, health-related behavior, plus access to services in their new location. Many migrant workers, esp irregular migrants, work in jobs in sectors such as in mining, construction, manufacturing and agriculture, where they are exposed to occupational risks such as injury and toxic agents. Studies indicate that migrant workers are generally at higher risk of injury and illness than native-born workers (Hargreaves et al 2019), (Rustage et al 2021). Migrant workers are also at greater risk of various forms of labour exploitation, which can have substantial implications for their work terms and conditions, especially long work hours, work-related stress and poor mental health (Hargreaves et al 2019), (Pega et al 2023). Migrants often have difficulty learning about and navigating local health systems, and challenges identifying and reaching service providers or affording health services depending on their legal status and entitlements. As a result, they may delay or avoid medical care, increasing the likelihood of exacerbating treatable conditions. Migrant populations living in dense urban slums may be at particular risk of communicable diseases, malnutrition, and poor sanitation (IOM 2017). Practitioners treating migrants may encounter challenges such as language differences which make communication difficult, or unfamiliarity with pathogens in the country of origin. Training for ‘cultural competency’ has emerged in a number of medical schools, as elsewhere, to help providers meet the needs of diverse groups and migrants’ varying interpretations of and responses to health and illness (Berger et al 2021). Formulating migrant-friendly health service is needed to achieve universal health coverage and the Sustainable Development Goals (SDGs) (Mosca et al 2020). ### Return stage Most migrants make one or many return visits between a destination location and their place of origin. Seasonal labourers, such as agricultural workers, are very likely to go back and forth multiple times related to harvest times (circular migration) (Davies et al 2011). Migrants previously living in destination countries with a higher standard of health care may have difficulty maintaining a continuity of care at the same level. They may even face eligibility barriers after not working at home for many years. Migrant workers might also return to their former residence with occupational health problems, psychological disorders or chronic or potentially fatal diseases. Health services may not be equipped to identify or treat the presenting problem, or the individual may not have the resources to pay for treatment. Conversely, migrant workers may return with greater income to afford better healthcare for themselves and their family members. Migrants may also return with greater skills and knowledge to contribute to their community (Davies et al 2011). In conclusion, the migration process is increasingly diverse and complex. Health risks and opportunities differ based on the type of migration and stage of the migration process. # 3. Migration and health policy ## 3.1 UN agencies working in migration and health | Organisation | Mission and Focus Areas | | ------------------------------------------------------ | -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | | [[International Organization for Migration (IOM)]] | - principal intergovernmental organization in field of migration, with 169 member states<br>- promotes humane and orderly migration | | [[International Labour Organization (ILO)]] | - tripartite UN agency bringing together governments, employers, and workers of 187 member states<br>- sets labour standards, develops policies and programmes to promote decent work for all women and men, including labour migrants | | [[World Health Organization (WHO)]] | - key agency directing and coordinating international health work through collaboration, with 189 member states<br>- role includes promoting access to quality, essential health services for refugees and migrants | | [[United Nations High Commission on Refugees (UNHCR)]] | - UN programme with mandate to protect refugees, forcibly displaced communities and stateless people | These organisations, along with other development-related organisations and national governments, are instrumental in the negotiation of global-level targets and frameworks. ==Migrants were largely left out of the Millennium Development Goals but are recognised explicitly in two SDGs – SDG 10.7: Orderly, safe, regular and responsible migration and mobility and SDG 17.18 as mentioned above==. International debate on implementation of the SDGs takes the principle of “leave no one behind” to include migrants, meaning migration-related factors must be acknowledged across both health and non-health related SDGs. Amongst the non-health SDGs, ensuring social protection for migrants is key to reducing poverty (SDG target 1.3). Reducing violence and related death rates (SDG targets 16.1, 16.6) and promoting peace will also address conflict, an important driver of migration (ODI 2016). ## 3.2 International agreements on migration and health [[International Health Regulation (IHR)]] were first developed in 1969 to address the threat of trans-border infectious diseases but were narrowly defined with only a few diseases such as cholera included. - Re-emergence of infectious diseases in the 1980s and 1990s including new diseases such as HIV and viral haemorrhagic fever - led to the IHRs being revised and adopted by the [[World Health Assembly (WHA)]] in 2005. - Later WHA and WHO Executive Board resolutions and decisions (2007, 2008, 2017) ==placed greater emphasis on migrant rights and needs, including that migrants== – like all individuals –have the right to the highest attainable standard of health, to equitable access to health services and services that are culturally, linguistically and gender- and age-appropriate. - In light of the COVID19 pandemic, the IHR were revised in 2021, noting the need to strengthen the evidence on travel-related matters, for example to address infectious diseases (Aavitsland P et al. 2021). Through a two-year process of negotiations, revised IHR were adopted in June 2024. Key changes include the creation of a new category of a ‘[[pandemic emergency]]’, stricter asks of Member States to report disease outbreaks within 24 hours, and a greater attention to migrant issues, finding that the Review Committee does not focus in sufficient detail on equity and solidarity of migrants as defined in response, including through financial assistance (Habibi et al 2024). ==The impact of the revised IHR remains to be seen==. However, focus on migration within the debates appeared limited. The [[New York Declaration for Refugees and Migrants]] was adopted by the UN General Assembly in 2016 and also commits to “people centred, sensitive, humane, dignified, gender-responsive approach” to migrants and refugees. As already mentioned, migrants are also explicitly recognised in several Sustainable Development Goals. ### [[The Global Compact for Safe, Orderly and Regular Migration]] The [[New York Declaration for Refugees and Migrants]] set into motion a process of intergovernmental consultations and negotations towards the development of a Global Compact for Safe, Orderly and Regular Migration, which has intended to become an international standard or agreement on migration. As a result of this process, the Global Compact was adopted in December 2018 and endorsed by the UN General Assembly. As such, it marks the first intergovernmental agreement on migration. However, it is non-binding to Member States and signals intent and commitment rather than concrete actions (Pecoud A 2021). (-) At the same time, the Compact has been criticised for side-stepping rather than addressing the complex political issues relating to migration because it does not articulate clearly enough 'what' should be done. Instead, it focuses on governance mechanism. One ambition by the migrant health community has been for the Global Compact to provide proactive management of migrants’ health challenges and realise migrants’ potential to have positive impact on population health (Gottardo C et al 2019; Deyakumar D et al 2019). ## 3.3 Immigration versus health: policy conflict? In some countries, the date on 'immigrants can sway elections', hindering migrant-inclusive health policies. Immigration is considered 'high' politics-that is, a national security concern and highly political in the public eye. Health is generally considered ‘low politics’ because it relates more to individual or social well-being, which has historically been considered not critical for the survival of a state (Brown GW et al 2018). When migrants’ rights to health are pitted against immigration goals of reducing the number of foreigners entering a country or preventing disease transmission across national borders, individual health will be of secondary concern. Punitive laws, xenophobia and the threat of deportation can also seriously affect the mental health of migrants. Europe provides two examples of how high and low politics have collided in relation to migrants. First, in financial crisis 2008, migrants were disproportionately affected in terms of job loss and consequent income loss, in the European Region. Poorer living conditions -> higher risk of infectious disease. [[Austerity measures]] reduced overall health and welfare spending and structural reforms to health sytems. These measured included imposing user charges or reducing entitlements for non-citizens, which decreased the availability of health care, especially for the most vulnerable migrants (Kentikelenis et al 2015). Second, between January 2015-May 2016, there was an influex of over 1.2 million people, including econmic migrants and refugees, crossing the Mediterranean Sea to Europe. Such mass movements are associated with overcrowding, poor sanitation, restricted access to clean water and therefore increased risk of infectious disease outbreaks, leading some instances to fear and stigmatisation of migrants in the destination country (Khan et al 2016). These fears are often unfounded, as exemplified by the spread of tuberculosis, which, is prevalent in some migrant communities but unlikely to be transmitted to host populations in high-income countries because of better housing and nutrition and limited close contact between the two groups (Khan et al 2016). ## 3.4 The politicization of migration Examples of infections where the role of migrants has been politicized or received significant media attention include the 2003 SARS, the Ebola Virus Disease outbreaks, and recently COVID-19 (Koinova et al 2023). Migrants moving from high to low prevalence countries may change the epidemiological patterns of disease in countries of destination. Tuberculosis, HIV, hepatitis B and strongyloidiasis are all more common in foreign-born compared to native-born residents in many high-income countries (Gushalak et al 2006). Policy responses to health and migration generally focus on national border control, but movement of people is not necessarily dictated by these borders but by other factors such as available transportation, social networks and natural boundaries, such as mountains and bodies of water. Ministries of Health or Social Welfare however are often responsible for policies on health care access and eligibility for migrants who have already arrived. However, immigration protectionist strategies, such as immigrant screening, are not aimed to prevent the influx of pathogens such as influenza (Selvey et al 2018) ### The COVID19 pandemic COVID dramatically highlighted many of the interactions between migration and health. First, link between mobility and spread of disease. At the same time, it underlined limitations of policies seeking to contain disease or new variants through restrictions on movement (Kucharski et al 2022, Russel et al 2021). Second, it highlighted specific vulnerabilities and aspects of labour migration, through the circular migration but also importantly showing increased vulnerabilities directly related to working and living conditions of migrant workers (Hayward et al 2021). Third, it underlined the limitations to and importance of [[UHC]] for migrants, including for wider population health. Analysis of geospatial data from Germany for example identified migratory background as an independent variable for higher incidence of COVID19 in addition to socioeconomic deprivation (Rohleder et al 2022). As vaccinations became more widely available countries had very strong and very publicly evident imperatives to vaccinate all people, including migrants. Many countries needed to adapt and target immunisation services to reach migrant populations thus underlining the importance of universal health coverage that includes migrants. ## 3.5 Migrant-sensitive health systems and [[Universal Health Coverage]] > Immigration or Home Affairs Ministries are often responsible for establishing national health-related requirements for different migrant categories. Ministries of Health or Social Welfare however are often responsible for policies on health care access and eligibility for migrants who have already arrived. In previous sessions, you learned about universal health coverage (UHC) and its importance in ensuring access to health services and the right to health. Providing UHC represents a major financial commitment particularly in developing countries that may already struggle to provide basic health services for their host population. Migrants are often excluded from risk-based insurance schemes, and irregular migrants can be completely invisible. Even where health-care access is free, irregular migrants may not utilize services because of registration barriers, including a fear of deportation where migrants are irregular (Vearey J et. al. 2018). As a result, they may face high out-of-pocket expenditures or simply not access care, resulting in avoidable illness and death. Internal migrants may also face challenges if provision of UHC is linked to being registered in a particular geographic area or health service (Guinto 2015, ODI 2016). In countries with decentralized health systems, discrepancies can occur between central government policies and local practice. In Spain for example, national-level policies dictate that asylum seekers and undocumented migrants are ineligible for publicly funded health services, however at the regional level laws and policies have been enacted overturning these restrictions (Cimas et al 2016). Some countries have explicitly sought to include migrants in their efforts to achieve UHC. Thailand, for example provides documented migrants the opportunity to participate in its government social security scheme which is funded through employee, employer and government contributions. Migrants who are unable to join this scheme can join an alternate Migrant health Insurance Scheme that is funded by contributions (Tschirhart et al 2021). Yet even though Thailand is recognised for its leadership in this area and compares favourably to other countries, (Onarheim K et al 2018), research identified several challenges for undocumented migrants seeking access to, for example, emergency obstetric care (Tschirhart et al 2021). Challenges may in some cases be due to migrants’ unclear legal status or their limited information about their rights, which may delay health care for fear of possible immigration consequences. In conclusion, migrant health policy-making is highly sensitive to political, social, and economic environments and public opinions. These competing pressures create policy tensions between border protection, disease control and the rights of migrants. Ensuring migrants access to health services requires services to be migrant friendly. Given that migration often follows a circular pattern, for example, it is important to consider continuity of care across borders, as well as the provision of care in border areas. ## Activity 2 Consider a country context with which you are familiar. Think of the political debate about migrants’ rights to or use of the health and welfare resources? What were the main political arguments in favour of and against including migrants in health and social welfare schemes? ### Feedback The arguments for include: +Human rights and equality based on international norms and standards. +Public health threat of delayed health-care seeking, creating the opportunity for spread of infection to the general public. +Chronic illness and injury leading to permanent disability, poor maternal and child health, ultimately greater morbidity and increased cost to the health and social service sectors. +Societies depend heavily on migrant labour. Migrant workers generally have less protective equipment and training and are at higher risk of harm. They have a right to care in exchange for their contribution to local economies. The arguments against UHC for migrants include: -Irregular migrants do not contribute to the social insurance system. -Migrants take employment options or lower wage structures, contributing to local unemployment. -Providing high quality health services to migrants will increase illegal and legal immigration; it will serve as an enticement. -Health systems will be overloaded by increasing especially ‘at-risk’ populations. # 4. Modern aspects of human mobility ## 4.1 Monitoring migration and health Monitor flow of international migrants, the inflows/outflows across international borders. Net migration in a location can be calculated, but monitoring health-related risks and needs of migrants is difficult, with no international standardised approach (Hanefelt et al 2017). Understanding and addressing the effects of migration on infectious diseases, such as malaria, often requires cross-border collaboration between countries in surveillance and response, which is also challenging. In recognition of these issues, SDG target 17.18 is to “Increase the availability of high quality timely and reliable data disaggregated by income, gender, age, race, ethnicity, migratory status … and other characteristics relevant in national contexts”. ## 4.2 Human trafficking and health People may be trafficked for forced low- or no-wage labour, including domestic servitude, agricultural work, commercial fishing, textiles, factory labour, construction, mining, and forced sex work, as well as bride trafficking, forced begging and petty crime. Estimates from 2021 suggest that 50 million people were living in modern slavery, of whom 28 million were in forced labour and 22 million were subjected to forced marriage (ILO et al 2022). The health implications of human trafficking are significant, including injuries and illness from physical and sexual abuse, occupational injuries, and psychological morbidity. Among trafficking survivors in Southeast Asia, nearly half (48%) reported physical or sexual abuse and 22% sustained severe injuries, including lost limbs, and reported symptoms indicative of depression and anxiety disorders (Kiss et al 2015). ## 4.3 Feminization of migration Increasingly, women are migrating independently for work, rather than as wives or dependents under a male head-of-household. For women who opt to migrate on their own, moving away from home and family for a job can mean increased equality and freedom, including control over their sexual and reproductive health when they move to places with more progressive cultural norms (Tittensor D et al 2017). # 5. Integrating activity Find an example of a national, bilateral or multi-lateral policy or programme for which the aim is to address migrant health or the health effects of migration. Examine this policy or programme and answer the following questions: +Describe the policy or programme and which migrant group(s) it targets. +Which health needs is the policy or programme trying to address? +Who is involved in implementation? +What are the weaknesses in the policy/programme and/or its implementation and how can it be addressed? +Does the policy consider how migrants can gain information about the service or programme and does it seek to address potential concerns, including for example fear of deportation or report to other national authorities? +Does the policy engage with or reference an international standard? Does it cover more than one country? # 6. Summary In summary: Migration and mobility are increasing throughout the world; this brings with it significant health considerations. It means that diseases travel alongside people, and it is important for everyone’s interest to consider the impact of migration and ensure universal health coverage. It also means that narrowly-focused national health policies and services are not suited for the vast numbers of people who are on the move. The effects of mobility on health are dependent on the type of migration (e.g. international or internal, voluntary or forced, documented or undocumented) and often related to the phase of migration (pre-departure, travel/interception, destination, return). While definitions are important, including legal categories which often determine access to services for people on the move, often clear definitions are lacking. 1. Forced or undocumented migrants may be at greater risk of poor health because they may use dangerous modes of transport during the travel phase or having less entitlement to services along the way and in the destination country. 2. International agreements call for migrants to enjoy the same right to health as everyone else. Yet political factors, including fear and stigma surrounding migration often prevent evidence and rights-based policy from being implemented. Migration is arguably not sufficiently addressed in current legal instruments. 3. The COVID19 pandemic highlighted the extent to which mobility can be linked to greater transmission of disease. It also demonstrated the specific vulnerabilities faced by people with migratory backgrounds. Addressing migration is essential to achievement of the Sustainable Development Goals but requires explicit inclusion of migrants for example in efforts to provide universal health care, and in monitoring and evaluation of health programs. # 7. References ## 7.1 [[Essential readings]] IOM (2017). Health of Migrants: Resetting the Agenda – Report of Second Global Consultation p54-61. Available at https://www.iom.int/migration-health/second-global-consultation Abubakar I, Aldridge RW, Devakumar D, Orcutt M, Burns R, Barreto ML, Dhavan P, Fouad FM, Groce N, Guo Y, Hargreaves S, Knipper M, Miranda JJ, Madise N, Kumar B, Mosca D, McGovern T, Rubenstein L, Sammonds P, Sawyer SM, Sheikh K, Tollman S, Spiegel P, Zimmerman C; UCL–Lancet Commission on Migration and Health. The UCL-Lancet Commission on Migration and Health: the health of a world on the move. Lancet. 2018 Dec 15;392(10164):2606-2654. doi: 10.1016/S0140-6736(18)32114-7. Epub 2018 Dec 5. PMID: 30528486; PMCID: PMC7612863. ## 7.2 [[Recommended reading]] Castaneda H, Homes S, Madrigal D et al. (2015). Immigration as a social determinant of health. Annu. Rev. Public Health 36:375–92 Zimmerman C, Kiss L, Hossain M. (2011). Migration and Health: A Framework for 21st Century Policy-Making. PLoS Med 8(5): e1001034. https://doi.org/10.1371/journal.pmed.1001034 Zimmerman C, Kiss L. (2017). Human trafficking and exploitation: A global health concern. PLoS Med 14(11): e1002437. https://doi.org/10.1371/journal.pmed.1002437