Migration and Health Research Paper

1. Historical Development of the Field

Demographers and social scientists have always been interested in migration, one of the major demographic processes which, along with fertility and mortality, determines population size, composition, and distribution (Pol and Thomas 1992) However, until relatively recently, there has been little interest in how migration impacts health, except perhaps in the area of mental health and psychological well-being. Early research, for example, had suggested that immigration to North America had negative consequences on the mental health of immigrants (see Friis et al. 1998).

Interest in the impact of migration on health has increased over the latter part of the twentieth century. Although most migration in the world today takes place within countries, there has been little interest in its impact on health primarily because it is not typically as disruptive as international migration. Even in the case of international migration, there has traditionally been little interest in the health of immigrants. Most health research has been conducted in Western societies where the focus has been on the health status and healthcare needs of native populations. Immigrants were either excluded or were too few, both in number and as a proportion of study samples, to yield reliable estimates of their health status and health needs.

Because the late twentieth century has seen increasing immigration to Western societies from poorer nations, scholars and policy makers have made a concerted effort to understand the health status and health care needs of rising numbers of immigrants and how they impact the host countries’ health and social service systems (Eschbach et al. 1999, Friis et al. 1998). There has also been some interest in the negative impact of dislocation and forced migration as well as in the impact of smuggling and trafficking of migrants on their health (Gushulak and MacPhearson 2000).

2. Methodological Issues

Friis et al. (1998) outlined a number of methodological issues in the study of how migration influences health. They argue that because migration results in changes in numerous environmental variables that cannot be adequately controlled, studies often reach mistaken conclusions about how migration influences health. They cite Kasl and Berkman’s (1983) formulation of the ideal study design that would involve migrants-tobe, non-migrants at the point of origin, and native residents at the point of destination. The health status and psychosocial characteristics of the three groups would be assessed initially and at several follow-up contacts. In addition, studies would need large sample sizes that would enable sufficient power to adjust for numerous confounders so that the impact of migration on health can be appropriately estimated.

Needless to say such studies are scarce with selection factors, type of migration, and differences in historical time and context often leading to biased conclusions.

3. Healthy Migrants

Despite the focus of recent research on negative aspects of migration, a number of studies have suggested that immigrants to Western societies appear to be as healthy as if not healthier than native populations. Markides and Coreil (1986) suggested such a ‘healthy migrant’ or ‘migration selection’ effect to explain the relatively low mortality rates and good health of Mexican Americans in the Southwestern United States. The term ‘epidemiologic paradox’ was applied because Mexican Americans shared similar socioeconomic characteristics and conditions with African Americans, yet their mortality and health conditions were similar to the more advantaged nonHispanic Whites. More recently, Hummer et al. (1999) undertook a comprehensive analysis of how racevethnicity and nativity are associated with mortality in the US population. They found consistently lower mortality rates among foreign-born persons in all major ethnic groups (Blacks, Hispanics, and persons of Asian origin) than among native-born persons. Interestingly, foreign-born Blacks along with persons of Asian origin had the lowest odds of mortality, with native-born Blacks having the highest odds of mortality.

Similar results were found with respect to other health status indicators by Stephen et al. (1994). Again, foreign-born persons were generally healthier than native-born Americans at all ages, in both genders and from all major ethnic origins. Such findings are not restricted to the United States. For example, Chen et al. (1996) found that immigrants to Canada, especially recent immigrants, have lower rates of chronic conditions and disabilities than native-born Canadians. Similar patterns have also been found in Australia (Donavan et al. 1992).

The above and other similar studies conclude that there is a ‘healthy migrant’ effect at work. Healthy people are more prone to immigrate than less healthy people. In addition, Western countries require medical screenings by prospective immigrants to ensure relatively good health, and most people immigrate for employment or occupational reasons which require a relatively good level of health. Finally, people who immigrate tend to have a positive outlook on their lives and futures, which is consistent with good health. Despite these recent findings, few studies have focused on positive aspects of the immigrant experience, and most focus on the health problems of immigrants and how they impact the host societies’ health and social service systems. Although many immigrants do have special health problems that demand attention, the almost exclusive focus on their health problems tends to perpetuate stereotypes that often foster anti-immigrant feelings (Junghans 1998).

4. A Model Proposed by Friisvet al. (1998)

Friis et al. (1998) have noted that the impact of migration on health may be approached using the well-known ‘stress-illness’ model, where migration is considered a major life event and can be conceptualized as a source of stress. Along with migration, acculturation into a new society is also a potentially stressful experience that can impact physical and mental health. As immigrants become more acculturated and integrated into the larger society, the level of stress they experience often is reduced.

As in the stress-illness model, Friis et al. (1998) hypothesize a number of factors that mediate and or modify the impact of migration and acculturation on health. These include social support and lifestyle factors. Social support may take numerous forms. These include the nature and type of social networks, support from family and friends, as well as from the community at large. Immigrants are often socially isolated because of linguistic and cultural barriers. This is often the case with older immigrants whose children become assimilated and acculturated into the host society which leads to intergenerational strains and further isolation of the elderly (Markides and Black 1995).

Friis et al. (1998) suggest that migration sometimes leads to lifestyle changes, such as poor diet, alcohol and smoking, reduced physical activity, and other personal behaviors that can have adverse health outcomes. For example, studies have shown decreasing intake of fruits and vegetables among immigrant children in Western countries and high rates of obesity among children and adults because of poor and overnutrition, factors which may be associated with increased incidence of certain chronic conditions (e.g., cardiovascular diseases and diabetes later in life). Another health outcome of interest is how immigration and level of acculturation influence health care utilization. As Friis et al. (1998) point out there has been little systematic information in both Europe and North America in this area. Clearly this is an area where more research is needed.

5. Special Health Concerns

As indicated previously, much of the literature has focused on specific health concerns and problems of immigrants. Some of these are addressed briefly in this section.

5.1 Communicable Conditions

Special health concerns often involving immigrants are communicable conditions, such as HIV AIDS and tuberculosis. HIV AIDS has been a worldwide epidemic for two decades that has attracted the attention of scholars and policy makers. Although it has probably spread through migration, it is not clear what the impact of migration on its prevalence has been in specific countries. Carballo et al. (1998) have noted that the prevalence of AIDS is lower among migrants than among natives in Italy and Belgium, while the opposite is the case in Germany, where most cases are traced to Africa, Asia, and the Americas. However, AIDS prevalence is lower in Germany among immigrants from Turkey and Eastern Europe than among native-born Germans.

Carballo et al. (1998) also note rates of HIV and other sexually transmitted diseases (STDs) are higher among immigrants in Sweden, especially those from Africa. They also note that there appears to be a higher risk of STDs in countries like Belgium, where migration has been primarily among males who are more likely than non-migrants to use sex workers.

Another major communicable disease of great concern in recent years has been the rise of tuberculosis as a major public health problem worldwide, especially in poor countries. It has also become a major concern in Western countries, where its prevalence is higher among immigrant groups, especially those from poor countries (Carballo et al. 1998). Although the overall impact on the host countries does not appear to be major, it has a major impact among the immigrant communities, especially where immigrants live in crowded and unsanitary environments, conditions that may promote the spread of tuberculosis.

5.2 Chronic Conditions

With chronic conditions accounting for the vast majority of deaths in Western societies, there has always been interest in how migration and ‘Westernization’ influence the prevalence of major chronic conditions. This has especially been the case for cardiovascular diseases (CVDs). Early research with Japanese and Japanese Americans showed an increasing gradient of coronary heart disease (CHD) mortality from Japan to Hawaii to California which was explained by changes in diet and lifestyle in general. Low CHD mortality was related to retention of traditional Japanese lifestyle (see discussion by Friis et al. 1998, p. 175).

Research in Europe has also examined CVD prevalence among immigrant groups. For example, high rates have been observed among immigrants from India in the United Kingdom. Stroke mortality is also high among immigrants from India and the Caribbean who have high rates of diabetes, a contributing factor to stroke (see discussion in Carballo et al. 1998, p. 938). High rates of diabetes have also been found among certain immigrant groups in the United States, especially among persons of Mexican origin. These high rates have been attributed to excess obesity and Native American admixture (Stern and Haffner 1990).

5.3 Mental Health and Psychological Well-being

As mentioned previously, early research in North America (e.g., Malzberg 1967) found higher rates of mental illness, as measured by high rates of first admission to mental hospitals, among immigrants than among non-immigrants. Nevertheless, based on the recent data indicating better physical health among immigrants to the United States, Canada, and Australia reviewed earlier, one would expect good overall mental health among immigrants today, especially recent ones. However, wide-ranging studies of mental health among immigrants are scarce.

There is also some evidence both from North America and Europe that migration may impact mental health and psychological well-being differently in different age groups. While younger immigrants often assimilate into the main stream through education and employment, their parents become increasingly isolated because of linguistic and cultural barriers. This situation often produces frictions and conflicts between the generations and high rates of depression and anxiety in the older generation (see Carballo et al. 1998 and Markides and Black 1995).

Marital problems have been noted in some immigrant groups, especially when migration involves separation of spouses. When reunification eventually occurs, separation and divorce are common. Separation and divorce impact negatively, especially on children and women, whose status in the local immigrant community is usually tied to marriage and family. Evidence from several European countries reviewed by Carballo et al. (1998) suggests that when immigrant couples break up they often have difficulty finding culturally sensitive support systems with social isolation, depression and other psychological problems being quite common.

Other European evidence also points to psychosomatic problems during the first years of migration, such as ulcers, headaches, anxiety attacks, sleeping disorders, gastrointestinal complaints, and alcohol and drug abuse (Carballo et al. 1998). These and other psychological problems appear to be worse among political refugees than among voluntary migrants. Yet very few studies of the mental health (or physical health) of refugees have been conducted. In addition, the mental health needs of refugees are usually neglected despite the fact that most are highly traumatized and stressed (Friis et al. 1998). With the number of refugees worldwide on the rise, there is a great need to better understand their unique experiences and mental health problems as well as to provide them with better mental and physical health care.

5.4 Special Problems Associated with Smuggling and Trafficking of Immigrants

Gushulak and McPhearson (2000) have provided a very valuable overview of health issues associated with trafficking and smuggling of immigrants. With rising globalization, the numbers of people wanting to immigrate to more-developed countries is on the rise. In addition, there is a growing demand for unskilled workers in developed countries and despite more stringent entry requirements a rapidly growing number of people (around 4 million each year) become victims of international trafficking.

There are a number of issues impacting on the health of illegally smuggled immigrants. For example, receiving nations have put in place certain health and other screening barriers which select relatively healthy immigrants. Persons bypassing legal channels are thus not health selected. As Gushulak and MacPhearson (2000) point out, the very existence of screening barriers may encourage less healthy persons to seek illegal means of migrating.

The type of transportation may also have health consequences leading to illness, injury, or even death. A tragic example was the case of 58 Chinese-origin immigrants who died while being smuggled to England in June of 2000. They apparently suffocated in a compartment of a truck carrying tomatoes. Eshbach et al. (1999) have documented hundreds of deaths per year at the United States–Mexico border among undocumented migrants, many of whom were being smuggled.

Illegally smuggled immigrants are sometimes victims of environmental conditions, such as extreme heat or cold. Lacking social and legal protection, they often become victims of violence. And, they are more likely to suffer a variety of psychosocial problems such as sexual abuse, isolation, and psychosocial illness (Gushulak and McPhearson 2000). As with refugees, there is a need to better understand and to better treat the mental and physical health problems of illegally smuggled immigrants.

6. Conclusions

The issue of how migration impacts health is complex and multi-faced. The type of migration (voluntary vs. involuntary, legal vs. illegal) is of great importance. There are issues associated with the point of origin, point of destination, the journey itself, as well as with the health of the migrants themselves.

Most research has taken place in Western societies and has focused almost exclusively on voluntary international migrants. This type of research can be approached using a version of the well-known stressillness model. Studies have focused almost exclusively on the health problems of immigrants despite considerable evidence that many immigrants are often healthier than non-immigrant native persons. This practice can lead to stereotyping of immigrants and to anti-immigrant sentiments.

With international migration of all types on the rise, clearly there is a great need to better understand the health and health care needs of migrants and to develop better ways to address their physical and mental health needs.

Bibliography:

1. Carballo M, Divino J J, Zeric D 1998 Migration and health in the European union. Tropical Medicine and International Health 3: 936–44
2. Chen J, Ng E, Wilkins R 1996 The health of Canada’s immigrants. Health Reports 7: 33–45, 47–50
3. Donovan J W, d’Espaignet E, Merton C, van Ommeren M (eds.) 1992 Immigrants in Australia: A Health Profile. Australian Institute of Health and Welfare, Ethnic Health Series, No. 1. AGPS, Canberra, Australia
4. Eschbach K, Hagan J, Rodriguez N, Hernandez-Leon, Bailey S 1999 Death at the border. International Migration Re iew 34: 430–54
5. Friis R, Yngue A, Perssan V 1998 Review of social epidemiologic research on migrants’ health: findings, methodological cautions, and theoretical perspectives 1998. Scandina ian Journal of Social Medicine 26: 173–80
6. Gushulak B D, MacPherson D W 2000 Health issues associated with the smuggling and trafficking of migrants. Journal of Immigrant Health 2: 67–78
7. Hummer R A, Rogers R G, Nam C B, LeClere F B 1999 Race ethnicity, nativity, and US adult mortality. Social Science Quarterly 80: 136–53
8. Junghans T 1998 How unhealthy is migrating? Tropical Medicine and International Health 3: 933–4
9. Kasl S V, Berkman L F 1983 Health consequences of the experience of migration. Annual Re iew of Public Health 4: 69–90
10. Malzberg B 1967 Internal migration and mental disease among the white population of New York State, 1960–1961. International Journal of Social Psychiatry 13: 184–91
11. Markides K S, Black S A 1995 Race, Ethnicity and Aging: the Impact of Inequality. Handbook of Aging and the Social Sciences, (4th edn.). Academic Press, San Diego, CA
12. Markides K S, Coreil J 1986 The health of Hispanics in the Southwestern United States: an epidemiologic paradox. Public Health Reports 101: 253–65
13. Pol L G, Thomas R K 1992 The Demography of Health and Health Care. Plenum Press, New York
14. Stephen E H, Foote K, Hendershot G E, Schoenborn C A 1994 Health of the Foreign-Born Population: United States, 1987–90. Ad ance Data from Vital and Health Statistics, 241: 1–10. National Center for Health Statistics, Hyattsville, MD
15. Stern M P, Haffner S M 1990 Type II diabetes and its complications in Mexican Americans. Diabetes Metabolism Review 6: 29–45