Migration and Health:Overview, Indicators and

Determinants

Alfonso Rodriguez-Lainz, PhD, DVM, MPVM

Division of Global Migration and Quarantine,CDC

Outline• What is migration?

• Who is a migrant?

• What is migrant health?

• Determinants of migrant’s health after resettlement

• Migrant health indicators

Migration: People on the move!

Migration: movement of people

• Across an international border (international migration) or within a country (internal migration)

• Different durations and patterns– (e.g., permanent, temporary, cyclical)

• Different causes– (e.g., economic, forced, family reunification)

Source: J. Weekers (IOM) Global Consultation on Migrant and Health, Madrid, Spain (3–5 March 2010); adapted from IOM Glossary on Migration (2004)

Who is a migrant?

Who is a migrant?• No universally accepted definition

• Countries and agencies use their own criteria, based and their own legislation and policies

• Definitions are not consistently used

• “Popular” terms

Migration-related terminology

Migrant

Immigrant

Foreigner

Migrant

workerAlie

n

Foreign born

Minorities

Latino

Illegal

Ethnic groups

Hispanic Mobile populations

Farmworker

Traveler

What are the international

recommendations?

International Migrant UN Recommendations (1998 and 2007)

• A person changing his/her country of usual residence … for at least 12 months

Sources: Sources: -UN Recommendations on International Migration Statistics (1998)UN Recommendations on International Migration Statistics (1998)- UN Expert Group Meeting on the use of censuses and surveys to measure international migration, UN Expert Group Meeting on the use of censuses and surveys to measure international migration, ESA/STAT/AC.132/1 (2007)ESA/STAT/AC.132/1 (2007)

Residence in new country

Some statistics …

Source: WHO (2010)

International migrants as a share of the total world

population

Source: United Nations Population Division

International migrant

3.1%

Native residents

96.9%

Top 20 countries with the highest % of international migrants, 2010

86.5

70.0

68.8

45.9

43.6

40.7

40.4

38.8

28.4

27.8

23.2

22.4

21.9

21.3

19.6

19.5

18.9

17.8

16.6

15.9

0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0

Qatar

United Arab Emirates

Kuwait

Jordan

Occupied Palestinian Territory

Singapore

Israel

China, Hong Kong SAR

Oman

Saudi Arabia

Switzerland

New Zealand

Australia

Canada

Ireland

Kazakhstan

Gabon

Lebanon

Gambia

Croatia

Source: United Nations, Department of Economic and Social Affairs, Population Division (2009). International Migration, 2009 Wallchart (United Nations publication, Sales No. E.09.XIII.8).

Note: Among countries with at least 1 million inhabitants

U.S.A: 13.5%

UK & France: 11%

International migrants: U.S definitions

U.S Census Bureau

• Native: anyone who is a U.S. citizen at birth. Includes:- born in the U.S mainland or territories OR- born abroad of at least one U.S. citizen

parent

• Foreign-born: anyone who is not a U.S citizen at birth

Source: Census Bureau, ACS

Foreign-born population,2009

• 39.4 million

• 12.7% of U.S population

• 11.1 million unauthorized

Sources: American Community Survey, 2008: Martin M & Midgley, June 2010; and Migration Policy Institute

Foreign born as a % of the total U.S population, 1850-2008

0

2

4

6

8

10

12

14

16

Per

cen

tag

e Peak: 14.8% (1890)

Top 20 countries of origin for foreign born (thousands), 2008

11,413

1,913

1,685

1,623

1,361

1,138

1,095

1,031

975

819

772

739

688

641

637

600

535

479

460

413

8,945

0 2,000 4,000 6,000 8,000 10,000 12,000

Mexico

China:

Philippines

India

China*

Vietnam

El Salvador

Korea

Cuba

Canada

Dominican Republic

Guatemala

United Kingdom:

Germany

Jamaica

Colombia

Haiti

Poland

Honduras

Russia

Other

*China excluding Hong Kong and Taiwan Source: ACS, 2008

Hispanic Origin and Race

Source: U.S. Census Bureau, 2010 Census questionnaireSource: U.S. Census Bureau, 2010 Census questionnaire

Race/ethnicity vs. Foreign-born

Source: American Community Survey, 2008

Percentage of foreing-born and natives among major race/ethnic groups, U.S., 2008

3.9 8.0

39.1

67.1

96.1 92.0

60.9

32.9

0

10

20

30

40

50

60

70

80

90

100

White alone,not hispanic

Black orAfrican

Americanalone

Hispanic orLatino

Asian alone

%

Native

Forein-born

Migration and Health

Phases of Migration

Adapted from Gushulak, 2010Adapted from Gushulak, 2010

Origin country

1. Pre-departure

4. Return

+Transit country

2. Journey

Destination country

3. Post-arrival??

Migration: a bridge to global health

Disease burden

Health risks:- Vectors

- Food safety

- Sanitation

- Others

Health beliefs/behaviors

Health infrastructure

Others

Disease burden

Health risks:- Vectors

- Food safety

- Sanitation

- Others

Health beliefs/behaviors

Health infrastructure

Others

ORIGIN COUNTRYORIGIN

COUNTRYDESTINATIONCOUNTRYDESTINATIONCOUNTRY

Disease burden

Health risks:- Vectors

- Food safety

- Sanitation

- Others

Health beliefs/behaviors

Health infrastructure

Others

Disease burden

Health risks:- Vectors

- Food safety

- Sanitation

- Others

Health beliefs/behaviors

Health infrastructure

Others

Migration

Prevalence gaps among countries

Migrant Health:beyond migrants themselves

• Health issues and risks related to migrant populations, AND the way in which migration affects:– Countries of origin, transit and

destination, and – Second and later migrant generations

(Adapted from Roux, 2004; IOM)(Adapted from Roux, 2004; IOM)

Determinants of migrants‘ health after resettlement

The post-arrival Phase

Individual factors-Biology and genetics -SES-Health beliefs/behaviors-Pre-existing health conditions-Migration status

Individual factors-Biology and genetics -SES-Health beliefs/behaviors-Pre-existing health conditions-Migration status

DESTINATION COUNTRY Disease prevalence

Health risks:- Vectors- Food safety- Sanitation- Others

Health beliefs/practices

Access to health care

Work opportunities

Housing

Many others (eg., language)

DESTINATION COUNTRY Disease prevalence

Health risks:- Vectors- Food safety- Sanitation- Others

Health beliefs/practices

Access to health care

Work opportunities

Housing

Many others (eg., language)

++

Individual factorsMigrants vs. U.S-born

• Genetic predispositions

• Natural or acquired immunity

• Younger age distribution – Exception: European

• Different gender distribution

Individual factors (Cont.) Migrants vs. U.S-born

• Lower education– Exceptions: Africans, Europeans, Asians

• Higher poverty rates– Exceptions: Asians, Europeans

• Limited language proficiency – Exceptions: English-speaking countries

Individual factors (Cont.) Migrants vs. U.S-born

• Health beliefs/behaviors

• Pre-existent health conditions– Health conditions prevalent in home

country or acquired during transit

• Migration (legal) status

Social determinants of health

• Social/political environment– (Anti-immigrant) Policies and regulations– Discrimination => xenophobia

• Poor housing

• Occupation– High-risk and low-paid jobs

Access to health care:Vulnerabilities

• Different health systems and practices• Legal limitations on access to care• Other barriers:

– Culture, language, cost– Limited awareness about available

services – Lack of health insurance

• Disparities in quality of care

Migrant health: a double jeopardy

Vulnerable minorities

• Low SES– Income– Housing – Occupation

• Culture• Discrimination• Others

HEALTHINEQUITIES

Access to health care

Migration-specific factors

• Limited legal rights• Language• Multinational exposures

(origin, transit, destination)

• Others

Migrant health: a complex picture

• The health of migrants varies across space, time, age, gender, across different countries of origin and type of migration

• Caution about making generalizations about the health of all migrants

Mladovsky, 2005; Ingleby 2009

Migrant Health Indicators

The state of migrant health research

• “… still in its infancy” (Ingleby, 2009)

• “The information is voluminous, but sparse for many issues and sometimes contradictory” (Cunningham, 2008)

Migration and Health Research challenges

1. Limitations of available data– No migration-related data– Small sample sizes– Linguistic & culturally inappropriate data collection

methodologies and instruments

2. Characteristics of migrant populations– Diversity– Mobility– Rarity– Hidden

Broad migrant health patterns

• Positive health indicators

• Negative health indicators

• Worsening of health with longer residence in the U.S

Positive health indicators: New immigrants’ health

capital

• Especially for recently arrived immigrants – Even after adjusting for age and other

variables

• “Healthy migrant paradox”

Positive health indicators for migrants vs. native

population

• Lower mortality rate• Higher life expectancy• Lower incidence and mortality due to some

cancers (e.g, breast, colon and prostate cancer)

• Perinatal health outcomes (e.g,, low birth weight)

• Less tobacco use and substance abuse• Lower prevalence of CVD and obesityCunningham S.A et al. Health of foreign-born people

in the United States: a review. Health & Place. 2008

Infant mortality rates, by mother’s place of birth and race/ethnicity of

mother, U.S, 2006

Source: Mathews TJ, et al. Infant mortality statistics from the 2006 period linked birth/infant death data set. National vital statistics reports; vol 57 no 2. Hyattsville, MD: National Center for Health Statistics. 2010

Past month Past month tobacco use,

U.S. born vs. foreign born by gender, 1999-2001

39.7

27.8 26.7

13.4

0

5

10

15

20

25

30

35

40

45

U.S born Foreign born U.S born Foreign born

Male Female

Pe

rce

nta

ge

Source: SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 1999-2001Source: SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 1999-2001

Negative health indicators for migrants vs. native

population• Access to care and quality of care• Preventive health services• Immunization coverage (especially adults)• Lower health literacy• Infectious diseases (eg., TB, hepatitis B,

HIV/AIDS)• Higher incidence and mortality due to some

cancers (eg., cervical, liver)• Occupational, transportation and home

injuries

Source: Kaiser Family Foundation Immigrants’ Health Coverage and Health Reform: Key Questions and Answers (December, 2009)Source: Kaiser Family Foundation Immigrants’ Health Coverage and Health Reform: Key Questions and Answers (December, 2009)

Health insurance coverage of non-elderly, by citizenship status, 2008

67 67

41

18 11

13

15 22

46

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Native citizens Naturalizedcitizens

Non-citizens

Uninsured

Medicaid/otherpublic

Private

Current Population Survey March Supplement, 2009Current Population Survey March Supplement, 2009

Source: 2007 California Health Interview Survey

Percentage of women 30 years and older with a mammogram within previous 2 yrs, California, 2007

Source: 2007 California Health Interview SurveySource: 2007 California Health Interview Survey

Particularly vulnerable migrants

• Victims of human trafficking• Refugees and asylum seekers • Unauthorized migrants• Labor migrants in high risk

occupations• Indigenous• Detained and deported migrants

Worsening of Health With Longer Residence

*Adjusted for age, sex, poverty, income ratio, BMI, smoking status, alcohol drinking status, marital status, survey year, region of birth migrants)

Diabetes prevalence* for foreign-born (by length or residence) vs. U.S-born

Diabetes prevalence* for foreign-born (by length or residence) vs. U.S-born

Thank you! Gracias!Alfonso Rodriguez-Lainz

jqi3@cdc.gov

References• Gushulak BD, Weekers J, MacPherson DW. Migrants in a globalized world – health threats risks and

challenges: an evidence-based framework. Emerging Health threats Journal 2009, 2:e10 http://www.eht-forum.org/ehtj/journal/v2/pdf/ehtj09010a.pdf

• Davis AA, Basten A, Frattini C. Migration: A Social Determinant of the Health of Migrants. International Organization of Migration, 2009 http://www.migrant-health-europe.org/files/FINAL%20DRAFT%20IOM.pdf

• International Migration, Health and Human Rights. WHO, 2003 http://www.who.int/hhr/activities/en/intl_migration_hhr.pdf

• Kandula NR, et al. Assuring the health of immigrants: what the leading health indicators tell us. Annual review of public health. 2004;25:357-76.

• Gushulak BD and MacPherson DW. The basic principles of migration health: Population mobility and gaps in disease prevalence. Emerg Themes Epidemiol. 2006; 3: 3

• IOM, Seminar on Health and Migration, Geneva 2004 http://www.iom.int/en/know/idm/smh_200406.shtml

• Migration and health: a review of the international literature (2003), Available at: http://www.msoc-mrc.gla.ac.uk/ Publications/pub/PDFs/Occasional-Papers/OP012.pdf

• McPherson DW, Gushulack BD, Mcdonald L. 2007. Health and foreign policy: influences of migration and population mobility. Bullletin of the World Health Organization, 85(3):200-206

References• Cunningham SA. et al. Health of foreign-born people in the United

States: a review. Health Place. 2008 Dec;14(4):623-35.

• Carballo M et al.. Migration and health in the European Union. Trop Med Int Health. 1998 Dec;3(12):936-44.

• Mladovsky P. Migration and Health in the EU. European Commission. 2007

• Beiser M. The health of immigrants and refugees in Canada . Revue Canadienne de Sante Publique, 96, Suppl. 2:S30S44. 2005

• Ingleby, D. European Research on Migration and Health. International Organization for Migration, Background Paper, 2009

• WHO. Health of migrants- Report by the Secretariat. A61/12 (April, 2008)

• WHO. Health of migrants – the way forward (2010)