migration and health the canadian experience – an overview seminar on migration and health 18-19...

Migration and HealthThe Canadian experience – an overview

SEMINAR ON MIGRATION AND HEALTH 18-19 October 2004

Guatemala City

Brian Gushulak MDMigration Health Consultants Inc.

ViennaAustria

migration health consultants Inc

What will I talk about?

• Why this issue is of growing importance

• What has been learned in the Canadian context that can assist as you anticipate and plan for the future


What is different at this time?

• Many of the current practices, focus an approaches are showing their limits– Designed for immigration

challenges but faced with the challenges of population mobility

– Significantly focused on infectious diseases

– Chronic non-infectious issues are growing importance


Major influencing factors

– Disparity• Linked to development

– Renewed interest in Public Health• Resulting from fear of disease• Risk of imbalance with real national impact

– Legislative initiatives • National and international


This presentation will not be technical but rather policy related

• The history of the process• The development of Immigration

Screening• The influences of Emerging and Re-

emerging Diseases– HIV in the 1980s– SARS, Avian Flu currently


Policy Initiatives

• Future challenges– Non infectious diseases

• Heart disease, diabetes • Malignancies

• Specific regional issues• New Directions in Migrant Health

– Screening for inclusion and population health improvement

– Mobility as a health parameter


The Origins of Migration Health

• Fear of imported epidemics– Lack of understanding of the disease– Serious or loathsome consequences

• Development of Quarantine in response to Plague– Isolation, separation, warning– Later examination of new arrivals for

disease


Why The History ?

• The history is important as it still resonates across the world– Founded on the principles of quarantine

• Several nations have recently completed or are in the process of amending quarantine legislation

• SARS and some emerging disease threats are causing nations to reconsider quarantine

• WHO is close to revising the International Health Regulations (a process that began in 1851)


Current Sociological Linkages

• Response to fear in the absence of effective control measures or treatment– “new” diseases, uncertain

treatment, limited understanding of risk

• Often associated with the international movements of people.– Several current

associations with globalization phenomena


Immigration Medical Screening

• Initial association with Quarantine– Infectious diseases– Screening on arrival

• Developed economic components– Ability to support

oneself– Likelihood of

becoming a “public charge”

migr ation heal th consul tants Inc

Photo: US National Library of Medicine


Immigration Health until the 1970s

• Routine practices by traditional immigration receiving nations– Australia, Canada, United States– Common factor was international

movement that had expanded beyond traditional colonial population flows

• Nations with primarily historically colonial migration did not develop as extensive screening legislation


Traditional Migration Health until the 1970s

• Infectious disease screening– Historical– National interests

and control programs• TB• STDs

• Legislatively separate from Quarantine

• Risks of cost or need for scarce medical services (Excessive Demand)– Primarily an interest

of Australia and Canada

– National Health Insurance Systems


Factors that Influenced the Evolution of Migration Health Policies

• Post Colonial population flows

• Post Vietnam refugee movements

• HIV / AIDS• Collapse of Soviet

Union• Emerging and re-

emerging diseases


Canadian Immigrant Source Regions Past 40 Years

(MacDonald BS Transatlantic Economic Issues and their Security Implications Atlantic Council Members Paper 03/02)

0

20

40

60

80

100

Europe Americas Asia Africa

1961 1971- 80 1991- 96 2000- 01


New Challenges

• Movements of large numbers of individuals across greater than previous diversity limits and boundaries– Reduced administrative control– Disease epidemiology– Culture and language – Economic levels– Social and behavioral practices


How those New Challenges Test the Limits of Traditional Migration Health Activities

• Border and frontier based• Transactional immigration

administrative roles rather than broad public health functions– Limited contact and follow up – Focus on acute or current status at time

of immigration formalities– Longer term implications assumed full

integration into host health system and similar outcomes.


Shift from Immigration to Population Mobility as a Component of Globalization

• Asylum seekers and refugees claimants challenge off shore screening

• Large numbers of visitors and transients for whom screening was never designed

• New disease threats that may out weigh traditional immigration interests

• Slow recognition that migration health outcomes have long term implications


Health Outcomes and Population Mobility

• Significant national impact• Long term implications• Potentially costly in terms of $$ and

programs• Extend widely beyond the health

sector• Implications for trade, security,

transportation and development


Diverse Health Environments influence and affect Disease Epidemiology

• The capacity of many national health systems is limited.

• These limits can affect the amount and resources available to manage a health issue.

• Those limits also affect disease disparities


Estimated TB incidence rates, 2000Source WHO Global Tuberculosis Control. WHO Report 2002. WHO/CDS/TB/2002.295

25 - 4950 - 99100 - 300

0 - 910 - 24

300 or moreNo estimate

Rate per 100 000


How does this relate to immigration?

• As nations control, manage or eliminate some health challenges the greatest statistical risk of recurrent threat comes from mobile populations from origins less able or with less capacity to manage those risks

• Example a disease for which immigration health programs screen - TB


Reported Tuberculosis in Canada by Birthplace

Source Data - The Public Health Agency of Canada – Tuberculosis Prevention and Control

0

10

20

30

40

50

60

70

80

90

100

Cdn-born Non-Aboriginal Cdn-born Aboriginal Foreign-born

% of C

ases


Tuberculosis in Canada by BirthplaceSource Data - The Public Health Agency of Canada – Tuberculosis Prevention and Control

20

30

40

50

60

70

80

Total Canadian Born Foreign-born

% of C

ases


Active Cases of TB in the Foreign Born : Canada 1988 - 2002

Source Data - The Public Health Agency of Canada – Tuberculosis Prevention and Control

0

500

1000

1500

2000


TB Cases in Foreign-born Persons, United States, 1986-2002

Source CDC National Surveillance System Highlights from 2002

0

10

20

30

40

50

60

70

80

Percentage of Total Cases


TB Cases in Foreign-born Persons, United States, 1986-2002

Source CDC National Surveillance System Highlights from 2002

0100020003000400050006000700080009000

10000

1986 1988 1990 1992 1994 1996 1998 2000 2002

Number of Cases


HIV


Leading Causes of Death

0% 5% 10% 15% 20% 25% 30% 35%

Maternal

Other

Respiratory & GI

Injuries

Cancers

Infectious Disease

CV Disease

Why do people die?

CV Disease (31%)

Infectious Disease (25%)

Cancers (13%)

Injuries (11%)

Respiratory & GI (9%)

Other (6%)

Maternal (5% )

Global deaths 1998 53.9 million Source WHO Infectious Disease Report 1999


Why do people die in Canada?All causes of death 1997

23%

32%

23%

9%

6%

4%

3%

0%

Cancer

Cardiovascular

Heart Disease

Acute Heart Attack

Cerebrovascular Disase

Chronic Lung Disease

Trauma

HIV/AIDS


Infectious Diseases

• 25 % of global deaths– Most in the developing world– Increased concern in the developed world– Fear of importation– Renewed interest in control measures

• Quarantine• Screening

– Often theses divide on the development index


This Fear of Infection Creates Situations of Very Low Tolerance of Risk

• Risks that are acceptable or not controlled in some regions are managed at great cost in others

• Blood borne diseases– BSE, Chagas’,

• Enteric Diseases– ETEC– Parasitic infections

• Tuberculosis


How Receiving Nations Manage those Risks can Affect Migration, Tourism, Trade and

Transportation• Screening of

travelers, workers, students

• Cargo, conveyances etc (Deratting)

• Travel Advisories


Issues of Regional Potential

• Several when the much of North America is a very low prevalence area for many infections– Chagas’– TB – Enteric infections– Malaria


Geographical origin of P. vivax malaria imported to Europe between January 1999 and September 2003 (n = 618)

http://www.malariajournal.com/content/3/1/5/figure/F1


Current Directions

• When faced with new infectious disease threats there is a tendency to return to traditional approaches

• This attention draws focus from equally important issues related to non-infectious illness


Those Traditional Approaches can have Extensive Consequences

• Quarantine and involved immigration departure or arrival screening are complex

• In globalized world events rapidly become international


New Directions

• Slow move away from Immigration Screening Paradigm

• Growing recognition of mobility as an integral component of globalization

• Greater awareness of impact of non-infectious disease


The Importance of Population Mobility

• As nations deal effectively with domestic health concerns, the likelihood of new challenges to those threats moves abroad.– Risk perception – Risk management– Economic impacts


The Population Mobility Paradigm

• Four Component Parts (each with health factors)– Pre travel component– Journey Itself– Arrival component– Return component


How the Components can Influence Health

• Pre travel component– Local environment and history impact

• Culture, economics, geography, political, social factors

• Journey itself– Duration, style, environment

• Refugees, transit, displacement, trafficking

• Arrival– Status, reception, integration

• Return– Time at destination, voluntary, assisted, forced


Current Trends

• Quarantine– Border focus

increasing– New legislation– International

Networks to monitor and advise on application


Current Trends

• Migration– Longitudinal Focus– Screening for

inclusion– Administration of

interventions• Malaria treatment• Immunization• ?HIV treatment


Significant Gap in the Migration Context

• There is as yet no integrated focus on how health and population mobility relate across the globe and across time– Immigration screening has administrative

limits– Other activities tend focus on groups of

migrants as opposed to the process of mobility– The appreciation of many of the long-term

implications is limited


There is still little attention to non infectious health issues

• On a population basis they are of greater impact

• The issues of disparity true for infections are also true

• Implications for the globalized work force


Coordinated Approaches would be Mutually Beneficial

• Development of more appropriate tools– More prospective capacity of immigration

screening / intervention– More cost effective

– Outcome Measures would be improved by

• Collective analysis and risk mitigation• Anticipatory planning• Longitudinal study


Benefits of an Integrated Population Mobility Focus on Health

• Share the acquired experience of the traditional immigration screening nations

• Assist in global health strategies

• Improve the health of migrants and host populations


Gratitude

• The organizers– Juan Pedro Unger– Karen Mujica– Alejandro Navarro– Luis Monzon

• The Government of Mexico

• CIC

migration and health the canadian experience – an overview seminar on migration and health 18-19...

Documents

colonial migration

traditional immigration

immigration challenges

current practices

emerging disease threats

current associations

quarantine risks of

policy relatedthe history