Migrant populations are very heterogeneous in origin, in experienced exposure to risk factors, conditions of living in the host country and access to health care services. No doubt these many factors will influence their health status. One way of looking at the health of migrants is to consider it in relation with the very process of migration.
Taking into account the successive stages of the migratory steps allows for a more systematic analysis of the factors influencing the present health condition of an individual or a community. The successive and interconnected steps are the predeparture phase, the journey phase of migration, the arrival and settling phase and for some migrants the returning phase. At each of these steps of the migratory process, several specific factors may have consequences and influence the final outcome.
The predeparture phase. This is characterised by the influences on health of the environment in which one individual or a group of migrants has lived. This refers to a broad spectrum of factors. One thinks immediately of exposure to endemic diseases such as malaria, tuberculosis, intestinal parasites or hepatitis. Nutritional factors such as sufficient intake of micronutrients, vitamins and proteins will shape the nutritional status and normal growth of children. Social and economic factors such as poverty, illiteracy, unemployment, occupational hazards, poor housing and unhygienic living conditions are among key factors shaping the future health status of migrants, as will exposure to insecurity, war, violence, torture and other human rights violations. Religion and cultural background are of course of key importance in influencing health belief and behaviours. Finally, experiences encountered in contact with the medical services in the country of origin and with other traditional and lay medical providers will also influence expectations of and rapport with medical services in the country of settlement.
The journey phase of migration. This may be very short and uneventful in the case of a regular flight to the new destination. For many refugees and migrants the journey may be a long process, characterised by uncertainty, deprivation, insecurity, abuse, trauma and sometimes life-threatening events. This may be particularly the case for illegal migrants smuggled into a new country. Several tragedies have been reported: for instance, drowning of migrants crossing the Gibraltar straits or off the coast of Florida; the recent discovery of 50 Chinese migrants found dead from suffocation in a trailer in Dover; and those frozen after a intercontinental flight hidden in the wheel compartment of an aeroplane. Women being sexually abused, repeated threats of being denounced to the local police, and the very process of being trafficked without proper documents, completely dependent on Mafia networks, place illegal migrants under great physical and psychological strain.
The postmigration environment. This may differ greatly according to the legal status of a particular person or community. The level of education, professional skills, language and communication skills will influence the capacity of migrants to adjust to the new cultural, professional and social environment and progressively interact with and integrate into the new society. Previous exposure to violence and trauma may pose a serious barrier to adaptation, as persons suffering from post-traumatic stress disorder (PTSD) may avoid contacts or over-react to new unexpected constraints or situations. Living conditions, such as overcrowding or isolation, may accelerate the transmission of diseases such as tuberculosis and varicella, or may have an important psychological impact. Restrictive policies aimed at discouraging newcomers from seeking asylum may have also a deleterious effect on the mental health of asylum seekers or migrants (Silove et al., 2000). Access to health services may be restricted. Arriving in the receiving country may also be a relief and gives the opportunity to start a new life, with access to services and better living conditions influencing positively the health of newcomers.
The return back home. This is being experienced by a growing number of migrants. Recently, a large proportion of refugees having fled the war in Kosovo have been given incentives to return home. Those who were not willing have been put under strong pressure to comply with this policy, some being deported against their will. The return to a country under reconstruction, where insecurity still prevails, with the possibility of retaliation towards those who have fled abroad, may pose specific risks to these persons.
In taking into account the successive steps of the migratory process, it is possible to build a clearer view of potential exposures and risk factors that may influence the present health condition of specific persons or a community. This can help primary care providers to identify the present complaint or illness with the previous events related to the person's migration process.
Thus, the health of migrants is largely influenced by specific living conditions, previous exposure to communicable diseases, deprivation or violence, professional risks, the degree of integration in the new society, the access to health care, the capability to communicate and the presence or absence of a community or family safety net. At present, most of the data on migration and health come from surveys on specific groups of migrants or services, or through medical screening programmes at the time of entry into the host country. Routinely gathered data on the health of ethnic minorities or of foreign-born residents are often lacking in this area. Thus caution should be exercised in extrapolating the conclusions of specific studies to all migrants and, in so doing, contributing to the negative perception of migrants and to some indirect form of discrimination.
A recent review of health issues and problems of migrants in the European Union found that, compared with the host population, migrants have less access to health services and often have a higher rate of certain conditions such as tuberculosis, HIV, hepatitis B, accidental injuries, psychosomatic problems and depression (Carballo et al., 1998). Does migration in itself constitute an unhealthy process and put people on the move at higher risk of disease? Do we have a biased view on the health of migrants from studies uncontrolled for socioeconomic disadvantages or unequal access to health services? (Junghaus, 1998). Migration is a very selective process and those arriving in industrialised nations as immigrants, refugees or asylum seekers may not be representative of the population from which they come. They are probably the stronger, mentally and physically.
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