Social exclusion: the health needs of migrants

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Social exclusion the health needs of migrants

• Martin McKee
• GHAC

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Who moves? Migration from Europe to North
America in the 19th century

• Wave 1 small-scale entrepreneurs seeking a
  better life (economic migrants)
• Wave 2 people fleeing persecution or destitution
  (refugees)
• Irish famine
• Scottish land clearances
• German liberals after 1848
• Dutch Afgescheidenen
• Eastern European Jews
• Portuguese peasants from Azores
• Wave 3 individuals joining family members

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Human trafficking

• US State Department estimates that
• 600,000 800,000 people were trafficked across
  transnational borders worldwide in 2004
• 80 of the victims trafficked across
  international borders are female
• 70 of those females are trafficked for sexual
  exploitation

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The victims dont only come from poor countries

• Katya, with a two-year-old daughter and a
  failing marriage in the Czech Republic, followed
  the advice of a friend that she could make good
  money as a waitress in the Netherlands. A Czech
  trafficker drove her along with four other young
  women to Amsterdam where, joined by a Dutch
  trafficker, Katya was taken to a brothel. After
  saying I will not do this, she was told, Yes
  you will if you want your daughter back in the
  Czech Republic to live. After years of threats
  and forced prostitution Katya was rescued by a
  friendly cab driver. Katya is now working at a
  hospital and studying for a degree in social
  work.

Source US State Department
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Child trafficking

• UNICEF estimate that 1.2 million children are
  trafficked across borders each year
• Sex workers
• Child soldiers
• Domestic labourers
• Bonded labourers

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The passage of time does not always overcome
problems

• The Roma population moved into Europe about 900
  years ago from Northern India
• They have co-existed with populations in central
  Europe for centuries
• The health of the Roma population remains much
  worse than that of their neighbours

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Percentage of population born outside country
(2002)
Source UN population statistics
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Net annual loss of population through migration
EU neighbours
Source UN population statistics
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Different migrants

• Permanent settlers legally admitted immigrants
  who are expected to settle in the country,
  including persons admitted to reunite families.
• Documented labour migrants
• temporary migrant workers are skilled,
  semi-skilled or untrained workers who remain in
  the receiving country for finite periods as set
  out in an individual work contract or service
  contract made with an agency.
• temporary professional transients are
  professional or skilled workers who move from one
  country to another, often with international
  firms.
• Undocumented labour migrants do not have a
  legal status in the receiving country because of
  illegal entry or overstay.
• Asylum seekers appeal for refugee status
  because they fear persecution in their country of
  origin.
• Recognized refugees those deemed at risk of
  persecution if they return to their own country.
  Decisions on asylum status and refugee status are
  based on the United Nations Convention Relating
  to the Status of Refugees, 1951.
• Externally displaced persons are those not
  recognized as refugees but who have valid reasons
  for fleeing their country of origin (such as
  famine or war).

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Increasing Ethnic Diversity Changing Ethnic
composition in London 1991-2001
Source London Health Observatory
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Asylum seekers, refugees and displaced people

• Pre-migration factors
• Transit factors
• Destination factors

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Health of persons smuggled

• Pre-migration
• poor living working conditions
• limited access to health care
• persecution human rights abuses
• imprisonment, torture, rape

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Health of persons smuggled Transit factors

• Environment
• dealing with criminals
• dependency
• risk of verbal, physical sexual abuse
• uncertainty, fear
• Transport method
• range from benign to lethal
• commercial air routes
• hidden under, within cargo
• confined, crushed, poisoned
• overland dangers
• topography or landmines
• boats may be unseaworthy

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Post-migration factors

• Illegal status
• vulnerable, open to exploitation, in debt
• poorly regulated work environments
• e.g. forced work in sex industry
• Limited access to health care
• lack of knowledge, money
• fear of detection
• employers may prevent access to care
• unregistered with health care providers
• inappropriate medication

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Permanent settlers

• For many, high levels of poverty
• Health needs often undocumented
• Where they have been assessed, differing patterns
  of disease

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Reported fair or bad health by ethnicity in
England
Health Survey for England 1999
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Differing patterns of disease (I)Death rates
among UK residents by region of birth
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Differing patterns of disease (II)Death rates
among UK residents by region of birth
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Possible explanations

• Poorer socio-economic status
• Important, but not the whole answer
• Worse conditions in early life
• Important for some causes, such as stomach cancer
  and stroke
• Genes
• Likely to contribute in some way, but role still
  unclear
• The thrifty genotype?
• Exposure to risk factors
• Supported by migrant studies
• Works both ways such as historically lower
  smoking rates in some migrant populations

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Access to health care?

• Remarkably poorly studied in most countries
• In UK, South Asian people were less likely to
• Receive secondary prevention following a
  myocardial infarction
• Have full investigation of possible IHD
• Receive revascularisation procedures
• In USA
• Transplant surgeons prefer to give kidneys to
  people like themselves, white, male and middle
  class
• Quality of physicians is poorer in areas serving
  African-American areas

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Death rates by ethnicity USA
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Death rates by ethnicity USA
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Experiences of racism and discrimination in the UK

• One in 8 ethnic minority people experience racial
  harassment in a year.
• 25 of ethnic minority people say they are
  fearful of racial harassment.
• 20 of ethnic minority people report being
  refused a job for racial reasons
• 20 of ethnic minority people believe that most
  employers would refuse somebody a job for racial
  reasons, only 12 thought no employers would do
  this.
• White people report their own prejudices
• 25 say they are prejudiced against Asian people
• 20 say they are prejudiced against Caribbean
  people.

Source Modood et al. 1997
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Mental health an area of particular difficulty

• Health beliefs heavily influenced by culture
• Refugees especially vulnerable to effects of
• Past trauma (including torture)
• Post-migration stress
• Co-existing physical disease
• In the UK, Afro-Caribbeans with schizophrenia
  much more likely than whites to reach care via
  police than via a family doctor

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Moving forward What is to be done?

• The scale and pace of migration can be expected
  to increase in the future
• Europe needs continued migration to pay for its
  future pension commitments, and to deliver its
  health care
• This will result in increasingly diverse
  populations, with diverse health needs, health
  beliefs, and expectations

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Moving forward The importance of context

• The nature of citizenship
• Multi-cultural model (e.g. UK, Australia)
• diversity accepted. Services should respond to
  cultural demands
• Uni-cultural model (e.g. France)
• citizenship conditional on acceptance of majority
  norms. Users should adapt to the way services are
  provided

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Moving forward Quantifying the problem

• Collecting data
• Routine collection of data on ethnicity allows
  monitoring of need and utilisation (e.g. UK)
• Rejection of ethnic monitoring because of
  concerns about data abuse (often reflecting
  historical experience) (e.g. Germany)