Improving the health of migrants

Abstract

Toxic narratives complicate rational debates and hinder workable solutions

Anti-immigrant rhetoric permeates today’s political discourse and soaks through much of society. In this highly politicised context, dominated by debates on immigration and border control, understanding and tackling what affects the health of migrants, their families, and communities is often overlooked and underserved. These gaps in understanding the relation between migration and health remain a challenge that policy makers, practitioners, civil society, and researchers must collectively embrace.^{1 2}

International attention focused through the prism of media and politicians is on migrants moving through “irregular” means—outside the laws and regulations that govern migration—and those who overstay their visas. However, the largest annual migrant flows globally are people moving within state boundaries for employment, to study, or because they are forcibly displaced. The health of internal migrants is often ignored in global debates and shielded by state sovereignty.

The United Nations estimates there were 258 million international migrants (people living outside their country of birth) in 2018, including 3.5 million asylum seekers and 20.4 million refugees.³ Nearly 60% are migrant workers, who mainly move along documented or legal pathways, meeting labour shortages in sectors such as healthcare in destination countries. Furthermore, most migrants stay within the continents in which they were born. Yet, this reality is overshadowed by the dominant narrative of a “migrant crisis” that focuses primarily on irregular migrants in Europe and North America.

The effect of migration on health is complex, arising from multiple determinants.² The conditions surrounding the process of migration—pre-migration, transit, destination, and return—may determine trajectories of health. For example, remittances sent home by a domestic worker overseas may enhance the nutritional status of children they left behind through access to better quality food and health services. However, the same migrant parent may have limited access to health and social protection in the country in which they work.

At the margins of policy

Disappointingly, health of migrants remains at the margins of policy making in countries at all income levels. Despite some progress,^{4 5 6} many still lack multisectoral action frameworks on dealing with the health needs of migrants.¹ Responses have traditionally been organised through disease control programmes, including health screening and quarantine at borders, and immigration health assessments for fitness to work and travel. Health authorities rarely work with other sectors, including civil society and migrant groups, to tackle migration health concerns.

Universal health coverage remains elusive for many non-citizens, especially for asylum seekers and low waged migrant workers and their family members, and some countries prevent irregular migrants from accessing healthcare, including lifesaving services.⁷ The adverse health effects and costs of exclusionary policies on both migrants and host communities are well documented.^{8 9} In response to increasingly restrictive policies on healthcare, frontline health professionals become “street level bureaucrats” resisting, or even supporting, domestic legal and policy frameworks to help, or hinder, healthcare for marginalised migrants.

Technical guidance to help governments develop migration health strategies is required. Multiple World Health Assembly resolutions, including development of the 2019 Global Action Plan on Migrants and Refugees, and commitments made by the Global Compacts on Migrants and Refugees must be matched by concrete efforts to improve migrant health globally, regionally, and nationally.

Health systems need to become “migration aware”—integrating migration and mobility into every level of healthcare planning. Importantly, such planning must move beyond state capitals and into provincial and municipal jurisdictions where integration and inclusive service delivery really matter.

Data, research, and analysis

Effective policy making requires accurate data and analysis to document realities and counter misperceptions about the scale of migration and its effects. Migration health is still in its infancy and continues to be under-researched and underfunded.¹⁰ The knowledge gap, especially in relation to low income countries, is glaring. Migrant workers, who comprise the majority of international migrants and come predominantly from low and middle income countries, are the focus of only 6.2% of total published research output on health of migrants.¹¹ Research is mostly concentrated on high income countries that “receive” migrants.

Countries need practical guidance on collecting good data on migration health. However, unless policy makers are shown the value of improving the collection, sharing, and analysis of migration health data it is unlikely to happen.¹⁰ Crucially, care must be taken to ensure that data collection systems are not reimagined by national immigration management authorities as surveillance systems and anchored with ethical and data protection safeguards.

New series

With this editorial we launch a new series from The BMJ. The series seeks to improve understanding of the complexities of delivering better health for migrants and communities affected by migration, tackle unhelpful stereotypes and prejudices aimed at migrants, and focus on the role of health in improving the societal response to migrants. Developed by The BMJ in collaboration with the UN Migration Agency (IOM) and the Migration Health and Development Research Network (MHADRI), the first three articles consider the migrant health system and political dimensions of navigating policy, politics, and diplomacy in this complex field.^{12 13 14}

Better health for migrants isn’t simply a moral imperative. It is an evidence informed, economically wise choice that will improve health for all. It is a choice that must be made in defiance of populism, prejudice, and political expediency.