Migration and health in the European Union

Tropical Medicine and International Health

volume 3 no 12 pp 936–944 december 1998

© 1998 Blackwell Science Ltd936

Migration and health in the European Union

Manuel Carballo, Jose Julio Divino and Damir Zeric

International Centre for Migration and Health, Geneva, Switzerland

Summary The paper gives a brief overview of a wide spectrum of health issues and problems, ranging from

communicable disease to mental health and family formation, which affect migrants and host countries.

keywords migration, European Community, sexually transmitted diseases, cardiovascular diseases, tuber-

culosis, mental health

correspondence Manuel Carballo, International Centre for Migration and Health, Geneva, Switzerland.

E-mail: [email protected].

Introduction

Migration has probably become one of the most important

determinants of global health and social development. People

are moving in greater numbers than ever before and they are

doing so at a faster pace and over greater distances. Even

under ideal conditions the uprooting, displacement and

resettlement involved in migration – be it voluntary or in-

voluntary – can pose complex challenges. Migration has

implications for those who move, those who are left behind

and those who host migrants. Its implications for the health

care systems of communities and countries involved can also

be far-reaching.

Massive population movement is not new to countries of

the European Union (EU). Emigration from them has his-

torically been an important and highly effective economic,

political and social means of adjustment, and most countries

have benefited from migration at one point or another in

recent times. The emergence of the EU as a powerful

economic entity, however, is now producing changes in the

direction of migration, and the member states are beginning

to be net importers rather than exporters of human

resources. This is unlikely to change any time soon. Indeed,

as the principles of free movement become more established,

and as EU membership expands, the potential for people to

move within and into the EU will increase. The challenge of

making population movement and resettlement healthy and

socially productive will become an even greater ethical and

pragmatic necessity.

In 1997, the International Centre for Migration and Health

(ICMH) was asked by the European Commission to review

the health implications of migration into EU countries. The

review covered a wide spectrum of health issues and

problems, ranging from communicable diseases to mental

health and family formation. This paper provides a brief and

updated overview of some of the more salient findings and

conclusions of that review, and highlights the growing need

to adress the issue of migration and health in the European

context.

This is not meant to be an exhaustive analysis of the situ-

ation. Indeed that would be difficult given the variation in

available information on the subject. In some countries little

information is systematically gathered in this subject area,

and few national health statistics anywhere currently

distinguish between migrants and others. Although some

countries are beginning to address the issue from an ethnic

minority perspective, for now there is a marked paucity of

routinely gathered data in this area. Much of the available

information comes from studies by research institutes and

individual researchers. These constitute a relatively sound

basis for assessing the broader dynamics of health and

migration, but many are small-scale studies and have been

designed using distinct methodologies and reflecting different

interests. Thus drawing generalizations from them requires

caution. We consider some of the trends that are emerging in

the area of communicable and noncommunicable diseases,

reproductive health, psychosocial and psychiatric issues, and

family life.

Tuberculosis

Of all the public health problems associated with population

movement, communicable diseases have historically most

captured the attention of policy makers and the public.

Tuberculosis has probably been the most worrisome of these

for immigration authorities. It may well come to the forefront

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Tropical Medicine and International Health volume 3 no 12 pp 936–944 december 1998

M. Carballo et al. Migration and health in the European Union

again, for in 1993 the World Health Organisation (WHO)

announced that TB had become a global emergency, with as

many as 10 million new cases predicted by the early part of

the 21st century.

TB is typically a disease of poverty. It thrives in

communities characterized by low education levels, poor

nutrition, inadequate housing, overcrowding (Almeida &

Thomas 1996) and limited access to preventive and curative

medical services (Rieder et al. 1994). Improvements in all

these conditions in Western Europe over the course of the

last 50 years have helped to significantly reduce the

problem, and the incidence of new cases in 9 EU countries

fell from 34.8/100 000 in 1974 to 14.3/100 000 in all 15 EU

member states by 1995 (WHO 1997a,b). Similar health

benefits have not been possible everywhere, however, and in

economically less developed countries and societies marked

by war and social upheaval TB has remained a pervasive

problem.

Because much of the migration within and into the EU

involves people moving from less to more economically

developed regions, a number of EU countries are seeing

changes in their TB profiles. In Denmark, where the incidence

of new cases has increased over the past five years, the

proportion of foreign-born cases has risen from 18% in 1986

to 60% in 1996 (Prinsze 1997). In England and Wales the

National Survey of Tuberculosis in England & Wales

(Anonymous 1983) estimated that 40% of all TB cases occur

among people arriving from the Indian subcontinent (Karmi

1997), and in the Netherlands (De Jong & Wesenbenk 1997),

where the incidence of reported TB rose by 45% between

1987 and 1995, at least 50% of these cases involve migrants.

Similar trends are being noted in Germany (Huismann et al.

1997) and France (Gliber 1997) where migrants are three and

six times, respectively, more likely to be diagnosed with TB

than nonmigrants.

There is little evidence that this presents a problem for

host communities, but the risk of spread within migrant

communities themselves may be considerable. Not only do

many migrants come from backgrounds where TB is still

common, but many of them also move into living

conditions that offer little protection from TB. Even in post-

industrial countries such as the Netherlands (De Jong &

Wesenbenk 1997), Austria (Hammer 1994) and France (Gliber

1997) many migrants enter substandard housing and social

environments that involve serious overcrowding and poor

sanitation, conditions which enhance the risk of TB spread

(WHO 1996; Gaspar & Silès 1997). Since many of them also

remain socially excluded from host societies, they fail to

effectively use the health care services available to them. The

situation is especially precarious for the growing number of

migrants who arrive on short temporary work permits, and

even more so for those who move unofficially.

The importance of social and economic conditions, es-

pecially housing, in the spread of TB has been highlighted by

health planners in Italy (Carchedi & Picciolini 1997) who

have referred to substandard immigrant housing and poor

access to health services as important precursors to TB,

including drug-resistant varieties. The problem is of course

not limited to Italy. A study of migrant agricultural workers

in a farming region of southern Spain found that 85% were

living in makeshift, highly overcrowded rooms opposite the

greenhouses and warehouses they worked in. Over 75% of

the dwellings had no running water or toilet facilities, 70%

no electricity, 95% no heating or air conditioning, and 65%

no refuse collection (CITE 1997). A report on Cape Verde

migrants in Lisbon equally highlighted the problem of poor

housing and the lack of basic amenities; over a third of their

houses had no piped water, 13% had no toilet facilities and

26% no organized sewage disposal (CITE 1997). A 1991

study (Gardete & Antunes 1993) found that 13% of 622 new

cases of TB involved migrants living in these conditions.

Interviews with Moroccan patients hospitalized with TB in

France (Nejmi 1983) have similarly reflected the extent to

which poor housing has come to characterize the situation of

migrants and its potential implication for the spread of TB

within migrant communities.

HIV/AIDS

Of all the diseases that can be sexually transmitted few have

raised the concern that has surrounded HIV/AIDS. The

possible role of population movement in the spread of

HIV/AIDS has begun to attract attention (Carballo & Siem

1996; Carballo et al. 1996; IOM/UNAIDS 1998) but the

relative role it has played in EU countries remains unclear. In

Belgium (Muynck 1997) and Italy (Carchedi & Picciolini

1997), for example, the prevalence rate for AIDS among

migrants is lower than it is among nationals, but in Germany

(Huismann et al. 1997) migrants now comprise 14% of all

AIDS cases, a disproportionately high number. Most of these

cases come from the Americas, Africa and Asia, while

carriers from Turkey and Eastern Europe, where HIV/AIDS

is still less common, are far less numerous (Huismann et al.

1997). In Sweden rates of HIV and other sexually

transmitted diseases (STDs) among migrants, especially

from Africa, also appear to be exceeding national rates

(Janson et al. 1997).

Just as with hepatitis B, the risk of STDs may be elevated

where the sex-selective nature of labour migration has

produced predominantly male migrant groups whose patterns

of sexual behaviour involve considerable recourse to sex

workers. In Belgium (Muynck 1997), STD morbidity is

significantly higher among unmarried male immigrants than it

is among Belgian males in general.

© 1998 Blackwell Science Ltd 937

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Cardiovascular diseases

Cardiovascular diseases (CVDs) account for about 50% of all

deaths and 33% of disabilities in the EU (WHO 1994). In the

United Kingdom (Balajaran & Raleigh 1992), people from

South Asia (primarily India) appear particularly prone to

coronary heart disease (McKeigue et al. 1993; McKeigue &

Sevak 1994), and both men and women from South Asia have

30–40% higher rates than people of English background and

people from other parts of Europe (Balajaran 1991). UK data

for stroke incidence also point to major ethnic variations.

Significantly higher than average rates are reported for Carib-

bean people (Balajaran 1991), and although mortality from

stroke in all groups has declined in recent years, stroke-related

mortality among men from the Indian subcontinent has

declined at a much lower rate than for other groups (Cruick-

shank et al. 1980). Diabetes mellitus, a contributing factor in

stroke, is also found twice as often among Caribbean and South

Asian people as among the British population overall

(Cruickshank 1989) and in Belgium noninsulin-dependent

diabetes is three times more common among immigrants than

among the indigenous population (de Muynck & Schiliemans

1986; Muynck 1997). In Sweden, where above-average rates of

obesity and CVD are reported for people originating from

Finland (Järhult et al. 1992), traditional Finnish dietary habits

may be a contributing factor. Hypertension-mortality also

reflects ethnic differences. People of Polish origin in the UK

(Balajaran 1991), for example, have excess hypertension-linked

mortality, and mortality rates among people from Ireland and

Scotland (where hypertension-related morbidity and mortality is

generally higher than in other parts of the UK) tend to reflect

the profiles of their regions of origin.

Cancer

Breast cancer is now the second leading cause of death among

women in the EU (Geddes et al. 1993; Muir 1993; Eurostat

1995a). Breast cancer patterns reflect national background,

length of residence and lifestyle-related factors. In the UK,

rates for cancer of the breast, uterus and ovary have tended to

be consistently lower among Italian-born women. Data from

Scotland on digestive tract cancers (Black 1993) also show

lower rates for Italian female immigrants, but their rates of

stomach cancer, on the other hand, tend to be higher. Time

sequence data nevertheless indicate that patterns of breast

cancer among immigrant groups are gradually beginning to

approximate those of the receiving populations, especially in

the case of people who immigrated early in life.

Reproductive health

Reproductive health of migrants presents one of the most

important, and still unmet, public health challenges. In the

UK, several studies (Balajaran & Botting 1989; Bundey et al.

1991; Chitty & Winter 1989) report that babies of Asian

mothers tend to have lower birthweight than other babies;

perinatal and postneonatal mortality rates are also higher

among babies born to immigrants from Pakistan and the

Caribbean. The situation in Belgium shows similar trends: in

1983 the highest perinatal and infant mortality rates were

recorded for babies born to women from Morocco and Turkey

(Muynck 1997). Despite overall national improvements in

maternal and child health between 1983 and 1993, high

perinatal and infant mortality rates persisted in the Turkish

community, and in 1993 they were still 3.5 times higher than

for the Belgian population as a whole (Muynck 1997). In

Germany (Huismann et al. 1997), rates of perinatal and

neonatal mortality also tend to be higher in foreign-born

groups, especially babies born to Turkish mothers. Much the

same has been observed among immigrant groups in Spain,

where premature births, low birthweight and complications of

delivery are all cited as common problems among women

from sub-Saharan Africa, Central and South America.

Among African women giving birth in Spanish hospitals, the

incidence of premature births is almost twice as high as for

Spanish women, and low birthweight is approximately 11.5%

compared to 5.5% (Jansa et al. 1994). African women also tend

to have higher rates of miscarriage (Teixidor et al. 1993). In the

case of babies born to mothers from Central and South

America, over 8% are underweight and 6.3% are premature

(Teixidor et al. 1993). Oller et al. (1997, cited in Gaspar & Silès

1997) note that unwanted pregnancy, poor knowledge about

contraception and where to get it are common problems, and

requests for abortion tend to be twice as common as among

Spanish women, especially by women from subsaharan and

North Africa.

Nutrition

Dietary habits are strongly culturally defined human

behaviours and also extremely unstable. Migration often

necessitates fundamental changes in what food people eat and

how it is prepared, forcing old nutritional habits and customs

to be adapted to new lifestyles. Breast-feeding is a case in

point. Breast-feeding is often taken for granted in traditional

societies but far less common in industrial and postindustrial

societies, where work pressures and the influence of formula

foods have helped erode breast-feeding. The impact of this on

newcomers can be important. Vietnamese women in the UK

have been reported as saying they lack the confidence needed

to initiate and maintain breast-feeding, especially when they

live in communities with few other Vietnamese families or

experienced women they can turn to for support (Sharma et

al. 1994). Assumptions by local health care providers that

women from traditional societies will persist with breast-


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feeding irrespective of other factors have not been borne out.

More importantly, one report pointed out that assumptions of

this kind can lead to migrant women not being allocated the

support they need. In one case this led to a decrease in the

prevalence of breast-feeding among Bangladeshi mothers

(Hilder 1993), which may have reduced their duration of

lactational amenhorrea and exposed those not using other

contraceptive methods to unplanned pregnancy.

Nutrition-related problems in the children of migrants are

not uncommon. Inappropriate use of breastmilk substitutes

and poor weaning has been linked to vitamin deficiency

rickets and ferropenic anaemia in infants of migrants in Spain

(Jansa & et al. 1994). In Sweden under-nutrition, stunting and

anaemia are frequent problems among refugee children

(Janson et al. 1997) and in the Netherlands vitamin D

deficiency together with protein-energy malnutrition is

reported to be a fairly common problem among immigrant

children (Meulmeister et al. 1990). In Germany, on the other

hand, obesity among children of non-German background

may be indicative of a tendency to parental overcompensation

(Huismann et al. 1997).

Accidental injuries

Occupational health and safety has become a major concern

in the context of migrant labour everywhere. Migrants tend

(at least initially) to move into low-skill, temporary

employment involving poor environmental conditions.

Because their work is often considered too short-term or

menial to justify investments in training, they are exposed to

avoidable accidental injuries. The problem is exacerbated by

lack of good communication with employers and supervisors,

frequent lack of familiarity with the machinery used, and

different attitudes to safety. In Germany (where, incidentally,

migrants make far fewer insurance claims than nationals),

immigrants have occupational accidents twice as often as

native workers (Huismann et al. 1997) and in France over 30%

of accidents resulting in permanent disabilities involve non-

French workers (Gliber 1997). Data from Belgium (Peeters et

al. 1982) similarly indicate that Moroccan and Turkish

migrants employed in heavy industries have a higher incidence

of accidents than nationals, and also that they have more

secondary psychological sequelae as a result. In the

agricultural sector exposure to pesticides and other chemical

products is often a chronic problem and in Spain it has been

linked to depression, neurological disorders and miscarriages

in migrant agricultural workers. Other health problems,

including dehydration and heart complaints linked to high

temperatures among workers in greenhouses, are also

common (Castelló 1992; Parron et al. 1992).

Migrants also appear to be more vulnerable to other types

of accidents. In Germany, non-German children in the 5–9

year-old age bracket reportedly have more traffic and domestic

accidents than German children (Korporal & Geiger 1990).

Children of Moroccan and Turkish migrants in the

Netherlands (De Jong & Wesenbenk 1997) also have more

domestic accidents, including poisonings and burns and more

traffic accidents than Dutch children. In France poor-quality

housing is an important risk factor in the frequent incidents of

lead poisoning among children of migrants living in old and

poorly maintained houses.

Psychosocial issues

Psychosocial health issues are often forgotten in the overall

scheme of things. They are nevertheless an important com-

ponent of the problem faced by migrants. Some EU countries

have adopted resettlement policies that stress geographical

dispersal of minorities and migrants in order to achieve faster

integration into mainstream society. There is little evidence

this has been effective, and the isolation that follows can

instead be highly detrimental to the mental health and social

integration potential of newcomers. This has been the case

with Vietnamese refugees in Finland (Liebkind 1996), where

younger immigrants were more able than older people to

adopt Western values and behaviours, but where doing so

prompted anxiety and depression among mothers who saw

themselves as losing their children.

Because migration often means separation of spouses,

marital problems are common. Even when families are eventu-

ally reunited, separation and divorce often follow, particularly

when one of the partners cannot find work. Reports (de Jong

1994) suggest that in families which benefited from

reunification schemes, men often find themselves sexually and

emotionally distant from their spouses and relatives. Some

have gone on to develop new relationships, while others had

simply idealized their families and family ties in ways

irreconcilable with reality. Others seem to lose face when

relatives complain about being brought into more precarious

economic conditions than expected from the letters and

telephone calls they received while still at home. If and when

migrant couples do separate, finding culturally sensitive social

support can be difficult and severe problems of loneliness, fear

and low self-esteem are common. Children of migrants who

separate are especially affected and women lose out, especially

in countries where their social status in the local immigrant

community is tied to spouse and family.

Problems also arise if children who learn the host language

more quickly than their parents are seen as deserting their

families and cultural heritage. In the absence of supportive

social networks to help children resolve this problem, they are

easily forced by parents into culturally marginal situations. In

Sweden a study (Neiderud 1989) reported that Greek parents

actively avoided using social services that might have relieved


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the load of childcare because of fears that their children

would integrate too much and too quickly into Swedish

society.

Swedish data (Svedin et al. 1994) also indicate that children

of immigrant parents who divorced while in Sweden had a

much higher symptom load than children of Swedish

divorcees. Because marital problems among immigrants often

lead to one of the partners returning home to the country of

origin with them, children are then deprived of the affective

role of the other parent. The absence of fathers is reported to

have adversely affected migrant children and adolescents

returning to Finland from Sweden, and the boys in question

were more prone to psychiatric disorders than local non-

migrant children (Moilanen & Myrhman 1989).

Psychosomatic problems are also common, and in the

initial period of resettlement, Moroccan immigrants in

Belgium are five times more likely to develop peptic ulcers

than Belgian nationals (Muynck 1997); stress-related ulcers

are a also a frequent source of morbidity among immigrants

in Germany (Huismann et al. 1997). Other stress-related

symptoms include frequent and severe headaches, anxiety

attacks, dermatitis, and sleeping disorders, all of which can be

detrimental to successful social and occupational integration.

In the Netherlands, Turkish immigrants are reported to have

high neurosis scores, more gastrointestinal complaints, and a

higher risk of abusing alcohol than nationals. The prevalence

of ulcers among both Moroccan and Turkish men is high, and

immigrants from the Antilles, Morocco, Turkey and Surinam

are 5–10 times more likely

to suffer from chronic tension headaches than their Dutch

counterparts (van Wieringen et al. 1986). In Sweden (Janson et

al. 1997), chronic anxiety, sleep disorders, and frequent

headaches are also common problems among recently arrived

refugees, and in Spain (Gaspar & Silès 1997) there are reports

of frequent hypochondria and paranoia among immigrants.

Psychosomatic disorders are additionally complicated by

cultural differences in how people perceive health, the body,

and the causality of disease. Frequent references to muscular

pain, heartache, tightness in the chest or shortness of breath,

for example, often reflect culturally prescribed ways of

referring to stress rather than actual symptoms. Health care

staff working from purely biophysical models of diagnosis do

not always appreciate this and misdiagnosis is a serious

problem (Mirdal 1985).

Alcohol and drug abuse may be a growing problem in the

context of migration. In the United Kingdom Indian male

immigrants, especially Sikhs, are manifesting new patterns of

alcohol abuse, as reflected in cirrhosis of the liver-related

mortality rates twice as high as those of English males

(Balajaran et al. 1984; Cochrane & Bal 1989). Irish male

migrants have traditionally been characterized as heavy

drinkers, and indeed do have higher rates of alcohol-related

mental illness than other groups. However, new evidence

(Greenslade et al. 1995; Mullen et al. 1996) suggests that they

are no more likely to abuse alcohol than other groups, but

that those who do, do so more heavily and with more

apparent consequences.

Drug abuse is probably a more serious problem. A recent

study (ICMH 1998) highlighted the extent to which migrants

in some settings are gratuitously offered drugs in their daily

lives and how difficult it is for them to find culturally

acceptable/sensitive help in prevention. In the United Kingdom

(Lipsedge & Turner 1990; Lipsedge et al. 1993), the influx of

drug users to the UK in search of better living conditions has

become an evident problem. In Amsterdam (de Jong 1994)

about a half of methadone bus programme users are foreign-

born, and so are about 25% of young women who

prematurely leave drug Youth Advice Centres. Approximately

45% of detainees in youth penitentiaries in the Netherlands

are said to be children of migrants, but this may of course

reflect arrest trends rather than real patterns of drug use.

The reasons for drug use among children of immigrants

vary considerably. In France (Ait Menguellet 1988; Yahyaoui

1992; Bendahman 1993; Yakoub 1993; Boylan 1995), it is seen

as a manifestation of social marginalization, and as an

expression of anger/frustration at the difficulties of

integration. A study of psychological stress and coping among

Greek immigrant adolescents in Sweden (Giannopoulou 1988)

tends to confirm this, and similar observations have been

reported from Germany (Akbiyik 1990). Patterns of drug use

among migrants and refugees, however, are not necessarily

very different from those of local populations, and there is

growing evidence that what differentiates them is the

immigrants’ capacity to make appropriate use of health and

social services (K.E. Sparrow, personal communication).

Among rural Turkish workers in Amsterdam (Sayil 1984),

where only a minority are able to speak Dutch, mental health

problems, including anxiety and neurosis, are reportedly

common and regrets are frequently voiced about the decision

to leave home and family because of contractual

arrangements. The pattern of emerging mental health

problems nevertheless varies with time. In Germany

approximately 13% of immigrants seen for depressive

disorders seem to develop them during the initial 12 months

away from home. Another 25% tend to develop problems

during the following two to five years, many of them referring

to a ‘longing for home’ and reporting exaggerated memories

of family, the way they lived and the scenes they saw as

children (Huismann et al. 1997). Selective recall and fantasies

about home and return are often described as the ‘migrant’s

opium’, and while they are not thought to be necessarily

serious, they can be psychologically debilitating (de Jong

1994). Nowhere is this more true than in the case of forced

migration where families are violently dispersed and where


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unresolved fears about relatives are common and persist for

long periods.

Schizophrenia is one of the most dramatic and serious of

mental health problems. It is highly disruptive of family life,

affecting not only patients but also immediate caregivers. In

the UK (London 1986), people of Caribbean, Irish and Polish

origin have the highest hospital admission rates for

schizophrenia. In fact Caribbean immigrants tend to be

diagnosed with schizophrenia three to six times more often

than non-Caribbean people (Dean et al. 1981; Cochrane &

Bal 1987; McGovern & Cope 1987; Littlewood & Lipsedge

1988), and in 16–29-year-olds it is up to 12 times more

common than among non-Caribbean adolescents (Karmi

1997). Schizophrenia is also more frequently diagnosed in

people from India and Pakistan, especially among men, than

among native British; even so, rates of schizophrenia among

Caribbean people are still three times higher than for people

from South Asia (Cochrane & Bal 1989). In Germany

(Lazaridis 1985) schizophrenia is also a frequent first

diagnosis; however, reports suggest that it is often revised on

review and redefined as neurosis or psychopathic problems.

Drug abuse-related schizophrenia (together with other

psychotic diseases) is also a fairly common problem among

migrants from Surinam and the Antilles in the Netherlands

(Selten & Sijben 1994).

The relatively high incidence of depression among mi-

grants has been associated with high rates of suicide. In the

Netherlands, where the unemployment rate among migrants

in 1994 was 31% compared to 13% for Dutch nationals, the

suicide rate among children of migrants was significantly

higher than in the general population (de Jong 1994). In

Rotterdam (de Jong 1994) children of Turkish immigrants are

five times as likely as Dutch children to commit suicide, and

young people of Moroccan background are three times as

likely to do so. In the United Kingdom (Patel & Gaw 1996;

Karmi 1997) suicide among South Asians is twice the

national average, and in the 25–34-year-old age group, 60%

higher. Suicide among women, especially women in the

15–24-year-old age range, is more frequent than among men,

as is attempted suicide.

Psychiatric morbidity among children may be linked to a

range of family, personal and environmental circumstances,

including culture conflict, job insecurity, regrets about leaving

home, family disruption and uncertain future opportunities.

Adults often leave children behind with grandparents, or

when they move together have to take jobs that involve work

schedules that keep them away from home and children

during nonschool hours. Affective relations often suffer, and

some studies (Ostek 1983) have reported that up to 20% of

preschool age Turkish children in Germany are looked after

by siblings, and over 50% of children under 15 by persons

other than their mothers.

Conclusion

Movement of people within and between countries has be-

come a central and necessary part of contemporary society.

The European Union is no exception to this and the pace of

movement in and around the EU is unlikely to diminish in the

foreseeable future. Most migrants move because of the push

of poverty, and the widening economic gap between the EU

and other regions will continue to prompt people to uproot

and move elsewhere, probably north. Mass population

movements are also being spurred by political and social

conflicts, and the numbers of refugees are swelling all over the

world.

Most types of migration are highly selective, and for a var-

iety of reasons people who move are often those who are

most able to do so from a health point of view. They may also

have a broader world view and a better idea of what

opportunities may exist elsewhere. Over time many of the

health indicators characteristic of migrants may approximate

national host country norms. Even so, migration is rarely

simple or easy and the growing pace of migration will bring

with it new health and social challenges.

How the process of migration can best be made a healthy

and socially productive process will depend on whether

countries can respond in ways that enhance equity while

respecting national resource limitations. In this regard,

evidence-based international policies on how to manage

public health in the context of migration are essential and

long overdue. Better and more systematic surveillance, and

planning for, the health of migrants are needed. Improved

information and education of migrants and those who

‘receive’ them with respect to health and social needs, cultural

and linguistic constraints, as well as opportunities for health

and social development are also important.

A number of specific issues call for immediate consider-

ation. The first concerns family health. Many countries and

employers still restrict migration to those who will be

gainfully employed and do not include close family members.

From the perspective of receiving countries there may be

sound economic and political reasons for this, but the

physical and mental health implications of these policies

deserve to be more carefully considered. Disrupting families

can impact on the behaviour of those who move and those

that are left behind. The implications for sexual and mental

health, alcohol and drug misuse can be serious. There is also

evidence that patterns of child care change and of absent

fathers or mothers in the context of migration. Even when

families are reunited, the work schedules of migrants as

economically marginal people often seem to be also

associated with lengthy absences by one or both parents.

High accidental injury rates of children of immigrants point

to the need for more alternative childcare facilities and

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support for migrant families. Policies and programs to help

children of migrants integrate socially and educationally may

also deserve review.

Reproductive health in the context of migration continues

to be a serious and persisting problem everywhere. Much of

the data on this may reflect the cultural and health

backgrounds of migrants as much as the resettlement

conditions in which they are living, but the reproductive

health issues of women migrants call for more attention than

they have been given in the past. More may need to be done

to ensure that migrant women actively participate in, and

benefit from, mother child health (MCH) services, especially

antenatal care in the case of those who are at high risk due to

their background. In this respect the social and cultural

aspects of reproductive health probably deserve special

attention.

The problem of substance abuse within the framework of

poor postmigration adjustment as well as other psychosocial

problems also deserves greater priority as a looming public

health problem. If substance abuse is indeed a reflection of

the frustration young migrants experience at not being able to

integrate easily and well, steps should be taken to focus more

on how to facilitate better and faster accommodation and

integration, especially of young people. Similarly, psychiatric

illness among migrants calls for more attention, and a focus

on if and how cultural differences and poor communication

affect diagnostic procedures and outcomes. Indeed the role of

language and socio-cultural background in determining how

patients are seen and managed by health care providers in

general probably requires further evaluation.

The growing spectre of tuberculosis has gone far to

highlight the poor social and housing conditions many

migrants live in. This is probably indicative of a greater social

and economic marginalization and its implications for health,

but it is a domain that may be tangible and more easily

remedied despite evident economic constraints. Ensuring

sound and healthy housing for temporary or short-term

migrants could go far in preventing ill health. It could also go

far in improving their sense of potential integration – even on

a temporary basis. If this can be achieved, other benefits

might also accrue.

Acknowledgement

The authors with to acknowledge the administrative support

of Mrs J. Coutin.

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