Migrant health issues: what are they and why do they matter?
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In this article on migrant health issues, the term migrant is used broadly to refer to all people on the move, unless a distinction is otherwise made. The term migrant includes labor migrants, asylum-seekers, and refugees. It does not include people who have immigrated to a foreign country through formal migration channels.
Migrant health issues: what are they and why do they matter?
Madison Salters explores the main migrant health issues experienced by migrants and refugees on the move, in camps, and in the workplace.
“Migrant” is a buzzword used by politicians, journalists, and probably, your least favorite uncle at holiday dinners. But when it comes to migrancy, and especially migrant health issues, misunderstanding, and hyperbole are par for the course.
While it is true that the world is facing a migrancy problem; that there are now, more than any other time in human history, greater numbers of displaced peoples; the burden of that problem, causes of it, and its solutions are often twisted to support one viewpoint or another—a certitude as old as migrancy itself. In the fray of all this political quarreling are the actual human lives. Life is invaluable: but in an increasingly hostile social landscape where local populations talk about the “cost” of refugees to the state, invaluable is a misnomer.
Though human lives are priceless, migrant lives add calculable value to the societies they enter. The “value” of immigrants, in USA alone, is a 1.5% rise in GDP per 1% migrant population increase. In raw numbers, that’s: three-hundred twenty-one billion, five-hundred eighty-five million dollars. Considering the US usually taps out between a 2-3% GDP increase per quarter in high times, that’s like a hit of adrenaline right to the veins of the economy.
Of course, the matter can’t be simplified to this degree and declared solved. It is still a refugee “problem” because over-burdened systems in various countries are not currently equipped to deal with the magnitude of new immigration, and less in resource, more in recourse. Legal systems and by their extension, the medical establishment, is blundering with the influx. To understand the pain points, we have to know the hard facts.
In 2019, there are an estimated one billion migrants—meaning one in seven people in the whole world is a migrant. But only 270 million of these are international migrants: the other 763 million are internal migrants, who are the responsibility of their country of origin. Of the less than one-third of migrants who go abroad, 68 million of these have been forcibly displaced: by war, disaster, climate change, or discriminatory laws by draconian governments. Increasingly, climate change refugees are becoming a blossoming issue.
Less than 14% of all cross-country migrants are currently hosted by first-world nations. The rest are hosted by nearby, usually second- and third- world nations. This makes sense, when you view migrancy for what it is: people desperate to leave a bad situation, displaced from their true homes—the majority of whom would like to return to those homes one day. It is difficult for first-world citizens to imagine that foreign people want to return home, to use, and enjoy the benefits of their own citizenship.
Even if home is a less developed nation, migrants usually would prefer to live there than elsewhere—a country where they speak the language, have legal rights, are able to attend school, have a job, and own a home. In the places they migrate to, though they sometimes have “better” infrastructure and public support, often they are entitled to none of these things, no medical coverage, a long time without access to work or education, and they are culturally outcast and discriminated against, even despised by local populations. Most refugees prefer to stay close to home, with return in mind (where possible) should the situation become less fraught.
But still, even with less than 14% of just 1/3rd of all migrants effecting first world nations, it stands to reason that these nations are nonetheless bearing a burden of rapid population increase, and with greater population comes new implications to healthcare—not all of them bad. Migrancy is forcing countries to look at their own medical establishments: vaccinations, cost of drugs, universal healthcare, healthcare access, multilingualism in healthcare, cost of insurance, and modernizing medical records.
It is also helping to bridge the gap between health meaning purely “physical” health, and instead, including equally mental health. Refugees and asylum seekers, who are often fleeing war or prosecution and have dealt with violence, trauma, PTSD, sexual assault, and trafficking, tend to suffer from mental illness at a much higher rate than physical illness or disability. Access to quality, humane mental health treatment is a must for all modern societies to maintain the welfare of their populations, and migrants can help shine a light on that importance.
Migrant health issues: people on the move
To understand fully the benefits migrants can have on a first-world healthcare ecosystem, it is first important to recognize the unique health issues and framework that migrants come from, and their categories. Of course, these systems should be built to benefit migrant situations as well, and while their medical needs are more unique in the environments they enter (cholera no longer being a major first-world threat, for example), the illnesses they cope with; both mental and physical; are also represented in the places they travel to, and more advanced care in these areas is of help to local populations as well. Refugees and asylum seekers are among the most vulnerable populations in the world, and the longer their journey is to safety across national lines, the more complex their relationship to healthcare becomes.
No migrant movement is a monolith: health concerns can vary greatly, depending on the ages, gender makeup, the reason for leaving, and cultural backgrounds of a group, and then from person to person within that group. Travel, for migrants, can often exacerbate health concerns like asthma and heart conditions, or take the form of new ones along the journey, diseases like typhoid or cholera born from living in unsafe and unsanitary conditions.
The long journey can be fraught with lack of access to reasonable shelter, exposure to unfamiliar pathogens, lack of access to clean water and bathing facilities, improper nutrition, stress on body and mind, and often, violence. Violence, and the threat for especially women and children of sex abuse or sex trafficking, create additional burdens of tension and anxiety. Often, the reasons for leaving a home abruptly or permanently are an additional cause of anxiety, panic disorders, depression, trauma, or PTSD. For those fleeing conflict zones, for example, there are much higher rates of sexually transmitted disease or sexual mutilation, especially including victims of rape, sexual abuses, and gender-based violence—common in times of war.
The most common migrant health issues and illnesses affecting populations on the move are: behavioral health issues, cancers, poor eye health, diabetes, women’s health (including pregnancy), children’s health (including lack of immunization), physical injury, oral health issues, hepatitis, tuberculosis, diabetes, and HIV/AIDS. Despite the relative scarcity of some on this list in first-world nations (TB, or Hep, for example, due to vaccination, check-ups, and safe water conditions), the majority of illness sampled in migrant populations are worldwide health concerns. While rarer illnesses are often a concern for first-world citizens; the threat of epidemic looms in many an imagination; the truth of the matter is that first-world populations are often immunized against the spread, so migrant populations pose very little threat to the host nation—especially as immunization is a legal step to being granted asylum.
The physical and mental state of migrants and refugees entering a country depends on the duration and difficulty of their journey, their access to varied resources and sanitation, their level of vulnerability, and access to recourse in the face of violence, exploitation, sexual assault and trafficking. Vulnerabilities include lack of access to clean water, safe routes, housing, sanitation, and electronic communication with other family or needed authorities, as well as language barriers.
The danger one must undertake to become a refugee, and the high stakes to family, health, career, and education, make it clear how one only does so under dire circumstances. 70% of Refugees who have died in the last year have done so attempting to cross the Mediterranean Sea—they drowned. Smugglers are aware of this vulnerable population and will offer refugees “lucrative” deals to take on sex work, bringing them into a country where they are undocumented and do not speak the language, becoming sex slaves.
Those who escape often have immediate healthcare needs. The scope of this is massive—children and the underaged, who account for more than half of all refugees, often find themselves parentless on the road. More than ten-thousand children have been reported missing in Europe alone after making it to the continent from Africa or the Middle East. The majority of them are assumed to have been trafficked.
Migration, along with being physically perilous—involving long stretches without food or water, and exposure to the elements—is also a major social health detriment. “Social detriments” of health include: legal health (access, recourse, protections), general socioeconomic welfare (access to money, use of banks, property ownership), cultural welfare (language and cultural fluency), environmental welfare, and even factors such as age, lifestyle, genealogy, and behavioral factors. In almost every single one of the categories, migrants will be well below the national average upon entering a country, meaning they have to accomplish much more in a shorter period of time to be able to be “on par” with local populations and to grow new lives from square one.
It is also important to remember that for migrants and refugees, who are almost never able to leave with full, accurate, and up-to-date medical records (some do not have these, to begin with), their reasons for leaving their home often qualifies as a medical condition. Trauma, torture, injury, sexual assault, human rights violations, cultural and genocidal violence, illegal seizure of land, and severe economic disparity are the most common reasons for making a deliberate move. For those who are forced to move, reasons include war, enforced migration, and increasingly, climate change.
Migrant health issues: people in camps
Migrant health issues transform again once migrants reach the “safety” of a camp in another nation. However, there are multiple types of camp, and each of these pose different threats to health and safety. In many middle to low-income countries, migrant and refugee camps are typically run by NGOs (in refugee contexts camps are managed under the auspices UNHCR, the UN Refugee Agency), and host nations often prohibit anything that gives the camp a “permanent” feel—which includes repairs to housing and improvements in sanitation and safety. The slow elemental decline of facilities is only patched, never enhanced.
At the refugee camps, the World Food Programme supplies rations, which come to 2,100 calories a day: but nearly 80% of the calories are usually in grain, the rest being salt, oil, and lentils. Fruits and vegetables are normally not provided, nor is meat or dairy, due to funding constraints. It is reported that a staggering 90% of refugees sell their food rations, in part because the rations do not meet dietary requirements and also may be culturally insensitive—they will certainly make a person ill, over weeks. Refugees who lose or have their ration cards or vouchers stolen are not “entitled” to food until the vouchers are replaced.
In most situations, no working rights are afforded at the camps; despite the proven providence and local economic boost this would provide; and so refugees become aimless and mentally bored. They take illegal jobs at great risk to themselves to ease burdens (illegal work may lead to expulsion), and many set up “shops” within the camps themselves. Patrols for violence and robbery are often left to the refugee community itself to set up, which is difficult in a multi-national, multi-lingual space. The overcrowding can lead to an unnaturally high rate of disease outbreak and epidemic, bugs and vermin, and malnutrition often makes recovery times lengthy and herd immunity impossible. Sex work is rampant in some camps, often with government workers of host nations paying women in the camps for sex. The feelings of worthlessness, helplessness, isolation, and the stress of displacement has significant effects on the mental health of refugees. In the first-world, the situation is very nearly worse. Illegal camps, such as Idomeni, in Greece, or France’s Calais “Jungle” can be more squalid and dangerous than ghettos. The French government looked to demolish Calais bit by bit, leading to cultural “turf wars” as people were pushed into closer quarters, which in turn led to a fire that injured many and took the only possessions of families with it. The daily threat of violence and expulsion weighs heavily and is a major cause of stress.
As for legal “first-world” camps, we have the United States to look to as an example of ill-health, and the current detainment centers. Recent US Policy on family separation saw President Donald Trump insisting on a “zero tolerance” policy for immigration, despite the USA historically being a nation of immigrants, and in fact, having one of the biggest intakes of immigrants—and understandably, with the world’s biggest economy. Introduced to discourage immigration, the Trump administration spent over a year ripping children away from their parents and even illegally adopting some of these children out to US citizens while parents were jailed. No measure was included to reunify families.
What is true of nearly all camps is that upon entry, far from paradise, they often increase a migrant’s health-related vulnerabilities. They often feature a lack of proper access to health services (refugees have lost pregnancies, and children have died of the flu in US detainment centers, for example), lack of either proper shelter OR outdoor access and fresh air, overcrowding, inadequate hygiene, and poor sanitation. It’s also very common for there to be inadequate access to nutrition (children being fed potato chips as meals in the USA, for example), little recourse to gain education or work for money (some families or single persons can be in detainment for years, derailing lives and making it impossible for them to afford outside help, even when finally outside of the system), and violence—either from guards, more common in places like the US, or from other refugees, more common in places like Calais.
The US’s recent policy allowing migrants to be held for 60 days during the 2019/2020 flu season led to several young deaths, and the ability of US camps to “indefinitely hold” families has been called inhumane, flying in the face of 1997’s Flores Settlement, which guarantees to release at least vulnerable children within 20 days. Pregnant women are also shown a lack of consideration—while in detainment, they often are not allowed to seek medical help for pregnancy complications, and women like Teresa of the San Ysidro detention center lose their babies when requests for medical attention are ignored. Miscarriages, in this situation, threaten the maternal life as well. Moreover, refugees who are given treatment and require drugs from commissary are then expected to pay for those drugs, with no access to their belongings, no working rights, no way to communicate back home and wire money, and no access to US healthcare systems. The coronavirus pandemic in the US has excabated these migrant health issues in detention.
The burden of lack of healthcare is unduly put on female and vulnerable children populations: only 3% of long-term detained refugees in the US are men. The US had hoped to make a strong play, under Trump, to discourage the migrancy of women and children especially; seemingly, because women may carry children, and children cannot be refused, whereas males are easier to exploit for illegal labor, at risk to their health, and also to discourage men from saving up in a country and then bringing their families over. Families are not always held together and are rarely given information on other members of family, leading to additional and completely unnecessary stress.
These are some of the migrant health issues that asylum seekers have to deal with, rather than local populations.
For local populations, it is important to know that a step to legal migration once a person or family has claimed asylum is mandatory medical screenings in the first world. This will determine if a refugee has an “inadmissible condition” which could be a public health and safety concern, such as mental disorders associated with a history of violence, or extreme substance abuse. It is often difficult for refugees to explain their medical history, as they are unable to take documentation with them, and there is not always a worthwhile translator present to help delve into their concerns.
Diseases which can be cured, such as internal therapies for malaria, do not bar a refugee from entering the state—it becomes the responsibility of the state to cure the vulnerable person, and to also protect the local population. Health, therefore, can be considered a right—the idea that active help, rather than “do no harm”, is the social imperative.
Medical screening exams in refugee detainment centers, while they can often be humiliating and sometimes even inhuman (lacking features in cultural competency, such as not providing a female physician for a deeply religious female patient or family, or not employing trauma councilors for those with PTSD), will include a physical exam, a mental health evaluation, and testing for gonorrhea, syphilis, tuberculosis, and, if possible, a review of vaccination records. This will involve serologic testing, chest radiography, nucleid acid amplification testing, an acid-fast bacillus smear, chest spectrums, and any and all required possible vaccinations. For those diagnosed with TB, all symptoms must be brought to their knees or the TB cured before entry—as with for all treatable diseases.
The influx of humans with health needs and concerns should be galvanizing to the medical establishment, seeing more doctors of various races, genders, and cultural competencies being hired to these positions.
And though health to local populations matters, refugee health matters equally, as all people are equal. Asylum seekers are not required to meet INA immunization requirements before entering into the US, for example. War, violence, and famine are generally seen as bigger concerns to someone’s health than gonorrhea is. Any immigrant who has an “inadmissible” condition may still enter the state after treatment, or if issued a waiver by the state.
Conditions on children’s health are especially abysmal in detainment centers, which should call for more empathy than ever. Reports from out of Texas show that children spend twenty-two hours per day stuck indoors, inside of metal-wired cages, in overcrowded conditions. For sentence: they are given bottled water and, mentioned earlier, plain potato chips. For bedding, they are given foil insulation sheets. There is little to no childcare for young children and babies, and often, older (and unrelated) children are left to change diapers and soothe tears—especially in situations where those children have been torn from relatives, held elsewhere.
Poor conditions can also lead to infestations, even in first-world detainment centers: lice, rodents, and certainly roaches. NGO camps also face significant structural problems that lead to health defects, such as mold, dampness, and overcrowding that creates widespread raspatory infections, and environmental factors are risks linked to tuberculosis. Especially in young and elderly populations, intestinal parasites take hold, along with pneumonia—diarrhea is a significant cause of death in child refugee populations.
People seeking safety and respite are met instead with dangerous standers of living and a relative stasis to work and education.
Migrant health issues in the workplace
Another common complaint by locals is that irregular migrants are somehow “reaping benefits” that are a limited resource (such as SNAP food cards, or jobless pay), are “stealing jobs”, or in some cases, are getting benefits regular citizens do not have access to (such as, free health care in the USA.) In fact, access to benefits; even sorely-needed ones; are more restricted for irregular immigrants, who are also are not fairly protected by the law. This creates serious health and safety concerns for those migrants.
Many irregular migrants, skilled and unskilled, are employed in jobs labeled the “3Ds”: the most difficult, demeaning, and dangerous. These jobs often come with dangerous and harsh working conditions, low wages, and a lack of occupational protections, lack of recognition and reward, no upward mobility, and many occupational health risks. Migrants, both legal and irregular, have a fear of taking sick time off, asking for sick pay, going to doctors who lack cultural competency, joining unions, and are especially afraid of whistleblowing when a situation becomes too unsafe or hazardous. For these people, there is no national insurance to fall back on, and they are offered no occupational health scheme—a means by which citizens are able to protect the health of their children, typically, as well.
In fact, migrant and seasonal workers—especially in farm or construction work—are considered one of the most underserved communities in the United States. Very little effort or funding goes into their study, and the witch-hunt like fury that stalks at their heels for “stealing work” or “stealing a place in the US” makes them wary of speaking out about their true and often harrowing experiences.
What we do know is that the total population of these workers is estimated at 5 million in the US alone, with 20% of that population being in California. Workers on farms especially are exposed to strenuous tasks and a large variety of occupational risks. Migrant health issues give rise to a multitude of health problems including: injury from accidents and machinery, musculoskeletal and soft tissue disorders, pesticide-related illnesses, raspatory conditions, reproductive health issues, dermatitis, communicable disease, eye and ear problems, and bladder and kidney infections, as well as climate-born illnesses. The lack of epidemiological study in these areas; for the workers and their dependents; means that there are several long-term health risks that cannot be properly assessed. Without being able to key into the issues, it is difficult to conquer them; standardized data is the key to creating barricades against health consequences and improving working conditions to reduce occupational health risks.
Those same types of migrants, of course, are also barred from bettering themselves via education. Irregular migrants cannot sign on for, much less afford in most cases if they could, a four-year degree. It’s a lose-lose that may show the darker side of the economic improvements first-generation immigrants bring, which luckily, is often improved by second-generation’s contributions and access.
Migrant health issues: solutions on the horizon
With so much to consider when it comes to migrant health issues, and with so many human lives at stake, it is no wonder that the seventy-second WHO Assembly in 2012 commissioned a global action plan entitled “Promoting the Health of Refugees and Migrants.” Delving into study and the creation of standardized data on the issue is much-needed, even as it is coming late. Still, it comes largely ahead of the world’s next migrant crises: ecologic migrants, driven to new countries by fires, floods, and droughts caused by climate change. Countries equipped to help must mobilize in healthier ways—and not just because it will help migrants. It will also help local populations.
Refugee access to health services has shined a light in many countries on the lack of access even host citizens have to affordable, free, and fast healthcare that is diverse and culturally competent—as well as being an indicator of country’s existing rights-based, humanistic justice systems. Migrant plight has forced nations to look inward and see the glaring flaws that exist in healthcare; medically and legally; and start to make moves to be more equitable and inclusive. By employing systems that can effectively help vulnerable populations, societies will cease to exclude its own poor and maligned citizens. Migrants have actually been a huge push for more affirmative policies across the globe—just look at the current conversation in the US surrounding the exorbitant cost of pills and medications; especially for people who are chronically ill; their reliance on GoFundMe and the like as the “best option” to prevent their own deaths.
When speaking of migrant health issues, health must also be defined as not only physical but also social and mental well-being. It is not the absence of illness, but the fight for wellness. When justice systems look at the migrant crises, they are forced to ask themselves: is health a right of people? If they say yes, then it is a right of migrants too, and in fact, all citizens and non-citizens; the incarcerated, children, groups held in less social esteem historically or currently; all who are people. Health is noted as a key feature of sustainable development. Remaining healthy allows one; anyone; to contribute productively to society. Staying healthy is a prerequisite to a robust economy: it ensures a continuation of work, education, and progress.
The more refugees that enter a country, the more not only systems, but individual hospitals will be forced to adapt to the burden: to hire medical staff with better lingual skills, and more cultural competencies that better reflect today’s multi-cultural societies rather than history’s structures of power.
The new effort to conduct research on migrant health will also help countries to review their healthcare system at a national-overhaul level. Empirical research requires systemic reviews, and meaningful data can be applied broadly. For example, the Migration Data Portal reports: “…the Government of Sri Lanka in partnership with IOM published a compendium of migration health research that presented key data on the health of migrant and mobile population groups by disease (e.g. Malaria)… Such research led to the formulation of a National Migration Health Policy and Action plan for Sri Lanka.” Empirical data can lead to new drives in research, new outreach programs, and new hospital centers that help local populations as well as migrant populations—after exposing the once under-served need.
Migrancy also helps healthcare hire more of the local population. With 400,000 health assessments needed in 2016 alone, new doctors, nurses, and therapists had to be trained and put to work. Researchers dealing with higher incidences of “rare” first-world diseases (such as TB) or “common” second- and third- world diseases now have many new people to help them understand disease patterns, and formulate better and longer-lasting solutions and drugs. It is promoting collaboration across national borders, as well. The more we look in to under-served communities (such as those who are malnourished) in a first-world society through migrancy, the more people can be helped in general—these systems can also be transplanted to countries suffering greater burdens, once developed.
Lastly, migrancy encouraging a rights-based approach to government policy: healthy working conditions, easier access, clearer routes to care, an understandable framework, new systems for data collection—all being applied at national levels. This includes a better understanding of the importance of mental health: more efficient mental health screenings and services, greater leading to a better understanding of mental health issues such as PTSD that are taken less seriously or have less incidence in countries not at war.
Migrants face more obstacles to health than almost any population in the world, and paradoxically, their suffering is creating better health trajectories for countries across the globe. They are changing the way nations handle chronic disease, the legal access and status of patients, treatment procedures, and justice in healthcare systems. They are building stairs, not walls—to allow better, more humanitarian communication across languages and state lines, to clear cultural barriers, handle discrimination, stigma, racism, and to look at socio-economic burdens of poverty, malnutrition, and lack of access: all of which effect local populations as well. It is creating visibility; it is helping to end trafficking; it is reminding us who are most vulnerable are, and that society exists to protect them.
Madison Salters
Madison Salters, an award-winning writer, essayist, and documentarian, was selected as a 2018 U Revolution Media Fellow in the writing category.
