Social exclusion: the health needs of migrants

1. Social exclusion: the health needs of migrants Martin McKee GHAC

2. 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

3. 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

4. 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. The victims don’t only come from poor countries Source: US State Department

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

6. 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

7. Percentage of population born outside country (2002) Source: UN population statistics

8. Net annual loss of population through migration: EU neighbours Source: UN population statistics

9. 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 theUnited 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).

10. Increasing Ethnic Diversity Changing Ethnic composition in London: 1991-2001 Source: London Health Observatory

11. Asylum seekers, refugees and displaced people • Pre-migration factors • Transit factors • Destination factors

12. Health of persons smuggled • Pre-migration • poor living & working conditions • limited access to health care • persecution & human rights abuses • imprisonment, torture, rape

13. 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

14. 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

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

16. Reported fair or bad health by ethnicity in England Health Survey for England 1999

17. Differing patterns of disease (I):Death rates among UK residents by region of birth

18. Differing patterns of disease (II):Death rates among UK residents by region of birth

19. 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

20. 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

21. Death rates by ethnicity: USA

22. Death rates by ethnicity: USA

23. 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

24. 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

25. 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

26. 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

27. 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)