POLICY AND PRACTICE
Health and foreign policy: influences of migration and population mobility
Influence de l'émigration et de la mobilité des populations sur les politiques sanitaire et étrangère
Salud y política exterior: influencia de las migraciones y la movilidad demográfica
Douglas W MacPhersonI,II; Brian D GushulakII; Liane MacdonaldI,III
IFaculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
IIMigration Health Consultants, 14130 Creditview Rd, Cheltenham, Ontario L7C 1Y4, Canada
IIICommunity Medicine Residency Program, McMaster University, Hamilton, Ontario, Canada
ABSTRACT
International interest in the relationship between globalization and health is growing, and this relationship is increasingly figuring in foreign policy discussions. Although many globalizing processes are known to affect health, migration stands out as an integral part of globalization, and links between migration and health are well documented. Numerous historical interconnections exist between population mobility and global public health, but since the 1990s new attention to emerging and re-emerging infectious diseases has promoted discussion of this topic. The containment of global disease threats is a major concern, and significant international efforts have received funding to fight infectious diseases such as malaria, tuberculosis and HIV/AIDS (human immunodeficiency virus/acquired immune deficiency syndrome). Migration and population mobility play a role in each of these public health challenges. The growing interest in population mobility's health-related influences is giving rise to new foreign policy initiatives to address the international determinants of health within the context of migration. As a result, meeting health challenges through international cooperation and collaboration has now become an important foreign policy component in many countries. However, although some national and regional projects address health and migration, an integrated and globally focused approach is lacking. As migration and population mobility are increasingly important determinants of health, these issues will require greater policy attention at the multilateral level.
RÉSUMÉ
L'intérêt international pour les relations entre mondialisation et santé va grandissant et ces relations sont de plus en plus évoquées dans les discussions de politique étrangère. De nombreux processus de mondialisation influent sur la santé, dont notamment l'émigration, et les liens entre émigration et santé sont bien documentés. Il existe de nombreuses interactions historiques entre mobilité des populations et santé publique, mais depuis les années 1990, l'émergence ou la réémergence d'un ensemble de maladies infectieuses suscitent à nouveau l'intérêt et ramènent ce thème parmi les sujets débatus. La maîtrise des maladies menaçant la population mondiale est une préoccupation majeure et des efforts importants pour lutter contre des maladies infectieuses telles que le paludisme, la tuberculose et le virus de l'immunodéficience humaine/le syndrome d'immunodéficience acquise (VIH/SIDA), ont été financés. L'émigration et la mobilité des populations jouent un rôle dans chacun des défis auxquels se heurte la santé publique. L'intérêt grandissant porté à l'influence de ces facteurs incite à considérer les déterminants internationaux de la santé dans le contexte de l'émigration. En conséquence, la résolution des grands problèmes sanitaires à travers la coopération internationale est maintenant devenue une composante majeure des politiques étrangères de nombreux pays. Néanmoins, même si certains projets nationaux et régionaux s'attaquent à la problématique santé et émigration, une approche intégrée et mondiale fait défaut. L'émigration et la mobilité des populations devenant des déterminants sanitaires de plus en plus importants, elles exigeront une plus grande attention de la part des responsables politiques au niveau multilatéral.
RESUMEN
El interés internacional por la relación existente entre la globalización y la salud está empezando a influir en los debates sobre política exterior. Aunque se sabe que muchos procesos globalizadores influyen en la salud, las migraciones destacan como un proceso esencial de la globalización, y la relación entre las migraciones y la salud está bien documentada. Si bien hay numerosas interconexiones históricas entre la movilidad demográfica y la salud pública mundial, las migraciones y la salud han despertado un renovado interés desde los años noventa con la aparición de las enfermedades infecciosas emergentes y reemergentes. Ulteriormente se ha prestado gran atención a la contención de las amenazas sanitarias mundiales y ha habido notables inversiones internacionales para enfermedades infecciosas graves como la malaria, la tuberculosis y la infección por el virus de la inmunodeficiencia humana/síndrome de inmunodeficiencia adquirida (VIH/SIDA). Las migraciones y la movilidad de la población son cuestiones que se plantean en todos los retos de salud pública. El creciente interés suscitado por la influencia de las migraciones y la movilidad demográfica en la salud está estimulando iniciativas de política exterior para abordar el impacto de las migraciones en los determinantes internacionales de la salud. Como consecuencia de ello, la respuesta a los retos de salud mediante la cooperación internacional se ha convertido hoy en un componente importante de la política exterior en muchos países, así como para la Organización Mundial de la Salud (OMS). Sin embargo, aunque algunas iniciativas de proyectos nacionales y regionales están orientadas a la salud y las migraciones, se carece aún de una perspectiva integrada y de carácter mundial. Así pues, habrá que prestar más atención multilateral en el plano normativo a las migraciones y la movilidad demográfica como determinantes cada vez más importantes de la salud.
Introduction
The growth of migration and population mobility, international trade and communication technologies are shaping global health. The relationships between these globalizing processes and health are introducing health into foreign policy discussions. Migration and mobility feature prominently in this dialogue by addressing the disease risks associated with increasing international population flows.
Population mobility encompasses the processes common to evolving patterns of human mobility, whereas migration reflects the legal and administrative aspects of the movement of individuals and groups. Relationships between migration, population mobility and health have long been acknowledged; however, they have received renewed attention due to the emerging and re-emerging infectious disease paradigm that has developed since the 1990s (see Table 1).1 This attention has been accompanied by requests at the national government and international nongovernmental agency levels for foreign policy initiatives to address aspects of health in the context of migration and population mobility.2
Governments are now starting to concede the limits of domestic policy as the sole approach to the growing global health challenges of increasing migration.3 As a result, health issues are being raised more often in foreign policy discussions.4 Recent health policy initiatives reflect the continued relevance of historical policy responses to similar health threats within the travel and transportation sectors.5-7 This paper reviews migration-related health issues relating to current and future foreign policy initiatives.
Migration, mobility and international health
Migrants are individuals who leave their legal place of origin and who cross international boundaries. Migration is commonly represented as a slow and unidirectional process resulting in permanent resettlement. However, modern population dynamics alter those concepts. Emigration and immigration continue to represent components of those populations that change their place of residence for work or study. Other, often larger, groups of migrants who are not immigrants in the legal or regulatory sense move regionally and internationally for varying periods of time.
Migrants may enter the host country by regular or unofficial means. Regular migrants may arrive for permanent or temporary residency; their international movements are regulated through mechanisms such as identity cards and travel documents (passports, visas and permits). These migrants are granted the rights to cross borders and remain for defined periods of time in a host country. These regulatory processes govern immigrants, refugees, participants in sanctioned humanitarian movements, migrant workers, travellers requiring visas or permits, international students, tourists and those travelling for business purposes. Irregular migrants, lack one or more of the following official authorizations to travel, enter, or reside in a host country. Irregular migrants are also referred to as illegal immigrants, asylum seekers and refugee claimants in various national jurisdictions, and may include individuals who have been smuggled or trafficked into the country. Irregular migrants also include migrants who were initially admitted legally to a host country, but who overstay their allowed residency period.
Nomads and internally displaced people share many characteristics with other mobile populations, but do not cross international borders. Nevertheless, they too may have health needs with implications for foreign policy. Together, these new patterns of population mobility influence and challenge existing international foreign policies relating to trade, economics and security.8-10
The health of migrants and non-migrants alike is influenced by determinants including genetics and biological factors, socioeconomic status, environmental exposure, and behaviour. Migrants may also display health characteristics that result from risks present in their country of origin or arising from the migration process itself.11 Health-care services at transit and destination locations can also be influenced by migration. Such services may experience high demand due to numbers of migrants, or due to migrants having different diseases or disease presentation in comparison to the host population. For diseases of public health significance, migrants may represent vectors for introduced and transmitted diseases in the host country.
Past approaches to migrant health
International mobility is central to the globalization of infectious and chronic diseases.12 Despite the paucity of globally cohesive foreign policy in this area, the history of health and foreign policy reflects long-term links to migration issues. Underlying health threats associated with international population movements have driven the development of national and international border control health policies. These policies reflect the volumes and diversities of populations moving between countries and regions with wide disparities in disease risk and prevalence.
Fear of imported diseases and their local consequences has historically been tempered by outward demands for trade, economy, exploration, exploitation and conquest. Even before the concepts of germ theory and transmissible diseases were properly understood, foreign-born migrants, returning traders, explorers, and military forces were perceived as potential public health threats. Greek, Roman and biblical literature is rife with descriptions of plagues and pestilence. Cyclic epidemics of leprosy, syphilis, cholera, smallpox, plague and typhus shaped European history, and consequentially regional foreign policy in relation to trade and health protection.13,14
International commercial activity has long been associated with the spread of infectious disease. The principles of quarantine emerged from the busiest shipping ports of 14th-century Italy, where initial border control measures centred on inspection and exclusion of goods, vessels and people with the aim of protecting inhabitants from imported plagues. As international health threats emerge, some countries are again augmenting their quarantine functions, reaffirming the port authorities' principles and practices of centuries ago. The operational challenges of addressing global public health threats at borders belies the reality of mass movements bridging international regions with marked health disparities over ever-shorter time periods. Even if effective medical screening at international borders were possible today, the shortest-incubating virulent disease of public health concern can be carried over a border before being clinically expressed.15
Border health practices can disrupt the trans-border flow of people and goods. The first international regulations on maritime sanitation resulted from meetings of 12 European countries in Paris in 1851. The discussions on maritime regulation in Europe evolved from the need to control the importation of Asiatic cholera and regional disease outbreaks that had re-emerged in 1832. These meetings produced accords reflecting the conflict between protecting human health and promoting commerce. The need to maximize health protection while minimizing interference with international trade became the guiding principles of the International Health Regulations (IHR)16 that originated from these first maritime sanitation regulations. The 2005 revision of the IHR retains the principles of quarantine, but also recommends early international notification and national infrastructure support to control outbreaks that could affect global public health.
The management of infectious diseases and advances in infection control practices prompted Surgeon General William Stewart of the United States Public Health Service to declare in 1969 that it was "time to close the book on infectious diseases". However, the international threat of infectious diseases still exists and persists through migration. By the early 1990s, emerging and re-emerging infectious diseases were once again established as credible public health threats.16 Plague in India,17 Ebola in central Africa18 and cholera in the Americas19 underscored the pandemic potential of regionally endemic diseases.
In what could be seen as a policy paradigm shift, the UN Millennium Development Goals20 linked local socioeconomic action (addressing education, poverty, hunger, gender equality, empowerment of women and development) directly to specific health outcomes. These health outcomes include improving maternal and child health and reducing the prevalence of human immunodeficiency virus (HIV), malaria and tuberculosis. At the same time, severe acute respiratory syndrome (SARS) in 2003,21 avian influenza22 and other infectious disease outbreaks23 have fuelled public, political and economic pressure for improved global management capacity for future epidemics of contagious diseases. Consequently, infectious diseases have returned as the leading concern in global public health. This focus has potentially detracted from the Millennium Development Goals' broader policy scope by diverting attention, resources and efforts away from existing health issues and towards global infectious disease threats. Nevertheless, the paradigm shift led by the Millennium Development Goals towards chronic and non-contagious disease issues continues to evolve to include other non-infectious disease risks of global public health importance.24,25
Migration policy implications
Modern migration is fuelled by pre-existing social, political and economic considerations, as well as by discrete environmental and political events, including disasters and humanitarian crises. Movements between different health environments in the past involved fewer migrants and slower transportation. The years 1950 through 2000 brought significant changes in international migration patterns. The end of the Second World War, the collapse of former European empires, conflicts in Africa and south-east Asia and the fragmentation of the former Soviet Union have been associated with large international migratory flows. These movements have involved increasingly diverse populations moving more quickly between source countries and receiving countries with often disparate social and physical environments. These temporary migrant populations and migrants who make multiple trips between host destinations and their countries of birth or former residency are increasing national-level foreign policy pressures in both source and receiving countries.
The volumes and diversity of migrants challenge current international policies. Efforts have been made to bridge the policy gaps between migration and economic outcomes, labour-force movements and international humanitarian issues.26-28 However, policy-makers have failed to address migration with respect to health and the boundaries of disparity through which migration occurs. At the national level, many migrant-receiving countries lack integrated migration and health policies and are unable to address these complex challenges. Issues that would benefit from a united approach include labour-market demand, family reunification and access to social welfare programmes, including health and education. Policies to date have been unable to address the risk of imported diseases and the additional impacts that migrants may have on health and social services.
Few existing international conventions mention migration and health. Those that do are limited in scope to the needs of extremely high-risk populations, including smuggled or trafficked persons and child slave labourers.29,30 Ratification and codification of these conventions in national legislation and their international enforcement remain variable and inadequate.
Communicable and noncommunicable disease control remains a foreign policy challenge at international and national levels. For example, immigrant medical screening programmes may be ill-equipped to identify and track significant public health concerns in arriving migrants, including chronic infectious diseases.31 Such programmes should be regularly reviewed and updated. Infectious diseases of international importance that are associated with mobile populations, such as SARS and pandemic influenza, demand effective policy and programme interventions.
Unfortunately, difficulties exist in timely programme implementation to counter new diseases among international travellers in terms of screening, reporting, notification and disease control. An integrated approach to foreign policy in health, trade, labour and security is needed to prevent diseases of public health concern from transmission via international travel. Existing public health emergency preparedness policies that address migration and global health are commonly based on medical screening and exclusionary measures whose limitations have been noted.32 Retrospective examinations of these approaches' effectiveness have focused on smallpox,33 a disease that was eradicated before the current dynamics of travel. The foreign policy implications of interventions such as national or regional mass quarantine are significant, given countries' current interdependency in relation to security, commerce and travel.34
Managing the migration of those with legal access rights, as well as the unpredictable movements of asylum-seekers and irregular migrants, poses significant policy challenges. Irregular migrant workers warrant specific foreign policy attention, given increasing flows of long-term and short-term migrants from resource-poor countries fuelling the labour needs of established and emerging economies. The new economies' growth attracts migrant workers to new destination regions, unlike those of past decades in North America, western Europe and Australia. Asia is now the workplace of 40% of the global migrant labour force. Over half of the 2.6 to 2.9 million migrant workers come from south Asia; the majority of the others originate in Indonesia and the Philippines.35 Mass movements to fill labour demands pose health, security and economic challenges.
Gender-sensitive foreign policies are required for female migrants, who are rapidly outnumbering male migrants across all labour sectors. Female migrants are over-represented in sectors associated with increased vulnerability, such as domestic services and the sex trade. Women's health issues are also interdependent with foreign policy, particularly in receiving countries that attract a greater number of female migrant workers because of opportunities to earn higher wages.36 A disproportionate number of female migrant workers are trafficked or smuggled, and many subsequently become enslaved. Whereas foreign policy has frequently neglected the rights and health of these women and other irregular migrants, policy-makers at the United Nations level have sought to raise greater awareness of the consequences of human smuggling and trafficking. Individual countries like the United States are now shifting their approach towards the punishment of traffickers, not their victims.37,38
The emigration of health-care workers from resource-poor countries merits special policy consideration. Managed migration policies in resource-poor countries favour immigration applications from well-educated and skilled workers. This approach facilitates an exodus of health professionals, contributing to a profound deficit of health-care workers in some regions.39 Monetary remittances from diaspora communities cannot counteract the double burden of regional disparities in health-care resources and in health needs. In Africa, the paucity of health-care professionals is a perpetuating factor in the HIV/AIDS (acquired immunodeficiency syndrome) pandemic. To mitigate their contributions to the human health-worker crisis, some resource-rich countries have entered into bilateral agreements with resource-poor countries to provide short-term relief workers, retain existing health-care workers and improve their training. An example is the United Kingdom's Department of Foreign and International Development's Emergency Human Resources Programme in Malawi.40 Some countries, such as Australia, Canada and the United Kingdom, are attempting to codify and apply more ethical international recruitment standards while they augment their own health professional complement. Yet migration programmes like the United States' H-1C visa program, the Shortage Occupations List in the United Kingdom and the Migration Occupations in Demand List in Australia continue to facilitate health professionals' emigration from resource-poor countries.41
Health and foreign policy trends
As migration health becomes a public health priority in migrant-receiving countries,42,43 migration can be expected to promote increased dialogue and policy at the international level. The Global Commission on International Migration and a high-level dialogue at the UN in September 2006 called for a collaborative global response to the challenges of migration.44 In its 2005 report, the commission noted that " ... the international community has failed to realize the full potential of migration and has not risen to the many opportunities and challenges it presents".45 Although migration has long been the purview of national policy, the commission urged a cohesive and collaborative international response to this phenomenon. The report set out principles for action to facilitate national efforts at global collaboration, but it failed to set out objectives relating to health, conceding, "... the report does not look in any detail at the psychological and health dimensions of the issue".
International social inequality and health disparity are significant policy challenges. As migrants bridge these issues between economically disadvantaged and advantaged areas, there are greater demands to develop effective and ethical foreign policy tools. Despite the limited focus on developing policies that address the health dimensions of migration, several small-scale initiatives have pioneered approaches to the management of health disparities in migrant populations. One example is a United States project that targeted a group of refugees for mass treatment of selected infectious diseases, achieving modest reductions in morbidity and mortality.46 This project demonstrated a secondary benefit for the refugee-receiving country by lessening the impact on health services.
Few programmes target pre-arrival health promotion or non-infectious disease prevention in mobile populations. Existing migrant-specific policies and programmes do not address maternal and child health, malnutrition, environmental health, chronic diseases, mental health needs or other conditions potentially amenable to early intervention and health promotion for disease prevention.
At the regional level, the European Union has guaranteed access to health services for migrant populations; however, European countries' commitment to migrant health-care rights is largely limited to emergency care.47 WHO has identified numerous international human rights policies that could be used to inform national and international programmes involved in delivering health care to mobile populations in migrant-receiving countries. These include universally applicable UN human rights instruments, International Labour Organization Conventions protecting migrant workers' rights and policy commitments articulated at global conferences on development, gender issues and racism.48 Whereas these policies assert migrants' rights to access health care that is sensitive to the migrant's culture, language, gender, race and ethnicity, existing mechanisms can neither enforce accountability of UN Member States, nor require ratification in signatory countries.
With the exception of the European Union, policy-makers at the national, regional and international levels have yet to develop foreign policies in health and migration. The existing international instruments do not provide clear guidance regarding the scope or duration of health services for migrants. In a globalized and ever more integrated world there remains a need for a collaborative global approach to health and foreign policy that extends beyond the traditional interventions.
Conclusion
Meeting health challenges through international cooperation and collaboration has become an important foreign policy component in many countries, as well as for WHO. Considerable attention is directed towards the containment of global disease threats of international importance. Significant international investment has been directed at infectious diseases such as malaria, tuberculosis and HIV/AIDS. Migration and population mobility play a role in each public health challenge. Although some national and regional project initiatives are directed towards health and migration, an integrated and globally focused approach has not yet developed. Migration and population mobility are increasingly important health determinants and require greater multilateral policy attention. 
Competing interests: None declared.
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(Submitted: 27 September 2006 - Final revised version received: 28 December 2006 - Accepted: 2 January 2007)
1 Correspondence to Douglas W MacPherson (email: douglaswmacpherson@migrationhealth.com).