By Prof. Ibrahim Abubakar, FRCP; Robert W. Aldridge, PhD; Delan Devakumar, PhD; Miriam Orcutt, MSc; Rachel Burns, MSc; Prof. Mauricio L. Barreto, MD; et al.
The Lancet, December 5, 2018
From the Executive Summary
With one billion people on the move or having moved in 2018, migration is a global reality, which has also become a political lightning rod. Although estimates indicate that the majority of global migration occurs within low-income and middle-income countries (LMICs), the most prominent dialogue focuses almost exclusively on migration from LMICs to high-income countries (HICs). Nowadays, populist discourse demonises the very same individuals who uphold economies, bolster social services, and contribute to health services in both origin and destination locations. Those in positions of political and economic power continue to restrict or publicly condemn migration to promote their own interests. Meanwhile nationalist movements assert so-called cultural sovereignty by delineating an us versus them rhetoric, creating a moral emergency.
In response to these issues, the UCL-Lancet Commission on Migration and Health was convened to articulate evidence-based approaches to inform public discourse and policy. The Commission undertook analyses and consulted widely, with diverse international evidence and expertise spanning sociology, politics, public health science, law, humanitarianism, and anthropology. The result of this work is a report that aims to be a call to action for civil society, health leaders, academics, and policy makers to maximise the benefits and reduce the costs of migration on health locally and globally. The outputs of our work relate to five overarching goals that we thread throughout the report.
First, we provide the latest evidence on migration and health outcomes. This evidence challenges common myths and highlights the diversity, dynamics, and benefits of modern migration and how it relates to population and individual health.
Second, we examine multisector determinants of health and consider the implication of the current sector-siloed approaches.
Third, we critically review key challenges to healthy migration. Population mobility provides economic, social, and cultural dividends for those who migrate and their host communities. Furthermore, the right to the highest attainable standard of health, regardless of location or migration status, is enshrined in numerous human rights instruments. However, national sovereignty concerns overshadow these benefits and legal norms.
Fourth, we examine equity in access to health and health services and offer evidence-based solutions to improve the health of migrants. Migrants should be explicitly included in universal health coverage commitments.
Finally, we look ahead to outline how our evidence can contribute to synergistic and equitable health, social, and economic policies, and feasible strategies to inform and inspire action by migrants, policy makers, and civil society. We conclude that migration should be treated as a central feature of 21st century health and development.
From the Conclusion
Migration should be urgently treated as a core determinant of health and wellbeing and addressed as a global health priority of the 21st century. Migration and global health are both defining issues of our time. How the world addresses human mobility will determine public health and social cohesion for decades to come. Our work for this Commission aimed to provide robust evidence on migration and health to examine the structures, systems, and contexts at the intersection of human mobility and individual and population health. By systematically presenting evidence on what is known about health and migration, it has been our intention to dispel populist myths about a perceived “other” and to suggest promising strategies for a highly mobile world. Amid international dialogues about safer, healthier migration, substantial gains can be achieved towards multiple SDGs (Sustainable Development Goals) by resisting the turbulence of nationalist xenophobic discourse.
In summary, our findings highlight that modern migration is a diverse and dynamic phenomenon, and the health of people who migrate generally reflects the circumstances of migration. Our evidence indicates that, with sufficient political will, the international community, states, and local providers have the knowledge and resources necessary to ensure that individuals who are most vulnerable to harm are not health-marginalised. But, at the same time, our findings suggest that attitudes, misperceptions, and cynical political motivations can hinder rights-based approaches to health for migrants, especially for people seeking safety and economic security for themselves and their family. We must ensure that a migrant’s equal right to health is respected and implemented.
Our multiple analyses also contradict myths about who is migrating where and the health burden of migration on recipient locations. Data for migration tell us that more people from LMICs are migrating within their own countries and region than across HIC borders, even if vocal political rhetoric implies otherwise. Additionally, migrants are, on average, healthier, better educated, and employed at higher rates than individuals in destination locations. However, many men and women who migrate are subjected to laws, restrictions, and discrimination that put them at risk of ill health. Particular mobile subgroups are especially likely to be exposed to migration-related harm and excluded from care, such as trafficking victims, irregular migrants, low wage workers, and asylum seekers. These highly vulnerable migrant subgroups are also frequently individuals who have been forced to move because of global economic and political forces well beyond their control. These global economic and political forces also apply to the populations left behind, when family members migrate for work or groups who are unable to flee from conflict areas or environmental dangers. The evidence indicates that through targeted rights-based laws; inclusive, migrant-friendly health systems; and mobile medical services, it is possible to reduce migration-related risks and increase peoples’ access and use of health services. Migration-informed laws, services, and public perceptions can increase determinants of good health. These determinants include social inclusion, safe employment with fair wages, good nutrition, decent housing and hygiene, and universally accessible health systems that do not result in potentially catastrophic costs for families.
Moreover, multiple opportunities exist to intervene to address health throughout the phases of a migrant’s journey. We believe that now is the time to call on our humanity and to take advantage of worldwide mobility to secure global health, especially for migrant groups who are most at risk of exclusion. We have the evidence, tools, and potential international political will via the UN Global Compact for Migration and the Global Compact on Refugees, and the SDGs.
The Commissioners have reviewed a mass of data collected by researchers from around the world. These data describe the scale and nature of migration and the many threats to the health of men and women and their families who are migrating. However, it is impossible to capture the entire distressing picture on the pages of a scientific journal. That would require the many individual accounts of tragedy, of children drowning in parents’ arms or dying by the wayside, or of individual heroism of people who risk their own lives to rescue them. For such stark realities, we can look to the few journalists and humanitarian organisations who have recorded these accounts, such as the now unforgettable picture of the lifeless body of Alan Kurdi being lifted from a Turkish beach. Anyone viewing these images should surely ask why the international community has done so little to live up to its commitments to advance the health of migrating populations, and especially individuals who have been forced to migrate. How can we explain this inertia?
There are no simple answers to these questions, but one indisputable reality is that, in the discourse on migration, health is far down the list of priorities. International meetings on migration are instead dominated by other considerations, such as domestic politics, national security, international trade, and commerce—especially when politicians ruthlessly exploit migration for their own purposes. These considerations almost always take precedence over the health needs of migrants. Indeed, if health is discussed at all, it is often unjustifiably framed as the migrant posing a threat to the population in the destination country, either as a vector for infections or a terrorist risk. Health and migration have competing, if not conflicting, policy goals. Health goals are inclusive (eg, better health for all, the Hippocratic oath) and international migration policy goals are exclusionary (secure borders, national trade). The other key challenges include financial issues and leadership.
Investing in the health of populations and individuals is generally an expensive long-term commitment, such as providing medical services over lifetimes. However, for state budgets, protecting borders and arranging deportation can seem a lesser investment for greater political gain often contrary to the more positive actual and perceived contributions of migrants by the public. Health leadership in the realm of migration policy making often seems to be considered as less important than other policy interests. Why are health leaders absent from the top table, engaging proactively in high level debates on migration? Instead, the health sector is often left to pick up the pieces of migration policies that leave the lives of migrants in tatters. Additionally, because the health sector will remain dedicated to these humanitarian ideals, policy makers can continue to prioritise security, exclusion, and trade, while discriminatory rhetoric re-enforces the neglect and abuse of migrants. A second, much simpler question is why do some migrants have better health and health services than others? The answer is quite obviously related to the individual’s social and economic status and the power this wields. Therefore, perhaps the greatest challenge to achieving health equity for disadvantaged migrating populations will be promoting rights and empowerment that enable individuals to assert their own rights to health.
Comment:
By Don McCanne, M.D.
Immigration and health are two often interrelated issues that appropriately command much attention, not only from political leaders but also by the public at large in nations throughout the world and especially here in the United States. The University College London-Lancet Commission on Migration and Health has provided us with a report that casts much needed light on the issues, providing an objective basis for discourse as we move forward with addressing the problems presented.
Leaders of other nations reading this report must be perplexed by the policy discussions in the United States. Here we spend far more money per capita on health care than any other nation, and yet we fall far short on access, equity and outcomes. Yet much of our political dialogue is on “the wall” – a physical barrier between the United States and Mexico that is irrational, expensive and not particular effective, but, worse, is not based the least on an understanding of the truth about migration and its social and moral ramifications.
What is particularly ironic is that we already understand the policy principles that would establish a firm foundation for beginning to address the problematic health hallmarks of immigration. Those principles are found in another hot political topic of today – Single Payer Medicare for All. Under such a program, all residents, including immigrants, receive the health care that they need, and all contribute their fair share into the system, including the immigrants as they are melded into our economy.
So simple. So why do we have to keep hearing about the wall? Any why does President Trump continue to listen to Stephen Miller?
Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.