National and international migration
According to the International Organization for Migration (IOM), a migrant is a “person who is moving or has moved across an international border or within a State away from his/her habitual place of residence, regardless of (a) the person’s legal status; (b) whether the movement is voluntary or involuntary; (c) what the causes for the movement are; or (d) what the length of the stay is” (). The term encompasses a wide array of categories. This chapter is oriented to present the health challenges faced by migrants and their host communities, emphasizing the special challenges faced by irregular and forced migrants who, because of their situation, are in conditions of high vulnerability ().
Migrations are often prompted by, and in turn can lead to, many situations of insecurity. Economic deprivation, disease outbreaks, food insecurity, environmental hazards, political and religious persecution, family separation, and gender, sex, and ethnic discrimination constitute several of the factors that may give rise to massive migration flows and affect the health of migrants during their migration path. These factors often place migrants at higher risk for occupational injuries, violence (including sexual violence), drug abuse, mental health disorders, tuberculosis, HIV/AIDS, and other infectious diseases (). In addition, there may be barriers to accessing health services, including restrictive policies and laws, high costs, language and cultural differences, stigma, and discrimination.
The social, economic, environmental, and political context within which migration takes place in the Americas is dynamic, presenting new challenges and opportunities in the health field that can help facilitate a dignified and safe migration process. This section examines health determinants and conditions of migration and health matters associated with migration in the Americas. It also examines global, regional, and national policy responses and proposes a path for the future to ensure the health of migrants and their host communities in the Americas.
Migration trends in the Americas
Migration is not a new phenomenon, despite its seemingly sudden rise to global attention. The movement of people, whether within country borders or across international borders, has been occurring for centuries and has recently become a major feature of globalization.
Figure 1. Total male and female international migrant stock in Latin America and the Caribbean (LAC) and Northern America in 2015 ()
In the Americas, the number of people who migrated across international borders surged by 36% in the last 15 years, to reach 63.7 million in 2015; of those, 808,000 were defined as refugees (see Figure 1). About 15.2% of the population of Northern America (Canada and the United States) and 1.5% of the population of Latin America and the Caribbean (LAC) are international migrants. Approximately 39% of this population in LAC and 26% in Northern America are 29 years old or younger and about 51% are females (see population pyramids in Figure 2). Forced migrants within country borders account for an estimated 7.1 million people, of whom 6.9 million are in Colombia (). Most LAC members are primary sources of emigration to northern high-income countries in America and Europe. Table 1 lists the top 10 emigration countries in LAC. Despite these flows from lower- to higher-income countries, migration between low- and medium-income countries and from higher- to lower-income countries has increased recently (). In addition, LAC has been experiencing a significant increase in extraregional irregular migrants. For example, according to IOM, Costa Rica experienced an inflow of over 5,600 irregular migrants between April and August 2016, primarily from Haiti and African and Asian countries ().
Table 1. Top 10 LAC countries for emigration in 2015 ()
|Home country||Number of people that emigrated||Proportion of people that emigrated from the total home country population|
According to IOM (), the Americas are characterized by four migration-related trends: a steady flow of returnees due to economic crises and inhospitable social settings in high-income countries; the receipt of remittances from migrants in high-income countries as an important source of income for several LAC countries; the trafficking in persons and smuggling of migrants; and the contribution of LAC communities in the United States, Canada, and Europe to the development of cultural, economic, and social ties with their countries and communities of origin.
Figure 2. International migrant stock by age and sex in LAC and Northern America in 2015 ()
The right to health of migrants and other related human rights in the Americas
The Universal Declaration of Human Rights proclaims that “all human beings are born free and equal in dignity and rights,” that every person is entitled to all human rights and fundamental freedoms, and that all persons “have the right to freedom of movement and residence within the borders of each State [and] the right to leave any country, including his own, and to return to his country” (). The Constitution of the World Health Organization (WHO) also clearly supports the right to health: “The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition” (). This right applies to all persons, wherever they are and regardless of their migration status.
According to the Office of the United Nations High Commissioner for Human Rights, there are 27 international legal instruments relevant to migration and human rights (). In particular, the International Convention on the Protection of the Rights of All Migrant Workers and Members of Their Families of 1990 () has been increasingly recognized and prominently reflected in the international agenda. As States Parties of the Convention, 18 governments of the Americas have acknowledged the need to integrate health needs and the vulnerability of migrant workers into their national plans, policies, and strategies. Accordingly, these governments have demonstrated a heightened appreciation for the development of health programs and policies that address health inequities and improve access to health facilities, goods, and services. It is important to note that migrant destination countries such as Brazil, Canada, the Dominican Republic, and the United States have yet to take action on the Convention.
In the Americas, the 59th Session of the Executive Committee of PAHO in 1968 began to discuss the relationship between health and international human rights instruments in the context of the technical cooperation that PAHO provides to its Member States (). In 2007, ministers and secretaries of health of the Americas underscored their commitment to the aforementioned international principle in the Health Agenda for the Americas (2008–2017). In doing so, they placed human rights among this instrument’s principles and values and reconfirmed the importance of ensuring the highest attainable standard of health by stating, “In order to make this right a reality, the countries should work toward achieving universality, access, integrity, quality and inclusion in health systems that are available for individuals, families, and communities” (). In 2010, the 50th Directing Council of PAHO agreed to work to improve access to health care for groups in conditions of vulnerability, including migrants, by promoting and monitoring compliance with international human rights treaties and standards ().
Social determinants of health of migrants in the Americas
Migration is regarded as a social determinant of health since the health of migrants is determined primarily by the conditions along the migration path. As illustrated in Figure 3, the health of migrants can vary according to personal characteristics, individual and relational factors, social and community influences, living conditions, and general socioeconomic, cultural, and environmental conditions (). In particular, irregular and forced migrants may travel to destination communities in precarious conditions. For example, many irregular migrants from Central America ride atop moving cargo trains colloquially known as La Bestia, or the beast, on their journey across Mexico to the United States. Along the trip they face physical dangers including amputation and death. In addition, they are subject to extortion and violence at the hands of gangs and organized-crime groups ().
Figure 3. Risk factors associated with migration at the individual, relational, community, and social levels of the ecological model ()
Migrants work in some of the riskiest industries in their destination communities, including agriculture, forestry, fishing, and construction. These types of work have higher rates of injury and fatality compared with other sectors. Migrant farmworkers are also more exposed to pesticides and their associated health risks. Moreover, their housing is associated with unsafe drinking water; crowding; substandard and unsafe heating, cooking, and electrical systems; inadequate sanitation; dilapidated structures; and food insecurity. For example, it is estimated that more than half of the migrant farmworker households in the United States suffer from food insecurity due to their limited access to transportation, food storage, and cooking facilities ().
Migration can also affect the health and well-being of family members who stay in the communities of origin by impacting on remittances and “brain drain” (i.e., the migration of educated workers to higher paying countries). On the one hand, remittances can improve the economic conditions of remittance-receiving households in communities of origin and can have a positive effect on their health and well-being. Households receiving remittances have improved human development outcomes including better access to health services, less crime, and better education. For example, a study in Nicaragua showed that about 48% of remittances are used to pay for health services, 27% for home improvement, 15% for education, and 10% for savings (). In 2014, there was an inward remittance flow of US$ 63.6 billion into LAC countries, with the top remittance recipients being Haiti (22.7% of gross domestic product, or GDP), Honduras (17.4% of GDP), EI Salvador (16.8% of GDP), and Jamaica (16.3% of GDP). On the other hand, family separation may lead to negative effects regarding health and well-being, including psychological trauma, material hardship, residential instability, and family dissolution. Moreover, remittances may generate tensions and inequalities between remittance-receiving households and households that do not receive them (). In addition, communities of origin can find themselves at risk of a “brain drain” of talent, depriving them of trained workers in key sectors of their economy ().
Migrants’ access to health services
Migrants, and in particular irregular and forced migrants, often have limited access to appropriate health services and financial protection for health. WHO reports that globally, migrant health needs are not addressed consistently and access to health services in recipient countries remains highly variable ().
Factors associated with health policies and the organization of health systems can constitute formal barriers to accessing health services. These include legal restrictions on entitlements to health services and financial barriers to irregular and forced migrants. In several countries in the Americas, only emergency and limited private charity health services are available to these migrants. For example, exclusionary policies and treatment resulted in limited health care service accessibility for male Latino migrant workers in North Carolina, U.S.A. (). User fees can also be seen as a formal barrier, creating inequality in access due to migrants’ limited financial means.
Inadequate health literacy, language differences, sociocultural factors, stigma, and perceptions of the health system may constitute informal barriers to access to health services (). Health beliefs and health-seeking behavior of migrant groups may be different from the host communities because of their needs and differences in social norms, culture, and organization of health systems in communities of origin. For example, a study of a shelter in Monterrey, Mexico, with migrants primarily from Central America, shows that migrants avoided public health services due to the need to work in order to survive and the constant fear of being traced (). In these situations, health education is often regarded as a solution that can improve health literacy and help migrants acquire the skills they need to maneuver in their new health system. Health education programs for migrant groups need to be appropriately targeted to reach them more effectively (). Limited proficiency in the host community language can also present a significant obstacle to accessing health services. For example, an analysis of U.S. Behavioral Risk Factor Surveillance System data from 2003 and 2005 showed that Spanish-speaking Hispanics reported far worse access to care than English-speaking Hispanics (). To the extent possible, patient information on health issues should be provided in whatever languages are necessary to reach potential users of health care services. In addition, health service providers should be trained on cultural sensitivity and appropriateness. Furthermore, limited understanding of the patient’s social norms and culture may also present an obstacle. For this reason, the role of the translator should include cultural mediation. Migrants may also be reluctant to make use of services because of stigma or anxieties about reactions within their own community. Mental health, for instance, is often stigmatized in migrant communities. For example, the perceived discrimination and the experience of humiliation have contributed to poor mental health and limited access to health services among Haitian migrants in the Dominican Republic (). Reproductive health, sexuality, pregnancy, and childbirth are sensitive topics that people may find difficult to discuss with a stranger. Often, one of the elements that helps overcome informal barriers to accessing health services is trust. Clients need to be confident that they will be treated with respect and receive appropriate and relevant services.
Areas of concern for migrant health
Health along international borders
International border areas are geographical spaces in which residents, regardless of which country they live in, share risks and protective factors that generate a health profile that is often different from that of populations in the rest of their country’s national territory (). Border communities can also be impacted by forced migratory movements including people displaced by war, sudden environmental events, violence, and political or financial crises (). Border population groups in conditions of vulnerability may also include indigenous groups whose conception of the land may give them a different recognition of country borders from that of the dominant population (). In other cases, border areas are poles of economic development that generate disorganized urban growth where basic services are limited (). Moreover, border communities tend to be distant from the national political center of the country and therefore have little influence on decision-making and the allocation of resources ().
The nature of cross-border political cooperation that exists can influence the health situation of the border population, and at the same time, it can determine how the countries and their respective border populations organize themselves to respond jointly to their health needs. For border areas in which the relationship is one of merely coexistence or even confrontation between countries, looking after health issues may foster understanding between them. For example, in 2012 Paraguay was politically suspended from regional country integration systems but continued participating in health projects. This shows that joint work on health activities can overcome political barriers, serving to tie neighboring nations together (). For border areas in which the relationship is one of interdependence between countries, there is a mutual interest in improving health conditions. However, in several cases, such interdependence may be asymmetrical. For example, there has been a financial asymmetry in environmental health collaboration between the United States and Mexico along the border. Most funds available for border programs have been provided by the U.S. Environmental Protection Agency, enabling this agency to have more control over the program agenda (). For borders where relationships are more integrated, the countries and their border communities make maximum use of existing resources (); examples include portable health insurance for border communities between Uruguay and Brazil (), health services shared between Ecuador and Peru (), and joint delivery of emergency health services between Chile and Argentina ().
Health interventions in border areas may create tensions between the national government and its border communities. On the one hand, border communities feel a need to resolve concrete issues in a space that is influenced by—and to some degree shared with—another country (). On the other hand, national governments have a constitutional mandate to safeguard national sovereignty (). Therefore, striking a balance between national and local interests is crucial when designing and implementing health interventions in border communities ().
Defining health priorities is one of the greatest challenges of cross-border cooperation since it must respond to the needs and assets of two or more countries. One criterion may be tackling health issues that are causing or may cause conflict between neighboring countries, such as the origin of an infectious disease in one country that could affect people, productivity, or trade in a neighboring country, or the use of the health services by residents of one country in a neighboring country, incurring additional costs to the latter’s health system (). Another criterion may be managing health issues that cannot be resolved without a binational approach. This frequently applies to vector-borne diseases and environmental contamination. A third criterion may be the interest of academic researchers, since border populations can become unique public health laboratories ().
Structures and mechanisms to address border health issues may be official or unofficial. For the former, the predominant actors are national and subnational governments including local governments in the countries that share the border (). Generally, the higher the public institutional level of participation, the better organized the structures or mechanisms, and the more long-term oriented their objectives are (, , ). However, they may also be more political, be slower to act, be less sensitive to the perceived needs and assets of border communities, and have more problems addressing issues on which the countries do not agree (). The opposite is seen when unofficial structures and mechanisms such as academic, private, or community-based institutions play the central role (, ). They often are more technical and have a more limited sphere of work and a shorter-term vision. They also tend to be transient or with limited sustainability. Many border areas address health issues through both mechanisms. For example, health issues in the United States—Mexico border area are addressed through formal national and state-level structures through the United States—Mexico Border Health Commission or more informal structures through binational health councils that are part of sister city arrangements ().
Depending on their objectives, the structures and mechanisms can be temporary or permanent. Countries in the Americas have developed structures and mechanisms to attend to border health issues that encompass the types mentioned, from short-term specific projects, to medium-scope programs, to permanent binational commissions (). The latter have been developed primarily for cases in which the needs of border communities have been made a national priority and placed at the highest level of the political agenda.
Humanitarian health assistance
Globally, about 201 million people were affected by disasters and conflicts in 2014, of which 141 million endured sudden environmental events and 60 million were forcibly displaced by violence (). In the Americas, the Inter-Agency Standing Committee (IASC) () estimates indicate that Haiti, Colombia, and Guatemala have the highest risks for humanitarian crises and disasters. According to the Office of the United Nations High Commissioner for Refugees (UNHCR) (), there was a five-fold increase in asylum-seekers from El Salvador, Guatemala, and Honduras, primarily of unaccompanied children, from 2012 through 2015. In addition, even as it strives to resolve decades of conflict, Colombia reported about 6.9 million internally displaced people.
In 2016, PAHO reported giving critical support to several Member States that have faced unexpected migrant flows, including 171,000 Venezuelan migrants in Colombia between October 2015 and May 2016; over 5,000 Cuban nationals who traveled through Ecuador, apparently intending to continue northward towards the United States but instead found themselves stranded in Central America in late 2015; and approximately 100,000 Haitians who were repatriated in 2015 from the Dominican Republic ().
A special concern during humanitarian crises is the need for adequate basic health services and sanitation in shelters and settlements. For example, in Colombia, even though 75% of the internally displaced people were affiliated with the national social security program in 2014, only 32% had access to health services. (Of those, 38% were males and 62% were females.) Barriers to health services include limited infrastructure, technology, and human resources in rural areas (). The low vaccination rate among Venezuelan migrants in Colombia also caused concern about a potential change in the host population’s health profile. Another major health concern was the increased risk of cholera outbreaks among deported migrants in the Haiti–Dominican Republic border area ().
Finally, the impacts of climate change—primarily on Small Island Developing States such as the ones in the Caribbean, and on indigenous communities–have led to discussions about decision-making regarding the potential need to migrate (). Climate-induced migration may cause forced displacement from rural to urban areas and from one country to another. The range and extent of health risks associated with future climaterelated population movements cannot be clearly foreseen. However, the evidence of movements of people due to similar situations indicates that health risks will predominate over health benefits ().
Migrant workers’ health
Current levels of human mobility have created serious challenges for migrant workers, becoming a political priority at national and supranational levels. Despite several migrant-specific instruments adopted by the International Labour Organization (ILO) during the past seven decades (Conventions No. 97, 86, and 143, and Recommendation No. 151) (), the dignity and rights of migrant workers are threatened because of limited national labor protection regulations and enforcement.
In 2014, the Fair Migration Agenda was adopted after the UN General Assembly High-Level Dialogue on International Migration and Development (). The Agenda seeks to make migration a choice and not a need by pursuing decent work opportunities in the countries of origin. It also aims to ensure fair recruitment and equal treatment of migrant workers by promoting bilateral agreements for well-regulated and fair migration between countries, countering unacceptable situations, and contributing to a strengthening of the multilateral rights-based agenda on migration.
According to the ILO (), in 2013 there were 150.3 million migrant workers worldwide (55.7% males and 44.3% females). They represented 4.4% of the global work force. The majority of international migrant workers were in high-income countries, about 24.7% in North America and only 2.9% in LAC, accounting for 20.2% and 1.4% of the work force in North America and LAC, respectively. They were concentrated in certain economic sectors, primarily in services (71.1%), industries including manufacturing and construction (17.8%), and agriculture (11.1%). Domestic service migrant workers represented 7.7% of all international migrant workers (with 73.4% of domestic service migrant workers being females) and were concentrated in high-income countries.
ILO estimates that in 2015 migrant workers sent US$ 601 billion in remittances to their home countries, evidence that their work is a driver for economic development in the countries of origin. At the same time, migrant workers fill labor gaps in countries of destination. Nonetheless, the unequal distribution of types of work, income, benefits, and job opportunities has raised questions of social justice, sustainable development, and health equity ().
Based on the impetus created by the adoption of the 2030 Agenda for Sustainable Development, ILO has developed several instruments for addressing migrant workers’ health rights and equity. For example, the gender equality in labor migration law, policy, and management tool kit () was created to support fair immigration and respect for fundamental rights of women migrant workers, seeking to offer them real opportunities for decent and healthy work.
It is vital that the international community acknowledges the shared global responsibility of developing collective and inclusive action, particularly in the context of the 2030 Agenda for Sustainable Development. Effective actions may include creating more productive and decent work in countries of origin; establishing more dignified, regular, and safer migration processes that meet real labor market needs and facilitate preservation of family units; and placing human rights, including health and labor rights, at the core of all interventions.
Communicable diseases can significantly affect the health and well-being of migrants, and have public health implications due to the potential importation of transmissible pathogens. In the Americas, the spectrum of communicable diseases in migrants may range from diseases that require acute recognition and management (such as malaria) to chronic illnesses with significant public health concerns (such as tuberculosis and HIV/AIDS). The recognition and timely management of infectious diseases in migrants requires knowledge of the geographic context, modes of transmission, and clinical presentation of a wide variety of infectious agents. Many of these infections may be unfamiliar to health care providers in destination communities.
In South America, small-scale gold mining draws people to the Guiana Shield from different countries, known in Brazil as garimpeiros. The Guiana Shield comprises Guyana, Suriname, French Guiana, and parts of Colombia, Brazil, and Venezuela. In 2014, miners in this region represented at least 13% of all malaria cases in the Americas. It is highly likely that the number is even higher due to underreporting, since many miners live solitary lives and try to avoid health facilities. Mining also prompts related movements within country borders, leading to malaria outbreaks. For example, malaria increased from around 21,000 cases in 2010 to over 52,000 in 2014 in the Sifontes municipality of Bolivar State in Venezuela due to an increase in the mining population coming from other parts of the country ().
The importation of cases is a major factor that can inhibit progress being made in the control of outbreaks and can defer elimination of the disease. For example, the district of Candelaria in Campeche State, Mexico, near the Guatemalan border, reported an outbreak of malaria in 2014 although it had had no cases in previous years. A change in migratory patterns was suggested as a possible reason for this outbreak. Malaria in Dajabon in the northwest corner of the Dominican Republic has also been attributed to mobility across the international border between the Dominican Republic and Haiti. This location is known for its binational market that attracts residents from both countries. Since 2005, approximately 2,000 Haitians have entered the Dominican Republic twice weekly to buy and sell their goods. The number of malaria cases reported subsequently increased from approximately 100 in 2005 to about 1,000 in 2007. This number has decreased in recent years (17 cases in 2014) due to focused interventions ().
While the preceding examples highlight how migration has increased the risk of malaria in the Americas, success stories are also present in the region. For example, Suriname’s Ministry of Health has succeeded in reducing the number of malaria cases by improving diagnosis and treatment to miners through trained individuals working in mining areas. Another example is the success story of Costa Rica. Since 2000, the Ministry of Health, in coordination with the private sector and the national health services network, has prevented the introduction of imported cases of malaria in Huetar Atlantica and Huetar Norte despite agricultural developments in these areas that led to an increased risk of malaria due to vector habitat changes and an inflow of migrants seeking work.
Migrants’ risk for becoming infected with or developing active tuberculosis (TB) depends on the TB incidence in their community of origin; living and working conditions in their communities of destination, including their access to health services; whether they have been in contact with an infectious case (including the level of infectiousness and how long they breathed the same air); and the way they travel to the destination countries (with the risk of infection being higher in poorly ventilated spaces). People who live in communities characterized by low levels of education, poor nutrition, inadequate or overcrowded housing, and with poor access to preventive and curative medical services are the most vulnerable to infection. Specifically, recently arrived migrants from endemic countries who often congregate in deprived communities within wealthy cities constitute high-risk groups. Fears of deportation and having contacts traced could prevent individuals from seeking medical assistance. Once in treatment, family support and migrant-sensitive health providers can become key factors facilitating adherence ().
In the Americas, migrant groups are associated with an increase in TB prevalence in low-risk countries. For example, the increase in TB incidence in Costa Rica between 2009 and 2011 was associated, among other factors, with the influx of Nicaraguan migrants. The increase in TB incidence in Chile was also associated with migrants from endemic countries ().
At the national level, migration has also influenced the incidence of TB in destination countries outside of the Americas. For example, Spain has one of the highest incidence rates of TB in Europe with approximately 20 cases annually per 100,000 persons, primarily international migrants. In particular, in Barcelona, the percentage of foreigners with TB increased from 5% to 32% with an incidence rate greater than 100 cases per 100,000 persons per year between 1999 and 2000 (). Studies conducted between 1998 and 2013 revealed that multidrug- resistant TB was 2.5 to 4.0 times more frequent in immigrant populations from Latin America, Eastern Europe, Africa, and Asia than in the native Spanish population. Multidrug resistant TB was diagnosed in 7.8% of immigrant population cases but in only 3.8% of native cases (). Moreover, studies using Spanish national surveillance data between 2004 and 2009 reported that TB was often diagnosed in later stages in migrant populations due to their limited access to quality, migrant-sensitive health services (). About 60% of TB cases in migrants were diagnosed in hospitals and not in primary health care facilities.
Migration can disrupt migrants’ access to HIV services. Barriers include lower and late access to testing and care and fear of discrimination and deportation (). For example, there are documented cases of Central American migrants having their HIV services disrupted when they travel through Mexico to the United States (). According to a cross-sectional study by Leyva-Flores et al. (), the prevalence of HIV among Central American migrants traveling through Mexico was 0.71% between 2009 and 2013 and peaked at 3.45% in the transvestite, transgender, and transsexual community, reflecting the concentrated epidemic in their countries of origin. In addition, it appears that there is a modest positive association between population mobility, measured by the net migration rate, and HIV prevalence in Central America and Mexico when socioeconomic cofactors are included by country (education, health, and income) (). Moreover, male migrants who stayed in border areas were more likely to engage in sex, and have unprotected sex, with female sex workers during their recent stay on the border compared with those in other contexts ().
The mental health of migrants is frequently affected by changes in their lives that result from the process of migration itself, and varies according to how their experience in the new situation and cultural context evolves (). In particular, uncertainty about the future and the process of moving from one cultural setting to another can be stressful, with potentially negative impacts on mental health outcomes ().
The conditions that create forced migration increase psychosocial stress on the individuals and families affected (). Migrants may be exposed to various stress factors in each phase of the migration path, and they experience different challenges during and after migration. These challenges could become risk factors for mental illness. For example, the reasons that cause or promote migration, such as a difficult economic and employment situation in the country of origin, the breakdown of social support, or possible trauma, as well as uncertainty about whether one will be accepted by the new host community or not and about the process of migration itself all have an impact on one’s mental health (). In the post-migration phase, other risk factors have been associated with mental disorders, such as the uncertainty about legal status, employment opportunities or lack thereof, loss of any preexisting social role, uncertainties about family and social support, and the difficulties of learning a new language and culture and adapting to these new norms ().
Many studies have reported that the process of migration can lead to a whole spectrum of mental health disorders, for example, psychoses (), posttraumatic stress disorders (), depression (), and suicidal acts (). Multiple factors and complex interactions will determine post-migration adjustment and the outcome of migration. The evidence of mental health disorders among populations who migrate between or within LAC countries is limited. Only a few studies report an association between natural disasters and mental disorders in the subregion (). Other studies show an increase in psychological issues in migrant children and adults due to political repression in their countries of origin (). On the other hand, there is significant evidence of mental health disorders in people who migrated from LAC to North America ().
While the aforementioned elements can have an impact on all migrants, some social groups may be exposed to additional risk factors that must be taken into account when considering possible psychosocial or mental disorders, in particular for women; children and adolescents; the elderly; lesbian, gay, bisexual, and transsexual (LGBT) people seeking asylum; indigenous populations; and people with mental disorders prior to migrating (). Preexisting mental health conditions can be intensified due to the same requirements of adaptation in short periods of time that many migrants without preexisting conditions experience ().
The assessment of risk for mental health problems includes consideration of pre-migration exposures, stresses, and uncertainty during migration, and post-migration resettlement experiences that influence adaptation and health outcomes. It is important that cultural elements are taken into consideration when assessing physical health and more clearly when dealing with mental health issues by the health system in the host community (). Furthermore, the right to receive pharmacological or psychotherapeutic treatments has to be preserved. Some evidence has been reported of satisfaction of the mental health services among immigrants (), but more research on the effectiveness of these services in immigrant populations is needed. Clinicians need to be aware of the mental health needs of immigrants and the challenges of delivering appropriate care to them ().
Violence is an increasingly important driver of migration in LAC (). According to 2012 estimates (the most recent available), 18 of the 20 countries with the highest homicide rates in the world were located in LAC (see Figure 4 for the top 10). Also, the rate of 23 homicides per 100,000 population for the Region of the Americas was nearly four times the world average (6.2 per 100,000)—higher than the average for the “fragile and conflict-affected” countries as defined by the UN (). Preliminary 2015 data suggest that after the end of a gang truce in 2012, El Salvador may have surpassed Honduras as the most dangerous peacetime country in the world ().
Figure 4. Countries with the highest homicide rates per 100,000 population, 2012 ()
Violence associated with transnational organized crime and gang activity in the Central American “Northern Triangle” (El Salvador, Guatemala, and Honduras) and Mexico has created what the UNHCR calls a “protection crisis,” forcing thousands of women, men, and children to leave their home (). Asylum applications by Northern Triangle migrants in Belize, Costa Rica, Mexico, Nicaragua, and Panama rose by almost 1,200% between 2008 and 2014, and the number of families and unaccompanied minors migrating north from Central America through Mexico towards the United States has risen sharply (). Meanwhile, civil war in Colombia has created the largest internal forced migration in the world (an estimated 6.9 million) (), as well as a large diaspora of refugees in surrounding countries such as Ecuador ().
Violence plays a particularly important role in female migration. A 2015 UNHCR study found that a majority of women interviewed after migrating north out of Central America and Mexico cited violence, including rape, assault, extortion, and death threats, as a primary motivation for leaving their communities; much of this violence was perpetrated by intimate partners, many of whom were involved in gang activity (). Often, women left after local authorities refused or were unable to provide protection. Conflict-related sexual violence has been a persistent feature of the armed conflict in Colombia, and an important reason why many women have been forced to leave their communities ().
While many migrants leave home to escape violence, they often face heightened risk of physical and sexual violence during the journey itself and within destination communities. Women and families migrating north from Central America and Mexico report high levels of extortion, kidnapping, rape, death threats, and abandonment in life-threatening situations along the migratory travel route (). Research in Colombia has documented “pervasive exposure to violence” and vulnerability to physical harm in forced migrant settlements (). In the United States, migrant populations report high levels of certain types of violence, including sexual harassment and assault among women migrant farm workers (). In sum, violence not only drives much migration in the Region but is an important human rights and public health problem during all stages of migration and displacement, including within communities where migrants and displaced populations settle.
Maternal and child health
The Americas is home to 6.3 million migrant children, about one-fifth of the global total. Approximately 80% of them reside in three countries: the United States, Mexico, and Canada, with the United States hosting the largest number in the world, an estimated 3.7 million. An alarming concern is the percentage of children who migrated from Central America, where almost half of all migrants are younger than 18 years of age, compared with an estimated 8%, 15%, and 15% from North America, South America, and the Caribbean, respectively ().
A distinct pattern in the Region is the number of children who have migrated on their own, many of them fleeing violence in their homes and communities, primarily from Colombia, El Salvador, Guatemala, Mexico, and Honduras (), and wanting to reunite with their families, many of whom are located in the United States ().
Migrating children and adolescents face barriers to accessing adequate health services during the migration path (). Studies have shown that children residing in households with noncitizen parents have trouble accessing health care and thus experience worse health outcomes (). A study in Argentina reported that migrant women had poor prenatal care and newborns required more medical care compared with newborns born to native-born mothers (). Similar challenges have been cited for children of internal migrants. In a study examining child mortality associated with maternal migration in Haiti, researchers reported that children born to migrants moving from rural to urban areas or vice versa experienced higher mortality (). Other situations faced by child migrants include being detained at borders, being left behind by migrating parents, and being forcibly returned to their countries of origin ().
Several countries are trying to improve access to health services for migrant children. For example, Guatemala is working with IOM on capacity- building for government officials to assist child migrants in transit, especially those who are unaccompanied or have been separated from their families (). In Brazil, policies have recently been adopted to assure equal access to coverage for all migrants including irregular migrants (). The increase in the number of unaccompanied and separated children who have been detained at the southern border of the United States () has led to increased cooperation between the United States and several Central American countries—led by El Salvador, Guatemala, and Honduras—in programs to reduce extreme violence and increase economic opportunities in countries of origin (). In order to make further improvements to health services for migrant children, it is necessary to better understand their specific health needs by collecting data disaggregated by socioeconomic status, geographic location, and migration status during the entire migration path ().
Adolescents face unique challenges during their migration path because adolescence is a time of rapid physical, mental, emotional, and social development, during which the influence of parents, peers, the media, and school plays an important role in their life. This is also when they first develop the capacity to reproduce and when they begin to take progressive responsibility for their own health and development. Adolescents may be forced to move with their families, forced to migrate without their families to seek a better future somewhere else, or left behind by migrating parents to take care of younger siblings.
On the one hand, migration can have positive results for adolescents, including increased opportunities for education and income. On the other hand, the potential increased health risks associated with separation from family, peers, school, and community requires careful consideration and response. There is growing evidence that the health and development of adolescents are profoundly affected by their relationships with these social settings. For example, studies in the English Caribbean countries and territories have documented associations between low levels of connectedness or emotional attachment with parents, peers, school, and community and increased risk of negative health outcomes and behaviors such as anxiety, depression, suicide ideation and attempts, unsafe sex, unplanned pregnancy, and substance use (). Studies also document the protective effect of high levels of connectedness on the emotional and physical well-being of adolescents (). With the interruption and separation from these social settings that comes with migration, it is critical that programs and services attempt to fill the gap and offer opportunities for adolescents to build meaningful relationships with peers, adults, and social institutions along their migration path.
A number of studies have shown differences in the risk for noncommunicable diseases among different population groups of recent LAC migrants to the United States and between recent international migrants and populations born in the United States. For example, recent migrants from South America to the United States have a lower prevalence of diabetes and being overweight than the average United States–born population and a lower prevalence than recent migrants from Mexico, Central America, and the Caribbean, too. Moreover, there appears to be an increased morbidity and mortality burden among Latinos born in the United States compared with Latinos born elsewhere. The decline in health status of subsequent generations of Latinos can be attributed to negative acculturation and to adopting unhealthy behaviors (poor diet, smoking, alcohol consumption, substance abuse, and physical inactivity) that are more prevalent in the receiving communities to which the migrants moved (). Furthermore, conditions related to communities of origin appear to have a protective effect on cancers but not on obesity and diabetes. However, over time, the rates of most cancers tend to converge towards the rates seen in locally born residents ().
Rural to urban mobility in low- and middle-income countries, such as the Andean countries, can also be detrimental to the health of migrants due to changes in dietary and physical activity patterns, enhancing the risks for cardiovascular diseases such as hypertension and obesity (). However, it appears that the impact of rural-to-urban migration on the cardiovascular risk profile is not uniform across different risk factors and can be further influenced by the age at which migration occurs (). Moreover, rural-to-urban migrants may have better access to health services than the populations who stay in rural areas ().
The situation of migrants has gained recognition in and prominence on global agendas. In October 2013, the UN General Assembly adopted the Declaration of the High-Level Dialogue on International Migration and Development, which recognizes that human mobility is a key contributor to sustainable development. In September 2015, the UN General Assembly adopted the 2030 Agenda for Sustainable Development, recognizing “the positive contribution of migrants for inclusive growth and sustainable development.” A central reference to migration is made under Goal 10 (reduce inequality within and among countries), under which target 10.7 is a commitment to “facilitate orderly, safe, regular, and responsible migration and mobility of people, including through the implementation of planned and well-managed migration policies” (). Finally, in May 2016, the UN Secretary General presented his report, “In Safety and Dignity: Addressing Large Movements of Refugees and Migrants” (). The report focuses on ensuring at all times the human rights, safety, and dignity of refugees and migrants. It calls for the development of national inclusive policies (including health policies), seeking to bring migrants into the receiving society and to provide access to basic services, including health services. As a follow-up to the UN Secretary General’s report, the General Assembly held a high-level plenary meeting in September 2016 to address the topic of large movements of refugees and migrants. At the meeting, Member States adopted the New York Declaration for Refugees and Migrants (). The Declaration endorsed a set of commitments related to refugees and migrants including women at risk; children, especially those who are unaccompanied or separated from their families; members of ethnic and religious minorities; victims of violence; older persons; persons with disabilities; persons who are discriminated against on any basis; indigenous peoples; victims of human trafficking; and victims of exploitation and abuse in the context of the smuggling of migrants. Specifically, the Declaration endorsed among other commitments, the need to address the vulnerability to HIV and specific health care needs experienced by migrant populations.
Specifically in health, the new WHO’s International Health Regulations of 2005 () were adopted “to prevent, protect against, control and provide a public health response to the international spread of disease in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference with international traffic and trade.” As of 2016, the status of all core capacities established in the International Health Regulations across PAHO Member States continues to be heterogeneous, with the lowest scores consistently registered in the Caribbean (). In 2008, the 61st World Health Assembly endorsed the WHO Resolution on the “Health of Migrants” (), and in 2016, the 69th World Health Assembly endorsed a report promoting the health of migrants () in support of migrant-sensitive health policies, information programs, and services.
Heads of State in the Americas agreed to establish an inter-American program within the Organization of American States (OAS) at the Third Summit of the Americas held in April 2001 (), for promoting and protecting the human rights of all migrants, regardless of their immigration status. The OAS recognizes that, given the scope, prevalence, and significance of the current migratory phenomenon, virtually every state in the Americas has become a country of origin, transit, destination, or return for migrants, and as a direct result of this, migration has become a priority in the Region (). Specifically regarding the health of migrants, the 55th Directing Council of PAHO in 2016 () adopted the Regional Strategy for Universal Access to Health and Universal Health Coverage () as the overarching framework for health system actions to protect the health and well-being of migrants.
At the national level, there are wide differences in the extent to which countries in the Americas have considered and implemented national migrant policies that include the health dimension. They range from free access to health services in the formal public system for all people in precarious economic conditions, including migrants, like in Argentina (), Brazil (), and El Salvador (), to ensuring health insurance coverage or health services in the public system only to migrants with legal residential status, like in the United States () and Canada (). The overall political climate in a country is an important factor that can help or hinder health systems in becoming more responsive to the needs of migrants (). The range of areas that need to be addressed by migrant-sensitive health policies should go beyond improving health services to encompass actions addressing the social exclusion of migrants and their employment, education, and housing conditions (see Figure 5).
Figure 5. Policy measures tackling the social determinants of health for migrants ()
The future of migrant health in the Americas
By adopting a resolution on health and human rights in 2010 (), agreeing on a Regional Strategy for Universal Access to Health and Universal Health Coverage () and Plan of Action for the Coordination of Humanitarian Assistance () in 2014, and adopting the global 2030 Agenda for Sustainable Development in 2015, the countries of the Americas have shown their commitment to protecting the rights of all people, including migrants. Thus, everyone can achieve the highest attainable standards of physical and mental health and commit to the development of health policies and programs to address health inequities and improve access to health services.
At the national and supranational levels, the strategic lines of action defined within WHO Resolution WHA61.17 of 2008 and PAHO Resolution CD55.R13 of 2016 on the health of migrants constitute the overarching framework for the health system’s actions to protect the health and well-being of all migrants. The agreed strategic lines of action on these resolutions are well aligned with the 2030 Agenda for Sustainable Development, and comprise the following:
- Ensuring inclusive health services responsive to the needs of migrants and readily accessible to migrants by eliminating geographical, economic, and cultural barriers;
- Improving mechanisms to provide financial protection in health for migrants with equity and efficiency;
- Adopting inclusive policy and legal frameworks that provide access to comprehensive, high-quality, and people-centered health services to migrants that are consistent with international human rights legal instruments;
- Ensuring the standardization and comparability of data among countries on migrant health; supporting appropriate aggregation and assembling of migrant health information and mapping of good practices; and
- Strengthening intersectoral action and development of partnerships, networks, and multicountry frameworks to address the social determinants of health of migrants; these should aim at shaping individual and community resilience and advocating for migrant-sensitive social policies and programs.
Furthermore, the countries of the Americas, in coordination with international entities, have shown a continuous commitment to ensuring that all people, including migrants, are able to access life-saving and essential health care during health emergencies such as internal and international massive force displacement due to sudden environmental events, violence, or other reasons. This includes HIV prevention, protection, and treatment; reproductive health services; food security and nutrition; and water, sanitation, and hygiene services. Key to the success of humanitarian health assistance is coordination with existing national disaster risk management authorities, promotion of mechanisms for coordination with other sectors, participation in regional and global health networks for emergencies, and implementation of a flexible mechanism for registry of qualified foreign medical teams and multidisciplinary health teams and for emergency response procedures (). In addition, the countries of the Americas should continue working toward attaining and strengthening core capacities required by the International Health Regulations, including migrant-sensitive surveillance, response, preparedness, risk communication, human resources, and points of entry ().
At the local and community levels, there is a need for a sustainable, equity-driven process that can bridge short-term humanitarian assistance during health emergencies with long-term universal access to health and universal health coverage for all migrants. Mainstreaming human security in country health plans can play this bridging role. In the Americas, PAHO’s Member States have demonstrated a heightened appreciation for considering the incorporation of human security into their country health plans by adopting the 2010 Resolution “Health, Human Security, and Well-being” (). A human security approach can help overcome challenges of national health systems with regards to the health care of marginalized communities such as migrants and their families. It would seek to address health threats in communities of origin, transit, destination, and return following a balance of individual and community-based interventions that are people-centered, context-specific, prevention- and promotion-oriented, comprehensive, and multisectoral within an integrated protection-empowerment framework. Human security can effectively guide health systems to be better prepared and to promote resilience in communities with migrants so that they move beyond a focus on survival to a focus on livelihood and dignity (). For example, the integration of the human security approach in health emergency plans would prevent, monitor, and anticipate acute migrant health-related threats by developing early warning and response mechanisms, as well as strengthen community ownership, resilience, and preparedness to identify and control these threats. Incorporating the human security approach in local health service models would provide migrant-sensitive services, as well as strengthen the health knowledge, mobilization, and decision-making power of migrants and of communities of origin, transit, destination, and return. Mainstreaming human security in country health plans requires a substantial capacity-enhancement program that is focused on research, training, and consolidation of multidisciplinary expertise. It calls for a multisectoral, multistakeholder strategy that articulates collective interests, establishes rights and obligations, and mediates differences using good governance principles such as promotion of equity, participation, pluralism, transparency, co-responsibility, and the rule of law ().
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