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The Challenges and Extent of Migrants' Poor Health

Migration is often accompanied by a deterioration in health, and migrants face many difficulties in accessing healthcare, including HIV treatment, when they move abroad. These were some of the messages which emerged from a two-day conference  about migration and the right to health.
Human rights, ethical considerations and the discrepancy between theoretical rights to healthcare and common practice were raised by a range of specialists including doctors, anthropologists and lawyers during the discussions at Senate House, University of London.
 
Presentations focused on a range of trends and experiences, including changing patterns of migration, the health of migrant women in Canada, and the health-seeking behaviour of HIV-positive southern Africans in London.
 
The event on 26 and 27 May was designed to help build a better interdisciplinary understanding of migrants and their health-related concerns. Co-convened by Dr Jasmine Gideon, of Birkbeck, and Dr Felicity Thomas, of the Institute of Education, the conference was supported by LIDC and the University of London’s Human Rights Consortium
 
Changing patterns of migration
Dr Mary Haour-Knipe, formerly of the International Organisation for Migration, gave a factual presentation which countered many of the preconceptions surrounding migration. She said there are 740 million internally displaced people worldwide – a far greater number than the 214 million international migrants, and a reflection that wars are increasingly occurring within countries rather than between them. Most international migration involves moving from one developing country to another, instead of from a poor country to a rich one, and half of labour migrants are now women. She showed how the poorest and richest in society generally don’t migrate, and the significant benefits of migration as migrants can increase their incomes fifteen-fold after moving.
Cheaper airfares and faster and cheaper ways of communicating by mobile phone and via the internet were also shown to contribute to the phenomenon of transnational families (where family members live in different countries simultaneously), and short-term and circular migration. Countries today are often simultaneously countries of origin, transit and destination for various groups of migrants, and the integration associated with traditional migration patterns in destination countries is increasingly variable.
 
Health worker migration
Rebecca Shah, of the University of Keele, highlighted ethical considerations and the trade-off between different human rights as she explored the impact of health worker migration. She showed how the ‘brain drain’ has led to critical shortages of professional health workers in poor countries, as well as an obvious correlation with poor health outcomes. Poor countries which invest in their health sectors fail to see a return on the investment, as health workers move abroad in search of higher wages or better jobs, leading to a ‘perverse subsidisation’ within healthcare.
 
Shah referred to the right to health in both poor and rich countries, as well as rights to free movement of labour, and satisfactory working conditions. As all these rights are exercised, however, they can lead to a ‘clash’ of rights, as they infringe upon each other. The responsibilities of poor countries to provide adequate healthcare are also undermined by constrained resources, so that their strong responsibility to provide healthcare is matched by a weak capacity to do so. Shah also explained how disease-specific aid can help undermine national health systems; in Rwanda international aid for HIV/AIDS dwarfs the funding levels of the entire healthcare system.
 
Poor health of female migrants in Canada
Dr Denise Spitzer, of the Institute of Women’s Studies, University of Ottawa, drew on interviews with female migrants to illustrate the severe decline in their health after their arrival in Canada. She suggested the onset of conditions including diabetes, high-blood pressure and high cholesterol was counterintuitive as women should be getting healthier after leaving war zones and developing countries to settle in Canada. Her analysis emphasised that the so-called healthy immigrant effect is short-lived because of the declining social determinants – work, worry and weariness – which undermine health.
 
Spitzer showed how the working life of a migrant is characterised by downward social mobility – 65 per cent of migrants drop to low-income status within the first 10 years of their lives in Canada. Their education and work experience are often not recognised by new employers and they are often reduced to carrying out low-skilled work, which leads to a loss of self-esteem and professional identity. Worry is also exacerbated in the new setting, particularly because of familial separation and shrinking social networks and support. One interviewee said: “Most of my family died in the war. I want my husband with me; I don’t have document [s], how can I bring my husband. I developed diabetes, and high-blood pressure, high cholesterol. I developed all of these things because I am thinking too much because my husband is not with me.”
HIV-positive migrants in the UK
Professor Jane Anderson, of Homerton University Hospital, described the numerous difficulties faced by migrants living with HIV in the UK.  She said this group face a “double burden” of stigma associated with their HIV and migration status. Her presentation highlighted how the health of migrants with HIV is “alarming”, particularly when compared to the health of HIV-positive non-migrants. This is largely because HIV-positive migrants present themselves for testing much later than other groups and their condition is then much harder to treat. She also emphasised inconsistencies, the confusing reality of treatment practices, and ethical considerations about providing testing without follow-up treatment. Whereas Scotland and Wales provide free care for all people living with HIV, overseas visitors are excluded from free NHS care in England. Emergencies in England are exempt, but what constitutes an emergency is difficult to define. Moreover, treatment is free for many conditions associated with HIV, including tuberculosis, if it is deemed necessary to protect the wider public, but it is not provided to treat the underlying HIV. Anderson said: “Healthcare providers are confused and patients are frightened. In today’s world, HIV is treatable, but not curable. One pill once a day keeps you well if you have access.”
Dr Felicity Thomas, of the Institute of Education and co-convenor of the conference, described  traditional healing practices used against HIV by some black African migrant communities in the UK. She stressed how migrants living with HIV adopt a range of strategies, including prayer and fasting, herbal medicines, and traditional healers. Many interviewees wanted to use herbal treatments alongside, or instead of, anti-retroviral drugs, but these can be counterproductive. Thomas said some herbal medications have adverse reactions, including increasing viral load and the likelihood of further HIV transmission. Recognising the attachment many have to practising traditional medicine, Thomas raised many questions, including: 
 
• What do we mean by rights to health, are we just referring to bio-medicine?
• How do we reconcile differences between belief and scientific evidence?
• Where do responsibilities to oneself and others begin and end?
 
Immigration and healthcare-related law in the UK
Sue Willman is Head of Public Law and Human Rights at Pierce Glynn Solicitors. She made a factual presentation on the requirements of international human rights law, and how this impacts on healthcare provision to migrants in the UK. Although the UK is not obliged to provide free healthcare to migrants, denying care to foreign nationals may constitute a violation of certain articles in international human rights treaties ratified by the UK. These include the right to respect for life and freedom from discrimination, alongside rights to the highest attainable standard of health. In 1989, the NHS introduced Charges to Overseas Visitors Regulations, “in order to deal with the perceived problem of health tourism”. Willman pointed out that for destitute asylum seekers who cannot afford any charge, the refusal of treatment which then leads to a deterioration in their condition would constitute a violation of their human rights. Rules limiting treatment for groups such as refused asylum seekers, or unlawful residents, have been challenged by patients who cannot pay and cannot return home. Emergency care and essential treatment of illnesses have special guidelines, but Willman pointed out that it is, in any case, difficult to define these categories. The extent to which international human rights law is binding in the UK, and how broadly it is to be interpreted within the UK, is likely to throw up many challenges for future migrant patients.
 
Overview of immigration and healthcare policy in the UK
Rayah Feldman, of South Bank University, gave a detailed account of immigration and healthcare policy in the UK, putting it into its historical context and throwing light on current practises. The notion of no healthcare or welfare for those from ‘outside the parish’ is long-held historically. Feldman and Rosalyn Bragg researched a paper on a range of policy aspects which block healthcare access for migrants – including charges for services, issues of eligibility, and NHS regulations on ‘enforcing the rules’, through hospitals making statutory enquiries into the status of migrants and their liability to be charged. In 2003, the issue of ‘health tourism’ became one of parliamentary concern after it was mentioned in a number of daily newspapers. The link between migrants, asylum seekers and perceived exploitation of the NHS gave rise to documents and regulations which called for more stringent checks, as well as bolstering negative public opinion of migrants and undermining integration strategies. However, Feldman informed attendees that not only had no data ever been collected on the actual number of migrants in the UK as ‘health tourists’, but also that unpaid migrant costs account for approximately 0.005% of NHS expenditure – a figure which may well be exceeded by the cost of developing and enforcing policy. Policies and attitudes towards migrants feed into each other to create an attitude of fear and mistrust, which manifests in health and welfare services.
 
Latin American migrants in London
Jasmine Gideon, of Birkbeck and co-convenor of the conference, continued by explaining the health problems faced by Latin American migrants in London. Barriers to accessing healthcare include their legal status (Latin Americans are not recognised as an ethnic minority in the UK), the lack of interpreting services in Spanish and Portuguese, racism, and lack of knowledge about the NHS. She said these challenges and mental health concerns are exacerbated by the poor living and working conditions faced by many migrants. The cultural norms and gender identities associated with Latin American machismo are also undermined as many men engage in low-paid and unskilled work, particularly in the cleaning sector. Increasingly migrants are adopting transnational health-seeking strategies: returning to Latin America for medical appointments, resorting to online and telephone counselling services based in Latin America, and sharing prescription drugs. These trends are significant, especially as estimates indicate there are up to one million Latin American migrants in London.
 
Turkish female migrants in London
Eleni Hatzidimitriadou of Kingston University presented the results of research conducted with communities of female Turkish migrants in London. She elucidated some of the main issues facing non-national women from traditionally collectivist or patriarchal societies, such as conflicting gender roles and the perception of them as ‘dependent’ migrants. This can leave them ‘voiceless’ as well as ‘powerless’ in welfare policy and service provision. In Hatzidimitriadou’s survey of 264 Turkish-speaking migrant women in the UK, 158 participants reported some form of mental health problems, traced back to difficulties in adjusting to life in the UK. These included cultural differences and ways of life that were hard to adjust to, as well as finding the English language a major barrier to adjustment. A follow-up survey was then carried out with two Turkish-speaking women’s groups in North London, in order to assess the nature and impact of migrant women’s community activism. One group focused on Social Change and the other on Personal Change for Turkish women. The activists and participants interviewed all mentioned that the social networks and spread of information in such groups benefited their mental health, through social and therapeutic aspects. Hatzidimitriadou concluded that community activism, as well as self-help and mutual activities, aid successful integration, whilst the role of groups in communicating health and migrant needs promote better use of services.
 
Health of migrants in Chile
Baltica Cabieses, a qualified nurse and research assistant at the University of York, focused on the social determinants of health for migrants in Chile. She described the high rate of migration, especially from Peru, Argentina, Bolivia and Ecuador, and characterised migrants as being young, and mainly living in the capital Santiago. The number of female migrants is rising, especially in the cleaning profession.
 
Cabieses cited the Chilean national survey of socio-economic conditions (the Casen survey) to show that migrants with a low socio-economic status generally suffer more from disabilities, health problems or mental health problems than the Chilean-born population. She also mentioned the Chilean healthcare system, which is mixed between public and private provision, and how the Casen census shows that  international migrants had a higher rate of no health provision than the Chilean-born population, leaving them more vulnerable than the local population. Stratifying by age, sex, living standards, education and location of residence all affected the results for the Chilean-born in their access to health provision, as well as the frequency of health problems. For migrants, their access to healthcare was affected to a far greater degree by their socio-economic status.
 
Culturally sensitive health services
Janaka Jayawickrama, of the Disaster and Development Centre at the University of Northumbria, spoke about the right to culturally sensitive health services for refugees and internally displaced peoples. He stressed that the right to health pledged in international documents, as well as rights to basic sanitation, safe water, housing, food and nutrition, refer to concepts which are understood differently between cultures, and that universal provision may therefore not be as straightforward as it seems.
 
Jayawickrama also drew attention to the current global health system, and its basis in Western medical scientific culture. A ‘Western’ way of viewing disease, the body and nature can detract from the contribution of other medical approaches, such as Ayurvedic and traditional Chinese medicines, which tend to be more holistic and focus on harmonious relationships with nature.
 
Migrants have often experienced severe trauma and destruction prior to moving. Jayawickrama pointed out that as familiar cultural value systems help us to feel comfortable, safe and healthy, a Western scientific approach to trauma may not be the most suitable way to help migrants. People who have experienced intense suffering would not necessarily be comfortable in the surgeries, hospitals and examining rooms of the Western medical experience. The provision of an equal level of care and comfort to all patients would require a different approach, focused on ‘bridging the gap’ between different value systems.
 
By Guy Collender, Senior Communications Officer at LIDC, and Tanbir Johal, work experience placement student at LIDC and MSc student at Birmingham University
 
Resources: Powerpoints and full programme
 
Wednesday May 27
 
 
 
 
Thursday 27 May
Accessing rights to HIV treatment in the UK: Jane Anderson, Department of Sexual Health, Homerton University Hospital
Ignorance of the law is no excuse: A consideration of international human rights law requirements to provide healthcare to migrants resident in the UK: Sue Willman, Pierce Glynn Solicitors, London