Infectious Disease Movement in a Borderless World Workshop Summary (2010) / Chapter Skim
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1 Migration, Mobility, and Health
1 Migration, Mobility, and Health
Pages 41-87
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From page 41... ...
Miller's essay reviews human migratory history, focusing on the contempo rary "Age of Migration" that began around 1970. This era "has witnessed major developments in human mobility affecting all areas of the world," Miller writes.
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The authors characterize "modern migration" -- the mechanism that drives Miller's "Age of Migration" -- in terms of its departure from traditional migratory patterns, and explore the challenges it presents for global health, and particularly for the control of infectious diseases. In order to "shift the paradigm" of disease control away from policies focused on geopolitical borders and individual infectious diseases, Gushulak and MacPherson introduce the concept of "population mobility" to replace traditional considerations of migration.
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. The term international migration, which the United Nations (UN)
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The United States admitted several groups of "displaced persons" and continued to admit Mexican temporary workers, which had resumed under a 1942 bilateral accord 6These laws instituted the National Origins system of visa allocation that, as subsequently revised, remained in effect until 1965. The system favored visa applicants of northern European background as opposed to applicants from southern and eastern Europe.
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have identified five developments that pre cipitated the Age of Migration by 1970. Latin America changed from being a net importer of international migrants to a net exporter.
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In 2003, the UN General Assembly also decided to hold a high-level dialogue on international migration and development in 2006. The Secretary-General's report on this meeting recommended a forum for UN member states to discuss migration and development issues further.
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There is mounting evidence that the worldwide financial and economic crisis of 2008-2009 has disproportionately adversely affected international migrants as has been the pattern in earlier economic crises such as in the mid-1970s. 12 Other measures of human mobility likewise attest to the growing significance of international migration.
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A number of scholars and policy makers have advocated temporary foreign worker admissions policies in OECD democracies as part of a circular migration strategy to promote mutually beneficial development in sending and receiving states. A certain skepticism about such advocacy appears in order.
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But there was considerable political sympathy for legally admitted foreign 15The lexicon of international migration specialists is replete with terms derived from non-English languages. Guestworker derives from the German Gastarbeiter, a word coined after World War II to replace Fremdarbeiter, foreign worker, as many foreign workers had died and suffered deprivations under Nazi rule.
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In return for coopera tion with Spain and the EU on management of international migration, including prevention of illegal migration and human trafficking, as well as readmission of citizens illegally entering the European space, Spain will provide for job training and then admit trained and prepared foreign workers for time-bound employment in sectors lacking adequate labor supply such as agriculture. At first glance, such policies may appear constructive, even progressive.
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The history of European structural funds designed to promote a more even playing ground within the European space deserves careful scrutiny by the NAFTA partners. Unfortunately, most OECD member states have ducked negotiations over international migration and development issues.
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American leaders of either party simply continue to endorse the benefits of globalization and free trade as evidence mounts that it increases socioeconomic disparities, both within and between states and societies. The circular migration advocacy risks generating false hopes that bilateral and regional cooperation on international migration will result.
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. Several of the public health and infectious disease challenges facing today's increasingly integrated and globalizing world have similarities in context to situations involv ing migration, illness, and disease that have occurred in the past.
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Following World War II, these efforts eventu ally merged into activities in the World Health Organization and were adopted as the International Sanitary Regulations in 1951. They were renamed the International Health Regulations in 1969 (Howard-Jones, 1975)
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In many circumstances those changes have not yet generated corresponding responses in migration health policy or program design. Given the importance and prominence of global infectious disease control in the context of human development, security, economics, and social integration, it is an appropriate and necessary time to consider the health implications of modern migration and population mobility (MacPherson et al., 2007)
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The requirement for systematic medical inspection to detect both noninfectious and some infectious diseases resulted in the expansion of port-of-entry medical activities. Extensive inspection station facilities were constructed at large ports such as Ellis Island in New York (Yew, 1980)
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. Approaches to infections of public health concern were also influenced by the sociological conditions present during the origin of immigration health policies and practices.
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Depending on location, the same or different terms may be applied to several functionally dif ferent populations. For example, the terms immigrant, refugee, and migrant may variously be applied to new legal residents from foreign countries, as well as refugee claimants, asylum seekers, temporary foreign workers, illegal and irregular migrants, and international students.
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The proportional contribution of the health and disease outcomes of this large mobile population cohort in terms of global health and disease management is also significant. In addition to its magnitude-derived importance, modern migration is functionally a much different process than the historical patterns of immigra tion when most immigration-related disease control activities were developed.
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Figure 1-1 COLOR.eps SOURCE: Reprinted with permission from Population Reference Bureau (2008b)
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Another significant factor influencing modern migration that has implications for the mitigation and management of health and disease risk has been the evolution of refugee and displaced persons movements. During the Cold War, many refugee movements had significant political overtones and intercontinental TABLE 1-6 Major Influences in Migration Dynamics Since the 1950s Influences on Modern Migration Differential regional population growth Decolonialization Availability, accessibility, and affordability of air travel Speed of travel Magnitude of international mobility Refugee and internally displaced persons producing situations -- civil, political, and environmental End of the Soviet Union Evolution of international labor market demands SOURCE: Based on data in Gushulak and MacPherson (2006)
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Modern labor migration frequently involves migrant women moving internationally or within nations from rural to urban settings. Finally, another factor in modern migration relevant to disease control activities has been the evolution of international travel.
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. How Modern Migration Will Functionally Impact on Global Health in the Future Activities to mitigate the risks of infectious diseases of public health sig nificance resulting from international migration reflect the characteristics of the migratory process at the time they were developed.
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Following the long-standing approach to quarantine and sea travel, interventions were instigated on the basis of reports of illness or death during travel or the detection of illness or disease on arrival. The duration of the migrants' journey and the time required to unload the vessels and process immigrants was considered to be sufficient to allow for the presentation of sig nificant infectious diseases, which de facto represented a differential prevalence risk to public health of the recipient population, to a degree where they could be detected through clinical screening.
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Health interventions and disease control practices often remained based in con cept and practice on administrative or traditional definitions of immigrants and emigrants and historical linear patterns of movement. How Modern Migration Processes Challenge Border Disease Control Policies The evolution and characteristics of modern migration dynamics present three sets of challenges in the context of modern border disease control activities.
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Triggers for health interventions or evaluations based on administrative classifications of migrants and other mobile populations will not provide sufficiently robust response mechanisms to deal with the modern diversity and disparity of those populations. The second challenge to traditional immigration health activities is a product of the technical and social evolution of the transportation industry.
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Then, during the initial phases of the revisions to the International Health Regulations in light of the expanding knowledge about emerging and reemerging infectious diseases, the role of the border and frontier in disease control began to be reconsidered. The technical and operational chal lenges posed by the arrival of international travelers who could now undertake an intercontinental journey within the incubation period of infections posing international public health significance became topics of interest at the international health policy table.
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Together these factors diminish the likelihood that new arrivals will present with clinical disease that was either acquired or developed during the journey. The challenges posed by travel, migration, and population mobility in the context of global infectious diseases of public health significance are regularly being recognized.
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. Border-associated technological solutions designed to reduce the introduction of important infections during urgent public health situations have been considered.
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The third aspect of modern migration that exceeds the intent and capacity of traditional immigration and border health policies results from changes in migra tion patterns themselves. The evolution of migration from a linear, unidirectional pattern to a more continuous and circular pattern of modern population mobility has not been accompanied by policy or programmatic design to accommodate these and future changes.
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, the risk of acquisition of unusual or resistant infections and sub sequent introduction into their new place of residence is present. Modern Migration and Global Infectious Disease Surveillance and Control Attempts to mitigate the impact of migration on the international epidemiol ogy of infectious diseases can be considered in the classic relationships between the host, organism, and environment.
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This belies the com plexity of the nature of transmissible infectious diseases that must include consideration of multiple microbial organism factors, such as incubation period, patency, latency, chronic infection and infectious states, transmissibility, viru lence, and infectious and noninfectious sequelae. The characteristics of micro bial contagiousness and virulence for human beings, and the availability of effective diagnostic, therapeutic, and specific preventative interventions, such as antibiotics or vaccines, have been more recent considerations in the international disease control approach.
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Chronic infections, infections with prolonged latent periods, and infectious with noninfectious consequences are emerging as important phenomena related to migration and may offer unique opportunities for effective mitigation and control. In nations where long-standing public health activities and programs have been effectively implemented and supported, several infectious diseases of previous historical importance are now present in low or very low prevalence levels.
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. Existing immigration health-related disease control policies with the histori cal focus on specific infections of acute epidemic potential or acute transmission do not accommodate chronic diseases or the consequences of infectious diseases.
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Critical and comprehensive analysis and evaluation of national and international responses to the 2009 H1N1 influenza pandemic will be essential if important shifts in approaches are to be achieved related to global health considerations and international population mobility. Public Health Challenges Increasingly Arise Beyond the Jurisdiction of Local Control Authorities Traditionally public health control activities responded to situations by addressing the current event while acting in a coordinated manner to prevent its recurrence or eliminating its source.
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Policies and programs intended to mitigate the risks of disease importation through migration would be more logically based on current factors or future modeling more directly related to risk and undesired health outcomes rather than specific diseases or historical patterns of immigration. The need to increase the flexibility of traditional disease list-based control methodologies to more effectively meet modern approaches to threat-risk assessment is reflected in the 2005 revision of the International Health Regulations that created a greater expectation on national surveillance and international reporting.
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Extending the process into the sphere of migration health is strongly supported by empirical evidence, recurrent international experience, and projections of the importance of population growth and mobility for the future of global health. New Approaches for Migration and Disease Control It is apparent that human migration will continue to be an important com ponent of global infectious disease distribution.
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• Functional approach to borders and boundaries. The potential for international spread of infectious diseases in association with migration remains a component of a world that contains health disparities and is ever more linked through mobile populations.
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Conclusions Designed to prevent the introduction of a limited list of diseases of his torical public health significance that arose beyond national boundaries, most immigration health activities play at best a minimal role in international disease control activities in the modern context. While required by some immigrantreceiving countries' national legislation, they are often based on the historical quarantine-derived strategies of exclusion and isolation, principles that for the most part only represent population-based public health approaches in very limited circumstances.
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Reviews of Infectious Diseases 13(4)
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Clinical Infectious Diseases 44(5)
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Clinical Infectious Diseases 44(10)
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2000. Population mobility and infectious diseases: the diminishing impact of classical infectious diseases and new approaches for the 21st century.
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Clinical Infectious Diseases 43(9)
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Clinical Infectious Diseases 47(10)
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International Journal of Infectious Diseases 8(1)
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Emerging Infectious Diseases 11(12)
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