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Demography

Global health in motion

A multidisciplinary team reviews the scientific evidence and challenges stereotypes regarding health and migration

258 million international migrants in 2017

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Migration is a global phenomenon involving one in seven people around the world, which can rarely be restrained by laws or walls. Ensuring the rights of migrants—especially access to healthcare—is necessary so that everyone, including the society receiving them, can benefit from this population flow. Such is the main conclusion of a report on migration and health that has just been released by the British scientific journal The Lancet, in partnership with University College London (UCL) in England. Based on evidence from an extensive review of studies on the subject, the Lancet paper challenges stereotypes and demonstrates the gap that exists between the health services available to migrants and their actual needs.

The UCL-Lancet Commission, which brings together not only health experts, but also specialists from sociology, politics, law, and anthropology, works from the perspective of examining the separation between what nations currently practice and the international standards designed to ensure minimum standards of human dignity. “It’s one of the greatest efforts made so far in the field of human migration and health,” says doctor and epidemiologist Mauricio Barreto, a retired professor at the Federal University of Bahia and coordinator of the Center for Integration of Data and Health Knowledge of the Oswaldo Cruz Foundation (CIDACS-FIOCRUZ) in Salvador. The only Brazilian among the more than 20 specialists who make up the commission, Barreto says that their objective was to systematize the knowledge produced in an area whose subject still has little scientific visibility: “It’s a very fluid population, which there is little interest in researching.”

In 2018, one billion people were in transit to or had settled in locations other than their place of origin, whether in their own countries or abroad. The United Nations (UN) estimated the world population in 2017 was at 7.6 billion. International migrants, contrary to common conception, account for the smallest share of this contingent: in 2017 they numbered 258 million, distributed mainly in Asia (80 million), Europe (78 million) and North America (58 million), according to UN data. Despite the predominance of domestic traffic, there is much more information available about international migration, since domestic flows do not involve migration controls. For this reason, most of the studies referred to in the report concern people living as foreigners.

Migration in numbers

  • 258 million international migrants in 2017
  • 80 million in Asia, 78 million in Europe, and 58 million in North America
  • Migrants who study or work contribute positively to the economy of their destination countries
  • The fertility rate among women is 2.1, and is trending downward
  • Migrants sent US$613 billion to their countries of origin in 2017
  • Among migrants, the predominant age group is 30 to 34, and 48% are women
  • In June 2015, 35 countries imposed some type of restriction on HIV carriers, according to UNAIDS
    • 5 completely blocked the entry of HIV-positive individuals
    • 4 required HIV-negative tests even for short periods of travel
    • 17 deported HIV-positive foreigners

“The health of those who migrate generally reflects the circumstances of the migration,” the authors write in the report. While migrants with professional skills or higher incomes tend to have better health conditions than the inhabitants in the host society, those with fewer skills and lower incomes tend to be more susceptible to occupational hazards, and receive inadequate medical care. Studies cited by the research show, for example, that in the United States, Latino construction workers are twice as likely to die as a result of work-related accidents than other workers in the industry.

Working conditions are not the only factor that influences this equation. The issues indicated by the UCL-Lancet Commission also include ethnic, cultural, and identity factors. The report understands discrimination as “a combination of prejudice against the other and a fear of losing something,” which has direct consequences for health. An article published in 2017 in the International Journal of Epidemiology found a correlation between the persecution suffered by Hispanic workers in the state of Iowa in the United States in 2008 and an increased risk of low-birth-weight babies in this community. And a study carried out in Sydney, Australia, with temporary and permanent refugees discussed the negative psychological consequences of living in uncertain conditions.

Migrants as a burden
The UCL-Lancet research is devoted to examining some of the principal myths associated with migration—erroneous stereotypes that, according to the authors, were “used for political gains” and ended up becoming publicly accepted. Based on studies from various fields of study, the report challenges five presuppositions concerning migrants that, while currently considered common knowledge, have not been substantiated by evidence. Namely, that migrants would overburden developed nations, be a heavy burden on health services, would transmit diseases, would have high fertility rates, and would harm the economies of the receiving countries.

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In response to the first question, the commission—which began in 2016, i.e. one year after the start of what has come to be called the “European migrant crisis”—shows that the greatest variation in the refugee population actually occurred in middle- to lower-income countries, those with per capita GDP under US$12,235 per year, according to the World Bank. The data is corroborated by the United Nations High Commissioner for Refugees (UNHCR). According to this institution, 85% of refugees are in developing countries; as of 2017, Turkey was the country with the most refugees in the world, with 3.5 million, equivalent to almost 14% of the total. “The countries most burdened today by international migration are developing nations. But the developed world carries on a discourse in which it figures as the biggest victim of the migrant flow,” says legal expert Deisy Ventura, a professor at the School of Public Health at the University of São Paulo (FSP-USP).

In general, according to UCL-Lancet researchers, the percentage of international immigrants worldwide varied little between 1990 and 2017, rising from 2.9% to 3.4%. Thus, although migration to high-income countries did increase from 7.6% to 13.4% during the same period, the majority of migrants live in middle- or low-income countries. In addition, those who move to rich countries include workers who contribute positively to the economy and students that pay for their own educations who, after completing them, return to their countries of origin. People in these categories total 155.1 million, or 60% of international migrants.

Contrary to the idea that migrants would overburden the health system of their destination countries, it’s often shown that the opposite is true and that the foreigners actually strengthen the system. More than a third of physicians working in the UK, for example, received their educations abroad, and 26% of those currently working in the British public health system are foreigners. Based on its systematic review of studies on global mortality patterns, the commission also concluded that migrants who chose to cross borders—those not forced to migrate—who ended up living in high-income countries tend to live longer than those in the receiving country. For example, according to parameters involving most of the internationally classified diseases, such is the case for those who move to study, find better jobs, or reunite with their families. Taking into account more than 15 million people from 92 countries, the study shows that among these international migrants, cancer mortality rates and cardiovascular and respiratory diseases are lower than in the host population.

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Regarding migrants’ health, the report disputes the notion that they transmit more diseases—historically one of the most persistent stereotypes, according to studies in this field. The risk of transmission between migrants and their host society is generally low, as shown, for example, by tuberculosis research cited in the report. In addition, the largest international flows are not made up of people intending to settle in another country. According to the World Tourism Organization (UNWTO), 1.4 billion tourists crossed borders in 2018, representing about five times the migrant population. “If we consider the circulation of people to be a health hazard, where would the real risk be?” Ventura asks, noting that there are international measures in place for controlling disease. She recalls the ebola outbreak that resulted in about 30,000 cases in West Africa between 2014 and 2016, according to the World Health Organization (WHO). More than 40 countries banned entry to people from the region, although there already were measures to ensure that they were not contaminated. For the UCL-Lancet commission, screening for disease during migration control—which could be an important tool for seeing that migrants arriving in those countries receive necessary care—often gives rise to xenophobia.

Another myth is that migrants have higher fertility rates than native populations, which would lead their communities to grow faster than that of the receiving society. Studies performed in six countries—France, Germany, Spain, Sweden, Switzerland, and the United Kingdom—show that the reverse is true. With the exception of Turkish migrants, the average fertility rates among migrants are less than 2.1 and show a downward trend, indicating that they barely exceed the level of population replacement.

Based on data consolidated in previous research, the report also shows that migrations do not harm the economy. On the contrary, the authors describe an “absolute consensus” among researchers regarding their economic benefits, although it is scarcely acknowledged publicly. In advanced economies, each 1% increase in the adult migrant population represents a 2% increase in per capita GDP. In addition, data from the Organization for Economic Cooperation and Development (OECD) indicate that the contributions made by the migrant population through the collection of taxes are greater than the benefits they receive, and that migratory flows are responsible for balancing market fluctuations and providing labor when needed. Low-income countries, according to World Bank data, received about US$450 billion sent by migrants to their home nations, which represented three quarters of such transfers in 2017. As regards Brazil, a study recently published by the Institute of Applied Economic Research (IPEA) corroborates the economic benefits of population mobility. Without the contribution of the non-Portuguese and non-Spanish migrants who landed here between the end of the nineteenth century and the beginning of the twentieth, per capita income would be as much as 17% lower than currently recorded.

In advanced economies, each 1% increase in the adult migrant population represents a 2% increase in per capita GDP

Local take
Due to the scarcity of studies carried out in the area of health and migration, Brazil contributed little to the review carried out by the commission. “Brazil is not the major focus of studies on migration and health, so it was not the most relevant,” says Barreto. Although several low-income countries appear to provide the context or population data surveyed in the studies, the discussions in the report often assume the viewpoint of high-income countries rather than the poorer countries. Nevertheless, particularities of the Brazilian context allow one to presume that the publication may contribute to the debates about migration in Brazil.

According to the Ipsos Institute’s 2018 “Perils of Perception” survey, Brazil is one of the countries that most overestimates the number of its migrants: survey respondents believed that migrants were 30% of the population when the actual number is 0.4%. Several factors explain the heightened perception of a phenomenon that, in terms of percentage, is small, according to sociologist Rosana Baeninger, from the Institute of Philosophy and Human Sciences of the University of Campinas (IFCH-UNICAMP), and a researcher at the Population Studies Center (NEPO). In addition to widespread coverage by the media and the global dimension of the population transfer, there is the fact that the most recent movement of foreigners into Brazil does not correspond to the country’s historical roots. “Between the nineteenth and twentieth centuries, migration was based on a state policy and brought in a white European population regarded as civilized—it was a successful policy that remained fixed in the Brazilian imagination regarding immigration,” says Baeninger. In recent years, however, the country has been a part of the so-called South-South migration. About 370,000 people, or more than 40% of the international immigrants registered in Brazil between 2000 and 2015, were Latin American or Caribbean, according to data tabulated by the NEPO Migration Observatory project. “These migrants come into a society that’s hostile to a non-white presence, and what’s more, they raise the issue of migration. Two prejudices overlap—one related to race and the other to their status as migrants from non-European countries,” says the sociologist.

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For Barreto, the fact that the report deals with migration-related prejudices makes it possible to carry out one of the most elementary tasks of science: providing evidence. “Carried out by a team with solid academic backgrounds and without preconceived views on the subject, the report shows that the evidence generally contradicts commonly held views or doesn’t support certain rhetorical constructions—such as those of some groups that take the opposing side of the migrant issue,” he says. Ventura underscores the study’s contribution to more general discussions: “The issue of healthcare changes the terms of the debate regarding international migration, since it recognizes the migrant as someone whose health must be taken into account. This immediately pushes the discussion into the field of ethics, and shows the necessity of receiving these people,” he observes. As one of the world’s most prestigious scientific publications in the health field, The Lancet proposes to intervene in contemporary problems through its commissions. In addition to groups that focus on topics such as obesity and Alzheimer’s, there are committees such as one set up in 2017 to study the health conditions of the local population confronted by ongoing conflicts in Syria.

The importance of focusing on migrants and refugees is also highlighted by the World Health Organization, which in January released its own report, also based on a literature review of the subject. The initiatives are in line with the objectives of the Global Compact for Safe, Orderly, and Regular Migration, an agreement promoted by the UN, and through which, since December, more than 160 countries have signaled their intention to follow best practices related to migration. The pact is seen by researchers at the UCL-Lancet Commission as an “unprecedented opportunity” to take actions aimed at improving migrants’ access to healthcare.

“Us” without “them”?

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More than 3 million foreigners landed in Brazil between 1872 and 1920, finding, especially after the abolition of slavery in 1888, an abundant job market. There is no doubt regarding the contributions these immigrants made to the nation’s development—to date, however, there has been no attempt to quantify it.

In their study “Brasil sem imigrantes” (Brazil without immigrants), Leonardo Monasterio and Daniel Lopes, researchers at the Institute of Applied Economic Research (IPEA), used algorithms to calculate what the Brazilian per capita income would be if there had never been any non-Portuguese or non-Spanish migration. Two methodologies were adopted, both beginning by using Italian, Japanese, German, and East European surnames. In the first method, researchers used municipal data to simulate the per capita income if the descendants of immigrants were not part of the world as portrayed by the Brazilian Ministry of Labor’s (MTE) Social Information Annual Report (RAIS), the Single Registry (social assistance enrollment) of the Ministry of Citizenship, and the taxpayer rolls of the Federal Revenue Service. In the second, they focused exclusively on the RAIS data. They concluded that the decrease in income would be 12.6% and 17%, respectively.

The hypothesis of the study is that, upon disembarking, foreigners possessed greater human capital than Brazilians, as measured by numeracy, i.e. the ability to deal with numbers. In the study, this was evaluated through historical documents that recorded the age declared by foreigners when landing in Brazilian ports.

“The literature indicates that populations that round off numbers less frequently generally have increased capacities for dealing with numbers,” says Monasterio. Thus, the greater the frequency of rounded numbers, the lower the numeracy—a relationship based on the premise that the accuracy with which numbers are treated is proportional to the complexity of the situations in which they are used, such as commercial transactions. This fact is echoed in data from the 1920s, when, according to the census, only 23% of Brazilians were literate, compared to 52% of foreigners. In a rapidly urbanizing country, the newcomers’ greater human capital allowed them to focus on more highly skilled economic activities than Brazilians.

Report
ABUBAKAR I, Aldridge RW, Devakumar D, Orcutt M, Burns R, Barreto ML, Dhavan P, Fouad FM, Groce N, Guo Y, Hargreaves S, Knipper M, Miranda JJ, Madise N, Kumar B, Mosca D, McGovern T, Rubenstein L, Sammonds P, Sawyer SM, Sheikh K, Tollman S, Spiegel P, Zimmerman C; UCL–Lancet Commission on Migration and Health. The UCL-Lancet Commission on Migration and Health: the health of a world on the move. The Lancet. vol. 392, n. 10164. 5 dez. 2018.

Scientific articles
FELLMETH G, Rose-Clarke K, Zhao C, et al. Health impacts of parental migration on left-behind children and adolescents: a systematic review and meta-analysis. The Lancet. vol. 392, n. 10164. 5 dez. 2018.
ALDRIDGE RW, Nellums LB, Bartlett S, et al. Global patterns of mortality in international migrants: a systematic review and meta-analysis. The Lancet. vol. 392, n. 10164. 5 dez. 2018.
LOPES, Daniel; Monasterio, Leonardo. Brasil sem imigrantes: estimativas de longo prazo baseadas em microdados. Texto para discussão, Brasília: Instituto de Pesquisa Econômica Aplicada, n. 2435, nov. 2018.

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