AMERICAN JOURNAL OF INDUSTRIAL MEDICINE (2009)

Immigration, Employment Relations, and Health:

Developing a Research Agenda
Joan Benach,1,2,3
Carles Muntaner,3,4
Haejoo Chung,5 and Fernando G. Benavides1,2

Background International migration has emerged as a global issue that has transformed
the lives of hundreds of millions of persons. Migrant workers contribute to the economic
growth of high-income countries often serving as the labour force performing dangerous,
dirty and degrading work that nationals are reluctant to perform.
Methods Critical examination of the scientific and grey literatures on immigration,
employment relations and health.
Results Both lay and scientific literatures indicate that public health researchers should
be concerned about the health consequences of migration processes. Migrant workers are
more represented in dangerous industries and in hazardous jobs, occupations and tasks.
They are often hired as labourers in precarious jobs with poverty wages and experience
more serious abuse and exploitation at the workplace. Also, analyses document migrant
workers problems of social exclusion, lack of health and safety training, fear of reprisals
for demanding better working conditions, linguistic and cultural barriers that minimize the
effectiveness of training, incomplete OHS surveillance of foreign workers and difficulty
accessing care and compensation when injured. Therefore migrant status can be an
important source of occupational health inequalities.
Conclusions Available evidence shows that the employment conditions and associated
work organization of most migrant workers are dangerous to their health. The overall
impact of immigration on population health, however, still is poorly understood and many
mechanisms, pathways and overall health impact are poorly documented. Current
limitations highlight the need to engage in explicit analytical, intervention and policy
research Am. J. Ind. Med. 2009. 2009 Wiley-Liss, Inc.
KEY WORDS: immigration; employment relations; public health research; working
conditions; health inequalities

1
Occupational Health Research Center, Department of Experimental and Health Sciences,
Universitat Pompeu Fabra, Barcelona, Spain
2
CIBER Epidemiolog|a y Salud Publica (CIBERESP), Barcelona, Spain
3
Health Inequalities Research Group, Employment Conditions Knowledge Network
(Emconet), Barcelona, Spain
4
Social Equity and Health Section, Centre for Addiction and Mental Health, University of
Toronto, Institute for Work and Health,Toronto, Canada
5
Department of Political Sciences, University of Toronto,Toronto, Canada
Contract grant sponsor: Fondo de Investigaciones Sanitarias; Contract grant number:
PI050497.
*Correspondence to: Joan Benach, Health Inequalities Research Group, Occupational
Health Research Center, Universitat Pompeu Fabra, Barcelona Biomedical Research Park,
C/Dr. Aiguader, 88, 08003 Barcelona, Spain. E-mail: joan.benach@upf.edu

Accepted14 May 2009

DOI 10.1002/ajim.20717. Published online in Wiley InterScience
(www.interscience.wiley.com)

2009 Wiley-Liss, Inc.

INTRODUCTION
International migration has emerged over last decades
as a crucial global issue that has transformed the lives
of hundreds of millions of people around the globe. In
1960 there were 76 million immigrants in the world (i.e.,
persons living outside their country of origin or citizenship),
which includes those migrating for employment, their
dependants, refugees, and asylum seekers. The number
immigrants increased up to 175 million in 2000, and to
191 million in 2005 [ILO, 2006]. About half of these
international migrants are economically active migrant
workers. Generally, migrants move from low to middle and

Benach et al.

high income countries mainly located in Europe, Asia, and

North America, searching ways to provide for their families
and to escape from unemployment, war or poverty [GCIM,
2005]. These migrant workers can function as wage control
tools as governments regulate the proportion of documented
and undocumented migrants (i.e., 15% of the global workforce). Undocumented migrants are particularly vulnerable
to health damaging employment conditions such as
servitude, bonded labor, trafficking, or slavery [Vogel, 2008].
Migration within countries has also increased dramatically most notably in China where there were about 30 million
migrant workers in 1989, 62 million in 1993, and 132 million
by the end of 2006, that is, 23% of the rural workforce [China
Labour Bulletin, 2008]. Nearly 18 million Latin American
migrants, legal and illegal, live in the United States, and the
pace of migrationdriven largely by the lack of economic
opportunity at homehas accelerated in the last 20 years,
despite U.S. immigration policies officially designed to
thwart it. Indeed, substantial percentages of the populations
of Mexico and many Central American and Caribbean
countries reside and work in the US [Council on Foreign
Relations, 2008]. The current economic depression however
has limited labor market opportunities for those migrants as
the official unemployment has soared above 8%. In low
income countries, large numbers of persons are forced to
migrate from rural to urban areas and into situations of
terrible vulnerability when subsistence agriculture is
replaced by cash crop economies under corporate control,
where corrupt governments militarize and force peasants out
of their land, or where ethnic groups and indigenous peoples
are evicted from their territories [Acharya and Marjit, 2000;
Bhattacherjee, 2000].
Migrant workers contribute to the economic growth
of high-income countries often serving as the labor force
that fills the 3 Ds jobs (dangerous, dirty and degrading
jobs) that national workers are reluctant to perform. Also,
immigrants and their families contribute by creating new
demands for housing and other products and services in their
receiving countries. On the other hand, countries of origin
may also benefit from their remittances. Recorded remittance
flows to low income countries (e.g., Guinea, Eritrea,
Tajikistan) are estimated at US $251 billion for 2007. Their
true size, including unrecorded flows through formal and
informal channels, is believed to be significantly larger. It is
estimated that remittance flows are more than twice as large
as total development aid and represent the largest source of
foreign exchange for numerous countries [World Bank,
2008]. On the negative side, migration represents a brain
drain of professionals in low and middle-income countries.
An important additional public health consequence is that
workers migrate away from their families leaving many
children alone. In the Philippines around 9 million children
(27% of the total youth population) are separated from one or
both parents due to migration [Yeoh and Lam, 2007], and in

Ecuador about 300,000 children and adolescents have

been left-behind by one or both migrating parents since
2000 [UNICEF, 2006].
Various sources of information indicate that public
health researchers should be concerned about the health
consequences of migration processes. A large array of
reports, books, documents, and case studies published in the
so-called gray literature show that migrant workers are more
represented in dangerous industries and in hazardous jobs,
occupations, and tasks. In most countries, migrant workers
are found in agricultural, food processing, construction,
semi-skilled or unskilled manufacturing jobs, and in low
wage service jobs. Immigrants are often hired as laborers in
precarious jobs with wages cannot support their families.
The precarious legal status of millions of irregular migrant
workers makes them more vulnerable to coercion.
Migrant workers tend to experience more serious abuse
and exploitation. In particular, forced labor most directly
affects migrant women working at the margins of the formal
economy with irregular employment [ILO, 2005a,b; WHO,
2006].
The second source of data comes from scientific research.
A recent systematic search found 48 papers published from
countries historically associated with immigration [Ahonen
et al., 2007]. While data are limited, the majority of studies
show that immigrant workers are at high risk for hazardous
occupational exposures, injury and death. Many studies refer
to occupational injuries, but there are also some analyses of
social exclusion, lack of health and safety training, fear of
reprisals for demanding better working conditions, linguistic
and cultural barriers that minimize the effectiveness of
training, incomplete surveillance of foreign workers, and
difficulty accessing care and compensation when injured.
All together these factors paint a worrisome picture
for the health of immigrant workers. In addition, migrant
status can be an important source of occupational health
inequalities. A recent global report on employment and
health inequalities suggests that migrant status is a key crosscutting axis linking employment and working conditions to
health inequalities through diverse exposures and mechanisms [Benach et al., 2009 forthcoming]. For example, the
impact of Korean employment conditions on workers
mental health is worse for immigrants, minorities and union
members because of their labor market vulnerability and the
hostility of management to union organizers and members
[Muntaner and Chung, 2009 forthcoming].
The impact of the global economic recession is likely to
heavily impact migrants since they are among the most
deprived workers. While there is still limited empirical
evidence, a number of negative effects of the global
economic crisis on migrants and migration have been
recently summarized [IOM, 2009]. First, there are restrictions on new admissions of migrant workers and non-renewal
of work permits. For example, a stop on all new entries of

Immigration, Employment Relations, and Health

foreign workers has been put into place in the Republic

of Korea, Malaysia and Thailand, and more restrictive
immigration policies are being adopted in Australia, Italy,
and Russia to protect the local labor markets and in response
to a decreased demand for foreign workers. Second, there are
massive job losses in employment sectors sensitive to
economic cycles such as construction and manufacturing,
as well as financial services, retail and travel/tourism-related
services, thus affecting migrants in these sectors. Third, in
countries such as Malaysia, Singapore, and Russia there are
reports of reductions in wages or their non-payment, the
availability of fewer working days and opportunities
for overtime, and worse working conditions, which are
more likely to affect migrant workers due to their weaker
bargaining power. Fourth, newly arrived migrants or
precarious migrant workers are not eligible for many social
benefits and therefore are likely to risk particular hardship
upon loss of employment. Fifth, there are growing instances
of discrimination and xenophobia against migrant workers,
who are mistakenly perceived as stealing local workers
jobs particularly in low-skilled sectors of the labor market
(e.g., protests by native workers in the UK against the
employment of Polish migrants). Sixth, there is an increase in
the return of unemployed migrants to their countries of origin
(e.g., from the Gulf States to India and from Malaysia to
Indonesia) where they are also likely to face high unemployment and poverty constituting a potentially disruptive
element to economic and social stability at home and there
has been a significant reversal of rural-urban internal
migration in countries like China where about 10 million
migrants have returned to their villages because of lay-offs in
the manufacturing sector in urban centres due to a steep
fall in export demand. Finally, the crisis is expected to
impact differently male and female migrant workers
especially in affected sectors of the economy dominated by
one gender (construction in which men predominate and
manufacturinge.g., textile industryin which women are
overrepresented). Job losses and worse working conditions
for migrants are likely to impact disproportionately migrant
women, who are overrepresented in the informal, lowskilled, and unregulated sectors of the economy (e.g.,
domestic and care work). For women, return could mean
losing the economic independence and for families a
reduction in income due to the end of remittances.

RESEARCH NEEDS AND CHALLENGES

The overall impact of immigration on population health
still is poorly understood. Existing reviews on this topic
are scarce, have tended to focus on specific immigrant
collectives, and include little information about similar
characteristics across different areas and groups. This is in
part due to the fact that generalizations are difficult across
periods, cohorts, nations, and ethnic groups. For example,

studies in the Canadian context show evidence of a healthy

immigrant effect, whereby immigrants, and especially
recent immigrants, are less likely than the Canadian-born
population to have poorer health. Yet other studies in
wealthy countries find worse health among immigrants than
among nationals [Ahonen et al., 2007]. Moreover current
empirical scholarship has only provided a limited description of the pathways and mechanisms linking migrants
employment and working conditions to health and health
inequalities.
Policies to achieve better employment and working
conditions among immigrants will require the implementation and evaluation of intersectorial programs. To identify
what works across different historical and political contexts
is therefore an urgent and essential task.
The above limitations highlight our need to urgently face
a number of challenges. The first one lies in the difficulty of
coming to a consensus about the fundamental nature of migration and its conceptualization. Terms such as ethnic minority, minority group, foreigner and migrant are often used to
refer to non-native populations. For example, foreign
migrant workers are foreigners that exercise an economic
activity remunerated from within the receiving country while
seasonal migrant workers are persons employed by a
country other than their own for only part of a year. There are
multiple potential ways in which various immigration statuses
affect populations health through employment and working
conditions. Therefore, we need to identify not only general
dimensions of migration but also multiple migration related
employment and working conditions in different social
contexts and for different types of jobs and workers.
A second related challenge is the need to develop
conceptual models to systemically understand empirical
evidence. These models will facilitate further investigations
and analysis of causal mechanisms. Explanatory models are
necessary for both guiding public health interventions by
identifying the main entry-points of action and the
evaluation of these interventions.
A third challenge concerns the need to obtain high
quality data and information systems, including reliable
estimates of international migration flows, national-level
data on the incidence and magnitude of migration, migrant
workers employment and working conditions, and the
health status of migrants. A major gap in international
migration research is the lack of consistent, comparable data
across countries. This limitation hinders effective public
policy initiatives that address the health-related impacts of
migration [Bilsborrow et al., 1997]. Most countries do not
have adequate national systems to monitor key occupational
health problems of migrants and most official and nonofficial statistics do not disaggregate migratory flows by age,
gender, ethnicity, and social class. Increasing population
mobility complicates the estimation of the number of
migrants. Governments and health agencies should establish

Benach et al.

adequate information systems and research plans to gather

data on migration processes and hard to reach or undocumented migrants [Garca et al., in press].
In many regions, neoliberal policies have produced a
growth of undocumented workers who face an extraordinary
array of occupational hazards as they work in a
hidden economy. In Spain, for example, undocumented
migration is estimated to be about 1.6% of the population
(540,000 persons) [OCDE, 2007]. Undocumented workers
often toil under precarious conditions, are exposed to
high rates of unsafe working conditions and experience
barriers to health services utilization [Sokas and Buchanan,
2009 forthcoming]. Oversampling of migrant workers and
data-pooling are two approaches that can be used to
address the statistical instability introduced by of small
numbers migrant workers in many studies. Overcoming these
data problems will help not only to obtain better estimates of
injuries, mortality and morbidity, but to properly monitor the
evolution situation of immigrants and their health problems
to elaborate health policies and prevention programs.
The fourth challenge is the development of public health
research with more comparable studies. Today there is neither
a comprehensive description of global migration work
processes and situations, nor their consequences on health
and quality of life. For example to the traditional migration to
rich countries such as Australia, Canada, Germany, or the US,
we need to consider the migration occurring to middle and
low-income countries (e.g., Gulf States, South Africa). We
need better descriptive studies using data on their employment
and working conditions, and their legal and illegal conditions.
Comparison between documented and undocumented immigrant workers could help us to understand better the legal
status consequences on health. Although there are many
studies on ethnic inequalities and health [Landrine et al., 2006;
Alterman et al., 2008], only a few studies have examined
ethnic discrimination among migrant farmworkers [Holmes,
2006; Alderete et al., 1999]. In addition, there is need for
research on new forms of displacements such as environmental refugees (in addition to political refugees and migrant
trauma survivors) due to growing environmental degradation
and declining land fertility, particularly in low-income
countries. This might result in millions of people vulnerable
to various diseases and all forms of exploitations including
forced labor [Benach et al., 2009 forthcoming]. Another gap in
current knowledge is the relationship between unemployment
and health in the poorest areas of the world, and more
specifically in countries with severe economic and social
crises, such as war, poverty and mass migrations in Iraq,
Afghanistan, and Africa South of the Sahara.
Finally, knowledge of the condition and health impacts
of the forced labor among immigrants is still very limited due
to its secrecy and lack of proactive roles of concerned
authorities [Vogel, 2008]. Studies on immigrants under
slavery and bonded labor have mainly given a qualitative

picture of disease patterns and the role of social determinants.

There is little understanding, however, of the demand pattern
for forced labor in different sectors, and hence it is necessary
to construct detailed spatial and temporal analyses of existing
and emerging regions of economic growth centers, markets,
product supply chain, and movement of labor forces [Benach
et al., 2009 forthcoming]. In that sense, international labor
agreement such as those in NAFTA or GATTS are essential to
understand recent growth of migration via guest worker
programs and their effect on migrant health [Vogel, 2008].
While in the last decades it has been accumulated experience
with surveys on working conditions in wealthy countries
(e.g., the European Surveys on Employment and Working
Conditions), it is necessary to carry out surveys on working
conditions in middle- and low-income countries, with special
attention to workers in informal employment.
A fifth challenge refers to the need to develop new
instruments and measures capable to analyze the specific
mechanisms through which employment and work may
damage immigrants health. There is the pressing need for
more powerful epidemiological designs that integrate
several levels of individual and contextual variables at the
national and regional level, as well as studies that integrate
quantitative and qualitative data. The use of mixed-methods,
integrating quantitative, qualitative and historical research
may contribute to a better understanding of the pathways,
mechanisms, and explanations linking unemployment and
health inequalities, as well as to evaluate the effectiveness
of interventions. A particular issue of concern is how to
ascertain exposure to hazards in a particularly mobile or
nomadic population. For example, occupational injuries are
common in street-corner day laborers, but calculating
injury rates is challenging due to the constantly shifting
denominator; workers enter and leave the workforce
frequently and perform different jobs every day [Sokas and
Buchanan, 2009 forthcoming]. Participatory research may
help to clarify some important issues, such as the dynamic
between informal and formal employment, decisions concerning leaving formal jobs and access to health care and
preventive resources.
A last challenge is the need to conduct analytical
research as well as detailed realist reviews to understand the
mediating mechanisms between the employment and working conditions of immigrants and their physical and mental
health, and their health behaviors. By focusing only at the
individual level we will remain unable to understand the
complex social issues involved. By looking carefully at
social class, gender, ethnicity and race, we can begin to
generate possible hypotheses about their effects on health
risk. There is thus a pressing need to generate models that
specify how macroeconomic processes, country-level and
regional factors, individual employment situations, and
health are interrelated. The research questions to be answered
are many. For example, what are the mechanisms underlying

Immigration, Employment Relations, and Health

the higher morbidity of immigrant workers? What are the

health damaging pathways among immigrants by social
class, gender, or ethnicity? What are the underlying pathways
and mechanisms explaining the different effects of precarious employment by migrant status [Benach et al., 2009
forthcoming] Are immigrants more exposed to workplace
discrimination resulting in a disproportionate exposure to
occupational hazards? How does the mechanization of
agriculture affect migration? Does migrants health status
improve after legalization? Does country of origin (e.g.,
Mexico) culture have an impact on coping mechanisms
among low-income migrants [Noh et al., 2007]? How does
NAFTA affect the working conditions of maquiladoras?
Does social class moderate the effect of migration on health?
[Borrell et al., 2008]? Or what is the health status of
undocumented versus documented migrants [Vogel, 2008]?

CONCLUDING REMARKS
Although its mechanisms, pathways and overall impact
are not well known, current evidence shows that the work
organization and employment conditions that many migrant
workers face are dangerous to their health. Areas where more
research and interventions are needed include the conceptualization of migration processes and situations, the establishment of surveillance systems with data on migration, the
conduct of analytical research, and the implementation and
evaluation of policies and interventions. More research and
comparable global data on the effects of migration are needed
in order to make employment and working conditions more
salient in migration debates and policies. Researchers should
also think about the larger social and economic structures
which may contribute to the poor health of immigrant
populations. A hypothesis increasingly confirmed is that
immigrant workers are the weakest link of labor market in
rich countries, especially hazardous in an economic crisis
period as the current one. Neoliberal economic policies for
example create new international guest worker systems
guiding the flow of migrants to fulfill corporate labor needs
[Benach et al., 2009 forthcoming]. If all international
immigrants recorded were to form a single political entity,
they would represent the worlds fifth most populous country.
Even if migration had a only modest impact on workers
health, given the growing number of immigrants globally, the
potential impact on the populations health would be large.
Research funding organizations and public health researchers must therefore start to give a much higher priority both to
investigate and to improve the health of immigrant workers.

ACKNOWLEDGMENTS
This study was partially financed by the project Work,
migration and health (ITSAL), by Fondo de Investigaciones
Sanitarias (PI050497).

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