Just as a bit of background, I am a Demographer and Sociologist by training,

though my tenure as Director of the Global Health Affairs Program has allowed
me to delve into the epidemiologic side of health AND the broader political
economy of health: the narrative frames, biases, and power dynamics through
which we view health and disease.

And now a caveat. I have conducted a great deal of research on patterns of

migration and migration’s impact on health, particularly for populations left
behind by migration.

I have also studied HIV/AIDS. I have studied the vicious cycle linking
homelessness and HIV/AIDS in the US. And I now study the impact of
HIV/AIDS on the health and welfare of affected families in South Africa.

But you may have noticed that I have never actually looked at migration and
HIV/AIDS together. With good reason. The migration to HIV/AIDS link is a
tremendously challenging subject that raises deep moral and political
concerns. The United States and South Africa share, moreso than most
countries, a near obsession with blaming public health problems on vulnerable
communities, migrants among them. I thus come to this symposium with some
trepidation about the thin line between the humanitarian approach to infectious
disease and the securitization of migrant health.

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Here is my official financial disclosure slide. I have absolutely nothing to report.
I am not a clinician but I hope that my perspective will prove enlightening as
you all embark on an impressive two-day program.

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As a social scientist, the best way I know to help is to try and highlight the
specific pathways linking migration to health, which is the primary goal of my
talk. Is migration bad for your health? (Pause)

This question does not lend itself to a clinical trial.

2) The answer is highly dependent on processes of self-selection into

migration. Who migrates often ends up being just as important as the actual
effect of migration.

3) I will conclude by setting out some Hippocratic principles for addressing

migrant health in a clinical or social context.

4) And just to set the stage for an exploration of migration and health, Cal
Wilson asked me to include a bit of background on migration levels, countries
of origin, and areas of destination. Fortunately some of my amazing students
at DU had just prepared a presentation on the US migration system, and so I
have appropriated their slides and give special thanks to Megan Banick,
Shreesh Bhattarai, and Erica Rosenfield.

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Is migration bad for your health? (pause) Depends on who you ask.

A helpful starting point for understanding the migration-health nexus is to understand

ourselves and our narratives. This stylized graph offers a way to map migration
narratives according to two key value distinctions. The x-axis is the continuum of
intellectual interest, from humanistic, qualitative narrative on the left to scientific,
quantitative evidence on the right. As a deeply personal experience for so many,
migration provides many stories, but it also produces a considerable amount of
statistical data, at least in some instances. The y-axis shows a continuum of
political identity, from a commitment to free markets on the bottom to socioeconomic
justice at the top.

1) Anthropologists and advocates set migration in a narrative of what goes wrong when
free-roaming capital and globalization grab an unsuspecting and vulnerable target.
False hope, mortgaged land, HIV/AIDS, and television sets for poor nations.
Exploitation for the migrants. And lost jobs in the host society.
2) Economists, on the other hand, often find positive effects. This is what should
happen when capital-rich, labor-poor societies find cheap sources of labor, and the
occasional tragedy is just part of the statistical error term.

As a demographer utterly bereft of an indigenous theory to call my own, I tend to move

between each of these perspectives, and end up in the center. I will let you all find your
own place on this graph.

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Before we assess the effect of migration on health, we need to
establish a study population. Who is affected by migration?

Of course it is the migrants themselves who bear the risks and

reap the benefits of migration most directly.

But decades of research on the social, economic, and

biophysical connections between migrants, their host
communities, and those they leave behind have forced us to
view migrant health within this broader continuum of migration-
affected populations. To be clear, it is not just that the left
behind are affected by migration, it is that they are in fact very
active participants in the process as initiators, financiers, and
distributors of the returns.

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So what is this migration thing?

Before I turn to migration and health, let me provide some

background on immigration in the US. Here is the total number of
legal immigrants to the US by year from 1820 to 2007. The pattern
may be familiar to many. A massive migration peak straddles the
turn of the 20th century, before the gates were shut tight in a wave
nativist anger, restrictive laws, and two world wars. Migration
reemerged with the Bracero program, which brought Mexican guest
workers during and after World War II, and has risen steadily ever
since. Today the annual number of legal arrivals almost equals
1900. That number constitutes a much smaller share of today’s
vastly greater population, but these numbers also don’t even
include undocumented arrivals.

So migration is big, at least by historical standards.

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A more easily measurable and stable picture of migration comes
from the foreign-born population of the United States -- including all
past immigrants who have not returned to their countries of origin --
represented here as a share of total population.

Notice how much more consistent the foreign-born share looks

compared to the number of arrivals. The share dropped from World
War I on, but even by the end of World War II, when almost no
migrants had arrived for decades, the share foreign-born still
remained over 8%.

Today, once we account for the best possible estimates of the

current undocumented migrant population, we see that by the
beginning of the Great Recession, the share foreign born had
almost approached the level seen in the early 1900s. We will have
to wait and see what happens next.

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So where do migrants come from?

Two patterns dominate the trend in national origins of US immigrants.

1) On the one hand, the US foreign-born population has come to

include a broader and broader representation of the world’s nations.
This began with the 1965 Immigration and Nationality Act, which
reopened the US to migrants of non Western European origin. It
accelerated with the opening of the Diversity Visa lottery program in
1995, which offered permanent US residency to a select few
applicants from countries not previously represented in the American
ethnic quilt.

2) Even as the US migrant population has grown more diverse in terms

of number of countries represented, it has also come to include an
unprecedented number of people from a single country, Mexico,
which alone accounts for 30% of the foreign-born population. Though
perhaps some folks would be surprised that the Mexican share is not
even higher.

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The regional share of the foreign-born further illustrates the
diversity of today’s immigrant population as well as the dominance
of migrants from Latin America, who together constitute 54% of the
foreign born.

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People are probably pretty familiar with where migrants move to.
The lion’s share of the foreign born live in six large states that also
have a high percentage foreign born, led by California and followed
by Texas, New York, Florida, Illinois, and New Jersey. California
alone accounts for about one quarter of the entire US foreign born
population. As you see, Colorado is also moderately high. But
immigration rates and foreign born populations are rising in a great
many states with little history of immigration, particularly in the deep
south.

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Because of the dominance of migrants from Mexico, the map of the
foreign born looks quite similar to the map of the Mexican born.
Migrants from Mexico don’t just dominate the overall flow, they also
dominate the literature on migration and health in the US and
globally, which can present challenges for producing generalizable
knowledge.

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So, back to the question. Is migration bad for your health?

From a standpoint of pure epidemiology we can classify the effects of migration,

both positive and negative, as economic; occupational or environmental; and
behavioral.

1) Economic relates both to the positive and negative effects of increased income
and to the potential risks of unemployment or debt.
2) Next, migrants face many occupational or environmental risks in the workplace,
in their homes, and in their communities.
3) Finally, and of greatest interest for this conference, migration may induce
changes in behavioral risks such as unsafe sex, drug abuse, or smoking.

In the journal AIDS, Organista and colleagues offer an illuminating account of how
the nature and impact of these proximate risks will be determined primarily by the
context of migration. First comes the socio-cultural context of the migrant-sending
community and the community of destination, including cultural practices, social
support networks, and patterns of vulnerability and resiliency.

Above that is the structural context. This includes the legal rights of migrants (or
lack thereof), including documentation status. Related to legal regime are the
conditions of the migrant journey itself and of segregation on arrival.
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Okay, before we try to answer our question the right way, let’s look at how existing
research has viewed migrant health. In a highly illuminating 2007 study by
Cunningham and colleagues reviewed 74 existing studies covering a total of 34
mortality and 196 morbidity findings on the migration-health relationship.

Of these 230 total findings, just over a half compared the health of migrants to the
health of natives. From an epidemiologic standpoint, this comparison could be useful
for understanding the unmet health needs of migrants, but in general the comparison
is unfair and unhelpful in understanding the health of migrants. A causal research
design normally looks within a comparable group and identifies those factors that
lead some to have poorer health than others. But migrants are not pulled from a
comparable population; rather they joined this population, coming from a diverse
range of nations and ethnic backgrounds, and generally from greatly disadvantaged
circumstances. Truly an unfair comparison.

Most of the remaining findings reviewed by Cunningham and colleagues take the
somewhat more reasonable approach of comparing migrants to their native co-ethnic
population, for instance comparing Mexico-US migrants to US-born Mexicans,
including those whose families have been here 400 years. A closer comparison, but
still not quite apples to apples.

Many people in the room will already know the common, consistent and replicable
result of this unfair comparison… ( drum roll please ) On most dimensions of health
and in most comparisons, migrants have better health outcomes than natives.

Let me repeat that. Migrants have better health than natives. (Wake up)
From mortality to morbidity. Adult to perinatal. Communicable to noncommunicable.
Migrants have better health than natives in about three-quarters of all comparisons.
(Uh oh)
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A similar migrant advantage pertains to direct comparisons between migrants
and the US born co-ethnics, as seen in this example from a paper by Gopal
Singh and Robert Hiatt in the International Journal of Epidemiology in 2006.

Using data from the National Health Interview Survey and the National Death
Index, they report differences in life expectancy at birth for natives and non-
natives among three race/ethnic groups. For women, we see that Latina
migrants have a two-year advantage over US-born Latinas and black migrants
have a 6 years advantage over Us-born black women. Differences are small
among white women, but favor the immigrants slightly. Note also that both
migrant and US-born Latinas live considerably longer than white women.

These basic relationships held for both men and women and for specific
morbidity outcomes.

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So in spite of some incredibly poor risk factors – like poverty -- immigrants
actually have better health outcomes than natives.

But this is a pretty unhelpful comparison. The US-born comparison groups

come from highly diverse backgrounds and it is really not clear how migrants
should compare to them.

Comparison of migrants to natives not only prevents us from making a fair

comparison, but it keeps us from distinguishing between two clear hypothesis
that could explain the immigrant health advantage

1) First is the role of self-selection. Migrants may be so healthy simply

because only someone who is healthy in the first place could endure the
move

Anyone who has been through DIA security can attest to that!

2) Alternatively, perhaps there is something about the social, cultural, and

structural context of migration or migrant communities that actually allows
them to remain healthy, which would have even more profound implications for
migrant health programming.

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As in any observational study, we really need to tackle the
selection issue before we can get causal.

After controlling for selection, we should be able to compare

the health of migrants to reasonably comparable individuals
from the same population who did not migrate, AKA the left
behind.

Of course we would also need to account for the fact that

the left-behind themselves might be affected by migration.
More on that later.

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We start with selectivity, and here we begin to explore the nexus of structural,
sociocultural, and individual factors.

The legal, historical, and logistical context of migration sets the stage for migrant
selectivity.

- Is it a hard trip? Then there may be more health selectivity as only the hardiest
can make the trip. Or it might just attract those who with a penchant for risk.
- Is it a skilled migration flow? Then educational selectivity might be exceptionally
high, as in the case of migration from India to the US.
- Is migration simply a matter of buying a visa and a plan ticket? Then selectivity
might be financial, as in the case of guest worker migration.
- Finally, do political or environmental conditions in the sending community push
migrants out of the home area, as in the case of refugee flows? Then the
selection might be less extreme, because everyone has to leave, but we might
start to ask what factors of selection leave some displaced people in the next
village over, some in a camp a hundred miles away, and some in Denver.

Structural factors don’t just determine who moves within a community, but which
communities send migrants. Does a migration system encourage migration from
communities fragmented by racism, injustice, and displacement, as in Apartheid
and post-Apartheid South Africa?

Or does it encourage migration from tightly knit communities that are able to
recreate their social world in the destination and to recruit more and more folks
from home to join them, as has been the historical case in Mexico?

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Recently a few studies have begun to explore migrant health selectivity by
comparing recent migrants to the left-behind. The Mexican Family Life Survey
actually surveyed a large random sample of Mexico’s population, measured
health, and then followed everyone 5 years later, even if they found their way to
the US. A 2008 paper by Luis Rubalcava and colleagues shows the surprisingly
limited extent of selectivity. The blue bars are the inter-survey migration
probabilities of those in poor health based on a variety of reported and observed
health markers, orange bars indicate the migration of those in excellent health,
so this is capturing the absolute extremes of variation. For women, those in
excellent health are two to three times more likely to migrate than those in poor
health, sizable but not overwhelming. For men, the force of selection is even
weaker and, in the case of urban men, it is actually negative, with men in poor
health more likely to migrate than those in excellent health.

Of course, this is only one mode of selectivity in migrant health. There may also
be selectivity in return migration, with the healthier more likely to remain in the
US and thus to be surveyed. Second, selection on community strength,
financial resources, or educational attainment may be equally important for
long-term health as initial health. Finally, this study, like most studies of migrant
health in the US and indeed the world, focuses on the Mexico-US migration
experience, which is both wildly overrepresented in the research literature and
quite unique. While the risks of the Mexico-US trip might demand greater
physical fitness, the well-traveled pathways and strong social ties linking Mexico
and the US might also make the move more accessible to all.

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A paper by Cynthia Feliciano offers some insight into just how unique the
selectivity context of Mexico-US migration is. She calculates a Net Difference
Index comparing US immigrants from specific countries to their origin
populations, basically the extent to which migrants have higher levels of
education than the left-behind, with 1 meaning that every single migrant would
have more schooling than every single non-migrant and 0 meaning that a
randomly selected migrant would likely have the same level of schooling as a
randomly drawn non-migrant.

A typical migrant from Mexico would have a 20% chance of having more
schooling than a typical non-migrant, a pretty minor difference that mirrors the
Rubalcava result. For India, by comparison, a typical migrant would have an 85%
chance of having more schooling than the typical Indian, meaning that migrants
from India bear almost no resemblance, at least in schooling terms, to their
former compatriots.

A quick bit shameless self-promotion: To address the gap in research on migrant

health, I have the great opportunity to join my colleague Fernando Riosmena
from CU-Boulder on an exciting new project that will broaden our understanding
of migrant health by looking at migrants from China, India, the Philippines, the
Dominican Republic… and of course Mexico. The goal, of course, is not really to
address health selectivity in migration, but to move past selectivity and
understand what happens to migrant health next.

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Whatever the extent of selectivity might be, we are finally, at long last, ready to
think about our original question. Is migration bad for your health? (Ugh)

We again compare migrants to the left behind.

1) We would first want to account for the individual economic effects of migration.
Migrants may be able to buy more health care with their resources, but they also
buy more junk food. They might experience an economic crisis. These migrant
resources can also affect the health of the left behind, for instance if monetary
remittances are sent home. The closer we get to comparing a migrant to an
individual who is actually comparable, say a non-migrant from his own village
rather than just some person from a random sample of the entire country, the
more likely it is that the left-behind person’s health is also affected by migration.
I’ll get back to that in a minute.

2) Next we move to the contextual side. Much of migrant health are programmed
well in advance by the origin community context. This includes the migrant’s prior
child development and health-seeking behaviors at the time of departure. In
comparing a migrant to a left-behind member of the same community, we could
assume both would be affected by the origin context in similar ways.

3) And so one major change is that as the migrant spends more and more time in
the destination community, his or her current health will come to be more and
more determined by the destination context rather than the origin context.
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4) Of course it’s not quite that simple. First, that destination context may look an
awful lot like the origin context in a great many ways if the destination community
consists largely of people from home, a so-called ethnic enclave. Second, just as
the left-behind are affected by the resources the migrant accumulates in the
destination, so they may be affected by the context in which the migrant lives.
Migrants to a community like Boulder may be able to bring their relatives up north
for valuable surgeries, while migrants exposed to the wonders of cigarette smoke
or drugs may bring these habits back to the fold.

5) Finally, all of this, the resources, the destination context, and the connections
between origin and destination are determined by the structural context of the
migration process. The awkward legal conditions of migration expose migrants to a
great many health risk behaviors as well as some, but not many, health protective
factors. The trip itself might expose them to injuries or violence, to specific
communicable diseases like tuberculosis, or to risk factors for chronic disease.
Insecure legal status on arrival may expose the migrant to numerous risks, most
notable an avoidance of any hospital or clinic.

And so for many conditions, we are left with a real paradox. Migrants may come
from socially disadvantaged settings with better health than either the typical
American or those they left behind. Over time, this health advantage may be
eroded both due to the structural risks of migration and due to the assimilation of
negative health behaviors common in this society. Those we might associate with
greater levels of disadvantage, say those who are living in segregated areas, may
in fact be protected by the so-called “Barrio health advantage”.

So migration can be bad for your health, but perhaps not as bad you think, not in
the way you think, and not in the conditions you might expect it to be bad..
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Given the potential benefits and risks of migration, we might try to move
beyond a blanket statement like migration is bad for your health and
instead look to identify the specific structural conditions could lead
migrants to experience poorer health conditions than either their origin
or host communities.

This is important in the context of HIV/AIDS. Given that migrants from

Mexico come from a nation and typically from communities with
extraordinarily low rates of HIV/AIDS; that they may be moving to ethnic
enclaves with relatively low HIV prevalence; and that their communities
may further protect their health, under what conditions should we expect
migrants to be at widespread risk of HIV/AIDS?

One answer, of course, is that such scenarios should be relatively

uncommon.

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But we can start to piece together a risk profile. First, there are
scenarios in which migrants fall into a political and often
physical vacuum, for instance as trafficked individuals or
bonded workers. Though thankfully these scenarios are also
somewhat uncommon at the population level.

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On a more widespread basis, we might start to look for situations in
which migrants are exposed to the worst risks that their origin societies
and host societies have to offer, and which structural conditions might
amplify these effects.

One powerful historical example comes from the African-Americans who

attempted to settle in Liberia in the 1820s. Research by Tukufu Zuberi
documents how a population that had lost some of its natural immunity
to malaria and other tropical diseases quickly and shockingly
succumbed to the local environment, with about one-third of the settlers
dying in the first year.

On a more mundane level, we can observe many examples of migrants

with high levels of metabolic risk and low rates of exercise who
encounter a sugar- and fat-rich diet in this country, with disastrous
consequences.

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Stepping away from our own context, I always return to this photo from my
own fieldwork in Bangladesh. In shuttling back and forth between the rural
Matlab fieldsite and the capital Dhaka, I generally had the benefit of a
speedboat and shuttle bus, but once, during the great flood of 1998, I had the
privilege of sharing the overnight motor launch with this man, who had been
seeing his family three days a month for the past 10 years. The boat was scary
enough, and the commute and the living conditions on arrival were far worse.
but at least he got to see his family once a month.

The tightening of the US border has encouraged family separation for

exceedingly long periods of time. While the recession reduced the flow of
migrants from Mexico to the US, rates of return migration remained about the
same. Given the difficulty of crossing again and the likelihood that low wage
jobs would open up soon, many migrants decided to ride out the recession on
this side of the border.

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The recession also further accelerated the move of undocumented migrants
to unfamiliar destinations, primarily in the midwest and deep south, as we see
in this county level representation of the foreign born.

A recent study by Emilio Parrado and Chenoa Flippen of Duke University looks
at the sexual behavior risks of migrants from Mexico to their own neck of the
woods, North Carolina, and begins to weave a more compelling story of
potential HIV/AIDS risk. The authors acknowledge many of the protective
factors in Mexican culture and in Mexican migrant communities in particular,
but note some unique contextual conditions that predispose to higher
HIV/AIDS risk: migrants coming from more vulnerable and fragmented
communities in souhern Mexico, an unfamiliar destination area where migrants
have fewer close relations or institutions already in place; and longer spells of
husband-wife separation.

Taken together, these factors could encourage the increased usage of

commercial sex workers who themselves come from highly vulnerable and
AIDS-affected communities. Here we start to see a plausible scenario for high
levels of HIV/AIDS risk, and one that might turn up in other parts of the US,
say in parts of Colorado.

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What is critical here is how the changing structural conditions of
migration to the US may conspire to place migrants at increasingly
higher levels of risk, detached from the support systems that have
sustained their predecessors, and exposed to new risks of depression,
sexual risk, and other adverse outcomes.

Through it all we should also remember the other side of the migration
equation, the left behind. Migrants will make many sacrifices – risky
trips, difficult jobs, skipping the doctor’s visit – in order to send as
much money as they possibly can back to their families

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Here is a result from my forthcoming paper with Bethany Everett of CU-
Boulder and Rachel Silvey of the University of Toronto that looks at the
impact of children’s migration on the survival of elderly Indonesians. We
find that elders having a migrant child are only half as likely to die in a
four-year followup period as those without a migrant child, an effect that
is far larger than any socioeconomic, gender, or regional health
differential observable in that society.

Migration is most assuredly good for their health.

This is the flip side of migrant health risks, that those risks are often the
product of efforts to maximize the welfare of those left behind.

In other words, any clear answer to the question “is migration bad for
your health” will depend on whose health and under what specific
structural and contextual conditions.

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In closing, some of you may be saying, “I didn’t come here to learn whether
migration is bad for health. Some migrants are sick ;; they need health care,
and I want to treat them in the best way possible. How does this help me?

Good question! And so allow me to close by offering some humble principles

for action that attempt to apply the do no harm principle to the population level.

1) First, avoid ecological fallacy. Just because your patients are sick doesn’t
mean that the population is sick. And that patient with the very scary health
risk behaviors might not be indicative of a pattern, but the exception that
proves just how healthy a community is. In other words, collect some data
whenever possible.
2) One good way to collect data is to raise health capacity. Remember that
many, if not most, migrant communities have numerous capabilities and
resiliencies already in place that preserve their health. Don’t institute
programs that weaken these capacities, for instance by building a
dependency or stimulating an environment of fear. Focusing on general
needs -- like access to preventive checkups and insurance -- might be
much more helpful than targeting diseases having uncertain cause or
consequence.
3) In such an engagement, be mindful of our ugly history. Many immigrant
communities have been subject in the past and present to targeting as
vectors of disease. In America today, migrants who could never get
prenatal or emergency care are not merely offered active tuberculosis
treatment, they are forced to adopt it. When you deliver infectious disease
care in migrant communities, know that people make this association.
Focus on human rights and on maximizing trust.

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4) Unusually high levels of disease, vulnerability to disease, and distrust of
health providers are all most likely to emerge under conditions of extreme
flux, when social and political roles are uncertain, when communities are
broken apart, when basic rights are not protected. Examples in our own
society would include trafficked populations, new immigrant clusters
attached to high-risk industries, areas unfamiliar with and perhaps hostile
to immigrants, and of course the ever-present border town.
5) These risks are amplified when legal restrictions make clinical outreach
impossible, positive health behaviors illegal, and negative health risks
normal. I’ve already mentioned the potential consequences of spousal
separation resulting from tightened borders. A more frightening scenario
involves an immigration regime so tight that border control agencies can no
longer perform basic disease surveillance functions. Medical expertise is
needed to address the consequences of immigration reforms for medical
practice, health outcomes, and health security.
6) Finally, conditions of flux and legal vulnerability are amplified when vulnerable
migrant populations make contact with vulnerable host populations. This is
particularly true when migrants and hosts are positioned in competition for
scarce resources, jobs, or votes, as in areas of population transition like
South Los Angeles. At such moments it may be both more effective and
more safe to focus on disadvantage rather than status, particularly since
natives may fare even worse than migrants. A careful approach to
measuring and targeting the conditions and worst consequences of
disadvantage offers the potential for enhancing impact, promoting doctor-
patient trust, and mitigating grievances between groups.

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In the end, migration, migrant, and native are just concepts, and
very quirky concepts at that, implying often paradoxical
relationships and outcomes. Our shared mission is to heal all
wounds. And with that, I thank you all for your time and for this
special opportunity to further the bonds between the University of
Denver and the University of Colorado.

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