Restrictive entry and integration policies are having an adverse effect on the health of migrants in high-income countries, according to the most comprehensive assessment of the impact of general migration policies on migrant health, published in The Lancet Global Health journal.
The systematic review and meta-analysis, synthesising all the available evidence from the scientific literature, finds that international migrants facing restrictive policies such as temporary visa status, detention, and reduced access to welfare are less likely to use general health services (hindering individual and public health), and are at greater risk of poor mental health and dying prematurely from any cause compared with native populations.
The authors say that efforts to improve the health of migrants would benefit from adopting a 'Health in All Policies' perspective, which considers the health effects of all migrant-orientated policies, and embracing a human-rights framework that emphasises the rights of migrants under international law. [1]
"The steady rise in international migration from an estimated 155 million people in 2000 to 258 million in 2017 has been met with increasingly hostile policy responses across the world--putting migrants at risk of ill-health and psychological damage, and profoundly undermining their human rights," says Dr Sol Pía Juárez, Stockholm University, Sweden, who co-led the research. [2]
Co-author Dr Andrea Dunlavy, University College London, UK adds: "More inclusive approaches to support the integration of migrants into their host societies is likely to have a positive effect on migrants' health and life opportunities, as well as benefiting local populations. While international law supports improving the health of migrants, its enforcement is weak, and countries must be held to account. Without sustained and strong political action, healthy migration policies will not be achieved, to the detriment of all." [2]
Contrary to widespread belief, migrants to industrialised nations are generally healthier than people in both the country they leave and their destination country [3]. Concerns that unfounded myths about migration and health have enabled governments to introduce hostile and restrictive policies in many countries was the focus of a recent Lancet Commission on Migration and Health [4].
In the UK, hostile policy responses have been highlighted by the Windrush scandal of 2018, with long-term migrants being deported midway through medical treatment, whilst attempts to withdraw legal protection to undocumented migrants in the USA has resulted in migrants being jailed and children separated from their parents.
Previous research on migrant health has largely focused on mental health, infectious diseases, or health inequalities between migrant groups, rather than looking at the effects of migration policies targeting social determinants of health such as access to labour markets, education, housing, and welfare services.
In this study, the researchers took the novel approach of isolating the effects of different public policy types (i.e., whether access to health-promoting resources and opportunities was generous, restrictive, or inclusive) at multiple stages of the migration process (i.e., entry, integration, exit) on health outcomes among international migrants.
They conducted a systematic review and meta-analysis of all quantitative studies examining the impact of non-health-related public policies on migrant health compared with other populations who had not been exposed to these policies between January 2000 and September 2017. Data were analysed for 46 articles conducted in high-income countries that focused on the health-related impact of integration (37 articles) and entry policies (nine articles; table 1). Pooled estimates from 19 articles were included in the meta-analysis.
Results suggested that more restrictive entry policies including temporary visa status and detention were associated with increased levels of poor mental health among migrants including psychological distress, depression, and anxiety.
Compared to groups exposed to less restrictive integration policies (particularly those related to welfare eligibility and documentation requirements), international migrants were more likely to report poor general health, and faced greater risk of poor mental health and adverse birth outcomes (e.g., infant mortality), and were at higher risk of premature death.
The mortality disadvantage was particularly striking in 'exclusionist' settings, such as Denmark, where some groups of migrants were twice as likely to die prematurely, compared to comparable groups of migrants in 'inclusive' settings, like the Netherlands (see figure 3B).
Welfare restrictions (as in the USA) were shown to limit migrants' use of general health-care services, but did not appear to markedly reduce public health insurance coverage or the number of uninsured (figure 4).
"Migration policies contribute to health inequalities and are key social determinants of health--impacting health directly through access to care, and indirectly via social and economic policies. Future research on how these policies impact medium- and long-term health, as well as whether the effects differ by gender, age, socioeconomic position, and reason for migration will be equally important for informing healthy migration policies," says co-author Ms Helena Honkaniemi, Stockholm University, Sweden. [2]
The authors note several limitations, including that the effects of migration policies have yet to be studied in low- and middle-income countries and across other dimensions of migration policy, such as housing and educational opportunities, and deportation and exit procedures. They also highlight some methodological limitations such as potential confounding (eg, differences in unmeasured factors which may have affected the health outcomes of the study), and a lack of natural experimental studies to isolate policy effects--which limit the conclusions that can be drawn.
Commenting on the implications of the findings, Prof Kayvan Bozorgmehr from Bielefeld University and University Hospital Heidelberg in Germany says: "The study represents a timely, innovative, and highly needed contribution to migrant health research... It forges a pioneering evidence base for the impact of non-health-related policies on migrants' health; especially in areas where the population already suffers remarkable vulnerabilities such as poor mental health and reduced access to obstetric care. This evidence-base is required to address harmful migration policies under the right-to-health framework, and to hold nations accountable for their obligation to respect the right to health in a non-discriminatory way."
However, he cautions, several questions remain to be answered: "How is the effect of non-health-related migration policies mediated, what are the mechanisms at work, and how can adverse effects be mitigated? What is the economic cost to society of restrictive policies? What are entry points for change, and which actors and tools can be leveraged to promote the human right to health, given that policymaking processes are often messy and the adoption of restrictive policies is driven by antimigrant ideology and power-acquisition motives?"
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Peer-reviewed / Systematic Review and Meta-analysis / People
NOTES TO EDITORS
This study was funded by Swedish Council for Health, Working Life, and Social Research; UK Medical Research Council; Scottish Government Chief Scientist Office. It was conducted by researchers from Stockholm University, Stockholm, Sweden; Karolinska Institutet, Stockholm, Sweden; University College London, London, UK; Centre for Data and Knowledge Integration for Health (CIDACS), Salvador, Brazil; University of Glasgow, Glasgow, UK.
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[1] WHO's 'Health in All Policies' approach is particularly relevant for the health of migrant populations, who are affected by both general and migrant-specific policies in the destination country, including those pertaining to entry (visa and entry criteria), resettlement (dispersal policies), short-term integration (language classes), long-term integration (anti-discriminatory policies in the labour market, democratic participation, and citizenship policies), and forced and voluntary return migration (deportation procedures). https://www.who.int/healthpromotion/frameworkforcountryaction/en/
[2] Quotes direct from authors and cannot be found in text of Article.
[3] https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)32781-8/fulltext
[4] https://www.thelancet.com/commissions/migration-health
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