II. Setting the scene

A. Migration and mobile populations

The International Labour Organization (ILO) recently estimated⁸ that over 90 million people (migrant workers and their families) are currently residing, legally or illegally, in a country other than their own. It should be noted that this lower estimate, compared with the 1995 estimate by the World Bank of 125 million people living outside their countries of origin, does not include people who had officially changed their original nationality.⁹ Table 1 below (taken from the ILO report) breaks down this figure by region.

⁸ ILO. Migrant Workers, International Labour Conference, 87^th Session 1999, Report III (Part 1B). Geneva, 1999

⁹ The lower estimate by the ILO may be due to naturalized citizens being excluded as part of migrant populations, but included within the World Bank scope of people living outside their country of origin.

Table 1. Estimate of the number of non-nationals by major region in 1995, excluding asylum-seekers and refugees (in millions)¹⁰

Region	Economically active	Dependants	Total
Africa	6-7	12-14	18-21
North America	8	8-10	16-18
Central and South America	3-5	4-7	7-12
South, South-East & East Asia	2-3	3-4	5-7
West Asia (Arab States)	6	2-3	8-9
Europe	11-13	15-17	26-30
Overall Totals	36-42	44-55	80-97

¹⁰ The estimate refers to foreign passport-holders, not to foreign-born persons because the latter include an unknown proportion of naturalized persons who no longer hold the nationality of their country of origin. The figures given here include both regular migrants and migrants whose status may be irregular as regards entry, stay or economic activity.

Some countries may be major senders of migrants, some major receivers, and in many cases, countries may be both substantial senders and receivers of migrants. The ILO has stated that in 1990, over 100 countries were major senders or receivers of migrant labour, with 68 countries listed as major receivers, 56 as major senders, and 24 as both a sending and receiving country.¹¹ Italy, Japan, Malaysia and Venezuela were noted to be among the new major receiving countries, and Bangladesh, Egypt and Indonesia among the new major senders.

¹¹ ILO. Migrant Workers, 1999, op. cit., p4

In 1996 about 7 million (~3%) of the United States population were born in Mexico. Of these, 2.7 million were estimated to be unauthorized migrants. Between 80 and 90 per cent of these migrants are male, mostly single or unaccompanied, between 15 and 34 years of age.

Movement within and between countries may be disproportionately heavy in some regions: in a region of Ziguinichor, Senegal, 82% of men aged between 20 and 40 migrate each year.

However, despite the perception that a typical migrant is male, the ILO Migrant Workers Report notes that about half the entire 1999 migrant population worldwide is female.¹² The Report draws the attention of governments to the particular vulnerability to exploitation and abuse of women migrant workers: "No longer only to be found among accompanying family members, women now make up an increasing proportion of migrant workers: for instance, nearly half a million Sri Lankan women are working in the Middle East, while there are 12 women for every man among migrants from the Philippines to other Asian countries... The Committee notes in particular the increasing tendency to 'import' women migrant workers for commercial - including sexual - exploitation through arranged marriages with foreigners or by getting them to sign contracts of employment that look tempting but rarely reflect the real situation. Their vulnerability lies principally in the fact that they are employed abroad and hence outside the legal protection of their country of origin, but is also due to the fact that they often hold jobs for which there is little protection under social legislation: domestic workers, manual workers (in agriculture, factories or export processing zones), hostesses or entertainers in nightclubs or cabarets, etc. Their situation is made worse by the lack of autonomy and the strong relationship of subordination that are typical of the jobs usually held by these workers; added to this is the fact that these women are usually young and poor, living in fear of losing their jobs, having had to leave their families in their countries of origin, do not speak the language of the country of employment, are unaware that they have rights that are being infringed, and usually do not know where to go for help."

¹² ibid, p105

Migration and gender issues are inextricably linked. As Singhanetra-Renard¹³ notes "Since women migrants almost invariably possess lesser bargaining power and legal rights than locals and particularly local men, the role of migration in the victimisation of women, and thus, the spread of HIV infection, cannot be ignored." In addition, a particular risk for women migrants is the wide scale and syndicated trafficking of women worldwide. These women, most of them very young and from economically depressed countries or communities, may be forced into sex work, frequently including unprotected sex.¹⁴

¹³ Singhanetra-Renard A. "Population movement and the AIDS epidemic in Thailand", Paper presented at the IUSSP Seminar on Sexual Subcultures and Migration in the Era of AIDS/STDs, Bangkok, Thailand, March 1994, p14

¹⁴ Ybanez RFC. "Breaking Borders: Migration and HIV/AIDS" AIDS action, Issue 40, July-September 1998

There are often specific pressures placed on workers who migrate. A WHO Background Paper on Long Term Travel Restrictions and HIV/AIDS¹⁵ notes: "Newly industrialized States may welcome migrant workers. But at the same time, they may seek to prevent such workers from acquiring long term settlement rights, so they can be sent home if they cease to be economically useful because of changing labour demands or because of age, illness or disability. Fixed term employment contracts and work permits may be imposed on migrant workers to ensure that they provide the employer and host country with a 'rotating stock of temporary labour'.¹⁶

¹⁵ WHO. Background Paper: Long Term Travel Restrictions and HIV/AIDS. WHO Global Programme on AIDS, October 1994, p4

¹⁶ Papademetriou DG. "International migration in North America and Western Europe: trends and consequences" In Appleyard R (ed). International migration today: Volume 1, trends and prospects. Paris, UNESCO, 1988, as quoted in WHO Background Paper, ibid.

The ILO has noted that, in general, countries adopt three approaches to social policies involving migrants:

· countries which accept migrants for permanent settlement on entry, such as Australia and Canada, appear more likely to favour social policies aiming at both social integration and 'multiculturalism'

· countries which issue permanent resident status after a number of years in the country are more likely to focus on 'assimilationist' policies

· countries who view migrants as primarily temporary workers are likely to favour voluntary repatriation and reintegration assistance. For example, Germany does not admit migrants for permanent settlement on entry, and devotes much of its social policy objectives to encouraging voluntary repatriation through the institution of the Coordinating Agency for Promoting the Reintegration of Foreign Workers.

Germany has become one of the main migratory destinations in Europe. Officially, almost 10% of the population is composed of migrants. However, if those living and working irregularly were included, the percentage would be significantly increased.

There are also three types of provisions relating to illegal immigration in national laws and regulations: those directed at migrant workers in an irregular situation; those aimed at punishing persons who organize or facilitate clandestine or illicit migrations; and those penalizing the illegal recruitment and employment of migrant workers. The ILO¹⁷ noted with concern that measures to combat clandestine movements of migrants were advocated to be targeted at the demand for clandestine labour rather than the supply; however, in practice, sanctions against migrants in an irregular situation are very widespread, both in sending and receiving countries. Sometimes these sanctions may be directed against the dependants of illegal migrants rather than the migrants themselves: for example, an Amendment in California, United States, in 1996, which attempts to discourage irregular immigration by barring children of undocumented migrants from state-funded education (from kindergarten to university).

¹⁷ ILO. Migrant Workers, 1999, op. cit., p130

Between 1989 and 1996, there were more than 900,000 refugees, 1.1 million internally displaced persons, and 4.2 million repatriates in the Commonwealth of Independent States (CIS). Environmental degradation has also resulted in hundreds of thousands of ecological migrants. In addition, legal and illegal transit migration increased. Between 500,000 and one million illegal migrants, particularly Afghans, Iranians, and Iraqi Kurds, are estimated to be living in the Russian Federation alone. Emigration, largely to the CIS, has increased dramatically from countries with ongoing armed conflict, such as Armenia, Georgia, and Tajikistan. With some notable exceptions, the greatest number of current migrants have moved for economic reasons, and in contrast with most other such movements, the age composition of the migrant population is very similar to that of the general population.

As noted in the UNAIDS Technical Update on Migration and HIV/AIDS¹⁸, population movement has increased in recent years because of:

· greater availability of rapid and (relatively) inexpensive air transport

· opening of once-closed borders, notably in Eastern European countries and the Commonwealth of Independent States (CIS), South Africa, and Economic Free Zones along China's east coast

· rising international trade and commerce, along with deregulation of trade practices and promotion of regional free trade

· increasing awareness of these imbalances including by populations in poorer countries.

¹⁸ UNAIDS. Technical Update on Migration and HIV/AIDS, UNAIDS, 2000

Substantial global movement of peoples is only expected to increase during the coming years. Migration has always been based on the desire for greater prosperity and/or escape from civil or natural disasters. By the year 2000, only some 20% of the world's population will live in developed countries, and economic polarization may contribute to increased migration. Similarly, as noted by Gellert,¹⁹ environmental problems associated with increasing industrialization such as rising sea levels from global warming, desertification and deforestation, may lead to significant increases in the numbers of ecological refugees.

¹⁹ Gellert GA. "International Migration and Control of Communicable Diseases", Soc. Sci. Med. Vol. 37, No. 12, 1993, pp 1489 - 1499

Given the growth in the numbers of countries adopting policies to lower immigration,²⁰ combined with this external pressure of increased global movement, the numbers and proportion of illegal and marginalized migrants in many countries can also be expected to increase substantially in the future.

²⁰ See, for example, Crossing Borders, op. cit.

B. Health needs and equity

Health has been recognized as a fundamental human right. The Constitution of the World Health Organization defines health as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity." In relation to non-citizens, most countries have defined their obligations in terms of essential care or care in emergency situations, with this concept being interpreted in different ways in different countries. Even in relation to officially accepted migrant workers, special arrangements to ensure real equity in access to health (compared with nationals) are rarely put in place.

There have been a number of reports documenting the reduced access to health care and the health consequences for migrants in many parts of the world.²¹ Bollini and Siem argue that the poor health outcomes observed are linked to the lower entitlements for migrants and ethnic groups in the receiving countries.²² They note: "Not only are they exposed to poor working and living conditions, which are per se determinants of poor health, but they also have reduced access to health care for a number of political, administrative and cultural reasons which are not necessarily present for the native population, and which vary in different societies and for different groups. Language, different concepts of health and disease, or the presence of racism are examples of such selective barriers."²³

²¹ See, for example, European Project AIDS and Mobility: AIDS & STDs and Migrants, Ethnic Minorities and other Mobile Groups; the State of Affairs in Europe, de Putter J (ed.). June 1998; Haour-Knipe M and Rector R. Crossing borders: migration, ethnicity and AIDS. London, Taylor & Francis, 1996; ILO: Migrant Workers, International Labour Conference, 87^th Session 1999, Report III (Part 1B). Geneva, 1999; Mishra SI, Conner RF and Magana JR (eds.) AIDS. Crossing Borders: The Spread of HIV Among Migrant Latinos. Colorado, Westview Press, 1996

²² Bollini P and Siem H. "No Real Progress towards Equity: Health of Migrants and Ethnic Minorities on the eve of the Year 2000", Soc. Sci. Med. Vol. 41, No. 6, pp 819-828, 1995

²³ ibid, p821

Of course, 'migrants' do not form a homogeneous group - Bollini and Siem note that the general trend to poor health outcomes may vary from one group of migrants to another and for individuals within a group - however, the general statement holds true in most parts of the world.

In general, the tendency for migrants to have less access to health care and resultant poorer health status is more marked for recent arrivals or for 'groups' who are otherwise more socially disadvantaged in the host society (e.g. North Africans in France, Bangladeshis in the United Kingdom, Indonesians in Malaysia). Tan²⁴ offers the term 'ethnic distance' to illustrate the elements of cultural differences and risk inherent in moves from one country to another, even where the same sending and receiving countries are involved. Using an example of two nationals of the Philippines moving to Hong Kong for work purposes, Tan notes that the ethnic distance for a young Filipina from a small village going to work as a domestic helper in Hong Kong is much greater than that for a young Filipino male executive also going to Hong Kong to take up a job with a multinational corporation. In cases where the sending and receiving countries are highly disparate in cultural values, this ethnic distance can be even more substantial.

²⁴ Tan M. "Migration and Risk", AIDS action, Issue 40, July-September 1998, p2

In addition, migrant workers with health problems often return to their home countries due to financial conditions, lack of proper immigration documents and ill health - this return is increasingly related to HIV/AIDS. Many countries have now experienced substantial numbers of nationals returning to die among their relatives or original communities.

This raises questions about the delicate balance required by governments and policy-makers between recognizing that migrants may be at risk of infection in their new environment, while avoiding, because of a common tendency to blame the 'other', any scapegoating of migrants for bringing HIV with them into the country/community. A recent initiative appears to be a good example of how to achieve this balance - Greece's Ministry of Health and Welfare is promoting an information programme with the slogan: "Taking Care of Migrants' Health at the Same Time as Our Own."

However, in the past there have only been rare instances of such approaches.

CARAM-Asia has reported on a number of violations of human rights of migrant workers that have an impact on their health and well-being. They have found that many migrant workers in South and South-east Asia experience oppressive working conditions, such as working 12 hours or more a day for six or seven days a week; inadequate food and unhealthy sleeping quarters provided by the employers, and other breaches. They note that sexual and physical abuses are yet other occupational hazards many migrant workers are confronted with. All these severe and abusive conditions of life and work can directly affect the immune system, and thus lead to migrants becoming immuno-compromised to various types of diseases and infections including HIV.

National statistics on disability and mortality may in particular underestimate the outcomes for semi-skilled and unskilled migrant workers - for example, Egger²⁵ et al. found that Swiss data missed out on significant numbers of these groups who had suffered occupational accidents and related disabilities but had then left Switzerland when they were too disabled or sick to work.

²⁵ Egger M, Minder CE and Smith GD. "Health inequalities and migrant workers in Switzerland", Lancet 816, Sept 29, 1990

In spite of the fact that migrant workers are selected for their good health and ability to work (the 'healthy migrant effect'), there is evidence that later in life many end up with a substantial burden of disability (the 'exhausted migrant effect').

However, specific interventions can be surprisingly effective: for example, Bollini and Siem²⁶ note that pregnancy outcomes (stillbirth and perinatal mortality) in Sweden were slightly better for foreign women than for Swedish women, even though many come from countries (notably Turkey) where perinatal mortality rates were very high compared with Sweden. They speculate that this may be due to the fact that, as reported by Sachs²⁷, considerable attention has been paid in Sweden to understanding cultural differences in mother and child care between Swedish and Turkish women, and to the provision of culturally appropriate services.

²⁶ Bollini and Siem, op. cit., p823

²⁷ Sachs L. Evil Eye or Bacteria. Turkish Migrants and Swedish Health Care. Stockholm Studies in Social Anthropology, University of Stockholm, 1993

One area of frequent neglect in respect of migrants' health needs is that of reproductive rights. The 1994 Cairo Conference redefined sexual and reproductive health within an ethical framework. The Conference acknowledged that:

- failure to address people's reproductive health needs is a matter of human rights and social justice;

- people have a right to make free and informed decisions about their reproductive lives;

- people have a right to information and care that will enable them to protect their health and that of their loved ones; and

- people have a right to benefit from scientific progress in health care.

Dr Gro Harlem Brundtland, Director-General of WHO, has stated that "defining reproductive ill-health as not only a health issue but as a matter of social justice provides a legal and political basis for governments to act."²⁸ She noted that "between 5 and 15% of the global burden of disease is associated with failures to address reproductive health needs. This burden hits people - particularly women - in the prime of their life, it hits when their potential, responsibilities, and productivity are at their highest. Globally, among women of reproductive age, more than 20% of total years of healthy life lost are due to three main groups of reproductive health conditions - sexually transmitted diseases including HIV/AIDS, maternal mortality and morbidity, and reproductive tract cancers. A further 10% of healthy years of life are lost due to conditions affecting the newborn." Anecdotal evidence appears to show that migrant women are affected disproportionately.

²⁸ World Health Organization. Statement by Dr Gro Harlem Brundtland, Director-General, World Health Organization, ICPD + 5 Forum, The Hague, 8-12 February 1999, p6

Another major lack in most countries is attention to the issue of migration and psychosocial health. As stated by Carballo and Siem, "The culture shock that often accompanies initial contact with a new sociocultural system can be psychologically complex and involve far more than the simple negation of access to local health and social services. Social integration and then acculturation is a complicated process involving linguistic, social, cultural, and conceptual transference processes that can denude migrants of everything they have previously been used to and which may have provided the basis for their identity. The migration of people from rural and often very traditional communities...to major industrial cities can equally involve a confrontation of widely different values, expectations, and ways of life. It is a process pregnant with psychological and psychosomatic problems which have remained poorly understood and even less well addressed by receiving countries."²⁹

²⁹ Crossing Borders, op. cit. p36

In addition to any specific issues, and as has been noted in many countries, the prevailing attitude towards immigration and 'foreigners' (or subgroups of 'foreigners') influence the response of the health care system to their special needs.

C. Concept of personal risk-takers

A number of papers have documented an association between human mobility and increased risk of HIV infection. For example, Chardin reported that while migrants make up 6% of the population of France, 14% of the reported cases of AIDS occur in migrants.³⁰ However, as Decosas and Adrien³¹ note, there are problems with many epidemiological surveys because they often lead to a focus on migrants rather than on the factors increasing vulnerability in mobile populations.

³⁰ Chardin C. "Access to new treatments for migrants living with HIV and AIDS: The Policy Maker's Point of View - the Political and Juridical Situation in France" in Access to New Treatments for Migrants Living with HIV and AIDS - Second Annual Seminar, National Focal Points, European Project AIDS & Mobility. Clarke K and Brg G (eds) October 1999, p15

³¹ Decosas and Adrien, 1997, op. cit., p578

Being a migrant, in and of itself, is not a risk factor; it is the activities undertaken during the migration process that are the risk factors.

People move for all kinds of reasons: business, pleasure, fleeing from political persecution or armed conflicts, seeking a better life for themselves and their children. This movement may not involve the crossing of any borders: in China, for example, about 100 million people are considered mobile between rural and urban areas, and from one urban area to another.

Increasingly, compared with earlier generations, many individuals in a number of countries have become bi-local or even multi-local, within a country or in a different country than the country of origin. Particularly for students but increasingly for many others, a pattern of circular mobility is part of life. As Singhanetra-Renard notes in regard to Thailand, "daily commuting, seasonal migration, periodic, short- and long-term circulation are undertaken by both the rural and urban population for employment, education, entertainment, as well as for other socio-cultural reasons."³²

³² Singhanetra-Renard, op. cit., p2

People's mobility tends to follow opportunities, taking place more frequently from rural to urban areas and/or from poorer to richer countries. But it definitely can be a two-way traffic: migrants who do well in the city or in another country will often return to their home villages bringing evidence of the good life.

And, while moving may increase vulnerability and lead to people engaging in higher risk behaviour, it is by no means axiomatic. For example, as Tan³³ writes: "rural women may not be able to break out of their low social status if they stay in their village. Their future is limited to an early marriage, often with little bargaining power and little support for reproductive and sexual health. Migrating to cities is still an option for social mobility and could actually mean a better quality of life and health. A shift to an urban environment, where sexuality-related issues can be more openly discussed, may also be beneficial."

³³ Tan M. op cit, p2

However, one of the characteristics of many mobile individuals, particularly those who are voluntarily mobile, is that they are risk-takers - they are gambling that a different environment will be beneficial to them. This concept of risk-taking may then lead on to choices they make in their private lives.

Sometimes people are able to move with their entire families. However, for much labour migration, this is not the case. In Asia, there is a large regional movement of female workers who provide domestic services; in many other parts of the world, single sex migration is predominantly male to sustain industries such as mining, construction and agriculture.

The changed circumstances may lead to increased personal risk: perhaps separated from family, from a regular sex partner, in single-sex housing, and with the stresses and vulnerabilities associated with the migration process. For some, there is a strong need for money to buy necessities or on which to subsist while waiting for employment. For others, the anonymity of being a foreigner, especially in transit areas, can increase sexual activities. Similarly, loneliness, frustration and peer pressure combined with easier access to drugs can make it hard for some to resist injecting drugs. And, of course, there may be drug dealers exploiting this vulnerability.

In some cases, moving may be undertaken so that the individual may engage in what might be illegal or considered shameful in their own neighbourhood. For example, CARAM-Asia has noted that "thousands of poor Vietnamese women come to Cambodia to earn [money] by engaging in sex work...one third of the commercial sex workers reported being born in Vietnam."³⁴

³⁴ Coordination of Action Research on AIDS and Migration, op. cit., p20

In many cases, mobility is related to a perceived upward social mobility. Singhanetra-Renard³⁵ documents that ways to social mobility for rural Thai can include:

- "Secure salaried employment in government, service, manufacturing or business enterprises even at the lower end of the hierarchy such as janitor, cleaner, or gardener, since it signifies a connection with city dwellers who have position, politically, financially or socially;

- Professional employment such as police, soldier, nurse, or secretarial job or any other position, including informal sector work, in which employees wear uniforms;

- Employment in enterprises which symbolize modernity or Western influence such as golf courses, discos, coffee shops, cocktail lounges, and karaoke bars;

- Marriage to a government official, Chinese, or others who have position, wealth, or connections."³⁶

³⁵ Singhanetra-Renard, op. cit., p9
³⁶ ibid, p9

However, Singhanetra-Renard also notes that routes to social mobility differ for men and for women, and that women will "often take a short-cut through commercial sex-work."

The numbers and proportion of communities affected by migration are not small: for instance, surveys in Africa found that between one-fifth and one-third of men and women reported living apart from their regular sexual partner, with one of two major consequences - sexual abstinence or having multiple partners.³⁷

³⁷ Cleland J and Ferry B. Sexual behaviour and AIDS in the developing world. London, Taylor & Francis, 1996, as cited in Haour-Knipe M and Aggleton P, "Social enquiry and HIV/AIDS", Critical Public Health, Vol. 8, No. 4, 1998, p261

This may lead to an outcome such as reported by Kane et al: a study of the nexus between migration and HIV status of Senegalese villagers found that 27% of the men who had previously travelled in other African countries and 11.3% of the spouses of such men were HIV-infected. In contrast, from the control group (414 people) who had not travelled outside Senegal in the previous ten years, only one man and one woman were HIV+.³⁸

³⁸ Kane F, Alary M, Ndoye I et al. "Temporary expatriation is related to HIV-1 infection in rural Senegal." AIDS 1993, 7:1261-1265

In Mexico, 25% of people reported to be living with AIDS in rural regions have a history of temporary migration to the United States.