Summary

The world is on the move.

Every year, over one million people emigrate permanently and in most years, nearly as many seek asylum. If we include in-country mobility, then there are probably two billion people on the move globally each year.

This paper addresses some of the issues involved in relation to the rights of migrants to health.

Firstly, there is no agreed definition of what is a migrant. Each country uses its own definitions in its regulations as to categories of travellers, migrants and new settlers. The paper utilizes a broad definition of migrants that encompasses all aspects of mobility in any population.

Secondly, what is encompassed in relation to rights to health? 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 health-related obligations in terms of essential care or care in emergency situations, with this concept being interpreted in different ways in different countries. Health care professionals often play a crucial role in deciding if a situation can be called an emergency. Could all health issues related to HIV/AIDS¹ be seen as falling within a global emergency?

¹ HIV = human immunodeficiency virus, AIDS = acquired immunodeficiency syndrome.

This paper argues for a number of changes to improve migrants' health (particularly in regard to HIV/AIDS, other sexually transmitted infections and reproductive health), at global, national and local levels. In summary, these include:

· Acknowledgment of the right to the highest attainable standard of physical and mental health. In relation to migrant populations, this might require attention to the right to affordable and accessible health services, the right to healthy working and living conditions, and the right to appropriate health education.

· Attention to, and compliance by all countries with international treaties and agreements to which they are a party, and to relevant international customary law. It appears that many countries sign international treaties/agreements but do not put in place the measures required for compliance with the letter and spirit of such agreements.

· General application of, and compliance with, the International Health Regulations.

· Measures to ensure major that sending, transit and receiving countries have joint/tripartite health access programmes in place to address all possible time and place points on the moving continuum for citizens/migrant workers, including pre-departure, the migration itself, the initial period of adaptation, successful adaptation, return migration, and reintegration into the original community.

· Health care services for travellers and migrant populations that move beyond emergency care, and address physical, mental and social well-being, particularly in relation to HIV/AIDS, other sexually transmitted infections, and reproductive health.

· Greater attention to prevention in health service policy and delivery for migrant/mobile populations, including widespread development and implementation of community-level interventions.

· For migrants and for mobile populations within countries, measures to ensure good access to health-related HIV/AIDS/STD/reproductive health prevention and care for all members of such populations. For example, appropriate health education may require the production of highly specific information material in a range of languages.

· Attention to the gender disparities often involved in migrant movements, both within countries and across borders, and to gender/power relationships which frequently govern women's access to information and health care.

· Understanding by major sending countries that contributions to the Gross National Product by migrant workers sending money back to their families may be balanced by pressure placed on health and social services, if a migrant worker returns to their home country ill or disabled.

The paper outlines key existing laws, policies and best practices in relation to the rights of migrants to health, and associated care, treatment, support and prevention, particularly in relation to HIV/AIDS/STD and reproductive health. The paper uses this framework of existing laws and policies to address ethical and economic dimensions, and to consider the effects of globalization and the implications of policies for migrant health. It concludes with recommendations for the development of policies to improve the health status of migrant populations.

Section Two of the paper sets the scene: A number of papers have documented an association between human mobility and an increased risk of HIV infection. However, 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.

The International Labour Organization (ILO) recently estimated that over 90 million people (migrant workers and their families) are currently residing, legally or illegally, in a country other than their own. Some countries are major senders of migrants, some major receivers, and in many cases, countries are both substantial senders and receivers of migrants. Movement within and between countries may often be focused on particular regions, with some regions in a country having disproportionately large numbers of population movement.

A number of reports have documented the reduced access to health care and the health consequences for migrants in many 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. In addition, migrant workers with health problems often return to their home countries.

Migration and gender issues are inextricably linked. 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, with concomitant increased vulnerability to exploitation and abuse.

Any international concerns in relation to movements of peoples are not expected to self-resolve. Substantial global movement of peoples is expected to increase during the coming years, with the numbers and proportion of illegal and marginalized migrants also expected to increase significantly.

Section Three of the paper considers issues involved in balancing international treaty obligations versus States' sovereignty, focusing on relevant declarations and treaties, the use of the International Health Regulations in respect of international spread of disease, and the effect of globalization. Section Four discusses access to health in terms of the financing of health care, the "new" public health, levels of access, the priority for early intervention, and the scope of intervention. Section Five describes a number of projects illustrative of some of the promising interventions under way in different parts of the world. Section Six outlines some of the particular implications for policy-makers of issues addressed within the paper.

The paper highlights a number of significant issues for policy-makers, including:

- The positive and negative effects of globalization;

- The ethical and economic imperative to ensure health care access for mobile and migrant populations;

- The real-life limitations on individual State's rights imposed by an international epidemic; and

- The need to address all time and place points on the moving continuum, including pre-departure, the migration itself, the initial period of adaptation, successful adaptation, return migration, and re-integration into the original community.

Progress in preventing the spread of HIV to and from migrants, and ameliorating the impact of HIV upon HIV-infected migrants has been made. Projects addressing other sexually transmitted infections and reproductive health for migrants and mobile populations are available in a number of countries and settings. The challenge now is to address more comprehensively the complex issues involved, in all countries and at all levels.