1. What is Migration Health? Alfonso Rodriguez-Lainz, PhD CDC Division of Global Migration and Quarantine 5 th Summer Institute on Migration and Health May 11, 2010

2. Outline What is migration health? What is migration? Who is an international migrant? Sources of international migration data Migrant health data sources Migration data: the way forward

3. What is Migration Health? Migration + Health

4. What is Migration Health? Migration + Health

5. What is Health? “ Health is a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity ” (WHO, 1948)

6. What is Health? “ Health is a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity ” (WHO, 1948) … it also applies to migrant populations (IOM, 2006)

7. Migration Health: beyond migrants themselves Health issues, conditions and risks related to migrant populations, and the way in which it also affects: –Population of origin, –Communities in the places of transit and destination, and –Second and later migrant generations (Roux, 2004)

8. Migration and the determinants of health Biological Behavioral Social environment Physical environment Policies and interventions Access to care MIGRATION- Related factors HEALTH

9. Migration-related factors Examples Migration process –Reasons for migration (forced vs. voluntary) –Mode of travel Country of birth Duration of residence (e.g., recent vs. long-term) Migration status (e.g., legal residents, temporary workers, refugees, unauthorized) Language proficiency Multi-country exposures (origin, transit, destination) –Culture –Environment –Disease prevalence –Living and working conditions –Access to care

10. What is Migration Health? Migration + Health

11. What is Migration Health? Migration + Health

12. What is migration? Photo: IOM

13. What is migration? There is no universally accepted definition and consistency in the use of terminology to describe migration

14. What is migration? Any process of movement of people, –either across an international border (i.e., international migration) or within a country (i.e., internal migration) –permanently or an a temporary basis, –whatever its causes Source: J. Weekers (IOM) Global Consultation on Migrant and Health, Madrid, Spain (3–5 March 2010); adapted from IOM Glossary on Migration (2004)

15. Who is an International Migrant? No internationally adopted definition

16. Who is an International Migrant? Immigrants? Aliens? Migrants? Illegals? Foreign-born? Migrant workers? Mexicans? Refugees? Foreigners? Ethnic groups? Minorities? Farmworkers? Seasonal workers Etc.

17. Why do we care about definitions?

18. To better understand migrant communities and migration patterns –Limit contradictory or misleading information Achieve comparability of migration statistics among countries Evidence-based program/policy-making

19. Great diversity among migrants Country of birth Migration pattern Reasons for migration Culture SES Education Occupation Language Migration status Health Risks Source: California Immigrant Integration Initiative of Grantmakers Concerned with Immigrants and Refugees

20. Migration Data Limitations Available data on migration has many limitations –“Enormous blind spot” –Even basic questions: e.g., How many? Demographics? “Old problem” Some improvements in recent years (Source: Commission on International Migration Data, 2009)

21. Initiatives to Harmonize and Improve Migration Data United Nations –Recommendations on statistics of international migration rev. 1 (1998) –Principles and Recommendations for Population and Housing Censuses rev. 2 (2007) European Parliament and the Council of the EU Regulation (EC) No. 862/2007 (2007) Commission on International Migration Data (2009)

22. International migrant definitions UN Recommendations

23. International Migrant UN Recommendations (1998) A person changing his/her country of usual residence “Country of usual residence”: Where a person has lived (or intends to live) continuously for at least 12 months Sources: - UN Recommendations on International Migration Statistics (1998) - UN Expert Group Meeting on the use of censuses and surveys to measure international migration, ESA/STAT/AC.132/1 (2007)

24. International migrants: Immigrant vs. Emigrant From the perspective of … –the country of departure the person will be an “emigrant” –the country of arrival the person will be an “immigrant” “Migrant”: –More neutral term –It disregards the direction of movement UN Recommendations on International Migration Statistics (1998)

25. Internal Migrant UN Recommendations (1998) A person changing his/her usual residence but within the same country –Rural to urban migration –Internally displaced persons (forced migration)

26. International Visitors Persons traveling to another country, and who are admitted for short stays for purposes of: –Tourism –Visits to friends or relatives –Business –Religious pilgrimages Do not intend to establish a usual residence in the destination country Not generally considered international migrants

27. Some statistics … International migrants214 million (2010) Internal migrants~740 million (2009) International visitors (recreational or business travel) 922 million (2008)

28. International migrants: Major categories Authorized migrants (temporary or permanent residence visas) Refugees Asylum-seekers Unauthorized migrants

29. Refugees A person with a well-founded fear of being persecuted for reasons of race, religion, nationality, social group or political opinion, is outside the country of his/her nationality and is unable or unwilling to avail himself of the protection of that country 15.2 million (2009) (Source: UN Convention Related to the Status of Refugees and the 1967 Protocol)

30. Asylum-seekers Similar to a refugee, but the person is in the country of intended residence at the time of his/her application 838,000 (2009)

31. Unauthorized migrants “A person who, owing to illegal entry or the expiry of his/her visa, lacks legal status in a transit or host country” –A.K.A: irregular, clandestine or illegal migrant (IOM Glossary of Migration, 2004)

32. Post-migration mobility patterns Settled permanently Internal migration Migrate to other country(ies) Return migration Circular migration

33. INTERNATIONAL MIGRATION DEMOGRAPHICS WEB-BASED DATA SOURCES

34. WEB DATA SITES o UN Population Division o Organization for Economic Cooperation and Development (OECD) o Research Centers, Think Tanks, Advocacy Groups: e.g., Migration Policy Institute

35. UN Population Division http://www.un.org/esa/population/migration/index.html Global Migration Database (1960-2010) CDs for purchase: –Trends in International Migration Stock: The 2008 Revision (CD) –International Migration Flows to and from Selected Countries: The 2008 Revision (CD) International Migration 2009 –Excel Table and Wall chart (Note: estimates of 2010 data)

36. Organization for Economic Cooperation and Development 30 countries (e.g., E.U. States, U.S, Canada, Australia, Mexico, Japan) OECD Migration Databases –http://stats.oecd.org/Index.aspx?datasetcode=MIG International Migration Data 2009 –Excel Tables (2007 data) –Reports : Sources and Comparability of Migration Statistics Report: International Migration Outlook, 2009

37. Migration Policy Institute Migration Information Source http://www.migrationinformation.org/ “Non-partisan” U.S and Global data Many reports and statistics

38. International migrant: Country-level definitions

39. International migrant Countries use different criteria: –Country of birth (i.e., native vs. foreign born) –Country of citizenship (i.e., nationals vs. foreigners) –Duration of residence –Legal admission categories –Purpose of entry –Country of residence –Ethnicity (e.g., Ethnic-Russian)

40. International migrant: U.S definitions

41. Department of Homeland Security U.S Census Bureau

42. Department of Homeland Security Immigrants (LPRs or Green Card): Aliens (or foreign nationals) admitted to the U.S. for lawful permanent residence, as defined in the Immigration & Nationality Act Naturalized citizens: immigrants that acquire the U.S citizenship (Nonimmigrant) temporary admissions –Temporary visitors (tourists and business travelers) –Temporary workers, students, others Refugees and asylees Unauthorized migrants (estimates)

43. Department of Homeland Security (Annual) Yearbook of Immigration Statistics Immigrants (LPRs)12.4 million Naturalized citizens14.3 million (Nonimmigrant) temporary admissions -Tourists/business travelers -Other temporary visas 33.3 million 3.7 million Unauthorized migrants11.6 million Source: http://www.dhs.gov/files/statistics/immigration.shtm

44. U.S Census Bureau Native: anyone who was a U.S. citizen at birth. Includes: -born in the U.S, Puerto Rico, American Samoa, Guam, the Northern Marianas, or the U.S. Virgin Islands, or -born abroad of at least one U.S. citizen parent -Foreign-born: anyone who is not a U.S citizen at birth

45. U.S Census Bureau Foreign-born population: 37.9 million –Naturalized citizens: 16.0 million –Non U.S citizens21.9 million –Does not collect additional migration status information (e.g., LPRs, temporary visas, unauthorized, refugees)

46. Race/ethnicity vs. Foreign-born Source: American Community Survey, 2008

47. Migrant (Farm-) Workers Occupational group ~1 million (average in 2006) 78% are foreign-born ~50% are undocumented Migration patterns –Settled 53% –Shuttler migrants*21% –Follow-the-crop migrants* 13% –Newcomers 13% Source: Kandel, William. Profile of Hired Farmworkers, A 2008 Update, Economic Research Report No. 60, Economic Research Service, U.S. Department of Agriculture, June 2008. *International or within the U.S)

48. American Community Survey (ACS) U.S Census Bureau Started in 2004 Replaces Decennial Census long form (in 2010) By mail => phone => personal visit Annual sample: 3 million households Local-level data Response rate: ~98% Annual release of data!

49. ACS Migration Data Place of birth/nativity U.S. citizenship Year of entry Ancestry Language spoken at home Year of naturalization (starting in 2008) Place of residence 1 year ago Health insurance coverage (since 2008) and food stamp participation

50. Accessing U.S Census Data 1.Public Use Microdata Samples (IPUMS) http://usa.ipums.org/usa/ Individual household level (no identifiers) American Factfinder (pregenerated tables) Website: http://factfinder.census.gov/

51. U.S Census Bureau Data Limitations Undercounts migrants –Many not be present at time of census –No participation Undocumented Distrust of government May be illiterate or speak languages not available in census forms –Census often misses unofficial dwellings

52. Encampment in an empty parking lot

53. Unauthorized migrants Estimation Methods Complex estimation calculations –Combination of data sources, and –Multiple assumptions U.S. Reports: –Department of Homeland Security –Pew Hispanic Center

54. Migration-relevant information on U.S health data sources

55. U.S health data sources (1) Data SourcesMigration-related variables Death registry Country of birth Birth registry Country of birth Parent’s country of birth Cancer registry Country of birth Caveats: -High % of missing or incorrect data - Misclassification is not random Usefulness depends on accuracy and completeness of migration-related data

56. U.S health data sources (2) Data SourcesMigration-related variables Notifiable diseases TB: country of birth & time in the U.S HIV: country of birth (recommended) Other diseases: none or limited Hospital discharge data None

57. U.S health data sources (3) Data SourcesMigration-related variables Population health surveys: - NHIS - BRFSS Country of birth & time in the U.S None

58. General-Population Health Surveys Limitations: –Few migration-related variables –Questionnaires not validated for other languages –Low response rate –Small sample size for migrants

59. International Migration Data Conclusions Many different sources of data Limited migration data Quality of data varies among countries and agencies within countries Comparability (definitions) issues Undercoverage (e.g., u nauthorized migrants) More recent data has better quality

60. Migration Data The Way Forward 1.Harmonize definitions and data collection methods 2.Include a standardized module of key migration questions on main data sources 3.Use/disseminate currently available data (Adapted from Commission on International Migration Data, 2009)

61. Migration Data The Way Forward (Cont.) 4.International coordination in data collection and exchange (including origin and destination countries) 5.Disaggregate data (e.g, gender, age, country of birth, time since arrival)

62. Migration Data The Way Forward (Cont.) 6.Collect data on comparison groups of non-migrants 7.Specialized migrant surveys

63. Opportunity Major further progress can be made: –in the short term, –with limited cost, –within existing institutions, and –by implementing a few simple steps (Commission on International Migration Data, 2009)

64. References International Organization for Migration (2004). Glossary on Migration Batalova J, Mittlestadt M, Mather M, Lee M. 2008. Immigration: Data matters. Washington, DC. Migration Policy Institute and Population Reference Bureau. http://www.migrationpolicy.org/pubs/2008DataGuide.pdf Center for Global Development. Commission on International Migration Data for Development Research and Policy (2009) Migrants Count Five Steps Toward Better Migration Data. http://www.cgdev.org/content/publications/detail/1422146/ UN Expert Group Meeting on the use of censuses and surveys to measure international migration, ESA/STAT/AC.132/1 (2007)UN Expert Group Meeting on the use of censuses and surveys to measure international migration, ESA/STAT/AC.132/1 (2007) International Organization for Migration. Managing Migration, 2004. www.iom.int//DOCUMENTS/PUBLICATION/EN/Migration_dec_2004.pdf