1. Migration and Health The Canadian experience – an overview SEMINAR ON MIGRATION AND HEALTH 18-19 October 2004 Guatemala City Brian Gushulak MD Migration Health Consultants Inc. Vienna Austria

2. migration health consultants Inc What will I talk about? Why this issue is of growing importance What has been learned in the Canadian context that can assist as you anticipate and plan for the future

3. migration health consultants Inc What is different at this time? Many of the current practices, focus an approaches are showing their limits –Designed for immigration challenges but faced with the challenges of population mobility –Significantly focused on infectious diseases –Chronic non-infectious issues are growing importance

4. migration health consultants Inc Major influencing factors –Disparity Linked to development –Renewed interest in Public Health Resulting from fear of disease Risk of imbalance with real national impact –Legislative initiatives National and international

5. migration health consultants Inc This presentation will not be technical but rather policy related The history of the process The development of Immigration Screening The influences of Emerging and Re- emerging Diseases –HIV in the 1980s –SARS, Avian Flu currently

6. migration health consultants Inc Policy Initiatives Future challenges –Non infectious diseases Heart disease, diabetes Malignancies Specific regional issues New Directions in Migrant Health –Screening for inclusion and population health improvement –Mobility as a health parameter

7. migration health consultants Inc The Origins of Migration Health Fear of imported epidemics –Lack of understanding of the disease –Serious or loathsome consequences Development of Quarantine in response to Plague –Isolation, separation, warning –Later examination of new arrivals for disease

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9. Why The History ? The history is important as it still resonates across the world –Founded on the principles of quarantine Several nations have recently completed or are in the process of amending quarantine legislation SARS and some emerging disease threats are causing nations to reconsider quarantine WHO is close to revising the International Health Regulations (a process that began in 1851)

10. migration health consultants Inc Current Sociological Linkages Response to fear in the absence of effective control measures or treatment –“new” diseases, uncertain treatment, limited understanding of risk Often associated with the international movements of people. –Several current associations with globalization phenomena

11. migration health consultants Inc Immigration Medical Screening Initial association with Quarantine –Infectious diseases –Screening on arrival Developed economic components –Ability to support oneself –Likelihood of becoming a “public charge”

12. migration health consultants Inc Immigration Health until the 1970s Routine practices by traditional immigration receiving nations –Australia, Canada, United States –Common factor was international movement that had expanded beyond traditional colonial population flows Nations with primarily historically colonial migration did not develop as extensive screening legislation

13. migration health consultants Inc Traditional Migration Health until the 1970s Infectious disease screening –Historical –National interests and control programs TB STDs Legislatively separate from Quarantine Risks of cost or need for scarce medical services (Excessive Demand) –Primarily an interest of Australia and Canada –National Health Insurance Systems

14. migration health consultants Inc Factors that Influenced the Evolution of Migration Health Policies Post Colonial population flows Post Vietnam refugee movements HIV / AIDS Collapse of Soviet Union Emerging and re- emerging diseases

15. migration health consultants Inc Canadian Immigrant Source Regions Past 40 Years (MacDonald BS Transatlantic Economic Issues and their Security Implications Atlantic Council Members Paper 03/02)

16. migration health consultants Inc New Challenges Movements of large numbers of individuals across greater than previous diversity limits and boundaries –Reduced administrative control –Disease epidemiology –Culture and language –Economic levels –Social and behavioral practices

17. migration health consultants Inc How those New Challenges Test the Limits of Traditional Migration Health Activities Border and frontier based Transactional immigration administrative roles rather than broad public health functions –Limited contact and follow up –Focus on acute or current status at time of immigration formalities –Longer term implications assumed full integration into host health system and similar outcomes.

18. migration health consultants Inc Shift from Immigration to Population Mobility as a Component of Globalization Asylum seekers and refugees claimants challenge off shore screening Large numbers of visitors and transients for whom screening was never designed New disease threats that may out weigh traditional immigration interests Slow recognition that migration health outcomes have long term implications

19. migration health consultants Inc Health Outcomes and Population Mobility Significant national impact Long term implications Potentially costly in terms of $$ and programs Extend widely beyond the health sector Implications for trade, security, transportation and development

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21. Diverse Health Environments influence and affect Disease Epidemiology The capacity of many national health systems is limited. These limits can affect the amount and resources available to manage a health issue. Those limits also affect disease disparities

22. migration health consultants Inc Estimated TB incidence rates, 2000 Source WHO Global Tuberculosis Control. WHO Report 2002. WHO/CDS/TB/2002.295 25 - 49 50 - 99 100 - 300 0 - 9 10 - 24 300 or more No estimate Rate per 100 000

23. migration health consultants Inc How does this relate to immigration? As nations control, manage or eliminate some health challenges the greatest statistical risk of recurrent threat comes from mobile populations from origins less able or with less capacity to manage those risks Example a disease for which immigration health programs screen - TB

24. migration health consultants Inc Reported Tuberculosis in Canada by Birthplace Source Data - The Public Health Agency of Canada – Tuberculosis Prevention and Control % of Cases

25. migration health consultants Inc Tuberculosis in Canada by Birthplace Source Data - The Public Health Agency of Canada – Tuberculosis Prevention and Control % of Cases

26. migration health consultants Inc Active Cases of TB in the Foreign Born : Canada 1988 - 2002 Source Data - The Public Health Agency of Canada – Tuberculosis Prevention and Control

27. migration health consultants Inc TB Cases in Foreign-born Persons, United States, 1986-2002 Source CDC National Surveillance System Highlights from 2002

28. migration health consultants Inc TB Cases in Foreign-born Persons, United States, 1986-2002 Source CDC National Surveillance System Highlights from 2002

29. migration health consultants Inc HIV

30. migration health consultants Inc Why do people die?  CV Disease ( 31%)  Infectious Disease (25%)  Cancers (13%)  Injuries (11%)  Respiratory & GI (9%)  Other (6%)  Maternal (5% ) Global deaths 1998 53.9 million Source WHO Infectious Disease Report 1999

31. migration health consultants Inc Why do people die in Canada? All causes of death 1997

32. migration health consultants Inc Infectious Diseases 25 % of global deaths –Most in the developing world –Increased concern in the developed world –Fear of importation –Renewed interest in control measures Quarantine Screening –Often theses divide on the development index

33. migration health consultants Inc This Fear of Infection Creates Situations of Very Low Tolerance of Risk Risks that are acceptable or not controlled in some regions are managed at great cost in others Blood borne diseases –BSE, Chagas’, Enteric Diseases –ETEC –Parasitic infections Tuberculosis

34. migration health consultants Inc How Receiving Nations Manage those Risks can Affect Migration, Tourism, Trade and Transportation Screening of travelers, workers, students Cargo, conveyances etc (Deratting) Travel Advisories

35. migration health consultants Inc Issues of Regional Potential Several when the much of North America is a very low prevalence area for many infections –Chagas’ –TB –Enteric infections –Malaria

36. migration health consultants Inc Geographical origin of P. vivax malaria imported to Europe between January 1999 and September 2003 (n = 618)

37. migration health consultants Inc Current Directions When faced with new infectious disease threats there is a tendency to return to traditional approaches This attention draws focus from equally important issues related to non- infectious illness

38. migration health consultants Inc Those Traditional Approaches can have Extensive Consequences Quarantine and involved immigration departure or arrival screening are complex In globalized world events rapidly become international

39. migration health consultants Inc New Directions Slow move away from Immigration Screening Paradigm Growing recognition of mobility as an integral component of globalization Greater awareness of impact of non- infectious disease

40. migration health consultants Inc The Importance of Population Mobility As nations deal effectively with domestic health concerns, the likelihood of new challenges to those threats moves abroad. –Risk perception –Risk management –Economic impacts

41. migration health consultants Inc The Population Mobility Paradigm Four Component Parts (each with health factors) – Pre travel component – Journey Itself – Arrival component – Return component

42. migration health consultants Inc How the Components can Influence Health Pre travel component – Local environment and history impact Culture, economics, geography, political, social factors Journey itself – Duration, style, environment Refugees, transit, displacement, trafficking Arrival – Status, reception, integration Return – Time at destination, voluntary, assisted, forced

43. migration health consultants Inc Current Trends Quarantine –Border focus increasing –New legislation –International Networks to monitor and advise on application

44. migration health consultants Inc Current Trends Migration –Longitudinal Focus –Screening for inclusion –Administration of interventions Malaria treatment Immunization ?HIV treatment

45. migration health consultants Inc Significant Gap in the Migration Context There is as yet no integrated focus on how health and population mobility relate across the globe and across time –Immigration screening has administrative limits –Other activities tend focus on groups of migrants as opposed to the process of mobility –The appreciation of many of the long-term implications is limited

46. migration health consultants Inc There is still little attention to non infectious health issues On a population basis they are of greater impact The issues of disparity true for infections are also true Implications for the globalized work force

47. migration health consultants Inc Coordinated Approaches would be Mutually Beneficial Development of more appropriate tools – More prospective capacity of immigration screening / intervention – More cost effective – Outcome Measures would be improved by Collective analysis and risk mitigation Anticipatory planning Longitudinal study

48. migration health consultants Inc Benefits of an Integrated Population Mobility Focus on Health Share the acquired experience of the traditional immigration screening nations Assist in global health strategies Improve the health of migrants and host populations

49. migration health consultants Inc Gratitude The organizers –Juan Pedro Unger –Karen Mujica –Alejandro Navarro –Luis Monzon The Government of Mexico CIC