Obesity: An Epidemic Weighing Down Migrant Populations

Not only is the world population rapidly growing in number, but it is also physically growing in size. According to recent estimates, over 500 million people worldwide are characterized as obese – a figure that has more than doubled since 1980. With the number of people touched by the disease at epidemic proportions, obesity is now one of the most pressing public health issues affecting the globe.

Although many people tend to associate obesity with the industry and material excess of developed countries, obesity is a rapidly growing problem in less developed regions as well. In poorer countries, where malnutrition has historically been (and still is) a major concern, the rate of obesity has more than tripled over the course of the past 20 years, especially among young people. Today, of the 42 million children considered to be overweight, close to 35 million live in developing countries. For the first time in recent history children everywhere are projected to have a shorter life expectancy than their parents.

In part, the rise of obesity among adults and children in the developing world can be attributed to rapid urbanization and migration from poor to more affluent countries. After migrating, many are exposed to lifestyles that involve less physical exercise and the consumption of high-fat, high-sugar diets. In order to blend into their new culture and/or cope with the stress that characterizes migration, migrants often abuse food intake and fail to understand the dangers involved in excess consumption of fast and cheap foods. The development of post-migration obesity particularly threatens certain ethnic populations – such as Latinos – that are seemingly more susceptible to significant weight gain.

More needs to be done to reach these groups with preventative messages and nutrition education. Encouraging migrants to maintain healthy eating patterns and to engage in physical exercise could be one of the more immediate ways of dealing with the epidemic of obesity globally. 

At the same time, it would be short-sighted to assume that migrants are the only ones at risk of developing this life threatening disease.  Greater efforts must be made in schools and the work place to provide as many people as possible with carefully-tailored information on obesity and its dangers.  If the issue of obesity is neglected, the world faces a massive  problem that will not only lead to countless deaths, but will also be incredibly expensive to manage.

-Julia Whall

Diabetes and Migration: A New Way of Looking at Diabetes Health Care

Noah Seelam/AFP/Getty Images/The Guardian

In recent years, there has been a growing awareness of the fact that non-communicable diseases, or NCDs, are no longer just diseases of the wealthy. It had long been assumed that they were more a phenomenon of developed countries, but recent evidence is showing drastic increases in rates of NCDs in developing countries as well. In the case of diabetes, around 80% of people suffering from the disease live in developing countries.

However, while great leaps have been made towards bringing awareness of diabetes to developing countries and poorer regions, what is often overlooked is the affect of movement on Type 2 Diabetes.  Migrants are a high-risk group for the disease, and are frequently forgotten in the discussion on how to approach diabetes care.  Migrants tend to be more likely to develop diabetes for a variety of reasons. The stress of migration and adapting to a new place, often with little support, can be a major inducer of T2DM.  Studies have shown links between high levels of stress and susceptibility to obesity and diabetes.  In addition, many coping measures for stress, such as overeating or smoking, are unhealthy and make a person more at risk for diabetes.  The change in environment also causes a change in diet and activity levels.  A high percentage of migration is from rural to urban areas, where activity levels often drop and quality of food may be lower, with fatty and sugary foods becoming more common.  It has also been found that it can be more harmful to experience a sudden shift to a worse diet and lower energy levels than to have always been exposed to them.

So what does this mean for diabetes care?  The issue with the high prevalence of diabetes in migrant populations is that they have very specific needs and cannot be treated in the same way as non-migrant groups.  Cultural and language barriers severely impair migrants’ abilities to prevent, diagnose, treat, and control diabetes. Lack of diabetes education makes it difficult for migrants to know how to prevent the disease, and fear or poor understanding of the health care system can lead to late diagnosis.  Poor communication with and mistrust of health care providers also reduces the chances of migrants fully understanding the treatments and following them properly.  This is not solely due to language barriers; cultural gaps also play a role.  If someone’s cultural views make it difficult to take advice from a doctor or nurse of a certain gender, or cause them to feel uncomfortable with certain treatments, it may result in them ignoring very important instructions.

It is necessary not only to understand these cultural barriers, but also to train health care professionals in how to deal with them.  Cultural sensitivity training would go a long way to ensure that treatment advice is communicated in such a way that both parties are understood clearly.  Working with community leaders can also ensure that information is effectively shared.  These simple strategies can help physicians with sufficiently reaching migrant communities and guaranteeing they are able to successfully manage their diabetes.  However, unless national or regional policies on diabetes care begin to take the unique case of migrants into account, this problem will only get worse, and the number of migrants going undiagnosed or not getting sufficient treatment will continue to increase.

-Sheona Sauna

TB Screening of Migrants and Implications for Europe

Copyright 2001, The Guardian

The UK government has recently announced that migrants from at least 67 countries who intend to stay more than six months will need to have a TB test before applying for a visa.  After years of progress in the global fight against TB, it has now clear that a major epidemic of the diseases  again and the WHO predicts the situation will become worse in coming years unless steps are taken to improve better prevention and treatment of the disease.

TB is not a new challenge to Europe.  TB was a major killer throughout the region and it has only been in the last 50 or so years that most (but not all) European countries have seen a major improvement in the prevalence of what is still a life-threatening disease.  Rightly or wrongly, TB has also been typically seen as a disease imported by newcomers and most so-called “receiving” countries have instituted steps to assess migrants for their TB status.  Some countries, such as the USA and Canada, have elected to screen people prior to their emigration or departure.  Others have adopted on-arrival screening policies and practices.

Screening for any diseases is always costly and open to problems of sensitivity and specificity. Additionally, we believe that many of the screening policies and practices currently in place have not proved particularly effective. Pre-migration screening, for example, does not pick up cases of exposure to TB during the course of migration and on-arrival screening appears not to pick up a large proportion of all the people that go on to develop TB well after arrival. Screening for TB has also been associated with both real and perceived discrimination. Some countries in the Gulf, for example, refuse entry to people with TB and the USA, Canada and Australia require people who test positive for TB to complete a course of treatment before reapplying for a visa. The fear of being rejected entry as a result of TB has lead to considerable corruption around pre-migration screening and to various other ways of avoiding screening. The reality is that a significant proportion of all TB identified in migrants after entry is probably linked to the working and living conditions into which migrants in most parts of the world are directed. Migrants typically move into low-income neighborhoods, poor quality houses that are overcrowded and poorly ventilated. Many TB experts believe these are the prime conditions for transmission of TB. Low-income migrations also tend to eat poorly and invest less in health care, thus exacerbating the risk of TB. If TB in migrants is to be prevented and controlled, existing policies and practices on screening need to be reassessed and steps need to be taken to tailor screening to the realities of exposure and reactivation of latent TB. TB screening also needs to be presented much more forcefully as a nondiscriminatory practice and as one designed simply to identify those people who should be and are eligible for quality treatment.

Manuel Carballo

World No Tobacco Day 2012: Tobacco and Migrants

Despite the progress achieved as a result of WHO’s Framework Convention on Tobacco Control and actions taken by many national governments, the consumption of tobacco products remains high and indeed may be increasing in some parts of the world and among certain social and demographic groups.  Today tobacco is estimated to be still killing more than six million people a year, including the more than 600,000 non-smokers who are regularly exposed to second-hand smoke.  For every one who dies, moreover, another 20 smokers suffer from life-threatening diseases.  In the EU alone, more than 650,000 people die every year from smoking-related causes such as cancer, heart disease, stroke, emphysema, bronchitis, and chronic airway obstruction.  Half of these deaths occur in the 35-69 year old age group which means a massive blow to the social and economic development of the countries they live and would otherwise have worked in.

Not all people are at equal risk of smoking or of smoking-related diseases, however.  While middle-income and well-educated people in North America and Europe are smoking far less than they did in 2000, and far less than lower-income less well educated people, women and adolescents are smoking more now than they used to do.  Globally, major differences are also emerging between countries.  In the USA, for example, strong anti-smoking policies and better public information have helped to dramatically reduce the number of people who smoke and major health benefits have already been achieved as a result of this.  In other parts of the world, especially developing countries, however, improved economic conditions and higher wages have led to a more buying power among people who used to be poor, and rates of tobacco smoking in these groups have grown.  For much the same reason, migrants have also emerged as a high risk population.

Migrants tend to move from poor backgrounds and move to settings where their incomes are higher than they were at home.  They also tend to live in ethnic minority communities where smoking is still popular.  In the USA and other countries where rates of tobacco smoking in the general population have fallen in recent years, rates of smoking among migrants have remained very high, especially among women.  One of the main reasons for this is that migrants tend to be overlooked by national health promotion and protection programs and smoking prevention campaigns often fail to reach them with meaningful information.  Migrants have rarely been seen as a priority by national health and/or social protection departments and in most countries little is known about the psychosocial factors that drive them to smoke.  This is especially so in the case of rural-urban migrants and irregular migrants who remain relatively invisible to national health authorities.

If global smoking rates are to be brought down and global health improved, much more attention will have to be given to this massive and still-growing population of people that is moving from one place to another in search of a better life, but which often sees its health deteriorate significantly as a result of smoking as well as other challenges.  The continued neglect of migrants by national anti-smoking campaigns will thus not only harm migrants, but will eventually adversely affect the public health of host countries and increase the health care cost burden on them.  Preventing smoking in migrant populations would be a win-win for everyone.

Manuel Carballo

How the changing demography is rendering medical education obsolete

Throughout the centuries, medicine was the profession of healing the sick, no matter the disease or the social context. Key diseases were identified and priorities were set for the well being of society, leading to diseases such as tuberculosis and leprosy being aggressively tackled. With time, the priority areas of the medical community and the ones of the ill diverged and Rudolph Virchow attempted to keep the profession from becoming increasingly isolated from the population and the root causes of illness: “Medicine is a social science, and politics are nothing but medicine at a larger scale. Physicians are the natural attorneys of the poor, and social problems fall to a large extent within their jurisdiction”.

In today’s globalized world, not only do diseases know no borders but also, migration has become ubiquitous. People are moving in greater numbers, traveling greater distances at an unprecedented pace, thus producing a new paradigm of multiculturalism and diversity within countries. Migrants, regardless of the political, economical or environmental drivers of their movement, carry with them what we call at ICMHD their “health print”. A Malian migrant settling in France will adapt to its environment relatively quickly and will even be subject to the host country’s specific health risk factors but the event of the migration does not erase this person’s past exposures to specific diseases and risk factors which he was subject to in Mali. Health professionals need to be aware of people’s migration history and take into account the impact of the risk factors and epidemiology of disease of the country of origin as well as  the migration itself. Overlooking one’s migration history can lead to erroneous diagnosis and treatment as well as poor health outcomes.

Medical students need to be exposed to the actual burden of disease of the world we live in. Today’s reality is that tuberculosis and hepatitis B, for example, are not only diseases they will encounter on their electives abroad or even when working at an inner-city clinic with vulnerable groups. A perfectly healthy migrant arriving in Switzerland might not seem to be at risk of developing tuberculosis, but if one digs a bit deeper, we might discover that this individual lives in overcrowded housing with other migrants, and that they might be carriers of active tuberculosis. Or he may every year visit his family in a high-risk tuberculosis zone. HIV in India is also a good example of the differential risk factors incurred with a particular history of migration. India has a very low HIV prevalence but is experiencing concentrated epidemics in towns where rural-to-urban migration is extensive. Among rural-to-urban migrant workers, the HIV prevalence is 10 to 20 times higher than the national average (National AIDS Control Organization, 2010). Would one think to screen a migrant worker from a rural area for HIV when HIV rates are much higher in urban settings?

To be a competent medical doctor, students need to approach the realities of migration – including its scope, magnitude, the implications for treatment and care, the effects on people’s integration in a host healthcare system and its impact on the epidemiology of disease – in a systematic and comprehensive manner. Migration is a complex and dynamic process and one can no longer predict the next major migration trend. For that reason that we believe at ICMHD that medical faculties need to include a Global Health component to their curriculum, both as an explicit course and by integrating such notions throughout the clinical rotations. Dr Piot, Director of the London School of Hygiene and Tropical Medicine, stated very bluntly the need for more Global Health education in medical curriculums in a recent New York Times article: “A very down-to-earth reason is just if you practice in the U.K. the likelihood that you will have patients who come from other places is extremely high”.

Currently, medical students all over the world are being increasingly vocal about demanding Global Health educations and courses and, because of the general unresponsiveness of medical faculties to any demands in this field, they themselves are taking the lead and learning by themselves, peer-educating each other about Global Health and creating their own programs (see New York Times article).

Yet again medicine is at a crossroads. We can no longer dismiss the health needs of migrants, who now represent the 5^th largest country in the world, or the vast impact migration has on the population. Medicine needs to reconnect with its roots and address the needs of the population, know effectively a global one.

Alexandre Lefebvre

Shooting Europe in the Foot: Europe’s Migration Migraine (Part 2)

A couple of weeks ago,we at ICMHD touched on the growing tendency for politicians to use the theme of migration in their campaigns and, more often than not, blaming migrants for many of the ills facing countries in this time of economic hardship. This diversion could easily cast a shadow on the numerous opportunities available for constructive national social and economic development and at the same time it could directly erode the health of the migrants populations.

In many ways Europe is at crossroads. Demographers and economists largely agree that falling fertility rates, a rapidly aging population, and the growing lack of interest of nationals in occupations they no longer see as financially or socially attractive is creating major challenges to development.  At a time when fewer young people are available to the economic market place and when a larger proportion of national budgets will inevitably be allocated to the care of the elderly, Europe is increasingly finding itself unable to maintain its social security systems and economic competitiveness.

If Europe pragmatically is to prosper socially and economically it must take up this challenge and proactively develop policies and programs designed to attract, absorb and integrate people in ways that will maintain the social capital base the continent needs to achieve these goals.

To date most European countries have done little to integrate migrants. Few have provided migrants with incentives to learn host languages and even fewer have developed outreach programs to incrementally transition migrants to link with the history and values of host societies.  Urban planning and housing schemes have rarely been designed to encourage physical integration and prevent the concentration of ethnic minorities in ghettos. Instead Europe has taken a laissez-faire approach to migration presumably assuming that with time newcomers are automatically absorbed into host societies.

Today many European countries are faced with ethnic minority communities characterized by poor socioeconomic profiles, limited educational and occupational mobility and poor health profiles and, increasinglysocio-political instability.

The response from many politicians has been to talk in sweeping ways about the negative impact of migrants and suggest that the answer is to radically cut the number of newcomers. Instead the time has come for European countries to step back and analyze what type of society they want and what they are willing to do to encourage and facilitate a true absorption and integration of the new people they so desperately need. Isolation is not a valid option in the world we live in today.

We would like to know your thoughts on the specific issue of how you view national European immigration policies and their effects on migrants’ health. Please feel free to share and comment!

Manuel Carballo

The Right To A Healthy Life: The Growing Problem of Gestational Diabetes Mellitus

©2012 Stock Connection and World of Stock.

Gestational diabetes mellitus (GDM) is a non-communicable disease caused by glucose intolerance.  Despite the fact that it can pose serious threats to pregnant women and their babies, GDM has been late in attracting the type and extent of global attention it deserves.  Typically seen as a disease that goes into remission at the birth of the baby, GDM can nevertheless present serious threats to the mother in the ten years following her pregnancy (risk of developing type 2 diabetes and developing GDM in future pregnancies) and to the young infant (Obesity, respiratory problems, and later type 2 Diabetes).

 How widespread or common GDM is, remains relatively unclear.  The absence of globally accepted standards for screening and treatment of GDM is one of the reasons for this, and even today there are still many countries that do not routinely screen for GDM as part of antenatal care.  The persisting lack of real attention to, and investment in, maternal health in general, is another underlying factor.

At ICMHD we believe GDM is a growing problem that is affecting some populations more than others.  Our research suggests that some ethnic groups are far more vulnerable to it than others, and we also believe that the process of migration can be a precipitating factor.   In a world in which the number of women on the move is now beginning to exceed the number of men, the problem of GDM in migrant groups and ethnic minorities calls for urgent attention.

ICMHD has made GDM one of its priorities and is working to improve international knowledge about its incidence and impact in different parts of the world and among different populations.   We believe every mother-to-be and her child has the right to a healthy life and we hope that by raising awareness about the problem we will encourage more countries and stakeholders to take it up.

 By: Emily Hertel

The Lost Count: Malaria Quantification and People on the Move

Live Savers: Mosquito nets help protect the most vulnerable, including pregnant women and infants. © UNHCR/Zalmaï

In the global efforts to combat malaria, accurate assessment of the public health burden of the disease and its distribution is central to monitoring, control, and decision-making. In an article published this month in The Lancet found that, the 2010 Malaria World Report released by the World Health Organization (WHO) underestimated global malaria mortality by 50 percent. The study led by Dr. Christopher J L Murray from Institute for Health Metrics and Evaluation (IHME) in Seattle estimated the 2010 malaria mortality to be 1.2 million compared to 655 thousands reported by WHO. The study used subnational population data to analyze trends in malaria mortality from 1980 to 2010. The study also found that there has been a systematic underestimation of global malaria mortality. Some of the limitations cited in the paper were the lack of representativeness and misclassification of deaths in the subnational data due to the variability in intensity of malaria transmission, incompleteness, and inconsistency of surveillance data. In addition, results from time-trend and time-series data analysis, which was used in this paper, can be affected if there is migration within the population under review.

We believe at ICMHD that this raises the problem of how to quantify malaria incidence, prevalence, and mortality when there are very large numbers of people on the move who do not fall within national health registration systems. The 2011 World Development Report estimated that by the end of 2009 there were some 42.3 million people displaced globally as a result of conflict, violence, and human rights violations. Of these, 27.1 million were internally displaced persons (IDPs) while 15.2 million were refugees outside their country of nationality or country of habitual residence. The United Nations and the United Nations World Tourism Organization has projected that by 2020 there will be 50 million environmental refugees and nearly 1.6 billion international tourist arrivals.

These figures make evident the urgency in developing more consistent methods on measuring malaria distribution and identifying populations at risk. The different approaches that have been used in determining malaria incidence, prevalence, and mortality have led to highly variable results. Moreover, many malaria trends analyses rarely factor in migrating populations.

At ICMHD we think that unless the international community is willing to pay more attention to migrants and other people on the move, malaria control efforts will fail.

By Talubezie Kasongo

Climate Change: A health hazard?

Pakistan 2010 Floods (Daniel Berehulak/Getty Images)

In November 2011, a group of ministers and senior representatives of governments from Africa, Asia, the Caribbean, Latin America, and the Pacific met in Dhaka, Bangladesh, to discuss the threat of climate change and the growing vulnerability of countries to the prospect of global warming. The Secretary General of the UN, Ban Ki Moon, was also present. The conclusion of the Climate Vulnerable Forum Dhaka Ministerial Meeting was to call for more concerted action to help countries adapt to the impact of climate change and take steps to mitigate its impact by creating carbon sinks, disseminating environmentally sound technologies and establishing a balance in the energy mix by focusing on renewable and alternative energy.

The emphasis the Dhaka ministerial meeting placed on limiting global warming, in this case to 1.5 degrees Celsius above pre industrial levels and progressively reducing greenhouse gas emissions, is symptomatic of the challenges facing the response to climate change. For while reducing greenhouse gas emissions will remain an essential goal to achieve, this will be difficult in an era of economic crisis and the felt need by countries to stimulate new industries and employment at the cost of greenhouse gas emissions.

As we move further into what is already a serious situation, it would be perhaps more important to address the fact that climate change is displacing millions of people and is expected to uproot and forcibly move some 250 million people in the coming years. At a time when countries everywhere are raising barriers to immigration and making life more difficult for refugees, asylum seekers, and economic migrant workers of all kinds, the prospect of up to 250 million people moving in search of human security portends massive social, economic, political and health challenges. This is where we should be placing our attention and finding ways of preparing for what may be involved.

Accommodating displaced people will constitute, if it does not already do so, a massive challenge in terms of availability of land, of housing, of sound water and sanitation, social and health services. At ICMHD we believe that a large proportion of the people who will be displaced will move towards large towns and cities either within their own countries or in neighboring ones. Many of these towns and cities are already overwhelmed. Unplanned and poorly coordinated rural urban migration has outpaced the capacity of many of them to absorb and provide the conditions needed for healthy life. The vastly overcrowded shantytowns and slums that now characterize many cities in developing countries are not only making the protection of health difficult, but are actually producing the conditions that facilitate disease.

ICMHD believes that far more attention should be given to this part of the climate change challenge than it has received to date. This is where meaningful action is probably possible in a shorter time frame and could help avert a major global disaster.

By Manuel Carballo

Health G20 : Promoting Health and Development on the G20’s Agenda

Health G20: A briefing on health issues for G20 leaders

Health G20 has been created by the International Centre for Migration, Health and Development in Geneva, Switzerland and the Dasman Diabetes Institute in association with Pro-Brook Publishing. The ICMHD Executive Director, Dr Manuel Carballo, and the Director, Professor Kazem Behehani,  are editors of the publication. Pro-Brook Publishing is a specialist publisher in the global healthcare arena.

The objective of Health G20 is to promote health and development on the G20’s agenda. Underlying all economies is a healthy population, Health G20 is there to brief world leaders on key disease areas, common problems and new developments to ensure that healthcare is not left off the agenda of this powerful grouping.

Health G20 could not have been published without the assistance of the Supporters. These Supporters range from healthcare NGOs, UN agencies, commercial companies and academic institutions (See Supporters)