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

Obama’s latest executive order: new possibilities for US immigrants?

Copyright 2010, Jason Redmond, Associated Press

President Obama has recently issued an Executive Order that suggests a major shift in his immigration policy.  While more immigrants have been deported during his administration than under any other president’s term since the 1950’s, he is now ordering a halt on deportations of young, undocumented immigrants who came to the United States before the age of 16, are now under the age of 30, and have lived in the country for at least 5 consecutive years, and are in good legal standing.  The order offers temporary residence and work permits to the young people who meet these criteria and helps them to get on the path towards legal citizenship.

Although President Obama’s Executive Order has stirred controversy in Congress, where Republicans and Democrats were seeking a bipartisan agreement on immigration, it will have an immediate positive effect on all the young people who came to the USA with their parents, and who have grown up as Americans despite their official legal status.  The Obama position is not a solution to the country’s longstanding internal battle with immigration, but it will bring comfort to hundreds of thousands of young people and give them hope for the future.  Many of them have been educated in American institutions and what the new Executive Order does is provides them with an opportunity to actively participate in and contribute to, the society they grew up in and identify with.

Migrants face a variety of impediments when they relocate to new countries.  Confronted by cultural differences, language barriers, and often subjected to poor working and living conditions, migrants are easily and quickly marginalized. This is made all the worse when immigrants are undocumented because they cannot be legally employed and their rights are rarely protected.  They typically live in very poor housing where they encounter problems of overcrowding, poor ventilation and heating, all of which frustrate and depress them as well as expose them to airborne diseases.  Without legal identification, many of them accept to be economically abused and exploited, refraining from calling on law enforcement officials for protection or seeking medical attention when they need it.

The situation is not necessarily getting better.  There have been legislative attempts to require hospitals to report illegal immigrants who seek medical attention at hospitals, and a bill introduced by Arizona lawmakers in 2011 calls for them to be profiled and stopped at the will of law enforcement officers.  A study of undocumented migrants in California and Texas reveals that between 50 to 70 percent of undocumented immigrants in these states do not get to see a doctor even once a year, meaning that they receive little if any, preventative healthcare.  Giving legal status to young migrants will allow them to seek the medical attention they require and it will put their health on par with that of their classmates and colleagues.

Granting temporary legal status will mean that the standard of living of young undocumented migrants in the United States can now improve.  The young people involved will, for the first time, be able to apply for driver’s licenses. They will be able to apply for financial aid, and work towards attending colleges and universities. They will be free (within a supply and demand economy) to seek legal employment and move toward health insurance benefits and an overall improved standard of living. While the President’s decision has spurred political controversy, it is a step in the right direction.  With a bit of luck it could help promote a better standard of living for migrants of all ages, but especially young ones.

-Laura Driscoll and Manuel Carballo

World Refugee Day 2012

Copyright 2011, UNHCR

As the world celebrates yet another Refugee Day it is important that we remind ourselves that the number of people being forcibly displaced across borders as well as within their own countries is once again increasing.  For a short few years it seemed as if the number of refugees was coming down and being overtaken by the number of internally displaced people (IDPs) who do not get a chance to get across borders.  Today, however, the picture is one of more and more people fleeing across borders as well as within their own borders.

Refugees and IDPs are people who are suddenly cut off from friends and relatives, and what are often called “significant others.”  They lose their personal belongings, and the homes and local industries they have invested in and developed over the years. They typically lose whatever national identity papers they had and become stateless.  Most of all, they often lose hope and are thrust into settings and situations where they gradually lose all sense of self-esteem and personal value.  Generations of people are being born and brought up in refugee and IDP camps where they take on the debilitating refugee mentality and identity.

Today’s refugees and IDPs are no longer as welcome as the ones who moved around Europe after the Second World War or even as recently as the Bosnian War.  States that previously opened their arms to refugees now impose time-consuming and psychologically stressful administrative procedures that further worsen the sense of loss and fragility.

Ironically, all refugee and IDP populations contain within them people of talent and creativity, people whom societies everywhere, including their own, would benefit tremendously from.  To be sure not all of them are going to be Einstein’s, but many of them could contribute to the social and economic development of the countries they are fleeing from and the countries they are fleeing to.

Hopefully Refugee Day 2012 will be a day of introspection by politicians and the public alike. The xenophobia that has been used and played with by all too many populists must be counter-acted and a better appreciation of what it is that refugees and IDPs go through must be fostered.  Countries should begin developing the type of policies and programs that would make the most of the presence of refugees and IDPs while at the same time respecting their civil and human rights and making sure they enjoy the benefits that all human beings merit.  The right to health, the right to education, the right to shelter, and the right to food are rights that need to promoted and protected everywhere and by everyone.  We need to remember that we could all be made refugees some day.

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

A New Opportunity for Europe

President-elect François Hollande’s campaign was marked by an absence of the rhetoric on immigration that has come to characterize much of the political narrative of France and Greece in recent months.  This may well have contributed to his success in a country in which over 10 percent of the population is foreign-born and in which a far larger proportion is descended from recent immigrants.  No one should assume, however, that the issue of immigration in France, or indeed elsewhere in Europe, has gone away.  Migration into the EU remains a challenge that will not go away.

Migration is ultimately a function of supply and demand and the financial crisis confronting Europe has already contributed to both a slight decrease in the number of people arriving in the EU and to the departure of others who were already here but decided to go back to their countries of origin.  The EU will nevertheless continue to be seen as a region of hope and opportunity by the hundreds of thousands of people living in situations of worsening poverty and political instability.  As such it will continue to receive many more would-be immigrants in the coming years.

The challenge President Hollande and other European leaders will hopefully take up sooner than later, is the need to develop a comprehensive and cohesive inter-country approach to migration that takes into account the size and pace of immigration states require, and also the ways in which newcomers can be socially and culturally integrated.  In developing its policies and plans for migration, Europe will have to address the fact that dramatically falling birthrates in most EU countries are urgently calling for new immigrants who can rectify the demographic imbalance that is emerging between the young and the elderly.  The policies and plans that will hopefully emerge will also have to take into account the types of skills that are increasingly called for in countries where aging populations require a type of domiciliary care that is labor intensive and which has proved difficult to satisfy without labor input from outside.  Hopefully, any evidence based approach will equally recognize the fact that defining migrants as “illegal” or “irregular” does little more than prevent them from participating fully in national taxation systems.  Conversely, regularizing migrants quickly increases the number of tax-paying citizens who because they are largely young and healthy, do not make huge demands on national health systems.

Encouraging and facilitating the social and cultural integration of migrants remains another part of the equation that must be taken up with a sense of urgency.  At no time in history has it been so clear that migrants who are not encouraged or allowed to socially and culturally integrate risk remaining outside mainstream society and never really identifying with their host countries and their values.  The answer to this challenge will not be simple, but avoiding residential ghettos and ethnically biased schools will contribute much to achieving the goal of integration and ultimately benefit all stakeholders.

Reducing the need to leave countries of origin is of course the solution to massive migration, and here the EU has a unique opening to engage in a new type of focused international development aid that targets the countries and regions where poverty, conflict and persecution are forcing people to uproot and emigrate.  Europe needs to come to terms with the fact that international aid focused around this theme can be as economically productive to donor countries as it is to beneficiary ones.  If well designed it can not only bring employment and a better quality of life to oppressed people, but also open up new trade opportunities and better political relationships between countries.  Sending unwanted migrants back home with financial incentives and a promise of training, which is what some countries are now considering, will always be more expensive than providing them with training and economic enterprise possibilities before they are forced to leave.  Hopefully, these are some of the issues President Hollande will take up, and if he does, that other European leaders will follow him on.

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

Providing psychosocial assessment and support for migrants: A critical urge

 

© UNODC

The number of people moving between and within countries is growing rapidly. However, despite the fact that communication and transportation systems are becoming more efficient and making migration easier, the fact remains that migration is always stressful and at times traumatic. The situation is being made worse as a result of the politicization of migration and the tendency to present migrants as the root of current financial and inter-cultural problems.

To date most of the focus on migration and migrants has centered around issues such as employment, housing and remittances. Psychosocial adaptation issues have been seen as far less important. At ICMHD, the psychosocial aspects of migration are considered a high priority. Studies have repeatedly shown that the risk of physical morbidity and mortality is higher among migrants than indigenous populations and migrants are far more likely to be subject to chronic anxiety, depression, psychosomatic complaints, posttraumatic stress disorders and other psychoses.

Migrants are exposed to stressors throughout the different stages of migration.  Prior to migration they often come from harsh living conditions in their country of origin and have experienced marginalization, social disruption and physical violence.  During the migration process, which can take months and even years, they are often exposed to even greater stressors such as poverty, living in political limbo, job insecurity, extreme exploitation in the work situation and violence.  Even after migration, they often encounter additional difficulties such as cultural conflict, occupational insecurity, social marginalization and in the case of some countries, political hostility in the countries they settle in.  Barriers such as language, religion, culture differences serve to accentuate these problems, amplifying the negative experience even more.  Studies also reveal that migrants have less easy access to local health care systems due to their lack of knowledge, problems of insurance, legal status and poor education.  Coping with these problems is never easy and many migrants turn to behaviors that while helping them deal with these immediate problems, nevertheless present serious threats to their overall health and well-being.  This is not to say that social support mechanisms are not available to migrants, for indeed these can be found in many forms. Evangelical church movements, for example, are increasingly evident in migrant communities everywhere and are rapidly playing the role that formal health care systems and mental health specialists might otherwise have played.  One of the difficulties that mental health specialists have encountered in the past has being their lack of training in cultural competency.  Their lack of familiarity with different cultures and customs has often led to major problems in terms of poor diagnosis and inappropriate treatment of migrants.  In a world that is increasingly heterogeneous in terms of culture, social background, language and beliefs the health sector must adjust its policies and practices and do everything possible to look at the arrival and eventual integration of migrants in a far more rational and long term vision manner.

At ICMHD, we believe that more research is called for this area and that the findings of good research need to become the basis for national policies and programs in the area of psychosocial welfare and integration of migrants.

Manuel Carballo and Madiha Nasir

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

Shooting Europe in the Foot: Europe’s Migration Migraine

Thomas Samson/Reuters

The presidential campaign in France has predictably focused, once again, on the issue of migration. Migrants represent approximately 11% of the French population. Many, if not most, have come from countries with a long and strong political and economic link with France. Most have probably seen France in a quasi-motherland manner. They, like migrants everywhere, are contributing to the social and economic development of France. Some are highly skilled physicians, nurses, engineers, lawyers, schoolteachers and others who quickly move in to stable and relatively well paying job situations. Others are less skilled and are taking jobs that nationals are increasingly reluctant to take on. As such, a large proportion of migrants in France, just as in other European countries, have today become the anonymous, easily forgotten workers who keep economies functioning and do so from behind the scenes.

The perennial concern in France about migrants is not unique to France alone but it is nevertheless visceral and prominent in political discussions. Every presidential candidate has felt it expedient to take up this theme and, with a few variations, essentially attempts to appeal to the masses by stating that France neither wants nor needs nor can further accommodate more migrants. The reality, of course, is that almost every European country has now come to terms with the fact that in a continent of dramatically falling fertility rates, migrants represent a lifeline for the economy. Without this substantial segment of the workforce many industries will become less efficient, but more importantly, in the absence of tax paying migrants, the social security systems of Europe will have a short shelf-life. It is speculated that the day will soon come when contributions to pension scheme by nationals are so restricted that future generations will simply not be able to draw on them.

In Germany where the proportion of migrants is higher than that of France, there has been little evidence of a politicization of the phenomenon. While this is not to say that foreign-born people in Germany are by any means more integrated or accepted; politicians have seen it fit not to focus political debates on or around them. There are many good reasons for following the German model.

Migration is a complex phenomenon and people who move; be it for economic or political security reasons are pressured in many psychological ways. There are many reasons that contribute to the constant outflux and influx of people from one place to another. These reasons are usually beyond their scope of control, rendering them to leave behind family, friends and cultures.

Politicization of migration and migrants does little more than force this essential population further on the margin of mainstream society. It increases their stress and anxiety and we know it makes them all the more vulnerable to a wide range of physical and mental health problems. If Europe is to avoid creating a marginalized and frustrated ghetto population who feel they are not wanted but know they’re needed, it must stand back and decide where it is heading with this phenomenon. Is Europe prepared to deal with a massive and detrimental fall in the size of its population? Is it willing to move forward and create a cohesive, productive and socially constructive Europe? If the latter choice is the aim then politicization of a process that has characterized every period in history and will have to come to an end and politicians will have no choice but to engage in more responsible and constructive political debates.

By: 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