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Public Health

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Themed Paper e Original Research

Globalization, migration, and ethnicity

U.A. Segal*

International Studies and Programs, University of Missouri e St. Louis, Fulbright Specialist & Fulbright Scholar U.S.

Department of State, St. Louis, MO, USA

a r t i c l e i n f o

Article history:

Received 1 August 2018

Received in revised form

25 April 2019

Accepted 28 April 2019

Available online 20 June 2019

Keywords:

Migration flows

Migrant integration

Perceptions of migrants

* Corresponding author. School of Social Wor þ1 314 516 6379; fax: þ1 314 516 6416.

E-mail address: [email protected]. https://doi.org/10.1016/j.puhe.2019.04.011 0033-3506/© 2019 Published by Elsevier Ltd o

a b s t r a c t

Objectives: This article presents an overview of global migration and the unique issues

facing immigrants, host countries, and practitioners, identifying considerations for

practice.

Background: Perceptions of the effects of human migration are major drivers of country

attitudes, policies, and programs. Increasingly complex global interconnectedness has

altered relationships among sending, receiving, and transit countries. The Global North,

with its aging and declining populations, requires a healthy and young workforce; the

Global South, with limited resources, a high birthrate, and an overall youthful population,

can fill the gaps of the former, but with several implications for receiving and sending

nations.

Methods and results: This article reviews literature and data on current migration world-

wide, with particular emphasis on immigration. Despite the complexities of human

migration and extant theories that dissect the phenomenon, the fundamental elements of

Lee's early push-and-pull theory of migration continue to hold true. Generally, people are

drawn to improved opportunities or leave challenging environments, whether temporarily

or permanently. Two salient dimensions undergird the study of migration: (1) migration

trendsdwho migrates and why, and the size and direction of migration flows; and (2) the

impact of migrationdhow migration changes receiving, transit, and sending countries.

Receiving/transit nations are particularly apprehensive about whether immigrants fill their

needs and how they impact resources. They speculate about immigrant preparedness for

the workforce, ability to integrate into the society, and consequences for the racial/

phenotypic profile of the nation. Immigrants also experience these worries.

Conclusions: Ethnicity, which is associated with common ancestry and culture, including

language, religion, traditions, and behavioral norms, often contributes to, and challenges, a

receiving nation's world view. This can have implications for several segments of its so-

ciety, including the health profession, which could find that in the delivery of services it

must grapple with the complex relationship between migrant, health, and health services

utilization.

© 2019 Published by Elsevier Ltd on behalf of The Royal Society for Public Health.

k University of Missouri e

n behalf of The Royal So

St. Louis One University Boulevard St. Louis, MO 63121, USA. Tel.:

ciety for Public Health.

p u b l i c h e a l t h 1 7 2 ( 2 0 1 9 ) 1 3 5 e1 4 2136

Introduction

In 2017, approximately 258 million people, about 3.4% of the

world's population, were considered by the United Nations to be migrants. This number has been rising steadilydhaving

been 173 million in 2010.1 The proportion of the population

made up by migrants has particularly increased in nations

with slow or negative domestic population growth. Further-

more, both migrant flows from sending to receiving countries

and movement within host nations have changed. No longer

are urban areas the only major magnets; many immigrants

make their homes in rural areas where ethnic and cultural

diversity are limited.2

Amid economic fears and rising nationalism, perceptions

of the effects of human migration are major drivers of country

attitudes, policies, and programs. While human beings have

migrated since time immemorial, increasingly complex global

interconnectedness has altered relationships among sending,

receiving, and transit countries. Migrants who move, volun-

tarily or not, always seek to improve the quality of their lives,

while receiving nations attempt to manage the size and profile

of entrants along a range of economic, practical, social, phil-

osophical, and attitudinal factors.

The movement of people has long ranging effects on the

individuals and groups who migrate and also on the receiving,

sending, and even transit countries. This article focuses spe-

cifically on global immigration or entry into a country, and

while recognizing the significance of several extant theories

and perspectives on migration3 and the complex interaction

of economic, political, legal, sociocultural, and demographic

factors,4e6 it underscores the continuing efficacy and under-

standable perspective of Lee's 1966, basic push-and-pull the- ory of migration.7 Generally, people move, either temporarily

or permanently, to enhance their lives. They may be pulled

toward improved opportunities in host nations or pushed to

leave challenging environments in their native countries or

both. While not in the scope of this article, practitioners will

need to assess country-specific migration in the context of the

current intricacies of a myriad of global, national, and regional

factors.

The debate

Nations around the world are torn about the benefits of

immigration, and while this discussion is not new, increasing

globalization and the ease of movement between nations and

across continents have recently heightened xenophobia,

economic fears, and nationalism. Most literature and empir-

ical evidence suggests that, on balance, economically and

practically immigrants benefit a receiving country. However,

concerns about cultural contamination, changing values, and,

most recently, the dread of terrorism tend to color host

country attitudes.

Those who support immigration identify at least the three

following points: (i) immigrants benefit the country econom-

ically, (ii) immigrants enrich the culture, and (iii) a country

with resources should help others in need. Conversely, those

who believe that immigration should be limited indicate

concerns that (i) immigrants deplete the country by taking

jobs and overutilizing resources, (ii) immigrants destroy the

culture, and (iii) immigration is a privilege that has to be

earned.

Overall findings indicate that immigrants tend to benefit

the economy, particularly in developed countries, as they

often take jobs not filled by natives and, being entrepreneurial,

frequently start businesses that hire natives and immigrants.8

However, migration may depress incomes and opportunities

for low-wage and less educated individuals.9,10 There is no

‘one size fits all’ model, and attitudes toward migrants are

highly complex,11 varying based on different immigrant

groups and the ‘threats’ perceived. Thus, economic fears, for

example in the United Kingdom, are around Eastern Euro-

peans, while security fears reflect perceptions of Muslims.12

The extent of immigrant integration also affects views of

their benefits. Regardless of academic findings of the advan-

tages of immigration, the ‘disconnect’ between academic

research and public perception is significant; economic ben-

efits seem to have little effect in offsetting perceptions of

immigrants as ‘the Other’.13

Depending on the prevailing sociopolitical and economic

conditions of the world, or particular countries, certain forms

of migration movements dominate media coverage. The

recent Syrian refugee crisis has focused the world's attention toward refugees, and the pervasive current view is that refu-

gees constitute the majority migrant group. However, they

make up only 10% of the all international migrants.14 At other

times, perceptions are that the Global North is being overrun

by unauthorized migrants, and nations are challenged and

changed by masses of ‘illegal’ people. The reality is that most

immigrants are voluntary migrants, not refugees, and most

enter a country with appropriate documentation.

It is, nevertheless, important to recognize that individuals

cross international boundaries under a range of circum-

stances, and these circumstances influence how they are

perceived and categorized which then affect the resources to

which they are entitled in the destination country. In addition,

even when they emigrate under similar circumstances, two

immigrants from the same country of origin may have very

different migration stories; much depends on their social and

economic status in the home country, their experience there,

their human capital,15 and their personal aspirations.

Globalization

The global economy, the ease of travel, and transnational

communication have enhanced international population

mobility and offered migration opportunities heretofore un-

available to many. Because of the several spheres of global-

ization, in the 21st Century, connections with countries of

origin remain strong and are accessible to almost all inter-

national migrants. Growing international remittances,16

expanding transnational communities,17 increasing interna-

tional labor migration (including seasonal and serial migra-

tion and guest worker programs18e20), and rising Diaspora

engagement are some impactful consequences of globaliza-

tion on migration. Furthermore, across disciplines, but

particularly in health services, is the continuing development

and expression of integrated health care and the integrated

p u b l i c h e a l t h 1 7 2 ( 2 0 1 9 ) 1 3 5 e1 4 2 137

workforce.21 This has opened migration opportunities in

health care for people in several health-related disciplines.

Immigrant groups: definitions

Research often classifies migrants by a number of variables:

national origins, educational level, gender, other demographic

characteristics, etc. However, it may be particularly useful to

understand them in the light of two salient factors, choice

(voluntary/involuntary movement) and visa status (autho-

rized/unauthorized entry). These two factors (Fig. 1) act in

concert to define the resources immigrants can access in the

host country, how they are perceived, and may suggest

immigrant social and/or human capital.

Immigrants/voluntary migrants Voluntary migrants move from their homelands because, on

balance, they believe their opportunities in another country

will improve. They carefully plan the exit, deciding when to

leave, by what route, with whom, and what to take with them.

They identify the destination, often mobilizing their networks

in the receiving country. Before leaving, most have identified

at least a temporary place to live, know something about work

opportunities, and have an idea of the environment to which

they are headed. Voluntary migrants are ‘pulled’ to a new

abode,1 and they may be authorized, with all the requisite

papers (Fig. 1, Quadrant I), or unauthorized, either entering

without appropriate documents or remaining after visa expi-

ration (Fig. 1, Quadrant II).

Refugees/involuntary migrants Refugees are compelled (‘pushed’) to leave their homes to

avoid dangerous conditions.1 Leaving unwillingly and quickly,

with little or no planning, and, on the spur of the moment,

they carry with them whatever they believe they will need;

they generally have no inkling of where they will go, how they

will travel, or how long it will take. They do not know whether

they will survive the journey or be harmed along the way,

falling victim to danger, exploitation, or harsh elements. They

may leave with family members but may get separated and

Fig. 1 e Immigran

may find that they are dependent on those they neither know

nor trust.

‘Refugees are persons who are outside their country of

origin for reasons of feared persecution, conflict, generalized

violence, or other circumstances that have seriously

disturbed public order and, as a result, require international

protection.’22 The United Nations High Commissioner for

Refugees (UNHCR) makes a determination whether particular

groups meet the identified criteria for refugee status and can

be granted international protection (Fig. 1, Quadrant III).

Asylum seekers/asylees Asylum seekers are outside their home country seeking

sanctuary but are in the asylum country without appropriate

authorization (Fig. 1, Quadrant II). They request international

protection, making application to the UNHCR or to the asylum

country seeking refugee status. While their applications are

pending, they are considered asylees and must prove the risk

of persecution in their homeland because of demographic

characteristics, not for economic reasons or because it is un-

safe in their home countries. A very small proportion of the

approximately one million asylum seekers worldwide are

actually granted refugee status.

All ‘victims’ are not refugees Determining whether someone is a refugee is not always

clear. Forced migration has ‘many faces,’ and even the legal

category of refugee can be interpreted in various ways;

different people may be identified as refugees in varying sit-

uations, places, and times.23 However, only UNHCR adjudi-

cated ‘refugees’ are entitled to international protection. This

does not, however, mean that individual nations cannot grant

asylum seekers the refugee status and provide them legal

entry and protection.

Victims of natural disasters

The UNHCR's definition of ‘refugee’ does not take into account all forms of forced migration. Thus, those forced to leave their

homes because of catastrophic events, such as natural

t categories.

p u b l i c h e a l t h 1 7 2 ( 2 0 1 9 ) 1 3 5 e1 4 2138

disasters, are not considered refugees. Although they may be

in ‘refugee-like’ situations, they are not eligible for the same

services as refugees.

Victims of family dysfunction/societal norms

Victims of family dysfunction, such as domestic violence, or of

societal norms, such as female genital mutilation, often seek

asylum outside their home countries. Although they are

harmed and are vulnerable, the UNHCR definition does not

qualify them for refugee status. Their experiences are either

idiosyncratic (to their particular families and situations) or

may reflect a societal norm (to which all are subjected), but

they are not correlated with membership in a group that is the

target of persecution.

Economic migrants

Extreme unemployment, poverty, and the inability to survive

in the poor economic conditions in the homeland do not

qualify one as a refugee. Although one may be a victim of the

country's economy, one is not persecuted because of one's ethnicity or race, thoughts, or beliefs, and one's life is not in danger. Economic migrants are, in fact, voluntary migrants

seeking improved economic opportunities.

Trafficked individuals Human trafficking is both an international and domestic phe-

nomenon, exploiting individuals for commercial purposes,

usually in the form of forced labor or sexual services and

prostitution.24 Internationally trafficked people often leave

their homes willingly but with little awareness of what is in

store,spending severalyears if not the restof their livesin what

is now also known as contemporary slavery.25,26 Although

many may have left their homelands voluntarily, they soon

realize that they are at the mercy of traffickers who may have

tricked them, and they are, in reality, involuntary migrants.

Temporary migrants Temporary migrants, such as seasonal or migrant workers,

often obscured in discussions of ‘permanent’ migration, also

substantially influence both sending and receiving nations.

Their movement is circular as they enter host nations for paid

work and return home when the work is completed. Often

exploited, they frequently work for low wages in hazardous

health conditions27,28 and are essential to a host nation's workforce. Many aspire to permanency, and although this is

becoming possible in some instances,29 it eludes most.

The second generation Although the children of immigrants, the second generation,

are born in the host country and usually counted among the

native population in national statistics, their experiences

require that they navigate at least two cultures. Nevertheless,

recent literature suggests that members of this group tend to

integrate themselves into the host country's norms, even when there are social and economic disadvantages.30 Overall,

their well-being seems to be correlated with their own

perception of their level of integration with the host

society.31,32

Migration flows

There is a general perception that most, if not all, migration is

from the Global South to the Global North. It is true that about

half the migration is from South to North, but it is also true

that within-region migration is substantial, with most mi-

grants moving between countries within a region.14

The Pew Hispanic Center, in February 2018, revealed its

findings of global migrant stocks, providing a fascinating

interactive map of migration flows, both in and out of each

nation, over the last three and a half decades.39 Clearly, all

nations are touched by migration, but most voluntary mi-

grants tend to move from middle-income nations to high-

income nations,14 often in the same region. Movement from

low-income countries to high-income countries does occur

but in disproportionately lower numbers. There is substantial

movement from low-income countries to other developing

countries within the same region.

Fig. 2 provides a recent snapshot of the leading migrant

receiving countries.33 The United States clearly has the largest

number of international migrants at almost 50 million; how-

ever, its share of the overall population is only 15.3%. On the

other hand, the 8.3 million migrants in the United Arab

Emirates constitute 88.4% of the total population of 9.4

million. The Pew Hispanic Center's interactive map, above, provides a decade by decade view of the flow of migrants

between nations. This reveals its origins and destinations and,

along with Figs. 2 and 3, allows insight into its potential eco-

nomic, social, political, and cultural impact on receiving

nations.

Refugees are more likely to move to bordering countries

and are overrepresented in developing nations. Eighty-four

percent of the world's refugees are found in developing countries, not in the developed nations of the Global North.34

Despite news reports of the influx of Syrian refugees to

Europe, the country that has hosted and continues to host the

largest number of Syrian refugees is Turkey; Pakistan,

formerly the leader in hosting refugees, fell to second place in

2016 and 2017, and is primarily host to Afghani refugees.34

Germany is the only country in the European Union that is

on the list of top 10 refugee hosting nations (Fig. 3).

When migrants from source countries are dispersed across

several receiving nations, their social, cultural, political, and

demographic impact is less than it is when large numbers

from one source nation settle in a single destination country.

Thus, the greater the share of the migrant population in the

host nation, as indicated in Fig. 2, the greater is its impact

across several spheres of society.

Perceptions of immigrants

Census figures in several countries of the Global North

continue to reveal dropping birth rates and increasing

longevity resulting in gaps in the labor force and concerns

about perpetuation of society and culture. The most im-

mediate and practical resolution to address labor force

gaps in the North is through increased and targeted

immigration; nevertheless, most nations have long been

Fig. 2 e International migrant population and migrant share of the population. https://www.migrationpolicy.org/programs/

data-hub/charts/top-25-destinations-international-migrants.

p u b l i c h e a l t h 1 7 2 ( 2 0 1 9 ) 1 3 5 e1 4 2 139

wary of foreigners, and particularly those from societies

socially, economically, and culturally different from them.

This was particularly evident in 2018, as thousands of

Syrian refugees and many other Middle Eastern and Afri-

can migrants attempted to cross into and through the

European Union (EU). Concerns of usurpation of jobs, ef-

fects on the economy, cultural contamination, changing

social identities, and resource allocations continue to

challenge several EU countries and were instrumental in

BREXIT, the decision of the United Kingdom to leave the

EU. The current political climate of protectionism in the

United States is increasing its nationalism, xenophobia,

and discrimination but has also influenced worldwide

perceptions of immigrants. The Global South, likewise,

does not necessarily welcome foreigners and is also highly

suspicious of Western influences and the ‘Americaniza-

tion’ of the world.

Native born individuals in several nations believe that

the sizes of their immigrant populations are significantly

larger than they are in reality.35 A recent telephone study

of over 24,000 respondents across 15 EU nations revealed

that natives felt migration to their countries should either

remain the same or be decreased. Many doubted if im-

migrants could truly be nationals if they were not either

‘born in the country’ or had ancestral ties to it.36 In these

days of relatively easy migration and at a time when

developed nations have declining workforces and need to

boost their working-age populations, these perceptions

can pose a challenge.

Increased interactions with immigrants as well as more

education, economic security, and higher socioeconomic

status tend to bolster acceptance of migration.37 Approval of

migrants is predicated on the receiving nation's economic need for them as well as on the level of congruence between

their social and political perspectives and values and those of

the host country. Xenophobia is frequently the offshoot of

lack of experience, knowledge, and unfounded fears that are

repeatedly fanned by the prevailing social, political, and eco-

nomic climate and affect both the migrant and the destination

nation. Overall, the current world view of migrants is nega-

tive, with 34% of those in the receiving nation preferring a

decrease in the rate of immigration, 21% comfortable with an

increase, and 22% believing that immigration should be kept

at the current levels.38

Regardless of public opinion, welcome, and perceptions of

the ability to integrate, the host country needs immigrants to

integrate fully and efficiently, and it is a shared responsibility

between the host and the immigrant. The host must provide

the opportunity and resources for integration in exchange for

the economic benefits offered by the immigrant; the immi-

grant must utilize these resources and make a commitment to

the host country in exchange for expected opportunities. Both

must work in tandem for the success of the integration

process.

Fig. 3 e Major refugee hosting countries. https://www.weforum.org/agenda/2017/06/eighty-four-percent-of-refugees-live-

in-developing-countries/.

p u b l i c h e a l t h 1 7 2 ( 2 0 1 9 ) 1 3 5 e1 4 2140

Migration, ethnicity, and race

Receiving/transit nations are particularly apprehensive

about how immigrants fill their needs and impact their re-

sources. They speculate about immigrant preparedness to

enter the workforce and the ability to integrate into the re-

gion and the culture. Immigrants also experience these

worries.

When the movement of people is to neighboring

countries, the likelihood is that there are phenotypic

similarities, and by the second generation, visible differ-

ences between migrant and host become negligible.

Movement across continents, on the other hand, results in

the melding of genetic variations. Migrants not only affect

the receiving nation's culture, they alter the racial/ phenotypic profile of a nation through entry and inter-

marriage, often disturbing the native population. However,

it is ethnicity, regardless of phenotype, which is

associated with common ancestry and culture, including

language, religion, traditions, and behavioral norms that

can contribute to, and challenge, a receiving nation's world view. When traditions clash, are devalued, or

interfere with established patterns of interaction and

behavior, fear and discrimination escalate, resulting in

barriers that seem impossible to navigate.

Furthermore, cultural differences can have implications

for several segments of its society, including the health pro-

fession, which could find that in delivering services, it must

grapple with the complex relationship between migrant,

health, healthy behaviors, health access, and health services

utilization. Migrants are likely to engage in practices that are

consistent with their own customs, including the extent to

which they1 utilize traditional medicine,2 adhere to patterns

of behavior that may be less than healthy, as in dietary

habits,3 evidence confidence in contemporary medicine and

practitioners,4 participate in preventative health care, and5

comply with medical directives.

p u b l i c h e a l t h 1 7 2 ( 2 0 1 9 ) 1 3 5 e1 4 2 141

Summary

This article, in providing an overview of immigration, has

sought to emphasize that with increasing globalization and

the inequitable distribution of resources, the flow of migrants

from countries with fewer opportunities to those with more

assets will both continue and increase. Declining populations

in the majority of the advanced economies require that their

governments establish programs that both attract migrants

and ensure their economic and social integration.

Among Swiss playwright and novelist Max Frisch's many famous quotes was his reference to immigrants: ‘We wanted

workers, but we got people instead.’ A receiving nation will

find that it must be prepared to accept immigrants with all

their complexities, recognizing that even as they bring their

many human and personal skills and strengths that benefit

the host country, their integration will change its national

profile and culture. Likewise, migrants must be aware that

economic integration usually requires sociocultural adapta-

tion which will also affect their cultures. Maximal benefits to

both the host and the migrant will only be realized when host

country policies, programs, and services are prepared to

recognize and adapt to diverse sociodemographic changes

even as immigrants learn to integrate into host country pat-

terns, and both realize that, in the final analysis, we are more

similar than we are different.

Author statements

Ethical approval

No ethical approval was sought as this is a conceptual paper.

Primary data were not collected from any source nor were

human subjects involved in this project.

Funding

This article is based on a presentation that was presented at

the 1st International Congress on Migration, Ethnicity, Race,

and Health held in Edinburgh, Scotland in May 2018 and which

was underwritten by the limited company, MERH Ltd, estab-

lished to run the Congress.

Competing interests

There are no competing interests.

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