Week 7: Population Health of the Former Soviet Union, India, and China

Journal of Travel Medicine, 2018, 1–7 doi: 10.1093/jtm/tay040

Perspective

Perspective

Drivers of migration: why do people move? Francesco Castelli*†

University Department of Infectious and Tropical Diseases, University of Brescia and ASST Spedali Civili General Hospital, Brescia, Italy and UNESCO Chair ‘Training and Empowering Human Resources for Health Development in Resource-Limited Countries’, University of Brescia, Italy

*To whom correspondence should be addressed. Email: [email protected]

Submitted 17 March 2018; Editorial decision 15 May 2018; Accepted 16 May 2018

Abstract

More than 244 million international migrants were estimated to live in a foreign country in 2015, leaving apart the mas-

sive number of people that have been relocated in their own country. Furthermore, a substantial proportion of inter-

national migrants from southern countries do not reach western nations but resettle in neighbouring low-income

countries in the same geographical area. Migration is a complex phenomenon, where ‘macro’-, ‘meso’- and ‘micro’-fac-

tors act together to inform the final individual decision to migrate, integrating the simpler previous push–pull theory.

Among the ‘macro-factors’, the political, demographic, socio-economic and environmental situations are major

contributors to migration. These are the main drivers of forced migration, either international or internal, and

largely out of individuals’ control.

Among the ‘meso-factors’, communication technology, land grabbing and diasporic links play an important

role. In particular, social media attract people out of their origin countries by raising awareness of living condi-

tions in the affluent world, albeit often grossly exaggerated, with the diaspora link also acting as an attractor.

However, ‘micro-factors’ such as education, religion, marital status and personal attitude to migration also

have a key role in making the final decision to migrate an individual choice. The stereotype of the illiterate,

poor and rural migrant reaching the borders of affluent countries has to be abandoned. The poorest people

simply do not have the means to escape war and poverty and remain trapped in their country or in the neigh-

bouring one.

Once in the destination country, migrants have to undergo a difficult and often conflictive integration process in

the hosting community. From the health standpoint, newly arrived migrants are mostly healthy (healthy migrant

effect), but they may harbour latent infections that need appropriate screening policies. Cultural barriers may some-

times hamper the relation between the migrant patient and the health care provider. The acquisition of western

lifestyles is leading to an increase of non-communicable chronic diseases that require attention.

Destination countries have to reconsider the positive medium/long-term potential of migration and need to be

prepared to receive migrants for the benefit of the migrants themselves and their native population.

Key words: Migration, drivers, push and pull factors

Foreword

According to the International Organization for Migration (IOM), as many as 244 million people were international

migrants in 20151 and the UN Department of Economics and Social Affairs estimates that the figure is as high as 257.7 million in 2017.2 Importantly, out of the 244 million claimed by IOM in 2015, 90.2 million moved from a south- ern country to another southern country, while only 85.3 million were people migrating from the south to the north, the remaining being individuals from the north migrating to

†UNESCO disclaimer: The Author is responsible for the views con- tained in this article and for opinions expressed therein, which are not necessarily those of UNESCO and do not commit the Organization.

© International Society of Travel Medicine 2018. Published by Oxford University Press. All rights reserved. For Permissions, please e-mail: [email protected]

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the south (13.6 million) or from the north to the north (55.1 million). At present, most international migrants are of working-age and live in Europe, Asia and North America (Figure 1). Apart from international migrants, an astonish- ing figure of 740 million people is estimated to have migrated internally within their origin country.1

Migration is as old as humankind. People have always moved in search of better living conditions for themselves and for their loved ones or escaping dramatic situations in their homeland. These two major drivers were the fundamentals of the ‘push and pull’ theory that was first proposed by Lee in 1966,3 encompassing economic, environmental, social and polit- ical factors pushing out from the individual homeland and attracting him/her towards the destination country.

Lee’s theory has the merit of being one of the first trying to identify in a modern and scientific way the drivers of such a complex phenomenon after Ravenstein first addressed them in Scotland in 1885.4 The main elements of the ‘push and pull’ the- ory will also be considered in this article for didactic purposes, but the Author recognizes that in the current global world real- ity is certainly much more complex and faceted, involving both local national realities and macro-level causes as well as meso- level and micro-level causes related to the link of the individual to his/her ethnic or religious group and the personal character- istic of the individuals respectively.5 (Figure 2) Recently, the ‘pull-push plus’ theory has also been proposed, which consid- ers predisposing, proximate, precipitating and mediating dri- vers of migration.6

Regardless of the theoretical framework adopted, the topic addressed by this article is difficult because sound scientific data are scarce, existing literature is mainly qualitative and often pre- sented as grey literature. In addition, geographical and cultural elements may influence the weight of the single determinant in different continents and in different periods. Finally, although the various drivers will be presented separately, we recognize that they are part of a unique complex scenario where they strongly interact.

Definition of migrants

According to the International Organization for Migration (IOM), a migrant is ‘any person who is moving or has moved across an international border or within a State away from his/ her habitual place of residence, regardless of (1) the person’s legal status; (2) whether the movement is voluntary or involun- tary; (3) what the causes for the movement are; or (4) what the length of the stay is’, a broad definition indeed. Under such def- inition, and strictly limiting our analysis to south-to-north migrants, two major broad categories may be identified:

(a) Labour (or economic) migrants (and family reunification) and (b) Forced migrants (asylum seekers and refugees);

whose reasons to migrate may differ, even if difference between the two categories are probably smaller that estimated once and the same migrating individual may fall in one or the other cat- egory at the same time.5

In this respect, it is useful to report below the synthetic defi- nitions of asylum seekers and refugees from IOM.7

Asylum seeker

A person who seeks safety from persecution or serious harm in a country other than his or her own and awaits a decision on the application for refugee status under relevant international and national instruments. In case of a negative decision, the per- son must leave the country and may be expelled, unless permis- sion to stay is provided on humanitarian grounds.

Refugee

A person who, ‘owing to a well-founded fear of persecution for reasons of race, religion, nationality, membership of a particular social group or political opinions, is outside the country of his nationality and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country (Geneva Convention, 1951, Art. 1A).’

Figure 1. International migrants by region of residence, 2015 Source: UN DESA, 2015. www.un.org/en/development/desa/population/migration/data/estimates2/estimates15.shtml, modified

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Drivers of migration

The factors acting together and determining the final decision of an individual to migrate may be subdivided in macro-elements (largely independent from the individual), meso-elements (more closely related to the individual but not completely under the individual’s control) and micro-element (personal characteristics and attitudes). Those that have been more extensively studied will be discussed in this article.

Inadequate human and economic development

Human development is enormously unbalanced in the various regions of the planet and the gap is increasingly wide. The eco- nomic and political reasons underlying this sad situation are beyond the scope of this article and will not be addressed here. The Human Development Index (HDI) is a composite index com- bining the performances of the different countries on health (life- expectancy), education (years of schooling) and economics (per capita income) proposed by the United Nations Development Program (UNDP).

The 2016 HDI top ranking includes 15 western countries (11 European, 2 North American, 2 in Oceania) and 5 Asian coun- tries among the first 20 ranked nations.8 At the opposite extrem- ity of the list, 19 out of the last 20 nations with the lowest HDI indexes are from Africa, a striking difference. However, during the first decade of the new millennium, many African countries experienced a remarkable economic growth, with gross domestic product (GDP) increases exceeding 5% in average according to the International Monetary Fund. Unfortunately, the consequent relative wealth has not been equitably distributed in the popula- tion and the subsequent world economic crisis since 2011 has slowed down the economic performances of most African coun- tries to a bare 2% yearly GDP increase. As a consequence, most jobs in developing countries are still in the informal sector, with little salary and social protection, thus nurturing the willing to find better job conditions elsewhere. Low performances in the health, education and economic sectors are a reflex of the

vulnerability of the health, education and productive systems which is caused by the lack of economic and human resources. With particular regard to the health sector, such situations that provide little professional and economic motivation pave the way for qualified health professionals to leave their origin coun- tries, a phenomenon known as ‘brain drain’ and creating a vicious circle.

Poor health services, little educated and qualified work force and poverty are a fertile background promoting migration of individuals in search of better life. New communication technolo- gies, largely available in urban settings even in developing coun- tries, allows people to compare the western lifestyle with the local situations where the luxurious houses and cars of expatriates (and local authorities…) often contrast with the poor living con- ditions of the local populations. The gradient of prosperity.

Migration and development are strictly linked and influence each other. Paradoxically enough, in fact, migration may be driven by both a lack of development and by an increasing socio- economic development in a specific country, at least in the initial phase.9

Demographic increase, urbanization

The world’s living population has increased in an unprecedented way during the last two centuries, from 1 billion estimated to live in the year 1800 to the more than 6 billion living at the beginning of the second millennium, to the roughly 11 billion that will probably inhabit the earth in 2100.10 The bulk of this massive increase is taking place in Asia and Africa, where high fertility rates, driven by infant mortality, and poor birth control programmes result in high annual population increase rates. On the contrary, the fertility rate in western industrialized countries is shrinking. According to the World Bank, the average fertility rates in high income countries was 1.7 children per woman in 2015, while it was 4.8 per woman in low-income countries.11

As a global result, the population of western industrialized countries is reducing in size and getting progressively old (aging population), while the young working-age population of the

Figure 2. Complex drivers of migration: macro-, meso- and micro-factors Source: Foresight: Migration and Global Environmental Change (2011) Final Project Report The Government Office for Science, London, modified

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developing countries is rapidly increasing. The African continent offers a striking example. From 493 million in 1990, the African population grew to 1 billion in 2015 and it is expected to rise to 2.2 billion in 2050 and to 4 billion in 2100!12

With particular regard to the African continent, the increas- ingly young population will probably exceed by far the other- wise improving—but not equitably distributed—economy, giving origin to the so-called ‘jobless generation’ phenomenon. This means that the increasing global wealth is not mirrored by a proportional number of jobs to satisfy the increasing expecta- tions of the growing skilled young generation, at least in the short-medium term.13

As a matter of fact, the flow of migration in relation to demographic increase could also be regarded in the opposite way, raising the question ‘why do so few people migrate?’14 In fact, even if the stereotype of migration proposes a model of ‘mass’ invasion of rich countries by migrants from low-income countries in terms of absolute numbers, the proportion of migrating people is quite stable (3.3% of the world population in 2015, 2.4% of the world population in 1960).

Climate changes

It is now almost universally accepted that the climate is becom- ing warmer and warmer at an increasing speed, causing health inequalities across the world15 apart from other unwanted effects. It is also accepted that the driving causes of such climate changes started with the industrial revolution, are mainly anthropogenic in nature and are largely due to the emission of greenhouse gases (in particular CO2, methane and nitrous oxide) by industrial activities from carbon-based energy. It has been estimated that 97% of such emissions occur in industria- lized rich countries, leaving a mere 3% emission coming out from low-income countries.16 The impact of climate changes is astonishingly severe in the south of the world, where 150000 are estimated to have died in 2000 from the consequences of the planet warming.17 Drought, flooding, increases in arthropod borne infections due to vector spreading in regions where the contrast measures are difficult to implement due to scarcity of means also indirectly impact on morbidity and economic agri- cultural revenues. The case of Lake Chad is extreme but enligh- tening. From the nearly 25000 square kilometres Lake Chad had in 1963, its water now covers a bare one-twentieth of its original extension, with severe impact on the fertility of the sur- rounding land. This shortage of water, food and agricultural resources forces people and livestock to move in search of a less hostile environment.1 Examples of land degradation induced by climate changes are multiple and represent a driving force for people to migrate by producing food insecurity and risk of health-related crisis.18

According to the IOM, environmental migrants are those ‘persons or groups of persons who, for reason of sudden or pro- gressive changes in the environment that adversely affect their lives or living conditions, are obliged to leave their habitual homes, or choose to do so, either temporarily or permanently, and who move either within their country or abroad’.19

It has been suggested that the environment may impact on migration flows by directly affecting the hazardousness of place

but also indirectly changing the economic, political, social and demographic context with very complex interrelationships.20

The ‘climatic migrants’, as they are sometime called, might possibly reach the astonishing figure of 200 million by the year 2050, according to the IOM.21 However, forecasts are difficult to make because sound scientific data on this topic are extremely scarce and do not permit reliable estimates.22 The assessment of the real impact of worsening environmental con- ditions, albeit logical, would greatly benefit from sound research studies.

Wars and dictatorship

Even now, at the beginning of the third millennium, many areas of the world—in virtually all continents—host bloody conflicts and social instability where armed parties fight or where rude dictatorships are ruling and denying social rights. Some are well-known to the public (i.e. Syria and Afghanistan), while others are not as is the case of the Horn of Africa (Eritrea, Somalia) and some areas of West Africa (Mali, Gambia) and the Sahelian region or in Central and Southern America.1 People may be denied basic human rights and the access to education and to a dignified life may be prevented, especially for females. Fundamentalism is such countries may easily grow, as it is the case with the deadly activities of Boko Haram in Northern Nigeria, that it is estimated to have caused the internal displace- ment of nearly 2 million people.23 It is to be noted that the majority of displaced people in warring nations are relocated within national borders, thus officially they are not considered international migrants, but rather internal refugees.

Land grabbing

Land grabbing is a phenomenon that has become increasingly important since the beginning of the new millennium. The term ‘land grabbing’ refers to the intensive exploitation of vast areas of land in rural areas of low-income countries by private inter- national enterprises or even by foreign governments in order to implement large-scale intensive cultivations (mainly biofuels and food crops) or to exploit minerals, forestry or the touristic indus- try. This happens to the detriment of the poor local population, which is poorly (and often forcedly) compensated and virtually obliged to leave the rural areas to reach the degraded urban per- ipheries within their own countries, where they often live a diffi- cult life in a different setting from the one they and their families have experienced for centuries. Psychological and physical impair- ment is frequent in such communities and international migration may then occur. Apart from this direct impact, the economic bene- fit of small-scale agricultural industry is of advantage of the local communities, while the intensive exploitation of lands as a conse- quence of land grabbing is mainly to the benefit of the private enterprise stock owners and the international market,24 leading to the progressive impoverishment of the increasingly resource-poor country. Together with environmental damages due to climate changes, the loss of small-scale land property and its turning into intensive exploitation causes a progressive land degradation, which leads to a progressive abandonment of native lands by a mass of people.25

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Religion

This issue will only be briefly alluded to, as it is too wide and complex to be adequately addressed in such context. The his- tory of humankind offers many examples of mass population movements caused by religion persecution or following the dream of a land where individual faith could be freely preached. However, these movements have often been the consequence of a political will as it has been the case of the conflictive Muslim, Hindu and Sikh movement across the newly created border between India and East Pakistan (now Bangladesh) in 1947. Similarly, Jews flowed to Palestine after the Second World War, also attracted by the law of return, favouring migration of Jewish people to the new state of Israel. In many other instances, religion has been the pretext for ethnic persecution and expulsion, as is possibly the case for the Rohingya Muslim population from Myanmar or the mass movements caused by armed fundamentalists groups such as Daesh or Boko Haram in the Middle East and sub-Saharan West Africa, respectively.

Sexual identity

A number of countries have a quite restrictive policy on sexual identity and LTGB people (lesbians, gay, transgender and bisex- ual people) face psychological and even physical violence, for- cing them to hide their sexual identity. The impact of such policies on international migration has recently been the subject of some investigation that is in its infancy. No doubt, however, that an impact exists, especially from countries where ‘mach- ismo’ is considered a value.26,27 A comprehensive overview of the issues related to the protection of social rights in those peo- ple forced to migrate due to their sexual orientation may be found in the 2013 thematic issue of Forced Migration Review.28

Education

A final note has to be dedicated to the education level of migrants. International migrants are often regarded as illiterate and poor people escaping poverty from remote rural areas. This stereotype is far from being true in most instances for both eco- nomic and forced migrants. Migrants in search of a better future usually have a more pronounced initiative, attitude and bold- ness than the average person, with some skills and financial resources needed to plan and fund a long-distance journey as it is the case for international migration.29 In most instances, they are more educated than their peers left behind in their origin country.30 Sometimes they are even more educated than their peers in the destination country.31 In addition, individuals from families or communities that already positively experienced migration in previous years are more inclined to migrate as their travel abroad is regarded as of possible benefit to the origin society.5 For such individuals, the existence of ethnic or family links in the destination country is a further driver of migration. The relationship between education and migration are twofold. From one side, the migration of educated people from low- middle income countries to OECD countries constitute a net loss of human qualified resources for the origin countries and a gain for the host country. A phenomenon known as ‘brain drain’. From the other side, the financial and ideational remit- tances from destination countries may also have an impact on

the education of non-migration children and adolescents in their origin countries.30

Personal willingness to migrate

All the above drivers of migration act, with different strength in dif- ferent places, to build the general frame at the macro-level of each specific geographical, economic and political situation. However, the meso- or even micro-levels are also important in driving the final choice of the individual to migrate. The influence of the ethnic group, the family support—both economic and societal—is of the upmost importance for a specific individual to make the final choice to migrate or to stay. Educational level and access to finan- cial means permitting to afford the migration travel have already been discussed above, but other factors such as ethnic and social customs are also important. The aspiration and desire to migrate is a crucial key factor that interacts with other external drivers of migration to build the final decision to actually migrate.32

Health challenges in the destination country

Regardless of the mix of drivers leading to migration in any individual person, migrants usually undergo a difficult integra- tion process in the hosting community. Conversely, the receiving country could also be obliged to adapt its social and health sys- tems to face the needs of the hosted population. In many instances, this process is not without conflict for the cultural and economic adaptations that it implies.

From the health point of view, although generalization is inappropriate due to the heterogeneity of provenance and epi- demiology of diseases in the origin countries, newly arrived migrants are usually healthy (the ‘healthy migrant’ effect) but more affected by latent infections than the host populations,33

requiring screening policies and links to care. Crowded and inadequate living conditions in hosting camps may also lead to infectious diseases outbreaks, as recently reported in France.34

However, despite the reported higher prevalence of selected infections in migrants, including potentially diffusive respiratory tract infections, the risk of significant spread in the receiving populations has been reported to be negligible, if any.35

Once resettled in the host country, foreign-borne individuals may face infectious exposure when travelling back—often accompanied by children born in the host country—to their countries of origin. They are then referred as VFRs (Visiting Friends and Relatives), and represent a significant proportion of imported diseases in western countries, as in is the case for imported malaria.36 Pre-travel advice in such VFR populations poses significant challenges to optimally address adequate pre- ventive measures.37 However, even the non-communicable dis- eases burden (diabetes, hypertension, metabolic disorders, cardio-vascular diseases, etc.) is increasing among migrants, as a result of changing alimentary habits in developing countries and to the progressive acquisition of western lifestyles after a few years in the receiving country.38

Finally, the cultural interaction between the migrant patient and the care provider is often not without conflicts. The emphasis on the possible exotic nature of otherwise ubiquitous illnesses or, on the contrary, the underestimation of culturally bound complaints (cultural barriers) are often aggravated by

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linguistic barriers leading to potential medical errors. The knowledge of culturally sensitive medical issues, such as genital mutilations, is generally poor in western physicians, requiring specific training and research.39

Conclusions

In conclusion, the migration flow is now a structural phenom- enon that is likely to continue in the next decades. While many migrants from low-income countries aim to reach more affluent areas of the world, it is to be appreciated that a similar, or even bigger, mass of people migrates to neighbouring low-income countries in the same geographical area.

Migration is always the result of a complex combination of macro-, meso- and micro- factors, the former acting at the soci- ety level and the latter acting at the family or even individual level. The prevalence of a factor over the other is unpredictable.

Among the ‘macro-factors’, the inadequate human and eco- nomic development of the origin country, demographic increase and urbanization, wars and dictatorships, social factors and environmental changes are the major contributors to migration. These are the main drivers of forced migration, both inter- national or internal.

Among the ‘meso-factors’, linking the individual to his/her ethnic group or religious community, land grabbing, communi- cation technology and diasporic links play an important role. The role of communication technologies and social media to attract people out of their origin countries is indisputable today. Awareness of living conditions in the affluent world—albeit often grossly exaggerated—contributes to nurture the myth of western countries as Eldorado. The ease of communication with the diaspora and family members who migrated previously rein- forces the desire of escaping from poverty to a challenging new life abroad.

However, ‘micro-factors’ such as education, religion, marital status and personal attitude to migration also have a key role to make the final decision to migrate that is an individual’s choice.

In any case, the stereotype of the illiterate poor migrant com- ing from the most remote rural areas and reaching the borders of affluent countries does not stand. The poorest people simply do not have the means to escape war and poverty and remain trapped in his/her country or in the neighbouring one. Some degree of entrepreneurship, educational level, social and finan- cial support is usually requested for international south–north economic migration and personal characteristics and choices also play a role. This phenomenon has a positive aspect, as the possibility of success of migrants increases as do remittances, but also a negative one, as the most active part of the origin country may be drained preventing local development.

Usually, even if generalization is inappropriate, newly arrived migrants are in good health, despite a higher prevalence of latent chronic infections (‘healthy migrant’ effect). However, marginalization in the host country may lead to a deterioration of such health status, a phenomenon known as the ‘exhaust migrant’ effect.

Host countries, which may have also an economic benefit from migration in the medium long-term, have to be prepared

to receive migrants for the benefit of the migrants themselves and their native population.

Conflict of Interest

None declared.

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