Special Article: Migrant Health and Migration Medicine:
Expanding the Scope of Activities of the ISTM

Increasing international mobility of persons and goods is one of the characteristics of today’s globalized world. The origin of this process of globalization is multi-factorial: demographics, communication, transportation, relocation of work opportunities and other factors all combining to dramatically change global patterns of movement. There are clear indications that this trend will continue over the coming years and that these issues will assume an important dimension with regards to health.

Traditionally, individuals or populations on the move are referred to as either travellers or migrants. International travellers number nearly one billion persons per year. Their journey involves the crossing of international borders on a two-way ticket, and their travel is often between rich countries, or from rich to visit poor countries. The duration of these journeys is often for only a limited amount of time. Their contact with foreign population is often in the form of sporadic encounters that may occur in comfortable hotels, although there is an increase in “exotic” or wilderness experience travel. These travellers may be exposed to poor hygiene and foreign pathogens and have some risk of bringing the consequences of that exposure home with them. However, as a whole, the experience is often considered to be recreational, and consequently even illness acquired in the manner may not be perceived as a significant hardship.

Migrants number approximately two to four million persons per year. They primarily travel on a one way ticket, usually from poor to richer countries, carrying with them the specific disease burdens of their country of origin. Their conditions of travel often include journeys of much longer duration than those of routine travellers, and migrants are often exposed to greater health risks than tourists. Migrants tend to have prolonged contact with new populations, experience new cultural practices and suffer some restriction in access to traditional health care at their new destination. There are several “sub-categories” of migrants including tourists, business travellers, humanitarian workers, students, military personnel, immigrants, refugees, asylum seekers, illegal migrants and others. Each category can be defined according to some specific characteristics but they all share common factors related to travel and the risk of some health consequences resulting from that movement process.

Changes in environment, exposure to new risks, differences in heath systems and access to medical services affect migrants’ health. As the world continues to experience the effects of globalization, distinctions between traditional travelers and migrants is becoming less clear, as the groups share more and more commonality. Thus, in an attempt to better understand the implications of mobility, it will be necessary to examine both the differences and the common characteristics, risk factors and consequences of international movement for both traditional travellers and migrants.

One of the basic health concepts of international mobility is the traversing of geobiological boundaries during the journey. This can be explained as a process of leaving one specific biological environment (with its own climate, temperature, pathogens, and vectors) for which a certain degree of adaptation exists, and the movement to other locations where the traveller is exposed to different biological characteristics. In today’s world this process is resulting in an increasing number of persons being exposed to new environmental stresses that have potential health consequences. The crossing of these epidemiological boundaries is also associated with an increased circulation of pathogens and vectors worldwide, resulting in the increased exposure of both the newcomers and the receiving populations to new disease challenges.

The movements of individuals and populations also imply the crossing of socio-cultural boundaries. Leaving family and community to move to another socio-cultural environment has extensive implications, both for the person moving and for the receiving population. Knowledge, beliefs and attitudes towards disease and health, the expectations of and perceived needs for medical services and access to health services or information may be very different between the travellers’ origin and destination. These differences can importantly affect the process of adaptation to a new environment for the newcomer and can influence the effectiveness of health care providers who serve migrants and travellers’.

The health aspects of the movements of persons are often perceived in terms limited to the risks of importing or exposure to communicable diseases. However, moving also implies changes in lifestyle, food habits, exercise; it imposes psychological stress and a certain degree of isolation. Each of those factors can affect the health and well being of the migrant traveller and can have potential consequences on physical and mental health. These various factors have a definite impact on the use of medical services with direct consequences on the cost of the services provided and their adequacy.

Assessing and monitoring factors that affect health and health services for the internationally mobile is crucial in order to anticipate and propose changes and adaptations to travellers health needs. Better and more detailed analysis of the relationships between mobility and health is needed to better serve migrant travellers and to ensure that resources are effectively utilized. Significant trends in patterns of disease distribution related to population mobility can be observed. For example, in many European countries an increasing proportion of new cases of tuberculosis is detected in foreign-born residents and newly arrived migrants. In some nations, the majority of reported malaria is noted to occur in foreign-born residents returning after visiting friends and relatives. Similar overrepresentation between illness and migration status exists in the areas of occupational health and domestic accidents. A clear understanding of the causes and risk factors involved is needed in order to be able to target adapted preventive interventions.

Other areas of current interest in the field include the access to and use of medical services by migrants, the characteristics and costs involved of those services, and the quality of care provided. In Switzerland, for example, the majority of live births is currently observed in foreign born parents, a situation that will have direct implications for a variety of maternal-child and daycare services. Similar situations also result in terms of the provision of culturally appropriate prevention information and messages to be given to mothers.

Drawing on the above examples of the health consequences of increased migration and global mobility it is possible to consider migrants as one cohort of a collection of global travellers. In that context the health characteristics of migrants, which reflect their geographic and socio-cultural origin, can represent a pattern of experience and knowledge that can be applied to groups of travellers. Considering traditional tourist travel for example, there may be lessons acquired by those who provide health services for arriving migrants that may be relevant for other travellers who may journey in the reverse direction. This wider approach to dealing with the health of travellers can both expand the scope and increase the coverage and practice of travel and migration health within a single shared framework of health risk determination and management.

Through this unitarian approach to the health issues common to all travellers, be they tourists or migrants, better prevention, treatment and understanding of travel associated illness and disease can be obtained. It is anticipated that as travel and population mobility increase, the overlap between traditional travel medicine and migration health will expand. Through that increased collaboration curricula, scientific background and the knowledge bases of the two fields will become progressively more common. The net result expected to be increased areas of common interest, investigation and reporting reflecting the globalization of travel, commerce and population mobility.

The increase in international mobility will be associated with new opportunities for ISTM. A broad range of ISTM supported activities could be developed to support the emerging field of migration medicine. Those activities, many of which can be based on or patterned after existing ISTM practices include;

• the study of and improvement in aspects of providing care for migrants, refugees, asylum seekers and immigrants, arriving in a host country,
• improving the science and practice of the initial medical screening and evaluation of migrants,
• the provision of specific medical services for migrant travellers,
• the acquisition of the necessary skills for providers who wish to expand their practice to broader groups of international travellers.

The delivery those activities implies participating in the collection and analysis of basic epidemiological data relating to illness and diseases of migrants, examining their health needs and use of medical services and the design of appropriate training material. All those undertakings will benefit from the facilitation of networking and diffusion of knowledge between those who deliver traditional travel medicine services and those who work in the expanding field of migration health. Many of ISTM members have expertise in the various fields of tropical diseases, travel medicine and several are also involved in providing services for migrants, refugees and immigrants. ISTM plans to build on this existing network of professionals to expand its scope of activities and broaden the concepts and practice of travel medicine.

For the ISTM Committee on Migrant Health

Louis Loutan, Brian Gushulak