The Migrant as a Traveler — Visiting Friends and Relatives

One of the many changes in the area of migration health during the past two decades has been the increasing mobility of many migrant populations after they have resettled in their new country of residence. The reasons behind increased travel in migrant communities reflect general factors of globalization common to other travelers, and to shifting geopolitical environments. These patterns of mobility have direct relevance for travel medicine. Better awareness of these changes by practitioners can provide increased opportunities for risk identification and risk management for this growing population of travelers.

Traditional patterns of immigration and refugee flows from the end of the Second World War to the mid-1980s tended to be unidirectional. Often, the financial limitations encountered by migrant family groups following arrival at their new homes did not offer the capacity for frequent return journeys to their place of origin. Depending on cultural, social and assimilation factors, family visits to the "old country" frequently took place many years after migration, or generations later. In the case of refugee movements during the East/West geopolitical environment before the fall of the Soviet Union, return visits to the migrants original home were even less common, and in some situations almost impossible during the life time of the original migrant.

Current travel patterns for many groups of migrants are now much different than those of relatively few years ago. The availability and ease of moderate and low priced travel allows frequent journeys to visit friends and relatives (VFR) remaining in the migrants source country, and also allows travel to other destinations, representing various health risks. Also, as military and political conflicts are increasingly resolved through international interventions, opportunities for refugees and asylum seekers to return to their previous homelands have increased.

While these patterns of increased mobility are related to general changes in global travel, there are some issues in VFR travel in migrant communities that can be associated with increased risks of travel-related diseases and ill health. VFR travel, even to the same destinations as traditional tourists, often varies in risk potential. These differences are observed in the duration of travel, accommodation and exposure to local risk factors, the awareness and appreciation of risk, the use of local food, water, and health care facilities, and the frequency of seeking pre-travel health advice. (1)

The purpose of VFR travel also differs from tourist travel in a number of aspects that include cultural, social and economic factors. Journeys are often of longer duration to allow for distant family members to spend time together to sustain the family network. In the developing world there is an increased risk of acquiring illness. VFR travelers are more likely to reside in the community as opposed to commercial accommodations. While these risks may be low or marginal in VFR travelers who were born and recently lived in the location, children born after immigration or those who have been absent from the local environment for many years may have decreased immunity to specific infectious agents, and may be more susceptible to common local pathogens. Malaria occurring in returning VFR migrant travelers is frequently noted in Europe and North America. (2), (3), (4)

While chronic risks of endemic disease (malaria, for example) are part of the normal existence for local residents, interventions to reduce risks may not be considered by the migrant traveler or their physicians. For these travelers the journey is simply a return home where risks to health in the travel medicine context are not considered in the same manner as in tourist travelers. Travel medicine preparations and counseling may not enter into VFR travel planning, or if they do the appreciation and risk acceptance may differ significantly from tourist travelers to the same destination. Examples extend beyond malaria prevention. VFR travelers may not realize that some infections commonly encountered in early childhood such as hepatitis A, for example, may have more serious clinical consequences in populations with low immunity such as in older children and adolescents who were born to migrants in the developed world. (5)

References:

1. dos Santos, CC, Anvar A, Keystone JS, Kain KC. Survey of use of malaria prevention measures by Canadians visiting India. Can Med Assoc J 1999, 160: 195-200.
2. Kain KC, MacPherson DW, Kelton T, Keystone JS, Mendelson J, MacLean JD. Malaria deaths in visitors to Canada and in Canadian travellers: a case series Can Med Assoc J 2001;164: 654-659.
3. Sabatinelli G, Ejov M, Joergensen P. Malaria in the WHO European Region (1971- 1999). Eurosurveillance 2001; 6: 61-65.
4. Holtz TH, Kachur SP, Mac Arthur JR, Roberts JM, Barber AM, Steketee RW, Parise ME. Malaria Surveillance — United States, 1998. MMWR; December 7, 2001 / 50(SS05);1-18.
5. MacPherson DW, Gushulak BD. Human mobility and population health. New approaches in a globalizing world. Perspect Biol Med 2001; 44: 390-401.

Brian D. Gushulak MD is Director General, Medical Services Branch
Citizenship and Immigration Canada (Author for Correspondence)

Douglas W. MacPherson MD, MSc(CTM), FRCPC
Director, Office for Public Health Security Centre for Emergency Preparedness and Response
Population and Public Health Branch, Health Canada