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For debate in the Standing Committee see Rule 15 of the Rules of Procedure
Pour débat à la Commission permanente – Voir article 15 du Règlement
Doc. 8650
9 February 2000
Health conditions of migrants and refugees in Europe
Report1
Committee on Migration, Refugees and Demography
Rapporteur: Lord Ponsonby, United Kingdom, Socialist Group
Summary
The growing scope of migratory movements all over the world raises specific health questions in both sending and receiving countries.
Migrants are particularly vulnerable to health problems. They often suffer from communicable diseases such as tuberculosis or hepatitis, as well as respiratory diseases associated with poor nutrition, cold, overcrowding, and inadequate sanitation, water supply and housing, compounded by limited access to health care.
The Assembly is greatly concerned that in many European countries there are migrants who fall outside the scope of existing health and social services.
The Assembly proposes several measures to improve the health condition of migrants and refugees in Europe, including the examination of national laws and policies with a view to their harmonisation and improvement as well as the development of guidelines in regard to the health of migrants and refugees.
I. Draft recommendation
1. The growing scope of migratory movements all over the world raises specific health questions in both sending and receiving countries.
2. Migrants are particularly vulnerable to health problems. Many migrants and refugees, in particular those moving from a poor socio-economic environment to Europe, suffer from communicable diseases such as tuberculosis or hepatitis, as well as respiratory diseases associated with poor nutrition, cold, overcrowding, and inadequate sanitation, water supply and housing, compounded by limited access to health care.
3. Moreover, due to their vulnerable situation and to cultural obstacles in host countries, migrants and refugees appear to be more exposed than the rest of the population to other types of health problems, such as reproductive, occupational and mental health problems.
4. Given the inevitable interdependence between the health of migrants and their host countries' populations, this issue is of general concern and should be given high importance.
5. The Assembly considers that the right to health associated with access to health care is one of the basic universal human rights and should be equally applied to all people including migrants, refugees and displaced persons.
6. The Assembly is greatly concerned that in many European countries there are migrants who fall outside the scope of existing health and social services.
7. The Assembly also expresses its serious concern that few countries have developed comprehensive health policies concerning migrants and refugees. In general migrants and refugees are not provided with health services that are socially and culturally adjusted to their needs.
8. Health care provision in the context of clandestine migration is another serious problem which requires further examination.
9. Consequently, the Assembly recommends that the Committee of Ministers:
i. examine national laws and policies in regard to the health of migrants and refugees with a view to developing a comprehensive, harmonised approach in all member states;
ii. organise exchanges of experience and information on the subject between the member states, with the participation of the appropriate governmental agencies and non-governmental organisations, including migrants’ and refugees’ associations;
iii. instruct the appropriate committee to develop, in consultation with the relevant governmental and non-governmental organisations, guidelines to be addressed to the member states on the health conditions of migrants and refugees in Europe;
iv. foster the standardisation of health screening and the criteria of its application to migrants and refugees;
v. review policies for the protection of migrants in the face of occupational risks;
vi. foster the setting up of a European system for the systematic collection and sharing of health care statistics concerning migrants and refugees;
vii. encourage the member states:
a. to develop specific information programmes for migrants and refugees covering their rights in the field of health care and education in prevention ;
b. to help associations of migrants and refugees to promote health education by financing the provision of educational documentation and through the training of staff recruited from migrant and refugee communities;
c. to encourage migrants and refugees to get involved in routine national and local health care and disease prevention programmes;
d. to examine more closely the problem of cultural obstacles in the way of access to health care including the question of translation/interpretation;
e. to establish programmes designed to train health care providers to be more sensitive to the needs and backgrounds of migrants and refugees.
Explanatory memorandum by Lord Ponsonby
Table of contents
Page
1. Nature and scale of the problem 5
1.1 Introduction 5
1.2 Migration in Europe 5
1.3 Nature of the issue in Western Europe 6
1.4 Central and Eastern Europe 6
2. Pre-migration health conditions 7
2.1 Poverty and health 7
2.2 Health related behaviour 8
3. Impact of uprooting and displacement on health 9
3.1 Disruption of family life 9
3.2 Psychosocial and physical health 9
3.3 Psychiatric illness 9
3.4 Schizophrenia 10
3.5 Suicide among children 10
3.6 Psychiatric morbidity and children 10
3.7 Substance abuse 11
3.8 Gender-related psychosocial health 11
4. Characteristics of resettlement and the impact on health 11
5. Policies and Practices concerning the health of migrants and refugees 12
6. References 13
Abbreviations
CIS Commonwealth of Independent States
EEA European Economic Area
EU European Union
ICMH International Centre for Migration and Health
STIs Sexually Transmitted Diseases
TB Tuberculosis
UK United Kingdom
UNHCR Office of the United Nations High Commissioner for Refugees
1. Nature and scale of the problem
1. As we approach the end of the 20th century, people everywhere are moving in greater numbers, and are doing so further and faster than at any other period in recent history. In 1990, using national census data, the United Nations estimated that there were over 120 million international migrants worldwide. This represented an annual growth rate of 1.9% over the period 1965-90, and that growth has continued since. In 1990, migrants accounted for over 15% of the population of 52 countries. Most of the migration reflected in these data was from developing to developed countries, but the movement of people between developing countries is also increasing as the pace of economic growth and the demand for labour between developing countries changes. European countries are no exception to this overall rule. Even countries in Europe that have traditionally been net exporters of migrants are now becoming net importers.
2. Impressive as these global migration figures are, they may nevertheless underestimate the true number of people living in countries other than where they were born (definition of migrant). Many countries do not have recent or up-to-date census data, and even if they did, a not-insignificant proportion of people crossing borders is neither registered nor necessarily picked up in or by routine census enumerations. For these and other reasons, including wide variability in quality of national data over time and between countries, exact estimates of the global size and nature of migration are difficult to arrive at.
3. An increasingly globalized world economy, improved facility of movement, better communications, more universally shared expectations with respect to standards of living, and visibly disparate levels in quality of life between countries are some of the factors that are triggering and encouraging this. In addition, political conflicts have created major displacements of refugees, many of whom have sought safe havens in European countries as well as elsewhere. There is reason to believe these same trends in economically motivated and politically forced movement will continue and possibly accelerate in the future.
4. The present report does not take full account of clandestine migration which constitutes an important factor in population movements. The particular situation of illegal migrants requires closer examination in the context of health conditions.
5. Mass migration is not new to Europe. Throughout recorded history most countries in the region have experienced both large inflows and outflows of people. Although this has been most pronounced at times of economic depression and conflict, population movement between countries in Europe has always been a feature of the cultural and socio-economic complexity of the region. Given the growing economic and political cooperation that is now emerging between many European countries, the opportunities and demand for more labour movement, as well as the credibility of it, will no doubt continue to grow.
6. Political and socio-economic instability in and around Europe has significantly increased the number of refugees and asylum seekers arriving in European countries. Few if any parts of Western Europe have not been affected by these flows of refugees. At much the same time, there has been a major movement of refugees within and between the countries of the Commonwealth of Independent States (CIS) and other countries in the region. As with
economically-motivated migration, there is again reason to believe that European countries will continue to see major movements of politically uprooted people from within the region and from outside.
1.3 Nature of the issue in Western Europe
7. Salt (1997) estimates that migration has been a key force in the demographic changes that have taken place in the demographic profiles of 12 out of 24 countries in Western Europe during the 1990s (Andorra, Austria, Belgium, Denmark, Germany, Greece, Italy, Liechtenstein, Luxembourg, San Marino, Sweden, Switzerland). Stocks of foreign-born people have increased significantly, and in the 1995-6 period, for example, there were about 19.6 million foreign nationals resident in Western Europe. Of these, approximately 33% were from other European Union (EU), European Economic Area (EEA) countries and Switzerland. In addition there were 1 million (5.65%) from Central and Eastern Europe, 4.7 million (27%) from other parts of Europe (mainly Yugoslavs and Turks), 3 million (17%) from Africa, and 1.7 million (10%) from Asia.
8. The origins and destinations of migrants to Western Europe vary considerably. In Luxembourg, Belgium, and Ireland, for example, over 50% of foreign-born people tend to be from other EU countries, while in Spain, the United Kingdom, France and Sweden the proportion is between 33-50%. In the case of most other EEA countries, the origin of most migrants is extra EEA. Much of this latter type of migration follows relatively well-established lines of movement, and typically involves migration from what were African colonies to countries such as Portugal, France, the United Kingdom and to a lesser extent Italy and Belgium (Salt, 1997).
9. Statistics on the number of refugees coming into European countries are highly variable and probably under-reflect the true magnitude. According to the Office of the United Nations High Commissioner for Refugees (UNHCR), at the beginning of 1998, there were almost 6,100,000 refugees or, as UNHCR terms them, “persons of concern to UNHCR” (UNHCR, 1998). The nature of politically motivated displacement means that many people move independently, and as best they can, while others do so under the ausspices of international agencies such as UNHCR. To what extent those who move alone are reflected in official statistics is not clear, especially since many of them do not go on to apply for the security and “benefits” accorded to official refugees.
1.4 Central and Eastern Europe
10. Migration within and from Eastern Europe and the former Soviet Union, just as in other parts of Europe, is not a new phenomenon either. Wars, changing political alliances and reformulation of borders have repeatedly stimulated the movement of ethnic minorities and workers in the region. Growing economic disparities between selected parts of East and Central Europe and between countries in the region and Western Europe are now prompting both regular and irregular (unofficial) labour migration. Much of this latter movement is of a short-term nature and has not resulted in any large resident immigrant population in neighbouring countries. The growing pace of unemployment in many countries of the region nevertheless suggests that the flow of labour-force-migrants could increase despite their limited employability in other parts of Europe because of occupational skills and language.
11. Although recent statistical data for migration in Central and Eastern Europe are not as readily available as for Western Europe, it is estimated that in 1995 there were 2.8 million
foreign-born people in the region. Of these, a significant proportion had probably moved from and between countries of the former Soviet Union. Since 1991, for example, over 1.6 million people are reported to have been officially granted citizenship by the Russian Federation, and the migration of ethnic Russians from other parts of the Commonwealth of Independent States (CIS) is still continuing (Zlotnik, 1998). The social instability facing ethnic Russians in many CIS countries has also meant a growing number of within-region refugees, and by 1996, over 500,000 ethnic Russian refugees had been registered in the countries of the CIS.
12. Net migration has apparently been a key factor in the demographic changes that have occurred in Croatia, Estonia, Latvia, Lithuania, and Slovenia (Salt, 1997), and may also have been an even greater determinant in three of the CIS countries, Belarus, Georgia, and Moldova. Refugee movements in and around former Yugoslavia have also been dominant factors in the overall movement of people in Europe and have certainly been responsible for recent changes in the demographic profile of Bosnia (ICMH, 1996) and Croatia.
13. An International Organization for Migration (IOM) survey (1993) of intentions to migrate indicates that the potential for emigration from these countries may continue to be high for some time, even though much of it may be of a temporary nature and does not necessarily involve people seeking permanent residence abroad. Some permanent immigration is nevertheless occurring in the region. In many cases it involves the return-migration of ethnic national minorities, and countries such as Hungary, the Czech Republic, and Bulgaria have been especially prominent in this respect. In Poland, Bulgaria, the Czech Republic and Hungary, there has also been a fairly sizeable influx of immigrants from countries as far afield as China.
2. Pre-migration health conditions
14. Migrants take with them a range of background characteristics, and because poverty and the need to search for better economic opportunities is one of the main push factors, migrants tend to come from poor backgrounds, bringing with them the disease profiles typical of those backgrounds. Diseases of poverty, especially tuberculosis (TB) and other communicable diseases such as hepatitis, and respiratory diseases associated with histories of poor nutrition, inadequate housing, overcrowding, poor sanitation and water supply, and inadequate access to health care are all features of migrants moving from poor socio-economic environments.
15. Of all the health problems associated with poverty and poor access to health care, tuberculosis has historically been the most worrisome. TB thrives in communities that are characterized by poor nutrition, inadequate housing, overcrowding, low education (Almeida and Thomas, 1996), and limited access to preventive and curative medical services. In Western Europe improvements in all these domains have effectively reduced the problem of TB, but similar health benefits have not been achieved in all other parts of Europe. In many parts of Eastern and Central Europe, especially those marked by war and social upheaval, TB has remained pervasive and is now a re-emerging problem with the possibility of becoming a multi-drug resistant problem. Diseases such as hepatitis A are also problematic and call for much more attention than they have been given to date.
16. While there is little evidence that these diseases present a major health threat for host or receiving communities, the risk of transmission within migrant communities is a problem. Migrants tend to move into social and economic environments that continue to expose them to poverty-related diseases. Thus even in countries such as the Netherlands (de Jong and Wesenbenk, 1997), Austria (Hammer, 1994) France (Gliber, 1997; Nejmi 1983), in Italy (Carchedi and Picciolini, 1995), Spain (Gaspar, 1997; Gardete and Antunes, 1993), and Portugal (Almeida and Thomas, 1996), sub-standard housing, overcrowding and poor sanitation are common. Because migrants also tend to remain socially excluded (at least initially) from host societies, they often fail to come into contact with, or effectively use, otherwise available health care services. This is especially marked in the case of migrants who move for short-term work, and even more so for “unofficial” migrants.
17. The possible role of population movement in the spread of HIV/AIDS has begun to attract attention (Carballo et al., 1996; Carballo and Siem, 1996; IOM/UNAIDS 1998) but the relative role it plays in European countries remains unclear. In Belgium (Muynck, 1997) and Italy (Carchedi and Picciolini, 1995), the prevalence of AIDS among migrants is lower than among nationals. In Germany (Huismann et al., 1997), on the other hand it is disproportionately high (14%), especially in the case of migrants from the Americas, Africa, and Asia. In Sweden (Janson et al., 1997) and in Belgium (Muynck, 1997), the rates of sexually transmitted infections (STIs) among migrants are exceeding national rates. Just as with hepatitis B, the risk of these diseases is high when the sex-selective nature of labour migration (governed by national policies) produces predominantly male groups of migrants whose patterns of sexual behaviour inevitably involve having recourse to relatively small groups of sex workers. Sexually transmitted diseases are becoming a major public health threat in many parts of East and Central Europe. The incidence of syphilis, for example, is increasing (Tichovova, 1997) and presenting new threats for HIV risk and for health and health care in general.
2.2 Health related behaviour
18. An additional and complicating correlate of cultures of poverty is the lack of familiarity poor people tend to have with health promotive/protective principles and practices. Chronic poverty creates sentiments of fatalism and the belief that little can be done at a personal level to avert what may be relatively preventable diseases and events. Beliefs such as these, while not unique to the poor, are more common among them and have the capacity to limit their participation in health-care seeking and the willingness to use disease prevention and treatment services. Educational background figures highly as a factor in this regard, and migrants from poor backgrounds may be handicapped with respect to their knowledge about disease causation. In addition, however, their limited experience with health care services and health care providers may itself have been unsatisfactory, and in the communities they move to they may find it difficult to relate efficiently to local health care service providers.
19. Together, these and other factors can be major obstacles to healthy migration, and especially so when steps are not taken by receiving communities and countries to “accelerate” and tailor their responses to the health needs of migrants. Regrettably, few countries have been able, or seen fit, to allocate the human and material resources needed to do so, and the poor health and health-related behaviour profiles “carried” by migrants tend to persist for some time, even in the midst of what objectively are better social and environmental conditions.
3. Impact of uprooting and displacement on health
20. Uprooting is always a psychologically distressing event. It involves disruption of family life and a radical interruption of traditional culture, values and “security”. Uncertainties about work and other vital life events that migrants may feel they have little control over exacerbate stress and anxiety.
21. Culture “conflict” in the early phase of contact with host societies is an important factor in psychosocial and mental health. Language difficulties are part of the cause and are a reason why many health problems, and especially mental health problems, tend to be mis-diagnosed in migrant groups (Lazaridis, 1985; Huismann et al., 1997).
22. The age and sex-selectivity of migration, as well as the policies governing labour and family migration affect family life in many ways, and almost always mean that families are unable to move as a unit. Reports from the Netherlands (de Jong, 1994) suggest that even beneficiaries of family re-unification schemes experience serious family problems and separation/divorce are common outcomes. After the initial stage of getting re-acquainted with their families, some spouses still found themselves sexually and emotionally alienated from their spouses and other relatives. When migrant couples do separate, the support options are likely to be more limited than for nationals, and problems of loneliness, fear and poor self-esteem are often exacerbated. Children of migrants who separate are especially affected and women can be significant “losers”, particularly in countries where their personal job opportunities as “singles” are limited and where their social status in immigrant communities is traditionally “tied” to marriage and family.
3.2 Psychosocial and physical health
23. The inter-relationship between psychosocial and physical health problems among migrants is a close one. During early contact and “integration”, migrants appear to be more likely to develop psychosomatic problems than nationals. Stress-related symptoms such as peptic ulcers, frequent severe headaches, anxiety attacks, dermatitis, and sleeping disorders have been frequently reported in European countries (de Jong, 1994; Huismann et. al. 1997; Janson, Svensson and Ekblab, 1997; Bischoff, Loutan and Burgi, 1997), as have hypochondria, paranoia, disability and impairment of work performance (Solas-Gaspar and Siles, 1997). Alcohol abuse and exposure to the potential abuse of other drugs are also not uncommon (ICMH, 1998). Somatisation of psychosocial problems can be an important source of confusion to health care staff who are not familiar with the process and impact of migration on psychological health (Ete,1995).
3.3 Psychiatric illness
24. Rates of psychiatric illness among different groups of immigrants vary considerably reflecting personal and group circumstances, including group cohesion, supportive coping mechanisms and cultural responses to stress. Data from the Dutch National Register (Uniken Venema et al., 1992; Selten and Sijben, 1994) and data obtained from psychiatric hospitals indicate that admission rates for mental health problems among migrants vary according to ethnic background but in general tend to be much higher that for non-migrants. Men are also much more likely to be admitted than women (Unikem Venema et al., 1995), and men appear to be more likely to discharge themselves from hospital before completion of treatment, irrespective of the cause of their hospitalisation.
25. Schizophrenia is one of the most dramatic and disruptive of mental health problems. In the United Kingdom, hospital admission rates for schizophrenia are highest for people of Caribbean, Irish and Polish background (London, 1986; Cochrane and Bal, 1987; Dean et al., 1981; Littlewood and Lipsedge, 1988; McGovern and Cope, 1987). Its incidence among 16-29 year-old people of Caribbean background is approximately 12 times higher than for British non-Caribbean adolescents (Karmi, 1997). Schizophrenia in people from India and Pakistan also appears to be higher than for the indigenous United Kingdom population, especially in the case of males, but rates for Caribbeans are nevertheless still three times higher than for people from Asia (Cochrane and Bal, 1989). In Germany, schizophrenia is a frequent (30%) initial diagnosis for immigrants (Lazaridis, 1985), but these diagnoses have often been redefined (neurosis and psychopathic problems) on second review (Huismann et al, 1997). Drug abuse related schizophrenia together with other psychotic diseases is not uncommon among certain immigrant groups in the Netherlands (Selten and Sijben, 1994), where migrants from Surinam and the Antilles appear to be especially at risk.
26. The relatively high incidence of depression among immigrants is associated with high rates of suicide, and children are especially at risk. In the Netherlands, where the unemployment rate among migrants in 1994 was 31% compared to 13% for Dutch nationals (de Jong, 1994), the suicide rate among children of immigrants was also considerably higher than in the general population. In Rotterdam, children of Turkish and Moroccan migrants appear to be more likely than Dutch children to commit suicide, and Surinamese children (particularly girls) have a 27.6 times higher rate than Dutch children (Oudshoorn, 1991, cited in de Jong, 1994). In the United Kingdom, suicide rates for women from the Indian sub-continent tend to be markedly higher than for men, and among women suicide rates are highest among girls aged 15-24. On the whole their rates of suicide are twice as high than the national average for the United Kingdom, and in the 25-34 year old age group, are 60% higher. Although data for attempted suicides are less precise, attempted suicide among young South Asian women is also reported to be high (Karmi, 1997).
3.6 Psychiatric morbidity and children
27. Psychiatric morbidity among children of immigrants probably reflects a wide range of familial, personal and environmental circumstances, including lack of identity, confused cultural affiliation, parental job insecurity, regrets about leaving home, family disruption and poor future opportunities. The fact that adult migrants are often forced to take low-status and difficult jobs also means their work schedules can keep them away from home and their children during non-school hours. Child-care often suffers as a result of this combination of stress and inconsistent parental presence. A study of immigrant children in Germany showed that 57% of Turkish children under the age of 15 years were cared for by people other than their mothers. Almost 20% of pre-schoolers were looked after by siblings, some of whom were not much older than the children they were caring for; and over half of all children between the ages of 7 and 14 took care of themselves (Oztek, 1986). A study in Mannheim also revealed that 69% of the children of Greek immigrants had lived the first years of their lives separated from their parents (Ballas, 1995). The language differences that often emerge between immigrants and their children can also often create severe conflicts between them and their parents who fear their children are “moving away” and adopting new values and alien patterns of behaviour. In Sweden there have been instances of immigrant parents avoiding childcare services because of this (Neiderud, 1989).
28. Substance abuse is frequently a reported problem among single immigrants, and a 1996 World Health Organisation (WHO) (Regional Office for Europe) report noted that the consumption of tranquillisers and anti-depressants by young immigrant people across Europe is growing. Alcohol abuse is also a problem (Cochrane and Bal, 1989; Karmi, 1997) and among people of Indian descent in the United Kingdom is reflected in rates of cirrhosis-related mortality which are twice as high as among English males (Balajaran et al., 1984). Drug abuse may be an emerging problem in the United Kingdom (Lipsedge and Turner, 1990; Lipsedge et al., 1993) and elsewhere (Davoli et al., 1996; de Jong, 1994). The reasons for drug use among children of immigrants vary considerably. One report (Ait Menguellet, 1988) suggests that drug use among immigrant youth may be a manifestation of social marginalisation, and an expression of anger. A study of psychological stress and coping among immigrant adolescents in Sweden (Giannopoulou, 1988) corroborated this and suggested that drug abuse was a consequence of difficult social integration. Similar conclusions have been reported from France (Yahyaoui, 1992; Bendahman, 1993; Yakoub, 1993; Boylan, 1995) and Germany (Akbiyik, 1990).
3.8 Gender-related psychosocial health
29. Among the more psychosocial (as opposed to psychiatric) problems faced by immigrants, those associated with gender differences have tended to be especially overlooked. In many ethnic and immigrant groups women are confronted by a complex set of problems related to relative social deprivation and conflicting value systems. They often come from traditional cultures and continue to live in families that continue to prize and expect traditional behaviours from women, even though they may also be expected to work and live in post-industrial settings that do not value these same roles. The resultant ambiguities of identity and poor self-esteem are serious for health and the capacity to function. In Germany where Mirdal (1985) reported very high rates of somatic complaints such as “tightness” (muscular pains, chest pains, shortness of breath, choking sensations) and anxiety, pregnancies were frequently impaired by a variety of psychological and psychosomatic complaints, and requests for pregnancy termination linked to suicidal tendencies, fear of manipulation, severe anxiety fits, psychosomatic disorders and extreme fatigue were common.
4. Characteristics of resettlement and the impact on health
4.1 Occupational health and safety
30. Among the health and social aspects of migration, occupational health and safety has become a major concern. Migrants tend to move into to low-skill jobs that are also low social status and unattractive to local labour forces. Many of these occupations, such as construction, heavy industry, and agriculture have been typical sources of employment for migrants and are also relatively high risk. Because much of the emerging migrant labour market is often seen as short-term, major investments in training and instruction have not been made, thus placing workers at higher risk of work related accidents. Language differences, poor communication with employers, lack of familiarity with modern machinery, and possibly different attitudes to safety may all be factors that lend themselves to the risk of work related accidents (Corvalan et al., 1994). In Germany, industrial accidents have tended to be higher among migrants working in industries with poor safety measures (Huismann et
al., 1997). Migrant workers are also proportionately over-represented in industrial accidents/injuries in France, where over 30% of industrial accidents resulting in permanent disabilities involve non-French workers (Gliber, 1997). Similar findings are reported from Belgium (Peeters et al., 1982) and Switzerland (Egger et al., 1990; Molinaro, 1994).
31. The type and rate of reported accidents varies greatly from one industry to another, but in general, occupational accident rates are approximately two times higher for immigrant workers than native workers in Europe (Bollini and Siem, 1995). In the agriculture sector, chronic and often unprotected exposure to pesticides and other chemical products is a common problem. The effects of pesticides and other products used in intensive farming are thought to be associated with the high incidence of depression, headaches, neurological disorders and miscarriages among migrant agricultural workers in Spain. In these same settings there is also a high incidence of injuries, including electrical burns, sustained during the construction and maintenance of greenhouses. Muscular disease, dehydration and heart complaints linked to high temperatures in greenhouse activities are common problems (Parron, 1992; Castello, 1992), and workers involved in agriculture do not appear to get much safety training or protection (Camargo et al., 1994). Because many agricultural industries are small and seasonal, health authorities often have limited access to them, and there are few systematic evaluations of local working conditions.
32. Immigrants are also more vulnerable to other types of accidents. In Germany, non-German children in the 5-9 year old age bracket are more vulnerable to traffic and other injuries (Korporal and Geiger, 1990), and in the Netherlands children of migrant workers are more involved in domestic as well as traffic accidents, than Dutch children (de Jong and Wesenbeek, 1997). Poor housing may be one of the risk factors involved. In France lead poisoning in older and poorly maintained houses constitutes a frequent problem for migrant children because of their concentration in low-income dwellings.
5. Policies and practices concerning the health of migrants and refugees
33. In general, few countries have developed comprehensive policies on migration. Indeed, even though economic pressures on countries are leading to a greater awareness of, and sensitivity to, the process of migration, as late as 1995 only 40% of countries around the world had actually introduced policies on the subject (UN, 1997).
34. During the 1970s the number of countries establishing policies designed to decrease immigration increased and by 1995, 33% of countries had done so (UN, 1997). Developed countries have introduced the most restrictive policies, but the trend is by no means limited to them. There has also been a growing tendency for countries to also attempt to reduce emigration.
35. For the most part, countries tend to address: (a) the number and type of migrants; and (b) the conditions of migrants within the country. Only a small number of countries are still seeking and/or admitting permanent immigrants, and even those are placing increasing emphasis on the educational and occupational background of the people they admit. Even with respect to non-permanent labour migrants, the last 20 years have seen a gradual trend away from dependence on foreign workers. Similarly, many developed countries that have traditionally been seen as safe havens have begun to limit the number of asylum seekers they are willing to accept. Undocumented migration nevertheless continues both on an organised
and a personal basis. While many countries have taken steps to try to stem this, the increasingly porous nature of borders and the improved facility of travel continue to make it difficult.
36. In almost all countries, legal conditions for permanent status have become more stringent and gaining citizenship has become increasingly difficult. Sensitivity to the needs of migrants is lacking in many national policies, even though family reunification policies have continued to be respected and indeed made more flexible. Even so, the issue of family reunification remains a controversial issue and encouraged return of migrants to their countries of origin and is often seen as one of the options before countries.
37. From the specific perspective of health, few countries have seen fit to ensure migrants with the type of socially and culturally tailored services they need, and in many parts of Europe there are migrants who are falling outside the scope of existing health and social services. This is especially true of undocumented migrants, who in many countries are increasing in number. Even such basic amenities as interpretation/translation for migrants requiring health care are lacking in most countries and there have been few programmes to train health care providers to the unique needs and contexts of migrants. Nor do there appear to have been many policies designed to ensure that migrants are accorded healthy housing and protection from occupational hazards. The data nevertheless indicate that because of economic and legal reasons, the housing and occupational environment of migrants often places them at a risk of communicable and non-communicable health problems.
38. In view of the growing nature of migration, and given the symbiosis that is inevitably created between the health of migrants and their host populations, this is an area that calls for much greater attention than it has been given to date. More will probably need to be done, for example, to systematically gather and share health and health care statistics concerning migrants and would-be migrants. More is also called for with respect to standardising definitions of migration, health screening and the reasons for it. Everywhere there is also an urgent need to involve migrants in routine national and local health care and disease prevention programmes.
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*
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Reporting committee: Committee on Migration, Refugees and Demography.
Budgetary implications for the Assembly: none.
Reference to committee: Doc. 8105 and Reference No. 2287 of 26 May 1998.
Draft recommendation unanimously adopted by the committee on 25 January 2000.
Members of the committee : Mr Díaz de Mera (Chairman), Mr Iwiński (Vice-Chairman), Mrs Vermot-Mangold (Vice-Chairperson), Mr Christodoulides (Vice-Chairman), Mrs Aguiar, MM. Akselsen, Amoruso, Mrs Arnold (Alternate: Mr Soendergaard), Mr Aushev, Mrs Björnemalm, MM. Bogomolov (Alternate: Mr Volodin), Brancati, Branger (Alternate: Schreiner), Mrs Bušić, MM. Chiliman, Chitaia, Chyzh, Cilevičs, Connor, Debarge, Mrs Dumont, Mr Einarsson, Mrs Err, Mrs Fehr, Mr Filimonov, Mrs Frimannsdottir, MM. Ghiletchi, Hrebenciuc, Ivanov, Jakić, Lord Judd, MM. Jung, Koulouris, Kozlowski, Laakso, Lauricella, Liapis, Lippelt, Luís (Alternate: Cesário), Mrs Markovska, MM. Mateju, Melo, Minkov, Moreels, Mularoni, Mutman, Ouzky, Pullicino Orlando, Rakhansky, von Schmude, Mrs Stoisits, MM. Szinyei, Tabajdi, Tahir, Telek, Thönnes (Alternate: Mrs Lörcher), Tkác, Vanoost, Verhagen, Wilkinson, Wray (Alternate: Lord Ponsonby), Mrs Zwerver, N..(Spain) (Alternate: Mrs Guirado), N..(Lithuania) (Alternate: Mrs Sadeikiené).
N.B. The names of those members present at the meeting are printed in italics..
Secretaries of the committee: Mr Newman, Mrs Nachilo, Mr Adelsbach.
1 The Rapporteur is grateful for the assistance of Dr Manuel Carballo, consultant, International Centre for Migration and Health, Geneva.