Migration as a social determinant of health

According to the WHO definition, the social determinants of health are the conditions in which people are born, grow, live, work and age, including health systems. These circumstances are shaped by the distribution of money, power and resources at the global, national and local levels, which, in turn, are affected by the policy. The social determinants of health are the main cause of health inequities - inequitable and preventable health differences observed within and between countries. In view of the growing concern about this persistent and growing injustice, WHO established the Commission on Social Determinants of Health (CSD) in 2005 to provide information on ways to reduce the problem (http://www.portal.pmnch.org/social_determinants / en /).
Already in 2008, the main recommendations were formulated, which included improving the conditions for daily life, overcoming the inequitable distribution of power, money and resources, and assessing the impact of measures taken (detailed in the SIXTY-SECOND WORLD HEALTH ASSEMBLY, May 22, 2009 and then expanded at the 2011 Brazil Conference).
Currently, more and more countries recognize that if health care helps to improve the health of the population, the socio-economic conditions on which the emergence and development of the disease depend are much more important. Nevertheless, in Russia, the concept of the social determinants of health is currently taking root rather hard. Although usually doctors and social workers somehow use them, without a designation, name or excessive attention. For most people it is obvious that health depends on the material situation of a person or the nature of his work.
Now, most scientists identify the following types of social determinants of health:
1. Material prosperity - poor people not only have less opportunities to receive medical care, but also live regularly under stress and socio-economic shortages.
2. Socio-economic conditions of the early childhood of an individual - many diseases in the present depend on their development on how a person lived in childhood, what nutrition and development he received, including during the period of intrauterine life.
3. Housing conditions, especially in the context of the formation of elite "rich" areas and criminal "poor", which give the so-called "cocktail effect" (1)
4. Unemployment and working conditions - all other things being equal, the health risks for the unemployed are higher. In addition, there are higher risks when working in hazardous industries or positions with high nervous tension (pilots, surgeons ...)
5. Social capital - low social contacts contribute to a decrease in the level of health, and for women, inter-family relations play a special role, and for men - communication with friends.
6. Lifestyle - one of the most famous factors: food, alcohol, smoking, physical activity, etc.
7. Migration is a factor that has only been taken into account in the last 2-3 years and is not recognized by everyone, although migration influences both the health of the migrant himself and the health of the people around him.
Seriously speaking of migration as a determinant of public health, we started talking a couple of years after the infamous "Arab spring" (2), when the influx of refugees into the countries of Europe, and then of America, increased dramatically.
The sharp increase in migration flows has brought the issue of migrants' health to a new global level, approaches to which until now have not been fully found. In particular, in Denmark and Scandinavia about 2 years have been planned scientific work in this direction, in 2014, a study was conducted in the US regarding migrants from Mexico.
Migration (Latin migratio - resettlement) - movement of people from one region (country) to another, in some cases large groups and over long distances (Vorobyova O.D. 2003).
Among modern trends in international migration, the following can be singled out:
• The growth of illegal migration (especially labor migration)
• The growth of forced migration, especially from countries in Africa and Asia (difficulties with the fact that a potentially able-bodied person brings with him several dependents - his wife and children)
• Increasing the demographic importance of international migration (in many countries, the increase in the population or its maintenance at the same level is provided by migration)
• Globalization of the world migration flows (practically all countries of the world participate in the migration process)
• Qualitative changes in the flow of migration (many countries have special programs to attract high-quality specialists)
• The dual nature of migration policy (limiting the "brain drain" (3) and attracting highly qualified immigrants)
In fact, Russia is in a very ambiguous situation in terms of migration processes. On the one hand, Russia is the second most attractive country after the United States for immigrants (as of 2013, 11.2 million people have emigrated to Russia - more than to Germany, Canada or Saudi Arabia), on the other hand - almost the same number of people and left Russia (as of 2007, 12.1 million people left Russia), which puts the country on the same level as migrant suppliers such as India, Pakistan or Mexico. In addition, the qualitative composition of those who have left and arrived is unequal: as a rule, people of the European race with the highest demand for education leave Russia and come from the Asian republics or the countries of South and South-East Asia with little education (the influx of Russian-speaking migrants from Ukraine has recently intensified). (Alexei Zhivov, Analysis: 2016).
The program of repatriation of compatriots and certain laws on the return programs of "useful scientists" are very weak - a few dozen people a year. Thus, in Russia, due to unequal migration, a situation is created for the lowering of the general level of the nation's education. This, in turn, makes migration a very acute process in terms of the social determinant of health. (Ivakhnyuk I.V., 2011).
According to the UN recommendations, there are 5 main types of migrants:
1. Foreigners admitted to the country of entry for education and training
2. Migrants entering work (labor)
3. Migrants entering the family unit or creating new families
4. Migrants entering a permanent settlement (possibly with the acquisition of citizenship)
5. Foreigners admitted to the country of entry for humanitarian programs (refugees, asylum seekers, etc.)
A separate category, as a rule, deals with illegal migrants who come to the country for any purpose and are outside the scope of migration, social and other services.
It is obvious that illegal migrants and migrants on humanitarian programs are the main problem elements, including in terms of health. Moreover, they are not always possible at all to be involved in social or medical programs.
Nevertheless, no matter what group of migrants we address, there are always two problems of migration as a social determinant of health: migration that affects the health of migrants themselves and migration that affects the health of local residents who live or work alongside migrants. In addition, migration definitely influences the work of physicians in particular and the entire health care system.
Therefore, migrants, as a rule, do not have an adequate idea of the health care system itself and do not know how to use it effectively. It is somewhat easier for those groups of migrants who came to receive education (because the host educational institution exercises the health care) and those that reunite with the family (in this case, relatives provide the help). The remaining groups have practically no opportunity to seek medical help on time, especially since it is economically unprofitable for the employer or even for social services, which leads to deliberate "concealment" of information. In some cases, diaspora or its individual representatives provide partial assistance, but this assistance is irregular and voluntary.
The insurance status in most cases of migrants is also uncertain. A significant part of them has no right to apply for the program of CHI, although the costs of VHI for them become prohibitive. In addition, VHI itself does not insure all diseases, such as tuberculosis. It is worthwhile to understand that migrants are people who originally spent considerable amounts of money on moving, which are also forced to rent housing (the rent cost for migrants is usually higher) and wages are usually lower than for citizens of the country, respectively, for them the treatment in private hospitals becomes absolutely is not available. What gives rise to the situation with an increased level of self-and interdependence, an appeal to unlicensed "underground" doctors, medical workers at the pre-hospital level (paramedics or nurses). As a result, this situation results in the emergence of neglected and complex cases of illness, calls for emergency services and often - the death of a migrant. In addition, illegal migrants cannot apply to any medical structure at all, since they do not have legal documents for staying in a given country. The mortality among illegal migrants from various diseases by some estimates reaches 30%. Surprisingly, the deaths of illegal migrants, even in the statistics of mortality, do not always fall, they are often buried in areas that are not intended for this purpose: in the forest zone, in landfills.
The health problems of migrants associated with the language factor. It is a recognized fact that in a new language environment, even a person who knows the language perfectly (which is a rarity among migrants) is usually lost. In addition, when you go to medical institutions, there are quite often cases of misunderstanding between the doctor and the patient. That in any case will affect the diagnosis and treatment, and in some cases may lead to an unintended medical error. In addition, the conditions of Russian hospitals are such that it is not always possible for a relative or an acquaintance who knows the Russian language better and can play the role of an interpreter. Moreover, Russian doctors in the modern healthcare system are often confronted with a deadlock (since for the admission of a patient who does not have an insurance policy or for an incorrect diagnosis identified during the check - the money for treatment of this patient is deducted from the doctor's salary) and most doctors simply find specious pretexts for not providing medical assistance to a migrant or performing temporary symptomatic treatment for him. Similarly, ambulance doctors try not to hospitalize migrants, leaving them for home treatment.
As for the situation directly with labor migrants, the conditions of their work are often such that the level of safety engineering is insufficient (or nonexistent), frequent situations with overtime work, unsanitary conditions. Moreover, even if the migrant has an idea that the working conditions should be better, he can not go out to the employer or apply to the trade union to settle the situation and preserve his health. The usual arguments are the fear of losing their jobs and the lack of trade unions for migrants as such.
The living conditions of migrants are also a recognized factor. The main problems - housing does not meet sanitary standards, crowded housing, and violation of the ventilation system and so on.
The acknowledgment of the fact that in most regions of Russia climatic factors strongly influence the health of migrants is also sufficiently argued. Historically, most migrants come from the southern regions and are often unprepared for the harsh Russian winters and frosts. Moreover, this becomes part of the sharp deterioration in the health of migrants, whose adaptation to climate requires considerable time and resources, which the migrant usually does not have. Canada and Alaska (USA) face the same problem. In fact, in Alaska, there is a special monetary assistance to people moving to permanent residence.
In addition, a psychological moment has an impact on the health of migrants. Recently, he is gradually gaining sufficient weight. The fact that moving to a country for permanent (or relatively permanent) residence requires a certain tension of the nervous system, which translates into stress and the development of psychosomatic diseases (even simple registration of documents for immigration often causes strong changes in the psyche, stressful illnesses, panic attacks And so on). As it is customary to consider, every migrant (even very successful) undergoes 3 stages of psychological adaptation to the new country: euphoria (from several days to several months), depression (very different in duration), activity (the beginning of psychological adaptation and adoption of a new country with her way of life). Especially in the context of the impact of migration on the state of human health, depressive is deemed dangerous. A drop in mood down to deeply depressed states, unmotivated anxieties, accompanies it and fears, sleep disorders, general weakness. Often during this period, there are attacks of suicidal activity. In this situation, psychologists or psychotherapists could be of great help, who are currently practically not involved in working with migrants.
Now consider the reverse situation - the impact of migration on permanent residents who are forced to live with them in the neighborhood or work in joint ventures.
The most important problem is related to the fact that migrants are the source of imported infectious and parasitic diseases. The most common diseases are eliminated at the stage of issuing visas - in most countries with active immigration programs, before applying for a visa, the applicant must pass tests for HIV infection, hepatitis B and C, and be tested for tuberculosis. However, the medical situation is such that if the survey period falls into a "negative window" (4) and the sick person receives a visa, which means that he will bring the infection. Of course, it is impossible to study all possible diseases. Therefore, infectious importations happen quite often. The most common imported infections include malaria, helminthiases, ascariasis, diphyllobothriasis, opisthorchiasis, poliomyelitis, diphtheria, whooping cough, trichocephalus, cholera, tuberculosis.
Despite the fact that in Russia migrants are recommended to purchase VHI policies (in fact, they have no more than 10% of migrants), they do not include the costs of treatment of most infectious diseases, and even more so - of tuberculosis. In 2014, the 67th session of the WHO adopted the Global Strategy to Counter Tuberculosis, which explicitly calls for facilitating the access of migrants (despite their status) to medical care in cases of tuberculosis, in practice this leads to the fact that the native inhabitants of the country are forced to pay for migrants. It is this fact that caused a lot of negative reactions from politicians and government officials. At the moment, the issue of treatment of tuberculosis in migrants remains unresolved (FGBIC "Central Research Institute of Tuberculosis" 2016). The problem also lies in the fact that many migrants are afraid to undergo a TB screening, because if they are positive they can be expelled from the country.
The situation with other infectious diseases is also difficult. According to statistical data, only 10% of migrants pass the survey for HIV and STIs. And informal surveys among migrants (usually conducted by volunteers from humanitarian organizations) reveal that in Russia at the moment it is faster and cheaper for a migrant to buy a medical book with all the necessary marks than honestly and for his own money (but much larger) pass all the necessary doctors and tests.
Given that some of the migrants are infected with infectious diseases, and moreover - do not have the opportunity to receive adequate medical care and without being isolated from neighbors, the spread of infectious diseases will already be very rapid among the indigenous people.
It is also an undeniable fact that migrants are people of a predominantly different nation, culture and religion. The indigenous population of Russia cautiously accepts the neighborhood with them because of deep mental contradictions. Accordingly, the neighbors of migrants often experience deep fear, stress or depression from their neighborhood. In addition, this leads to a deterioration in the health of the indigenous population, especially since many of them are also deprived of adequate psychological assistance. Stressful moments often contribute to the accumulation of aggression from both sides, which eventually results in conflict situations with fights (especially among youth) right up to the use of weapons. In the unsettled neighborhood, in conjunction with the cult of "rejection" of migrants in Russian society, the health of both sides of the conflict suffers, from the psychological level and the development of psychosomatic diseases and ending with injuries and injuries of varying severity.
As for the health care system, now it is not adapted to provide medical assistance to migrants. As I already wrote above - most doctors do not want, and often do not have the opportunity to provide full-fledged medical assistance to migrants, since their payment falls entirely on the doctor's shoulders. This testifies to two independent facts. First, migrants in Russia are unprotected in the medical plan and very often do not know how to protect themselves while avoiding deportation. Second, doctors in Russia are also unprotected from monetary punishment in case they allow themselves to show human qualities of participation and sympathy for their neighbor, which forces them to deny migrants assistance or to provide it in a minimal amount.
The Russian health care system, in my opinion, is currently in a transition period at the initial stages of the formation of a system that is fully adequate and adequate for both the indigenous and migrants. Therefore, certain problems may well be permissible if the development of scientifically and economically justified amendments and corrections is in parallel.
Of course, it is impossible to solve the migration problem at once, as a social determinant of health, but it is possible to make significant progress towards its solution if efforts are intensified in this direction. Moreover, it should be decided not only by the health system, but also with the involvement of migration and social services, ministries of foreign and internal affairs, the Ministry of Labor, economic and analytical departments. In addition, it is necessary to create a positive image of the migrant in the mentality of Russians, which will definitely help overcome many psychological and social barriers, which means that without the intervention of medicine will improve the health of both migrants and indigenous people.
Based on the above information, we can draw the following conclusions:
• In the modern world, Russia, according to the classification of the International Labor Organization, the International Organization for Migration is simultaneously a country of immigration and emigration. Migration processes play an important role among the conditions that determine the internal development of the country and its position in the international arena.
• Migration has a major impact on the population structure, since it is most vulnerable to people under the age of 30, single or family, but without children. Elderly people and families with children migrate less often, so migration distorts age structures in places of influx and outflow of population.
• Migration has a significant impact on the health of the population. Pendulum migration (regular trips to a place of work or study outside their permanent place of residence) increases the number of contacts that contribute to the spread of infectious diseases, leads to an increase in stressful situations, injuries, and affects the health indicators of the population. The health indicators of migrants are often worse than those of indigenous people.
• Taking into account all the above facts, migration should undoubtedly be defined as a social determinant of health and its further study must necessarily go in this direction.
• The study of migration processes is of great importance both for the state as a whole and for the health care system. These processes affect the ecological situation, the epidemiological situation, the structure of the morbidity and mortality of the population.
According to the conclusions, it is necessary to undertake the following efforts to improve the health of migrants and the indigenous population that takes them into their societies:
• Establish and develop a working relationship between the Ministry of Health (its specialized departments), diaspora groups, and healthcare institutions to implement coalition projects and programs to optimize migration processes from a public health perspective, ensure access of migrant workers to health services and health information.
• To promote the development of legal centers that provide services to migrants for a small fee for issuing visas and legal documents for staying in the country; support the development of specialized non-profit organizations that provide similar services (transfer at least some of the illegal migrants to legal migrants by simplified schemes).
• Ensure compliance with laws on labor protection, as well as safety standards and rules that protect migrant workers from environmental and occupational health risks.
• To instruct migrant workers on safety issues in the workplace, in the common language or in the native language of migrants.
• To promote the coverage of the health of migrants in the media and the education of indigenous people on this issue, to improve the attitude of the country's citizens to labor migrants and their families, which will eventually lead to better health on both sides.
• Improve the access of labor migrants to information on health, nutrition, reproductive health, HIV / AIDS, tuberculosis, syphilis and other STIs, as well as other infectious diseases, tobacco, alcohol and other drugs, as well as on the basics of health assessment.
• To regulate the issues of medical insurance, to clarify its necessity both among migrants and among their employers.
• To improve the work of medical institutions so that doctors can provide medical assistance to migrants without fear of applying sanctions against themselves.
• Improve the work of the psychological service, which could assist migrants in a depressive stage or in the event of conflicts with the indigenous population.
• Revise the work of the migration service, which regulates the qualitative and quantitative composition of emigrant and immigrant flows with a view to controlling the qualitative composition of the country's population.
Migration as a determinant of public health is of great importance for Russia and undoubtedly, this issue needs further development and scientific justification for the ongoing migration reforms.
Notes:
(1) "Cocktail effect" - a combination of risks in the area of residence: high crime rate, lack of clean air, lack of well-groomed territory and parks, undeveloped transport network, lack of shops and consumer services and others, while - the more problems in the area of residence , the more potential problems in the health of the population that resides in it.
(2) The Arab Spring is a wave of protests and uprisings that arose in 2011 in large numbers in many Arab countries, some of which grew into protracted civil wars. (Korotaev AV, Zinkina Yu.V., Khodunov AS (Ed.) 2012.)
(3) "Brain Drain" - is a process of mass emigration in which specialists, scientists and skilled workers leave the country or region for political, economic, religious or other reasons. At the same time, the countries from which the specialists are being leached cause very significant economic, cultural, and sometimes political damage, and, on the contrary, the countries that receive and provide immigrant specialists acquire huge and cheap intellectual capital (Maxim Kireev, 2010).
(4) "Negative or serological window" is the period of the disease after the virus enters the human body, but before the active period of antibody production begins, when it turns out that the body is already sick or infected, but serological tests cannot determine it and give a negative result for the presence infection.
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