Geneva Health Forum Archive

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How far are the ‘left behind’ left behind? The psychological and physical wellbeing of family members of international labour migrants.

Author(s) Kolitha Wickramage1, Chesmal Siriwardhana2.
Affiliation(s) 1Health Unit, International Organization for Migration, Sri Lanka, Sri Lanka, 2Institute of Psychiatry, King's College London, United Kingdom, United Kingdom.
Country - ies of focus Sri Lanka
Relevant to the conference tracks Governance and Policies
Summary International labor migration has become a crucial engine in economic development for many countries worldwide. Even though the enormous contribution from international migrant workers to Sri Lanka’s economic development is well documented, politically encouraged, socially accepted and commercially stimulated, little is known on the actual health and social consequences of the ‘left behind’ members of their families. Despite the growing importance on migration for global development, the public health implications for migrants and their families have received little attention and empirical research into measuring impacts have been scarce.
Background ILM from Sri Lanka has grown ten-fold during the past decade, with 23.8% of Sri Lanka’s total labour force currently employed abroad. In what was once a highly feminized labor force, today 49% percent of ILMs are women, and out of these, 86% are ‘domestic housemaids’ with the majority (over 93%) employed in the Middle Eastern countries. ILMs contributed 4.1bn USD to the Sri Lankan economy in 2011 (second highest contributor). Many ILMs also choose continuous cycles of re-migration (‘circular migration’) to increase their savings potential. Even though the enormous contribution from international migrant workers to Sri Lanka’s economic development is well documented, politically encouraged, socially accepted and commercially stimulated, little is known on the actual health status and health consequences of the ‘left behind’ members of their families. The WHA resolution on health of migrants prompted public health attention and called for an evidence-based research agenda on migration health. In the current study, the association of spousal migration with socio-demographic factors and health status of ‘left-behind’ family members (spouse, children and care givers) were compared with families without a history of migration, using standardized instruments with diagnostic values.
Objectives Despite the fact that nearly one-in-ten Sri Lankans are employed abroad as International Labor Migrants, very little is known about the impact of their migration on the health status of the families they ‘leave behind’. The findings from this study will be useful to form an evidence-based approach in the National Migration Health Policy for Sri Lanka. In addressing the social and health impacts and determinants on the reliance for migration for development the challenge for policy makers lies at the nexus of migrant rights and economic gain through remittances and responsibility. In order to advocate for migrant sensitive health policies, empirical evidence is needed to determine the true health consequences of labour migration on families 'left behind'.
Methodology This national study utilized both quantitative and qualitative methods to study associations between the health status of ‘left-behind’ spouses, children and caregivers, and comparative non-migrant families. A cross-sectional study design with multi-stage random sampling was used. We surveyed a total of 1990 persons; 875 adults (from 410 migrant and 410 non-migrant families), 820 children from 410 migrant and 410 non-migrant families matched for both age and sex, and 295 school teachers linked to these children. Socio-demographic and health status data were derived using standardized pre-validated instruments. Univariate and multivariate analyses were used.
Results Nearly one-in-three migrant families were from single-parent households. Forty-four percent of left-behind children had some form of psychopathology, with over a quarter of those under 5-years being underweight or severely underweight (29%). Association of emotional, hyperactivity, conduct problems and having any psychiatric diagnosis was strongest in children from migrant family households [Odds ratio 1.62 (CI: 1.16-2.27)], and was exacerbated in families where the sole parent was the overseas based migrant worker. Significantly high levels of depression were found in caregivers [12.3% (CI: 12.23-12.31)] and spouses from left-behind families [25.5% (CI:25.47-25.60], with physical health status showing similar trends.
Conclusion Findings provide empirical evidence on the health consequences for heavy out-migration for the families ‘left-behind’. These are relevant for many labour ‘sending countries’ in Asia relying on ILM remittances. Whilst cross-sectional studies can only suggest, but not prove a cause–effect relation, this study highlights a number of major challenges for policy makers at the nexus of balancing rights, remittances and health consequences. We advocate the adaptation of migrant sensitive health policy frameworks guided by the 2008 World Health Assembly Health of Migrants Resolution, which promotes safe, healthy and economically beneficial ‘migration for all’.

Irregular migration: malaria re-introduction in elimination settings.

Author(s) Kolitha Wickramage1, Sharika Peiris 2.
Affiliation(s) 1Health Unit, International Organization for Migration, Sri Lanka, Sri Lanka, 2Health Unit, International Organization for Migration, Sri Lanka, Sri Lanka.
Country - ies of focus Sri Lanka
Relevant to the conference tracks Infectious Diseases
Summary Irregular migration in the form of human smuggling and human trafficking is recognized as a global public health issue. Beyond the criminality and human rights abuse, irregular migration plays an important, but often forgotten, pathway for malaria re-introduction. We describe 32 cases of Plasmodium falciparum that were detected in 534 irregular migrants returning to Sri Lanka via failed human smuggling routes from West Africa in 2012, who contributed to the largest burden of imported cases in Sri Lanka which had entered elimination phase. Active surveillance of the growing numbers of irregular migrant flows becomes an important strategy as Sri Lanka advances towards goals of malaria elimination.
Background Sri Lanka is heralded as a ‘success story’ for malaria control in Asia having succeeded in reducing malaria cases
by 99.9% since 1999 and is aiming to eliminate the disease entirely by 2014. Since the end of the protracted civil conflict in 2009, there have been an unprecedented number of migrants leaving Sri Lanka to countries such as Australia, Canada and the UK via ‘irregular migration’ routes. An irregular migrant is defined as someone who, owing to illegal entry or the expiry of his or her visa, lacks legal status in a transit or host country. Irregular migration takes many forms, ranging from human smuggling to trafficking of persons for purpose of exploitation. Globally, the numbers of undocumented cases have increased despite spending on enforcement measures at the major destination countries.
Objectives This report focuses on a migrant flow of major importance for malaria importation that, until recently, has received little attention from public health authorities.
Methodology From the end of 2011, local and international law enforcement authorities intercepted people-smuggling operations from Sri Lanka to Canada across nine West African nations: Togo, Benin, Guinea, Sierra Leone, Mali, Ghana, Senegal, and Mauritania. In close coordination and partnership with the Governments of Sri Lanka, Canada and West African nations, IOM assisted these irregular migrants who were intercepted or detained, and returned to their place of origin. From January to December 2012, all irregular migrants returning from West African countries were subjected to malaria screening upon arrival at the Bandaranayke International Airport (BIA) in Sri Lanka. Screening was conducted on site using the rapid diagnostic test kit CareStart™ Malaria HRP2/PLDH, with 98% sensitivity and 97.5% specificity for Plasmodium falciparum, and microscopic examination of blood smears, collected at the airport and performed at the national reference laboratory. Health personnel from the airport medical unit, Anti-Malaria Campaign (AMC) and IOM officials were involved in facilitating the on-arrival screening process. Under a directive from the Anti-Malaria Campaign, repeat RDTs were carried out for all returnees at the district level within one week of their arrival at home destination. This intensive follow-up was carried out with the collaborative efforts of both the AMC and IOM field staff.
Results Of the total number of returnees screened (n=534), 32 were positive for P. falciparum. Nearly two thirds (n=19) were identified at the point of entry at the BIA and 13 during district level follow-up. The total number of malaria cases from irregular migration routes accounted for 76% (32/42) of the total number of P. falciparum cases detected in Sri Lanka in 2012. This route contributed to 46% (32/70) of the total number of imported malaria cases in the same year. Imported cases overtook indigenously acquired cases of malaria for the first time in Sri Lankan in 2012, contributing to three-quarters of the total malaria burden (70/93). The largest number of irregular migrants (n=17) had returned to Jaffna district which has the highest API of >0.2 to 0.3 in comparison to other districts in Sri Lanka.
Conclusion Malaria incidence in returnees from source countries has proven to be a sensitive predictor of malaria risk, particularly where there is sub-national transmission. The fact that the largest number of migrants returned to districts with the highest API indexes reported nationally is also significant. Re-introduction and risk of spreading the parasites occurs when there is a long-term return into areas of endemicity with presence and prevalence of the mosquito vector. For this reasons the close follow up and monitoring performed by the AMC and IOM field based teams is an important strategy. Unlike other categories of inbound migrants, such as tourists, who may also import malaria to the country, returning Sri Lankan citizens from endemic areas are more likely to be exposed to mosquito bites and hence are more likely to contribute to the spread of malaria upon return to their homes within locally endemic regions. Other inbound migration categories include: returning Sri Lankan labour migrant workers, Sri Lankan armed forces personnel from UN peace keeping missions, and returning students. The attack rate for malaria in this migrant group using irregular modes of travel is considerably high (sixty cases per 1,000) when compared to the risk of contracting malaria for regular travellers returning from West Africa at three per 1,000. For the migrants themselves, their ‘illegal’ status and clandestine nature of movements enhanced health vulnerability, including having little or no access to health care in transit countries.