Hi, my name is Marie Norredam. I'm a doctor and associate professor at the Department of Public Health at the Faculty of Health Sciences and Medical Sciences at University of Copenhagen. At the Danish Research Center for Migration, Ethnicity, and Health where I work as a research leader, we are about 10 to 15 people working specifically with issues related to the health of immigrants and ethnic minorities in Denmark and abroad. In this short lecture I wish to address why migrant health is an important global health topic, the key concepts of migration and ethnicity and how they are related to health, how barriers may arise in access to health care for migrants, and lastly, give some examples from a Scandinavian context on differences in health outcomes between migrants and ethnic Danes. Today there are about 240 million international migrants corresponding to about 3% of the world's population. In most European countries, migrants make out about 8 to 10% of the population. However, internal and international migration is even more widespread, for example, in African countries. So increasingly, both in low and high-income societies, we've become more multicultural, making health of immigrants and ethnic minorities an important new area of interest. This emerging field of research and clinical practice is important to address for several reasons. As a consequence of increased migration, healthcare systems and healthcare professionals are increasingly met by cultural diverse patients and, therefore, need more knowledge on this. Secondly, health promotes integration and integration promotes health, so from a pragmatic societal perspective, healthy migrants are needed to contribute in a social economic sense to the immigration country. Thirdly, from a moral perspective it's important to address migrants health issues to ensure immigration countries adherence to human rights principles and the promotion of equity in health for all, as stated in several human rights documents and WHO declarations. Several areas are of concern for migrant health under these overarching themes; determinants of health, health outcomes, access to healthcare and healthcare policies. I should add that there is no generally used definition of the field, but it stands on the shoulders of social medicine, international health and several clinical disciplines and, often, the research field is embedded in public health institutions where a multidisciplinary approach is used engulfing both humanities, social sciences, and medicine. Different population groups are of concern including so-called ethnic minorities who have been established over years in the immigration country and who may include indigenous people but also asylum seekers, refugees, family reunified immigrants, and work and student immigrants are of concern. However, research mainly focus on long-term migrants, that is persons who move to a country other than that of his or her usual residence for a period of at least a year. Migration and ethnicity are two closely interrelated key concepts. Apart from migration and ethnicity, this model shows that social factors and genetic diversity form part of a series of complex interacting determinants of migrants health. Migration is not only a geographical movement from one place to another but also a socioeconomic, psychosocial and environmental life event. Migration includes new phenomena like circular migration of work migrants, remigration of elderly migrants, and inverse economic migration of young Europeans to former colonial countries due to economic recession. Traditional migration is created due to pull and push factors. Pull factors may be economic incentives or human rights protection and push factors, for instance, human rights abuse or famine. Migration and health is related because a number of risk factors for ill health is related to the different phases of the migration process. Pre-migration risk factors are related to events in the country of origin such as famine, war, trauma, and problems of accessing healthcare. During the migration process, migrants may experience lack of access to water, food, and medical care. Post-migration risk factors for ill health include limitations in access to healthcare due to political grounds as well as language barriers, marginalization, discrimination, etc. In line with this, migrants health is increasingly studied from a life course perspective, as seen in this model. For example, we know that exposure is already in utero and may affect later disease development in adult life. A few words about the other key concept, ethnicity. It is about identity and implies a sense of group belonging based on ideas of common origins, history, cultures, experiences, and values. So it encapsulates cultural norms and ways of acting which may affect perceptions of disease and interactions with healthcare professionals. Ethnicity is often operationalized into a static concept, like country of birth, which almost implies some inherent characteristics, but really, ethnicity is a dynamic concept that may change over time and from place to place. Consequently, the ideal is to ask individuals themselves how they perceive their ethnic belonging named self-identified ethnicity. Formal and informal barriers may affect migrants access to health care. Formal barriers, for example, include economic but also legal limitations to access to health care. In Denmark, we have a free access healthcare system yet undocumented migrants may face legal limitations as they are only entitled to emergency room care. In contrast, access to healthcare for undocumented migrants in Sweden is more liberal and includes chronic diseases to some extent. Additionally and also importantly, informal barriers exist on the side of the migrant patient and the healthcare staff or system. They include language, culture, newness to the healthcare system, but also healthcare professionals lack of cultural competency. Differences in health outcomes exist between migrants and local born. I now want to give you a few examples concerning mortality taken from a Danish context. A Danish national register-based study showed that women from Pakistan and Somalia had a prenatal mortality which was respectively, 62% and 111% higher compared to ethnic Danes. These alarming results were, among other things, explained by suboptimal access to prenatal care for migrant women. Another Danish register-based study of a cohort of 60,000 migrants who had arrived since the early '90s to Denmark showed that refugee women had approximately a 4X excess mortality from infectious diseases compared to ethnic Danish women, and refugee men had approximately a 2X higher excess mortality from infectious diseases compared to ethnic Danish men. Results were explained by excess morbidity, reflecting disease patterns in the countries of origin, but also by delay in diagnosis as well as compliance problems. A totally different picture we're seeing when we look at cancer mortality in the same migrant cohort. Refugee and family reunified immigrant women, respectively had a 25% and 64% lower cancer mortality compared to ethnic Danes. Refugee and family reunified immigrant men had respectively 14% and 45% lower cancer mortality compared to ethnic Danish men. So to sum up, migrant health is an emerging discipline closely linked to equity in health and human rights in health. Migration and ethnicity are two complimentary key concepts vital for understanding migrants health. Migrants may experience formal and informal challenges in accessing health care in immigration countries and some health outcomes are worse for migrants compared to local born, like prenatal mortality or infectious disease mortality as shown, but other health outcomes, like cancer mortality, are not worse for migrants. There are also protective factors about being a migrant which, when we know more, the general population may also benefit from. Thank you for your attention.
