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Migration and the Health Effects of International Trade

Equality, Equity and Policy: Migration and the Health Effects of
International Trade


Migration is the permanent relocation of an individual from one country to another. As of the year 2005, 191 million people (3% of the world’s population) were living outside their country of birth (United Nations Population Division, 009). There are a variety of different reasons for migration, and migration is often split into two categories - voluntary migration and forced migration. However, some reasons for migration apply to both voluntary and forced migrants, therefore it is more useful to think of reasons for migration in two categories: ‘push’ and ‘pull’ (see Table 1). Push factors drive a migrant out of their country of origin while pull factors attract migrants towards a particular destination country.

Table 1: Push and pull factors

Push Factors

Pull Factors

  • war

  • poverty

  • hunger

  • environmental or natural disasters

  • political instability

  • discrimination

  • economic depression

  • employment opportunities

  • political and religious freedom

  • study/academic opportunities

  • family members

  • quality of life

Migrants are a diverse group (e.g. economic migrants, students, refugees, asylum seekers) and therefore the relationship between health and migration is complex. On the one hand, there is a social selection involved in migration (known as the ‘healthy migrant’ effect), since migrants are often younger and healthier compared to both their population of origin and people from the host country of a similar ethnicity.  Most evidence of the healthy migrant
effect comes from North America, where researchers have found that migrants have a health advantage, which diminishes as individuals become more assimilated into the host society. On the other hand, the migration process may involve a number of stressors and strains that may increase migrants’ morbidity in several ways (figure 1).

Figure 1: The influence of the migration process on migrant’s morbidity.

Source: Kristiansen et al, 2007

Conditions affecting health in the country of origin and during the journey may include war, torture, loss of relatives, long stays in refugee camps (which may have poor sanitation and overcrowding), imprisonment, and socioeconomic hardship. After arriving in the host country migrants may experience imprisonment, long-lasting asylum seeking processes, language barriers, lack of knowledge about health services, loss of social status, discrimination and marginalisation.

Kristiansen and colleagues (2007) note that coping with a new language, as well as a new political and social context can be extremely stressful. The effect of migration on the mental health of individuals depends on the magnitude of strains in the recipient country and can be mediated by the migrant’s social resources (i.e. social networks, language skills, education level, etc.).

Migration may also affect risk perception and risk behaviour. Feelings of loss and psycho-social issues related to lower social positions, unemployment and being in a minority may lead to a feeling of lack of connection between
current risk behaviour and future health effects (i.e. migrants may be forced to focus on their current feelings rather than the future health effects of their current health behaviour). For example, a new migrant, separated from friends
and family in an urban environment (feeling more anonymous and less constrained by social norms) may turn to prostitution or drugs as a way to escape loneliness, frustration and social isolation.

Migration also has health implications for the country migrants have left. Individuals who emigrate for economic opportunities may cause a ‘brain drain’ in their country of origin, when a large number of individuals with technical
skills or knowledge leave, potentially depleting the local infrastructure.This particularly affects healthcare because there are often economic incentives for healthcare professionals to migrate. The World Health Organisation (WHO) has
long recognised that migration of health personnel from developing to developed countries increases the existing imbalances in the global health workforce and can cause deficiencies in local provision of services in developing countries (Mejia et al, 1979). This migration is often demand-led when developed countries experience shortages in medical professionals. Hagopian et al (2004) estimate that 23% of American physicians received their medical training outside the USA. The majority of foreign trained physicians (64%) in the USA came from middle or low-income countries. In the UK, 31% of doctors and 13% of nurses were born overseas (Glover et al, 2001). While countries of origin may benefit from some remittances (e.g. migrant’s wages sent back), the adverse implications for developing countries greatly outweigh these relatively small benefits. To address the problem of brain drain, Pang and collegues (2002) recommend “a global perspective, agreed ethicalprinciples between
countries, and a systematic approach usingthe convening power of international organisations.”

Finally, there are health implications of migration in the host (destination) country. Some host countries are worried about the presence of infectious diseases in migrants, and screening of migrants (though a contentious human
rights issue) has been adopted, to varying degrees, by several countries throughout the world (Patterson, 2003).  While some migrants may be generally healthier than the population (i.e. the ‘healthy migrant’ effect),
other migrants may have pre-existing health conditions that can strain local health care systems. For example, increasing retirement migration (where older adults, who often require more health care, migrate to warmer destinations - e.g. Spain, Florida), can present a challenge for recipient health care systems.

The health effects of international trade

The effects of increased international trade are both direct and indirect, as well as positive and negative (see Table 2).

Table 2: Some of the direct and indirect effects of increased international trade.

Direct Effects

Indirect Effects





  • Increased availability of goods beneficial to health (e.g. pharmaceuticals, food)

  • · Increased availability of goods hazardous to health (e.g. firearms, alcohol (see Box 1) and tobacco)

  • Migration of health professionals

  • Potential spread of infectious disease

  • Poverty reduction

  • Stimulation of development

  • Better living conditions

  • Greater knowledge dissemination

  • Increasing "interconnectedness" encourages countries to respond to what happens outside their borders when developing health policy and interventions.

  • Increased transportation

  • Greater use of fossil fuels

  • Pollution

  • Climate change, potentially including droughts, floods and rising sea levels.


The World Trade Organisation (WTO) has recognised that trade policies can have a substantial impact on health (WTO and WHO, 2002). Trade policies such as tariffs, patent protection, and free trade have both direct and indirect effects on health.

Fox and Meier (2007) outline four main trade agreements that have had direct effects on health and also outline the indirect effects of trade policy on health. These are described in table 3.

Table 3: The link between trade policies and health

Direct Effects of Trade Policies

Indirect Effects of Trade Policies

Trade Related Intellectual Property Rights (TRIPS). Forbids breaking pharmaceutical patents except via Article XX(b) when “necessary to protect human, animal or plant life or health”. TRIPS restricts access to generic medicines, which makes drugs particularity costly for those without insurance and in the developing world.

Agreement on the Application of Sanitary and Phytosanitary Measures (SPS). While recognizing the right of countries to take measures to protect health and life, SPS minimizes the chances of these measures being used as trade barriers.

Regulatory standards governing human, animal and plant health shall by default be based on recognised international bodies. More restrictive regulation must be based on scientific risk assessment .(For example, the EU ban of hormone-treated beef was judged to be unsupported by science and not addressing defined risks)

Technical Barriers to Trade Agreement (TBT).  Creates universal standards to protect human life and health provided these standards are not surreptitious protective shields. Encourages use of internationally agreed standards in product regulation. Regulations must be least trade-restrictive necessary. (TBT has implications for water supply, food production, and labelling of foods and drugs).

General Agreements on Trade in Services (GATS).  Establishes rules for trade in services including the movement of consumers and providers across borders to receive and supply health care with a view
towards progressive liberalization. (May lead to privatization of health care)

Unjust trade laws hamper the economic development of poor countries and perpetuates the advantage of rich countries via:

  • Non-tariff  barriers to trade against exports from developing countries;
  • Volatility of commodity prices.

Trade liberalization has deprived countries of tariff revenue (a much needed revenue stream in the developing world).

Source: adapted from Fox and Meier, 2007

Trade policies have the potential to conflict with public health interests. The WTO aims to remove restrictions on free trade and trade liberalisation increases the sale and consumption of some goods that are detrimental to health
(See Table 2 and Box 1).

Box 1: Trade policy and alcohol.

The excess consumption of alcohol is related to a wide variety of negative health outcomes including morbidity, mortality, and disability. Therefore, the objective of alcohol control policies is to limit alcohol consumption, often through taxation, restriction on hours of sale, advertising restrictions, etc. The level of domestic consumption of alcohol depends upon the interaction of international demand and supply and the development of international trade policy. This presents a fundamental conflict of interest between public health alcohol policies and free trade agreements, which seek to remove restrictions on the buying and selling of goods. Article XIV of the GATS states: “nothing in this Agreement shall be construed to prevent the adoption or enforcement by any Member of measures necessary to protect human, animal or plant life or health”. However, it is unknown how robust the exemption paragraphs will be in the long run and so far the exemption has been interpreted by the WTO restrictively (i.e. when tested, trade arguments have prevailed over other considerations).  Therefore, the GATS seems unlikely to protect health-based alcohol measures.

Source: Endel, 2006



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© Rebecca Steinbach 2009