Adverse health effects of restrictive migration policies: building the evidence base to change practice
Authors: Kayvan Bozorgmehr, Rosa Jahn
Journal: The Lancet Global Health (2019)

Migration policies and health often collide. Migration policies are rooted in concepts of state sovereignty and determine who can stay in a country and who must go, who can access services and who is excluded. In contrast, health policies are governed by the international human right to health, which must be respected on a non-discriminatory, inclusive basis. Nations are obliged not to infringe upon the right to health for all, including people migrating for work, seeking asylum within their borders, or who are undocumented.1Committee on Economic, Social and Cultural RightsSubstantive issues arising in the implementation of the international covenant on economic, social and cultural rights—general comment no.14 (2000). UN Economic and Social Council, Geneva2000Google Scholar Tensions arise when migration policies adversely affect the health of migrant or host societies. However, evidence of the effects on health of migration policies targeting social determinants of health such as access to labour markets, education, housing, health care, social security, or welfare services is rare. Migrant health research has been predominantly concerned with mental health and infectious diseases,2Sweileh W Wickramage K Pottie K et al.Bibliometric analysis of global migration health research in peer-reviewed literature (2000–2016).BMC Public Health. 2018; 18: 777Crossref PubMed Scopus (93) Google Scholar or with health inequalities between specific migrant groups and host populations, whereas policy and systems issues have been sidelined.2Sweileh W Wickramage K Pottie K et al.Bibliometric analysis of global migration health research in peer-reviewed literature (2000–2016).BMC Public Health. 2018; 18: 777Crossref PubMed Scopus (93) Google Scholar, 3Hanefeld J Vearey J Lunt N et al.A global research agenda on migration, mobility, and health.Lancet. 2017; 389: 2358-2359Summary Full Text Full Text PDF PubMed Scopus (28) Google Scholar, 4Abubakar I Aldridge RW Devakumar D et al.The UCL-Lancet Commission on migration and health: the health of a world on the move.Lancet. 2018; 392: 2606-2654Summary Full Text Full Text PDF PubMed Scopus (357) Google Scholar At a time in which international migration is at its peak5International Organization for MigrationWorld Migration Report 2018. International Organization for Migration, Geneva2018Google Scholar and policy responses are becoming increasingly hostile, Sol Pía Juárez and colleagues6Juárez SP Honkaniemi H Dunlavy AC et al.Effects of non-health-targeted policies on migrant health: a systematic review and meta-analysis.Lancet Glob Health. 2019; (published online March 6.)http://dx.doi.org/10.1016/S2214-109X(18)30560-6Summary Full Text Full Text PDF PubMed Scopus (66) Google Scholar have pulled together the evidence on the effects of non-health-related policies on migrant health in a systematic review and meta-analysis published in The Lancet Global Health. The study represents a timely, innovative, and highly needed contribution to migrant health research. Previous systematic reviews have examined the health effects of specific policies (eg, detention)7Filges T Montgomery E Kastrup M The impact of detention on the health of asylum seekers: a systematic review.Res Soc Work Pract. 2018; 28: 399-414Crossref Scopus (31) Google Scholar, 8Robjant K Hassan R Katona C Mental health implications of detaining asylum seekers: systematic review.Br J Psychiatry. 2009; 194: 306-312Crossref PubMed Scopus (266) Google Scholar or the health of specific migrant groups (eg, undocumented migrants).9Martinez O Wu E Sandfort T et al.Evaluating the impact of immigration policies on health status among undocumented immigrants: a systematic review.J Immigr Minor Health. 2015; 17: 947-970Crossref PubMed Scopus (269) Google Scholar However, policy effects on migrants have not yet been rigorously isolated through the use of comparison groups exposed to different policies and contexts. The range of non-health-related policies at multiple stages of the migration process has also not been comprehensively examined. Applying a strong policy perspective, Juárez and colleagues6Juárez SP Honkaniemi H Dunlavy AC et al.Effects of non-health-targeted policies on migrant health: a systematic review and meta-analysis.Lancet Glob Health. 2019; (published online March 6.)http://dx.doi.org/10.1016/S2214-109X(18)30560-6Summary Full Text Full Text PDF PubMed Scopus (66) Google Scholar examined the effects of different policy typologies (generous, restrictive, inclusive, assimilationist, and exclusionist) on health outcomes among international migrants at different migration phases (entry, integration, and exit). Their systematic literature search spanned 17 years and yielded 31 528 unique records, of which 46 primary articles (two of these articles reported on the same study) were ultimately included in the analysis. 19 studies qualified for random-effects meta-analysis and all 46 underwent narrative synthesis. The key findings of Juárez and colleagues6Juárez SP Honkaniemi H Dunlavy AC et al.Effects of non-health-targeted policies on migrant health: a systematic review and meta-analysis.Lancet Glob Health. 2019; (published online March 6.)http://dx.doi.org/10.1016/S2214-109X(18)30560-6Summary Full Text Full Text PDF PubMed Scopus (66) Google Scholar were that restrictive entry policies have adverse effects on mental health (standardised mean difference 0·44, 95% CI 0·13–0·75), while international migrants exposed to restrictive integration policies were at higher risk of poor mental health (narrative synthesis), poor self-rated health (odds ratio [OR] 1·67, 1·35–1·98), adverse birth outcomes (narrative synthesis), reduced utilisation of health-care services (OR 0·92, 0·85–0·98), and increased all-cause mortality (OR 1·38, 1·10–1·65) compared with relevant comparison groups exposed to less restrictive policy contexts. The findings related to all-cause mortality deserve particular attention; international migrants and refugees have a mortality advantage compared to host populations (standardised mortality for migrants 0·70, 0·65–0·76; for refugees 0·50, 0·46–0·54), but no mortality advantage exists for asylum seekers (standardised mortality 1·05, 0·89–1·24).10Aldridge RW Nellums LB Bartlett S et al.Global patterns of mortality in international migrants: a systematic review and meta-analysis.Lancet. 2018; 392: 2553-2566Summary Full Text Full Text PDF PubMed Scopus (116) Google Scholar This evidence highlights the relevance of between-group differences in migrant health, such as by residence status.10Aldridge RW Nellums LB Bartlett S et al.Global patterns of mortality in international migrants: a systematic review and meta-analysis.Lancet. 2018; 392: 2553-2566Summary Full Text Full Text PDF PubMed Scopus (116) Google Scholar Juárez and colleagues further add to this evidence: they show that within-group inequalities in mortality exist among comparable categories of migrants depending on their policy context.6Juárez SP Honkaniemi H Dunlavy AC et al.Effects of non-health-targeted policies on migrant health: a systematic review and meta-analysis.Lancet Glob Health. 2019; (published online March 6.)http://dx.doi.org/10.1016/S2214-109X(18)30560-6Summary Full Text Full Text PDF PubMed Scopus (66) Google Scholar The pooled mortality among migrants in exclusionist settings, for example, was more than twice that among comparable groups of migrants in inclusive contexts (OR 2·14, 1·71–2·57).6Juárez SP Honkaniemi H Dunlavy AC et al.Effects of non-health-targeted policies on migrant health: a systematic review and meta-analysis.Lancet Glob Health. 2019; (published online March 6.)http://dx.doi.org/10.1016/S2214-109X(18)30560-6Summary Full Text Full Text PDF PubMed Scopus (66) Google Scholar Several limitations, however, remain. Most studies included in Juárez and colleagues' systematic review were controlled before–after (20 [43%] of 46 studies) and cross-sectional (19 [41%] studies), followed by few cohort or time-series studies (six [13%] studies). Causal inference is hence limited, primarily by potential residual confounding—eg, socioeconomic status or unmeasured factors affecting the health outcomes under study. Natural experiment designs, powerful11Craig P Katikireddi SV Leyland A Popham F Natural experiments: an overview of methods, approaches, and contributions to public health intervention research.Annu Rev Public Health. 2017; 38: 39-56Crossref PubMed Scopus (219) Google Scholar yet underused,12Petticrew M Cummins S Ferrell C et al.Natural experiments: an underused tool for public health?.Public Health. 2005; 119: 751-757Crossref PubMed Scopus (222) Google Scholar could strengthen causal inference in future research, especially to study the health effects of resettlement and dispersal or return and deportation policies among migrants. The synthesised evidence is further limited by an uneven distribution of the policies under study across geographical regions. The findings on all-cause mortality, for example, are based on estimates obtained from a single study of migrants from Turkey and Morocco in three countries (the Netherlands, France, and Denmark).6Juárez SP Honkaniemi H Dunlavy AC et al.Effects of non-health-targeted policies on migrant health: a systematic review and meta-analysis.Lancet Glob Health. 2019; (published online March 6.)http://dx.doi.org/10.1016/S2214-109X(18)30560-6Summary Full Text Full Text PDF PubMed Scopus (66) Google Scholar Little contextualisation of the health status of migrants and scarce use of theory in primary studies further weaken the synthesised evidence. Additionally, several questions remain unanswered by the available evidence. How is the effect of non-health-related migration policies mediated, what are the mechanisms at work, and how can adverse effects be mitigated? What is the economic cost to society of restrictive policies? What are entry points for change, and which actors and tools can be leveraged to promote the human right to health, given that policy-making processes are often messy and the adoption of restrictive policies is driven by antimigrant ideology and power-acquisition motives? Despite these limitations and unanswered questions, Juárez and colleagues' systematic review and meta-analysis6Juárez SP Honkaniemi H Dunlavy AC et al.Effects of non-health-targeted policies on migrant health: a systematic review and meta-analysis.Lancet Glob Health. 2019; (published online March 6.)http://dx.doi.org/10.1016/S2214-109X(18)30560-6Summary Full Text Full Text PDF PubMed Scopus (66) Google Scholar represents a bold contribution to the field. It forges a pioneering evidence base for the impact of non-health-related policies on migrants' health; especially in areas where the population already suffers remarkable vulnerabilities such as poor mental health and reduced access to obstetric care. This evidence-base is required to address harmful migration policies under the right-to-health framework, and to hold nations accountable for their obligation to respect the right to health in a non-discriminatory way. The role of public health is now twofold: to add to the evidence base and to use the available evidence to direct policy change. We declare no competing interests. Effects of non-health-targeted policies on migrant health: a systematic review and meta-analysisRestrictive entry and integration policies are linked to poor migrant health outcomes in high-income countries. Efforts to improve the health of migrants would benefit from adopting a Health in All Policies perspective. Full-Text PDF Open Access