Keywords

Introduction

Migration often brings tremendous benefits to the people who move and the places they move to. Yet shifting your life from one place to another can also be a tremendously disturbing event, with long-lasting consequences. This is particularly the case for individuals who do not feel fully in charge of the process of moving, a situation common to many children and adolescents involved in migration. In extreme cases, refugees and other forced migrants, those resorting to smuggling or trafficking, and those attempting to conceal themselves from authorities face the greatest fear, the greatest risks, and the least control. Thankfully, these people represent a small minority of global migrants, albeit a highly mediatized one. Yet choice is a broad spectrum, not a forced/voluntary binary. There are plenty more people who have some agency, yet nonetheless move reluctantly, who leave established homes with regret and fragile hope that they are moving to something better.

For many millions who move, migration does bring something better, from improved educational opportunities to quality of life in retirement. This chapter is written in the firm conviction that migration, including refugee movement, is mostly a good thing, for the individuals concerned, and for the places they move to. Yet, even when it goes well, there are challenges. Migration was recognized as an important social determinant of health in a resolution of the World Health Organisation (WHO) more than 10 years ago (WHA61.17) and this has been followed up by further calls to focus more on migrant health. These global resolutions do not focus specifically on mental health, although this is clearly a significant issue: the isolation, loneliness, and culture shock experienced by migrants may be exacerbated by a hostile reception, xenophobia, or racism, even for those moving within countries. This chapter considers these challenges and migrants’ capacity to resist them. It falls into three sections: first an explanation of definitions and data that are used to organize assessments of migration; second, a review of some recent research on migration and wellbeing; and finally a brief review of patterns of urbanization, estimated as the most significant global movement of people between now and 2050.

Definitions and Data

In most cases, migrants are in a minority in the places they leave, the places they arrive and the places they travel through. In each case, they differ from the wider population in important ways which are likely to have important health implications. Yet data on migration is notoriously poor quality. Migration which attracts most attention is international migration – that is migration crossing an international border. On a global scale, there are 272 million international migrants (in 2019), 3.5% of the global population (UNDESA 2019a). A larger number of migrants do not cross international borders, currently reckoned to be 763 million (IOM 2019). Yet even this most basic data of numbers of international and especially internal migrants is patchy. Countries with regular censuses and robust civil registers have reasonably accurate data, whereas data is much more uncertain or absent in countries experiencing conflict or struggling to maintain accurate administrative records. Even in countries with good data, information on undocumented migrants, the most vulnerable and excluded population, is entirely lacking, though this gap is usually filled in with estimates. Data is therefore skewed in important ways with details of the most marginalized systematically absent: in wealthy countries information is broadly comprehensive (except for those without legal status), whereas migration to and particularly within poorer countries is substantially undercounted. Global data on migration is often modeled to fill in these gaps and is based on estimates or projections.

Refugees are one notable exception to this global trend. The UN Refugee Agency (UNHCR) maintains good data on those populations under its control, chiefly those in refugee camps and those urban refugees registered with the agency. UNHCR also provides regular statistical updates on other groups of forced migrants, mainly internally displaced people. This data confirms the concentration of refugees in poorer countries. In 2018, wealthy countries hosted 16% of the world’s refugees while over 30% were hosted by countries officially classified as “least developed” (UNHCR 2019). Yet even here, such an authoritative presentation hides the fact that an unknown number of refugees, particularly in urban areas, are not counted. In this chapter, refugees as a group is subsumed under the category of migrants – by definition refugees are international migrants since they must have left their country of origin. This is not to dismiss the specific difficulties faced by refugees, but a recognition that it is difficult to draw a clear distinction between refugees and many other migrant groups.

Although data on numbers and locations of refugees is often more reliable, than for migrants in general, more detailed information, even on basics such as gender or ages of migrants, is still limited. This paucity of information is widely recognized and there have been several recent international efforts to improve the quality of migration data (Global Migration Group 2017). Since information on who and where migrants are, and even how many of them move in particular ways, is so uncertain, particular health-related information is absent at any aggregate level. Analysis and policy interventions are therefore based upon observed trends and patterns rather than established relationships at anything other than very local levels. This uncertainty has also encouraged a broader focus on the social determinants of health, rather than a narrow, medicalized approach where information is severely lacking. This has involved a very substantial growth in interest in research around wellbeing and migration.

Migration and Wellbeing

There are three ways in which migration may be relevant for health, health-seeking behavior, and wellbeing in general. First, the context of migrants’ area of origin may lead to particular patterns of ill health or particular expectations of health provision. In the case of mental health, the poor development of psychiatry and continued stigmatization of mental illness in large parts of the world is likely to reduce the willingness of migrants from those areas to seek professional medical support. Second, the migration process itself has become longer and more dangerous for many people in recent decades creating new health risks and separating migrants from established health providers. The importance of the 2008 WHO resolution (WHA61.17) was to recognize migration itself as a social determinant of health beyond its impact on access to health care. This relates to the third reason why migration may have an impact on health, which concerns its impact on the post-arrival situation. Migration certainly affects direct access to health care, indeed efforts made to restrict migrants’ access to health care in wealthy countries have increased substantially in recent years. Yet migration also affects all other aspects of an individual’s life. This may include housing, employment, or education and the nature and quality of migrants’ relationships with members of their local community and (distant) family. All of these will influence migrants’ health and in particular their wellbeing.

Wellbeing takes a much broader definition that offers one way of implementing the WHO’s concerns with the social determinants of health. In the UK, the Office for National Statistics (ONS) uses a set of four subjective wellbeing questions which appear in a very wide range of very large n surveys at national and European level and increasingly across the OECD (OECD 2013). These four questions are all measured on a 1–10 scale and concern: 1. life satisfaction (“overall, how satisfied are you with your life nowadays?”), 2. worthwhile (“overall, to what extent do you feel that the things you do in your life are worthwhile”),; 3. happiness (“overall, how happy did you feel yesterday?”), and 4. anxiety (“overall, how anxious did you feel yesterday?”). These questions allow widespread international comparison. The ONS also uses the Warwick-Edinburgh Mental well-being scale on a scale of either 14 or seven items (Warwick 2019).

Possibilities for comparison internationally or with larger populations have made these measurements popular in smaller, bespoke survey work as well. This is illustrated by two research projects with two very different migrant groups. Both projects highlight the value of the social determinants of health approach. The first project involved research with refugees resettled to the UK and second, called “Migrants on the Margins” examined the impacts of migration to slums in Colombo (Sri Lanka), Dhaka (Bangladesh), Harare (Zimbabwe), and Hargeysa (Somaliland). In the first project, the use of this common scale allowed a comparison between refugees resettled to the UK and the general UK population. The most startling conclusion of this project was that even 5 years after arrival, refugees had markedly lower levels of subjective wellbeing than the general population. Refugee’s levels of wellbeing correlated with the stability of housing and employment and quality of contacts with people they met daily in statistically significant ways. Surprisingly, it was also related to the reported quality of contact with refugees’ friends and family overseas highlighting the important emotional significance of these transnational connections.

This research was longitudinal with three time-points, 1 year apart. Important generational differences in wellbeing with the group of resettled refugees emerged that were particularly apparent over the 3 years of research. Those under 18 were not included in the survey. Since the first survey was conducted 5 years after arrival, we did not interview anyone who was under the age of 13 when they arrived in the UK. Yet even within this narrower band of childhood, significant differences emerged. At 13, children were able to enter the UK education system with relatively few barriers, particularly if they had some English. By 16 the advantages of education disappeared since, by the time they had reached the necessary level of English, they were over 18, no longer eligible for free education and so finished schooling without basic qualifications. This produced a marked difference in wellbeing between these different groups that became more pronounced over time as those without UK educational qualifications faced much greater barriers in the labor market. These findings around the significance of wellbeing have already begun to inform UK policy around refugee resettlement (Collyer et al. 2018). The findings of the second study on migration to cities are more complex and require some background around what has become the most significant movement of people in the world.

The Growing Significance of Urbanization

The growth of cities is the dominant demographic trend of the twenty-first century. Despite the uncertainties of data, there is no disagreement that a majority of the world’s population now lives in cities. The world’s population became majority urban sometime in 2009 (UNDESA 2010). Cities grow in three ways. The first is the natural growth of urban populations, although around the world fertility of urban populations is lower than rural populations. Second is through migration to the city, and movement from nearby rural areas is the main driver of this in poorer cities. Given the low fertility of urban populations, migration is now estimated to be the most significant driver of urban growth. Finally, cities grow as rural areas surrounding cities are reclassified as urban. This is simply a mark of official recognition that the first two processes of growth have been going on beyond the official urban boundary but it helps explain sudden jumps in urban population as large areas change classification overnight. It also helps explain why estimates of city populations vary so widely: there is often no clear definition of the extent of the “greater” city beyond the official boundary and data on populations living there may be similarly limited.

This growth is often unplanned. In 2018 more than a billion people in the world lived in slums (UNDESA 2019b). Given the significance of this movement of people on a global scale, it is vital to understand more about how it functions as a social determinant of health. Many of the factors affecting this are specific to particular urban contexts, but some valid generalizations can be made. Just as migration from a rural to an urban area has a virtually universal impact on reducing fertility, it also appears to reduce subjective wellbeing, certainly for low-income groups who are more likely to move to slum areas. The Migrants on the Margins project used the same four ONS subjective wellbeing questions in surveys of approximately 4,000 households in slums in Colombo, Dhaka, Harare, and Hargeysa. Research has only just concluded, but initial findings indicate that of the many uncertainties facing new urban residents it is the insecurity of tenure that has the most direct impact on their reported wellbeing (RGS 2019). This impacts the entire family.

Many residents reported stigmatization based on the neighborhood in which they lived and children were unwilling or unable to attend schools outside the neighborhood. Insecure tenure reduces residents’ willingness to invest in their homes and increases the likelihood of forced evictions. Forced evictions disrupt livelihoods and education, particularly when new residential locations are some distance away, which was particularly common in Dhaka and Harare, given the shortage of housing in desirable locations. Even where access to healthcare is possible evictions cut such connections. Evictions also destabilize relationships with other members of the community and in extreme cases of marginalization prevent such relationships forming in the first place (RGS 2019). The impact on the wellbeing of movement to cities is potentially dramatic. The most straight forward response to this is the legalization and gradual upgrading of squatter areas of housing. Where this is impossible due to the physical danger of particular locations, a movement to nearby accommodation. The greatest barriers to ameliorating these negative health impacts are political and greater access to research that can help here too.

Conclusion: Migration and Urbanization as Social Determinants of Health

The data on migration is not sufficiently good to make any clear generalizations about migration and health, less still about the specificities of mental health as it affects children and adolescents. Nevertheless, some clear patterns are discernible. Migration is now widely recognized as an important social determinant of health, including mental health. Agency is important for migrants. Where they chose to move and do so under circumstances largely of their organization, migration is much more likely to be beneficial. Where migrants have less choice, wellbeing is more likely to be affected. As this short overview has demonstrated, this is particularly the case for refugees, though other groups of forced migrants may be similarly affected. It is also the case for poorer migrants. Those who have little choice about where to live due to limited resources are more likely to end up in exploitative, dangerous, or unsanitary conditions. The movement of people from rural areas to slums is one of the most significant demographic trends that are likely to continue throughout the twenty-first century. Here too, there are ways of ameliorating negative impacts on migrants’ wellbeing, as long as the political will exists to implement them. As data improves and research continues opportunities to support this will increase.

Cross-References